Namibia TB Prevalence Survey Report 2019

1
NAMIBIA TUBERCULOSIS DISEASE PREVALENCE SURVEY REPORT 2019

CONTENTS
PREFACE ................................................................................................................... VI
EXECUTIVE SUMMARY ..............................................................................................VII
ACKNOWLEDGEMENTS ............................................................................................. VIII
LIST OF ABBREVIATIONS .............................................................................................IX
1. INTRODUCTION ........................................................................................................ 1
1.1 COUNTRY PROFILE ........................................................................................... 1
1.2 BURDEN OF TUBERCULOSIS IN NAMIBIA ....................................................... 1
1.2.1 TUBERCULOSIS NOTIFICATIONS .................................................................. 1
1.2.2 TUBERCULOSIS NOTIFICATIONS .................................................................. 2
1.2.3 TUBERCULOSIS CASE HOLDING................................................................... 4
1.2.4 TB/HIV ............................................................................................................... 5
1.2.5 DRUG RESISTANT TUBERCULOSIS .............................................................. 5
1.3 THE NAMIBIAN HEALTH SECTOR ..................................................................... 6
1.3.1 HEALTH POLICY .............................................................................................. 6
1.4 JUSTIFICATION FOR THE SURVEY .................................................................. 6
1.5 SURVEY OBJECTIVES........................................................................................ 7
1.5.1 PRIMARY OBJECTIVES ................................................................................... 7
1.5.2 SECONDARY OBJECTIVES ............................................................................ 7
2. SURVEY ORGANISATION ........................................................................................ 8
2.1 NATIONAL STEERING COMMITTEE .................................................................. 8
2.2 NATIONAL TUBERCULOSIS LEPROSY PROGRAMME .................................... 8
2.3 TUBERCULOSIS DISEASE PREVALENCE SURVEY TECHNICAL WORKING
GROUP ................................................................................................................ 9
2.4 SUBGROUPS ...................................................................................................... 9
A. ADVOCACY COMMUNICATION AND SOCIAL MOBILIZATION SUBGROUP ..... 9
B. CLINICAL MANAGEMENT SUBGROUP ............................................................... 9
C. DATA MANAGEMENT AND INFORMATION TECHNOLOGY SUBGROUP ..............
.................................................................................................................................... 9
D. LABORATORY SUBGROUP ................................................................................. 9
E. LOGISTICS AND ADMINISTRATION SUBGROUP .............................................. 9
F. RADIOGRAPHY SUBGROUP ............................................................................... 10
2.5 CENTRAL COORDINATING TEAM ..................................................................... 10
2.6 PRINCIPAL INVESTIGATOR ............................................................................... 10
2.7 SURVEY COORDINATOR ................................................................................... 10
2.8 SURVEY FIELD TEAMS ...................................................................................... 10
2.9 SURVEY FIELD COORDINATORS ..................................................................... 11
2.10 LOCAL SUPPORT TEAMS ................................................................................ 11
2.11 EXTERNAL TECHNICAL ASSISTANCE GROUP .............................................. 11
3. SURVEY METHODS .................................................................................................. 12
3.1 SURVEY DESIGN ................................................................................................ 12
3.2 SAMPLING FRAME AND CLUSTER CHARACTERISTICS ................................ 12
3.3 SAMPLE SIZE ...................................................................................................... 12
3.4 SAMPLING STRATEGY ....................................................................................... 12
3.5 TARGET POPULATION ....................................................................................... 13
3.5.1 INCLUSION AND EXCLUSION CRITERIA ....................................................... 13
3.6 SURVEY PREPARATIONS .................................................................................. 13
3.6.1 DATA COLLECTION INSTRUMENTS .............................................................. 13
3.6.2 ORIENTATION WORKSHOP FOR MOHSS REPRESENTATIVES .................. 13
3.6.3 TRAINING ......................................................................................................... 13
3.6.4 EQUIPMENT TESTING AND ON-SITE VALIDTION.......................................... 14
3.6.5 PRETESTING AND PILOTING OF SURVEY INSTRUMENTS......................... 14
I
3.6.6 PUBLICITY AND AWARENESS CAMPAIGNS .................................................. 14
3.7 FIELD PROCEDURES ......................................................................................... 15
3.7.1 HOUSEHOLD LISTING AND ENUMERATION ................................................. 15
3.7.2 FIELD CLUSTER SITE OPERATIONS ............................................................. 15
3.7.3 MOP-UP ACTIVITIES ........................................................................................ 18
3.8 CENTRAL PROCEDURES .................................................................................. 18
3.8.1 CENTRAL LABORATORY PROCEDURES ...................................................... 18
3.8.2 CENTRAL RADIOLOGIST READING PROCEDURES .................................... 19
3.8.3 DECISION BY THE CLINICAL MANAGEMENT SUBGROUP .......................... 19
3.8.4 MANAGEMENT OF PARTICIPANTS WITH HEALTH NEEDS ......................... 19
3.9 POST-SURVEY FEEDBACK MEETINGS ........................................................... 20
3.10 QUALITY ASSURANCE..................................................................................... 21
3.11 DATA MANAGEMENT..................................................................................... ... 21
3.12 STATISTICAL ANALYSIS FOR THE DETERMINATION OF TB PREVALENCE
ESTIMATION RATES ..................................................................................................22
3.13 ETHICAL CONSIDERATIONS ........................................................................... 23
3.14 DEFINITIONS .................................................................................................... 24
4. RESULTS ................................................................................................................... 26
4.1 CENSUS OF SURVEY POPULATION ................................................................. 26
4.2 PREVALENCE SURVEY CASCADE ................................................................... 28
4.3 SURVEY PARTICIPATION ................................................................................... 28
4.3.1 PARTICIPANTS VS NON-PARTICIPANTS........................................................ 28
4.4 SCREENING RESULTS ....................................................................................... 32
4.4.1 SYMPTOM SCREENING .................................................................................. 32
4.4.2 FIELD CHEST X-RAY ....................................................................................... 33
4.4.3 ELIGIBILITY FOR SPUTUM COLLECTION ..................................................... 34
4.5 LABORATORY EXAMINATION ............................................................................ 35
4.5.1 SUBMISSION OF SPUTUM .............................................................................. 35
4.5.2 FIELD LABORATORY TESTING ...................................................................... 35
4.5.3 CENTRAL LABORATORY TESTING ................................................................ 37
4.5.4 CENTRAL CHEST X-RAY RESULTS ................................................................ 41
4.6 BACTERIOLOGICALLY CONFIRMED PREVALENT TB CASES ........................ 41
4.7 ESTIMATING THE TB PREVALENCE IN NAMIBIA ............................................. 43
4.7.1 WORKING CASE DEFINITION (CLINICAL SUBGROUP DECISION).............. 43
4.7.2 REVISED CASE DEFINITION .......................................................................... 45
4.7.3 FINAL PREVALENCE ESTIMATES .................................................................. 46
REGIONAL VARIATIONS IN PREVALENCE ............................................................. 47
4.8 HIV RESULTS ...................................................................................................... 49
4.8.1 HIV STATUS ...................................................................................................... 49
4.9 OTHER FINDINGS ............................................................................................... 50
4.9.1 HOUSING .......................................................................................................... 50
4.9.2 SANITATION ..................................................................................................... 51
4
4.9.3 ELECTRICITY AND HOUSEHOLD FUEL ......................................................... 52
4.9.4 SOURCE OF HOUSEHOLD INCOME .............................................................. 53
4.9.5 CURRENT AND PREVIOUS TB TREATMENT ................................................. 53
4.10 PRESUMPTIVE TB CASES ............................................................................... 54
5. DISCUSSION ............................................................................................................. 58
5.1 SURVEY CENSUS .............................................................................................. 58
5.2 SURVEY PARTICIPATION ................................................................................... 58
5.3 HIV ....................................................................................................................... 59
5.4 CHEST X-RAY ..................................................................................................... 59
II
5.5 SPUTUM TESTING .............................................................................................. 60
5.6 TB PREVALENCE ................................................................................................. 61
5.7 LIMITATIONS OF THE SURVEY .......................................................................... 63
6. PROGRAMMATIC IMPLICATIONS AND RECOMMENDATIONS............................. 64
7. ANNEXURES ............................................................................................................. 65
7.1 ANNEX A: MOHSS ETHICS APPROVAL LETTER .............................................. 65
7.2 ANNEX B: INFORMATION SHEET FOR CONSENT ............................................66
7.4 ANNEX C: PARTICIPANT CONSENT FORM ........................................................67
7.5 ANNEX D: NAMIBIA TB DPS: ENUMERATION/ HOUSEHOLD LISTING
FORM 01 (F01)...................................................................................................... 68
7.6 ANNEX E: NAMIBIA TB DPS: REGISTRATION FORM 5 (F5) ..............................71
7.7 ANNEX F: NAMIBIA TB DPS: SYMPTOM INTERVIEW FORM 6 (F6) ..................72
7.8 ANNEX G: NAMIBIA TB DPS: CHEST X-RAY FORM 7 (F7) ................................ 74
7.9 ANNEX H: NAMIBIA TB DPS: MEDICAL OFFICER FORM 8 (F8) ....................... 76
7.10 ANNEX I: NAMIBIA TB DPS: CAD4TB FORM 9 (F9) ......................................... 77
7.11 ANNEX J: NAMIBIA TB DPS: ELIGIBILITY FOR SPUTUM COLLECTION
FORM 10 (F10) .................................................................................................... 78
7.12 ANNEX K: NAMIBIA TB DPS: IN-DEPTH INTERVIEW FORM 11 (F11) ............ 79
7.13 ANNEX L: NAMIBIA TB DPS: FIELD BACTERIOLOGICAL EXAMINATION
FORM 12 (F12) ................................................................................................... 82
7.14 ANNEX M: NAMIBIA TB DPS: HIV TESTING FORM 13 (F13) .......................... 83
7.15 ANNEX N: HIV FOLLOW-UP FORM .................................................................. 84
7.16 ANNEX O: NAMIBIA TB DPS: DATA COLLECTION FORM FOR
CENTRAL RADIOLOGIST ................................................................................... 85
7.17 ANNEX P: LIST OF SOPS FOR THE SURVEY ................................................. 87
7.18 ANNEX Q: NAMTBCOLLECT SPECIAL FEATURES ......................................... 88
7.19 ANNEX R: SUMMARY OF DATA SOURCES, STORAGE AND SECURITY ...... 89
7.20 ANNEX S: LISTS OF PARTICIPANTS AND THEIR ROLES .............................. 90
4.10.1 PARTICIPANTS: FIRST DATA CL EANING WORKSHOP .............................. 92
4.10.2 PARTICIPANTS: SECOND DATA CLEANING WORKSHOP .......................... 92
4.10.3 PARTICIPANTS: THIRD DATA CLEANING WORKSHOP ............................... 93
4.10.4 PARTICIPANTS: DATA ANALYSIS WORKSHOP ............................................ 93
4.10.5 PARTICIPANTS: REPORT WRITING WORKSHOP ....................................... 94
REFERENCES ............................................................................................................... 95
III
FIGURES
Figure 1: Estimated TB incidence per 100,000: top-ten Countries in the world 2017 ....... 1
Figure 2: Trend of estimated tuberculosis prevalence and incidence in Namibia
2000-2016 ......................................................................................................... 2
Figure 3: Trends in TB Case Notification Rates from 2007 to 2017 in Namibia ................ 2
Figure 4: Regional distribution of TB case notification rates (all forms and
new bacteriologically confirmed) 2017 ............................................................... 3
Figure 5: Regional distribution of new and relapse TB cases by region, 2017 ................. 3
Figure 6: Age-sex distribution of new and relapse TB cases reported in Namibia
in 2017 ............................................................................................................... 4
Figure 7: Treatment outcomes for new bacteriological positive TB cases by region,
2016 cohort ........................................................................................................ 4
Figure 8: Trend on coverage of HIV care services for TB patients, 2007-2017;
Namibia ............................................................................................................. 5
Figure 9: Trend of confirmed DR-TB cases reported in Namibia 2007-2017 .................... 5
Figure 10: Survey Organization ........................................................................................ 8
Figure 11: Central Coordinating team ............................................................................... 9
Figure 12: Survey Field Teams ....................................................................................... 10
Figure 13: The flow of field activities during the survey .................................................. 16
Figure 14: An illustration of the data synchronizing processes ....................................... 22
Figure 15: Age and sex distribution of enumerated and eligible populations .................. 27
Figure 16: Namibian population estimate, 2016 ............................................................. 28
Figure 17: Flow chart demonstrating survey participation .............................................. 29
Figure 18: Age and Sex distribution of participants relative to the eligible
population ...................................................................................................... 30
Figure 19: Participation rate of cluster over time (July 2017 to Mar 2018) ..................... 30
Figure 20: Number of TB cases per cluster .................................................................... 44
Figure 21: Cluster variation in the cluster-level pulmonary TB prevalence
rate per 100,000 ............................................................................................. 44
Figure 22:Cluster level prevalence using the revised case definition............................... 45
Figure 23: Known HIV status ........................................................................................... 48
Figure 24: Distribution of participants across rural and urban setting ............................. 50
Figure 25: Type of housing used by participants versus TB cases ................................. 50
Figure 26: Sanitation by access to piped water .............................................................. 51
Figure 27: Sanitation by type of toilet .............................................................................. 51
Figure 28: Access to Electricity ....................................................................................... 52
Figure 29: Main heating fuel............................................................................................. 52
Figure 30: Main cooking fuel ........................................................................................... 53
Figure 31: Participants who were on TB Treatment before ............................................. 54
Figure 32: Participants currently on TB treatment ........................................................... 54
Figure 33: Presumptive cases by sex ............................................................................. 55
Figure 34: Presumptive cases by setting (urban/ rural) .................................................. 55
Figure 35: Presumptive tb cases by occupation ............................................................. 56
Figure 36: Presumptive tb cases by source of income ................................................... 56
Figure 37: Presumptive tb cases by education ............................................................... 57
Figure 38: Health seeking behavior of people with presumptive or confirmed TB........... 57
Figure 39: Status of TB prevalence surveys in 2018 ...................................................... 78
IV
TABLES
Table 1: Definition of a TB case in the survey ................................................................. 19

Table 2: Eligible vs Ineligible survey population .................................................... ......... 26
Table 3: Participants vs non-participants among those eligible to participate ................. 31
Table 4: Coverage by Chest X-Ray and Symptoms ........................................................ 32
Table 5: Symptom screening results ............................................................................... 33
Table 6: Field Chest X Ray findings ................................................................................ 34
Table 7: Sputum eligibility and Field Xpert MTB/RIF results ........................................... 35
Table 8: Sputum eligibility and Central laboratory results ............................................... 36
Table 9: Sputum eligibility and Combined central Xpert and culture results ................... 37
Table 10: Sputum eligibility and smear results ................................................................ 38
Table 11: Smear Microscopy vs central culture and Xpert MTB ...................................... 39
Table 12: Smear results and combined central results ................................................... 40
Table 13: Correspondence between field and central reading of chest X-Ray ............... 41
Table 14: Final outcome by sputum eligibility .................................................................. 42
Table 15 Case Outcome .................................................................................................. 42
Table 16: Intersection between working and revised case definitions ............................. 45
Table 17: Final prevalence estimates (per 100,000 population) ...................................... 47
Table 18: Regional variations in tb prevalence rates ....................................................... 48
Table 19: Prevalence of TB as determined by nationwide surveys in
selected countries ............................................................................................ 58
V
PREFACE
Namibia is among the countries worst affected by the tuberculosis (TB) epidemic in the world. Like the
rest of Southern Africa, this problem is largely attributable to socioeconomic challenges as well as the
relatively high HIV prevalence.
The Ministry of Health and Social Services is currently implementing the Third Medium Term Strategic
Plan (MTP-III) for TB and Leprosy to provide strategic direction for the management of TB in the country,
modelled on the World Health Organisation’s (WHO) End TB Strategy. Resources from the Government
of the Republic of Namibia (GRN) largely complemented by the Global Fund to fight HIV/AIDS,
Tuberculosis and Malaria (GFATM) and the United States President’s Emergency Fund for AIDS Relief
(PEPFAR) have been committed to facilitate implementation of TB control activities as outlined in the
strategic plans. Funds from these sources were also used to conduct the first TB disease prevalence
survey (DPS).
To better inform the implementation of TB control activities in the country, it is necessary to quantify the
magnitude of the disease. This was the first ever nationwide TB disease prevalence survey in Namibia.
Namibia has joined a few countries in the region to have completed such a survey. The results of this
survey will be used to inform the development of strategies to better manage the TB epidemic in our
country.
I take this opportunity to extend my gratitude to the team that completed this survey, notably Dr Farai
Mavhunga, the Principal Investigator and his team in the NTLP; Ms Irish Goroh, the Survey Coordinator;
Ms Anne-Marie Nitschke for her leadership in ensuring the survey was possible; Dr Abbas Zezai and the
team at KNCV TB Foundation for their unwavering support and technical contributions; Dr Simon Agolory
and the team at CDC for the technical and financial contribution; Ms Izumi Morota and the team at UNDP
as well as the significant support received from Namibia Statistics Agency. I will also mention the
significant commitment demonstrated by the late Ms Sarah Mwilima, whose contribution saw that the
bulk of the funding for this survey was realised. I appreciate all the community members that participated
with no incentives, and all the health care workers and community members that volunteered to assist
the survey team.
It is my hope that the report will provide useful information on the true burden of TB in Namibia and its
implications, and that it will serve to spur action for stakeholders to join hands in the work towards ending
TB in Namibia.
………………………………………….
Benetus Nangombe
Executive Director: Ministry of Health & Social Services
VI
EXECUTIVE SUMMARY
This is the first tuberculosis (TB) disease prevalence survey to be conducted in Namibia. The aim was to
determine the prevalence of bacteriologically confirmed TB among the adult population in Namibia.
Alternative estimates of prevalence based on routinely collected data are imprecise, and it is estimated
that a significant proportion of TB cases go undetected and/or unreported. The survey field activities took
place between July 2017 and March 2018. A multistage stratified cluster sampling strategy was followed
to achieve an adequate representation of the Namibian adult population. Out of a total of 4,129 national
clusters, 68 were sampled in rural and urban areas in all the 14 regions in order to achieve the desired
sample size of 34,000.
The survey consisted of house to house listing of residents in the selected clusters, followed by cluster
site screening for TB. The screening for TB included symptoms interview and chest x-ray (CXR)
examination of all participants, followed by sputum testing for those with symptoms or abnormal chest x-
rays as read by field medical officers and x-ray reading software. Sputum testing in the field was with
GeneXpert equipment installed in mobile vans, while additional testing with culture or Xpert MTB/RIF was
conducted at the Namibia Institute of Pathology’s Windhoek Central Laboratory. TB cases were defined
as those with two positive bacteriologic results or a single positive bacteriologic result and a suggestive
CXR result as read by a specialist radiologist.
The household listing and enumeration identified 56,922 individuals, of whom 32.6% were children under
five who were not eligible to participate. Of the 38,353 who were eligible to participate, 29,495 (76.9%)
actually participated in symptom interview and/or CXR screening. This was 86.8% of the desired sample
size. Of the participants, 10,884 (36.9%) were eligible for sputum collection based on symptoms,
abnormal CXR or inability to perform CXR.
Of the sputum tested in the field, 115 participants had positive results, while 52 had a positive central
culture result; 18 had a positive central Xpert result and four had both positive central Xpert and central
culture result. In all, 138 participants had positive bacteriological results, but 119 fit the original survey
case definition. A revised case definition during the analysis brought this up to 123 individuals.
Applying multiple imputation and inverse probability weighting, the final prevalence of bacteriologically
confirmed TB in Namibia is 465 per 100,000 (95%CI, 340-590), which is within the range previously
estimated by WHO. The prevalence is higher in males (643/100,000) than females (304/100,000).
According to this survey, the prevalence of TB in Namibia falls within the range previously estimated by
the World Health Organisation confirming Namibia’s high TB-burden status. The higher prevalence in
males suggests a male-driven TB epidemic, as has been observed in other studies. Targeted
interventions need to specifically address TB in males, given both the high prevalence and their lower
participation in health-seeking activities. Additionally, the country should invest in strategies to find and
treat undiagnosed TB patients, as the majority of TB cases found during this survey were not on
treatment.
VII
ACKNOWLEDGEMENTS
The National TB and Leprosy Programme wishes to acknowledge the following persons and institutions
for their significant contributions to the survey:
• The Director and the team at the Directorate of Special Programmes for the leadership and
coordination efforts
• United Nations Development Programme
• World Health Organisation
• KNCV Tuberculosis Foundation
• Centers for Disease Control and Prevention (CDC)
• United States Agency for International Development
• Global Fund
• Namibia Statistics Agency
• Namibia Institute of Pathology
• Advanced Community Health Care Services Namibia (CoHeNa)
• iMarketing Consultants, Namibia
• Namibia Radiation Protection Authority (NRPA)
• Ministry of Safety and Security, Namibian Correctional Service and the Namibian Police Force
• Ministry of Urban and Rural Development
• Ministry of Education and all the school heads that assisted with space
• City of Windhoek Municipality
• All 14 Regional Governors and their office staff and councilors
• All 13 Regional Health Directors and their staff
• Community health care workers from different organisations, including those from the government
(health extension workers) who participated in the fieldwork
• All health care workers and community members who participated in the local support teams
• All community members who participated in the house to house enumeration and those who came
for TB screening.
VIII
LIST OF ABBREVIATIONS
ACSM Advocacy, communication and social mobilisation
AFB Acid-fast bacilli
ART Antiretroviral therapy
BD-MGIT Becton Dickinson’s mycobacteria growth indicator tube
CAD4TB Computer Aided Detection for TB
CBTBC Community-based TB care
CDC United States Centers for Disease Control and Prevention
CHPO Chief Health Programmes Officer
CHW Community health worker
CNR Case notification rate
CPT Cotrimoxazole prophylactic therapy
CSV Comma-separated values
CXR Chest X-ray
DCC District Coordination Committee
DM Direct microscopy
DOT Directly-observed treatment
DPS Disease Prevalence Survey
DRS (anti-tuberculous) Drug resistance survey
DR-TB Drug-resistant TB
DSP Directorate of Special Programmes
DST Drug susceptibility testing
DTLC District Tuberculosis and Leprosy Coordinator
EA Enumeration area
ELISA Enzyme-linked immunosorbent assay
FM Fluorescence microscopy
FMI Fraction of missing information
GDP Gross domestic product
10
IX
GFATM Global Fund to fight AIDS, TB and Malaria
GNI Gross national income
GPS Global Positioning System
GRN Government of the Republic of Namibia
HCT HIV counselling and testing
HEW Heath Extension Workers
HIV Human immunodeficiency virus
HPCNA Health Professions Councils of Namibia
HTS HIV Testing Services
IEC Information, Education and Communication
IPW Inverse probability weighting
KNCV Koninklijke Nederlandse Centrale Vereniging (Royal Netherlands Tuberculosis

Foundation)
LED Light emitting diode
LTFU Lost to follow-up
LIS Laboratory information system
MDG Millennium development Goals
MDR-TB Multi-drug-resistant tuberculosis
MO Medical Officer
MoHSS Ministry of Health and Social Services
MOTT Mycobacteria other than tuberculosis
MTB/RIF Mycobacterium tuberculosis / Rifampicin
MTP-I First Medium-Term strategic Plan (for TB)
MTP-II Second Medium-Term strategic Plan (for TB and leprosy)
MTP-III Third Medium-Term strategic Plan (for TB and leprosy)
MySQL My-Structured Query Language
NAMPHIA Namibia Population-based HIV Impact Assessment
NGO Non-governmental organisation
NICD National Institute for Communicable Diseases (South Africa)
11
X
NIP Namibia Institute of Pathology
NRPA Namibia Radiation Protection Authority
NSC National Steering Committee (for TB and Leprosy)
NSP New smear-positive
NTLP National Tuberculosis and Leprosy Programme
PACS Picture archiving and communication system
PHC Primary health care
PHP Hypertext Preprocessor
PI Principal Investigator
PITC Provider initiated counseling and testing (for HIV)
PLHIV People Living with HIV
PTB pulmonary tuberculosis
QC Quality control
RMT Regional Management Team
RTLC Regional Tuberculosis and Leprosy Coordinator
SDG Sustainable Development Goals
SE Standard Error
SOP Standard Operating Procedure
STATA Statistics and data (proprietary software)
TB Tuberculosis
TBL Tuberculosis and Leprosy
TWG Technical Working Group
UMI Upper Middle Income
UNAM University of Namibia
UNDP United Nations Development Programme
USAID United States Agency for International Development
VCT Voluntary counselling and testing (for HIV)
WCRL Windhoek Central Reference Laboratory
WHO World Health Organisation
12
XI
1. INTRODUCTION
1.1 Country Profile

Geographically, Namibia is located in South-west Africa and has a land surface area of 824,295 km2
making it Africa’s fifth largest country. Based on the population census conducted in 2011, the country
was projected to have a population of 2,368,747 people in 2017, with just over half of the population
(51.1%) living in rural areas and 48.9% in urban areas.(NSA, 2014) The country has an ethnically and
culturally diverse population with eleven different language groups. The country is divided into 14
administrative regions that are further subdivided into 35 health districts.(NSA, 2013)
The World Bank classifies Namibia as an upper middle-income (UMI) country, with a Gross Domestic
Product (GDP) of USD14.5 billion and a gross national income (GNI) per capita of USD 5,250 in 2018
(World Bank Group, 2018). Despite the UMI status, many Namibians continue to experience poverty and
social deprivation. The proportion of the population living below the national poverty line was 26.9% in
2013.(National Planning Commission, 2015) Additionally, the World Bank estimated that Namibia’s Gini-
index was 57.2 in 2015, suggesting significant inequalities in wealth distribution in the country (National
Planning Commission, 2018).
1.2 Burden of tuberculosis in Namibia

1.2.1 Tuberculosis notifications
Tuberculosis (TB) is a communicable disease of major public health significance in Namibia. The disease
is one of the most frequent causes of hospitalization in public health facilities. Namibia ranked ninth
highest in the estimated incidence rate of TB in the world after South Africa, Lesotho and Kiribati, which
were top three respectively (Figure 1) (World Health Organization, 2017).
F IGURE 1: E STIMATED TB INCIDENCE PER 100,000: TOP - TEN C OUNTRIES IN THE WORLD 2017
PN Guinea
Namibia
Gabon
Timor-Leste
DPR Korea
Mozambique
Philippines
Kiribati
Lesotho
South Africa
0 100 200 300 400 500 600 700 800
The estimated incidence of TB in Namibia has been on the decline from 2004 to 2016. Despite this
decline, Namibia did not reach the Millennium Development Goals (MDGs) and Stop TB target of
reducing incidence by 50% relative to the 1990 levels. Namibia has since adopted the End TB Strategy
as well as the Sustainable Development Goals (SDGs).
13
1
F IGURE 2: T REND OF ESTIMATED TUBERCULOSIS PREVALENCE AND INCIDENCE IN N AMIBIA 2000-2016
1400
1200
1000
800
600
400
200
Estimated TB incidence/ 100,000 Estimated TB prevalence/ 100,000
1.2.2 Tuberculosis notifications

A LTHOUGH THE C ASE N OTIFICATION R ATE (CNR) HAS DECREASED FROM 743 PER 100,000 IN 2007 TO 392 PER
100,000 IN 2017, IT IS STILL AMONG THE HIGHEST IN THE WORLD .
Figure 3 shows trends of TB CNR of ‘All Forms’ and ‘New Smear-Positive PTB (NSP)’ from 2007 to 2017
in Namibia.
F IGURE 3: T RENDS IN TB C ASE N OTIFICATION R ATES FROM 2007 TO 2017 IN N AMIBIA

800
CNR PER 100,000 POPULATION
700
600
500
400
300
200
100
0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
All forms TB 722 665 634 589 545 529 488 442 436 410 392
NSP 242 239 219 208 210 206 199 194 197 181 136
YEAR
Source: NTLP Annual Report 2017-2018
The distribution of TB cases in the country is not uniform. There are significant regional differences in TB
CNRs with Omaheke Region ranking the highest and Omusati Region the lowest in 2017 (Figure 4).
Khomas Region, however, had the largest absolute number of TB cases, as expected from its total
population (Figure 5).
14
2
F IGURE 4: R EGIONAL DISTRIBUTION OF TB CASE NOTIFICATION RATES ( ALL FORMS AND NEW
BACTERIOLOGICALLY CONFIRMED ) 2017
900
800
CNR/100,000 population
CNR All Forms CNR New PTB bact confirmed

700
600
500
400
300
200
100
0
F IGURE 5: R EGIONAL DISTRIBUTION OF NEW AND RELAPSE TB CASES BY REGION , 2017

1600
1400
New Relapse
Number of cases notified
1200
1000
800
600
400
200
Of the 8,575 new and relapse TB notifications in 2017, 812 (9%) were children under the age of 15
years. According to notified cases, the epidemic is significantly skewed towards males from the age of
25 years and above. As shown in Figure 6, adults 15-44 years are at higher risk, with higher CNR for
the specified age group.
15
3
F IGURE 6: A GE - SEX DISTRIBUTION OF NEW AND RELAPSE TB CASES REPORTED IN N AMIBIA IN 2017
1200
Male Female CNR Male CNR Female
1000
800
600
400
200
0
0-4 5-9 9-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+
1.2.3 Tuberculosis case holding

The treatment success rate for new bacteriological positive TB cases in Namibia improved from 64% in
1997 to 87% for the 2016 cohort. In the 2016 cohort, 5% of the patients died while on treatment, 2%
failed treatment and 5% were declared lost to follow-up.
Figure 7 shows the treatment outcomes for new bacteriological positive cases by region, indicating the
regional variation in treatment outcomes.
F IGURE 7: T REATMENT OUTCOMES FOR NEW BACTERIOLOGICAL POSITIVE TB CASES BY REGION , 2016 COHORT
Cured Completed Died Failed LTFU Not evaluated
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Regions
16
4
1.2.4 TB/HIV
Human Immunodeficiency Virus (HIV) contributes significantly to the high prevalence of TB in Namibia.
The estimated HIV prevalence rate for the general population aged 15-64 years was 12.6% in
2017.(ICAP, MoHSS and CDC, 2018) HIV prevalence among TB patients peaked at 67% in 2006
gradually reducing to 36% in 2017.
All public health facilities offer access to HIV counselling and testing, with a high coverage of antiretroviral
treatment (ART) for those eligible. ART coverage has improved to 96% in 2017 owing to revisions to the
eligibility criteria for starting ART in HIV-infected TB patients over the years. Figure 8 shows the trends
on coverage of HIV care services for TB patients from 2007 to 2017 in Namibia.
F IGURE 8: T REND ON COVERAGE OF HIV CARE SERVICES FOR TB PATIENTS , 2007-2017; N AMIBIA
100
90
80
70
Percentage
60
50
40
30
20
10
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
% tested for HIV 54 67 74 76 84 89 92 92 95 98 98
% HIV Positive 59 59 58 55 50 47 45 44 40 38 36
Proportion on ART 17 37 35 43 54 71 80 84 92 90 96
1.2.5 Drug Resistant Tuberculosis

The first anti-TB drug resistance survey conducted in 2008-9 showed a Multi Drug resistant-TB (MDR-
TB) prevalence of 3.8% (95% CI: 2.8%-5.1%) among patients newly diagnosed with TB and 16.5% (95%
CI: 13.0%-20.8%) in patients previously treated for TB.
F IGURE 9: T REND OF CONFIRMED DR-TB CASES REPORTED IN N AMIBIA 2007-2017
450
400
350
300
Number of cases
250
200
150
100
50
0
Y2007 Y2008 Y2009 Y2010 Y2011 Y2012 Y2013 Y2014 Y2015 Y2016 Y2017
MDR TB (Excl XDR) 116 201 275 214 192 206 174 137 190 195 219
PDR-TB 7 47 80 63 46 41 19 14 17 17 10
Other RR 0 0 0 0 0 0 103 206 127 165 174
XDR 3 20 17 8 2 4 6 6 3 10 14
Total 126 268 327 285 240 251 302 363 337 387 417
17
5
The second survey in 2014-15 showed the prevalence of MDR-TB to be 3.9% (95% CI: 3.1%-4.7%)
among patients newly diagnosed with TB and 9.2% (95% CI: 7.1%-10.3 %) among patients previously
treated for TB. In 2017, Namibia reported 417 confirmed DR-TB cases. This is higher than cases reported
in earlier years, which may be attributed to improved diagnosis as the new diagnostic algorithm for TB
introduced in 2017 allows more sensitive rapid molecular tests (Xpert MTB/RIF) to be performed on the
first sample from all presumptive cases.
1.3 The Namibian Health Sector

1.3.1 Health Policy
The Primary Health Care (PHC) approach guides the formulation and development of health policies in
Namibia. The MoHSS Strategic Plan (2017/2018 to 2021/2022) highlights the reduction in the incidence
and prevalence of communicable diseases. The key guiding principles to realise this reduction are:
equity, accessibility, availability, affordability, community involvement, sustainability, inter-sectoral
collaboration and quality of care. In 2017, the NTLP launched its Third Medium Term Strategic Plan
(MTP-III) for TB and Leprosy 2017/2018 to 2021/2022. The plan is designed to accelerate Namibia’s
progress towards national and international TB targets and is closely aligned to the End TB Strategy.
Namibia has decentralized provision of health care services with four levels of care (national, regional,
district and community). The MoHSS has 14 regional health directorates and 35 health districts. The
NTLP operates within this hierarchical management framework. The public health system comprises a
national referral hospital, intermediate hospitals, district hospitals, health centers, clinics, outreach points,
social welfare service points and Directly Observed Treatment (DOT) points. The MoHSS has also
initiated and implemented the Community Healthcare Workers’ (CHW) programme.
1.4 Justification for the survey
The gap between notified cases reported by the NTLP and the incidence estimated by WHO suggested
that Namibia was missing approximately 30% of TB cases when the survey was conceived. The missed
TB cases are generally responsible for the growing spread of TB. Consequently, the high number of TB
cases places a burden on health and social services infrastructure.
Currently, TB cases in Namibia are primarily detected through passive surveillance with infrequent active
surveillance among selected groups. While the number of people diagnosed and reported through the
country’s surveillance system for TB is well documented, the number of people with active TB at any
given time is unknown. There is limited or no data on the following groups:
▪ patients with TB treated outside the public health sector,
▪ patients with symptoms compatible with TB at any given time, including the proportion who are being
appropriately investigated, and
▪ patients with TB but have not accessed the available health services.
A prevalence survey is the best tool currently available to measure a country’s true TB burden, critical for
informing resource allocation and public health interventions. It was, therefore, pertinent that Namibia
conducts a TB prevalence survey in order to address knowledge gaps that existed in addressing the
national TB burden.
18
6
1.5 Survey Objectives
The TB disease prevalence survey aimed to quantify the burden of TB in Namibia in order to identify
ways to improve TB control and ultimately end the TB epidemic.
1.5.1 Primary Objectives

The primary objectives of the survey were to:
▪ Measure the prevalence of bacteriologically confirmed TB among the adult population (≥15 years) of
Namibia following symptomatic and X-ray screening,
▪ Update population-based estimates of the burden of disease (measured as TB incidence, prevalence
and mortality) using results from the prevalence survey combined with in-depth assessment of
surveillance, programmatic, and other survey data, and
▪ Provide a baseline for future measurement of trends in the burden of disease caused by TB.
1.5.2 Secondary Objectives

The secondary objectives of the survey were to:
▪ Determine the prevalence of symptoms suggestive of TB among the Namibian adult population,
▪ Determine the prevalence of abnormal chest X-ray findings among the Namibian adult population,
▪ Assess the demographic and socioeconomic factors associated with presumptive TB cases,
▪ Characterize health-seeking behavior of people with presumptive or confirmed TB, and
▪ Identify barriers to health seeking and contact with MoHSS services among people with TB or those
with symptoms suggestive of pulmonary tuberculosis.
19
7
2. SURVEY ORGANISATION
The scope of the TB Disease Prevalence Survey (DPS) included the implementation of a wide range of
activities to facilitate data collection. Various stakeholders contributed to conceptualizing and
development of the protocol, execution of field activities as well as the final steps of the survey, which
included data cleaning and validation as well as report writing. Below is an illustration summarizing the
survey organization.
F IGURE 10: S URVEY O RGANIZATION
2.1 National Steering Committee

The National Steering Committee (NSC) for Tuberculosis and Leprosy (TBL) comprises various
stakeholders who provide guidance and advice on implementation of TB and leprosy control initiatives in
the country and meets regularly. Relevant to the TB DPS, the TBL NSC was responsible for resource
mobilization, coordinating involvement of various entities in addition to monitoring, and where needed,
intervened in the implementation of the survey.
2.2 National Tuberculosis Leprosy Programme

The National TB and Leprosy Programme (NTLP) formed part of the Central Coordinating Team. The
NTLP, through a designated lead, provided technical coordination, led the protocol development process
and had direct oversight over the survey activities. NTLP programme officers were part of the various
sub-groups for the survey. Moreover, the NTLP oversaw and coordinated the recruitment of survey staff
and compliance to quality assurance. NTLP officers formed part of the data cleaning and validation as
well as the report writing. The NTLP were responsible for providing periodic updates to the NSC as well
as the Ministerial Executive Committee.
20
8
2.3 Tuberculosis Disease Prevalence Survey Technical Working Group
The overall responsibility for implementation of the survey rested with the TB DPS Technical Working
Group (TWG). It was made up of representation from key stakeholders and the coordinating team. The
TWG provided guidance on technical aspects of the survey and primarily oversaw the development of
the study protocol, obtained ethical approval of the protocol, and implemented the survey activities to
finalization of the DPS.
The TWG held weekly technical meetings during which it received updates from the Survey Coordinator
on all aspects of the survey. In turn, the TB DPS TWG reported and provided updates to the National
Tuberculosis and Leprosy Steering Committee (TBL NSC) during its quarterly meetings.
2.4 Subgroups
In order to operationalize the survey, subgroups (task teams) were established to develop and finalize
Standard Operating Procedures (SOPs), manuals and guidelines for the survey. These subgroups were
also responsible for monitoring field activities and providing technical support where necessary. Central
Coordinators headed all subgroups under the supervision of the Survey Coordinator.
a. Advocacy Communication and Social Mobilization Subgroup

The Advocacy Communication and Social Mobilization (ACSM) subgroup was in charge of all internal
and external communication regarding the survey. The subgroup was also responsible for all community
mobilization activities as well as ensuring compliance to ethical requirements. It developed a
communication strategy and oversaw its execution as well as coordinated the development and
dissemination of all communication with electronic and print media outlets.
b. Clinical Management Subgroup

This subgroup was responsible for providing guidance to field teams on the interpretation of abnormal
clinical, laboratory and radiographic findings, as well as the appropriate clinical management of survey
participants as required. It monitored and ensured the adherence to case definitions outlined in the
protocol and prevailing national guidelines.
c. Data Management and Information Technology Subgroup

This subgroup provided technical guidance on monitoring and evaluation aspects of the survey. It was
responsible for the development of the data management plan, refining data collection tools, provide
information technology systems requirements and training on their use. Additionally, the subgroup
ensured high quality survey data, and correct application of data management software and tools.
d. Laboratory Subgroup
The laboratory subgroup oversaw the provision of diagnostics and compliance to quality assurance
procedures. The subgroup ensured identification and provision of appropriate laboratory equipment and
supplies to field teams. Additionally, it was tasked to ensure appropriate collection of specimens, safe
transportation of specimens to the central laboratory, monitoring of sputum results and resolving
conflicting results as needed. The work of the subgroup involved close collaboration with Namibia
Institute of Pathology (NIP), the main laboratory services provider to the MoHSS.
e. Logistics and Administration Subgroup

This subgroup ensured availability of all requisite resources for the survey, including human resources.
It also monitored and ensured the welfare of field team members in addition to overseeing and
coordinating all survey logistics. This subgroup monitored expenditure incurred during the survey,
21
9
allocated equipment and resources to field teams, organised training and meetings, and was responsible
for transportation of survey personnel, equipment and supplies for field activities.
f. Radiography Subgroup
The radiography subgroup ensured quality and safe radiographic practices in the field and that images
are interpreted and stored appropriately. In addition, this group ensured re-reading of CXR images at
central level.
2.5 Central Coordinating Team

The Central Coordinating Team was made up of the Survey Coordinator, programme officers from the
NTLP and a team of full-time central coordinators for the various thematic components. This team
assisted the Survey Coordinator to ensure smooth execution of the survey. This team occasionally
supplied reserve members to assist field teams in the event that some of the field team members became
unavailable. Below is an organogram of the central coordinating team. In addition to the full-time
coordinators, a part time Clinical Coordinator was seconded from the NTLP.
F IGURE 11: C ENTRAL C OORDINATING TEAM
Survey
Coordinator
Laboratory Assistant Manager

Radiography Field Survey
Data Manager Coordinator / Logistics
Coordinator coordinators (x4)
Coordinator
Assistant Data Manager /

Systems Administrator
Central Data Clerks
2.6 Principal Investigator

The Principal Investigator (PI) for the TB DPS was the Chief Medical Officer of the NTLP. The PI was
overall in-charge of the survey and on behalf of the Ministry of Health and Social Services (MoHSS) was
responsible for ensuring that the survey took place and every stakeholder participated in their role.
2.7 Survey Coordinator

The Survey Coordinator (Survey Manager) oversaw implementation of the day-to-day activities of the
survey and coordinated central and field activities. This included receiving field reports from team
leaders, training of survey staff, piloting and pre-testing of tools. The Survey Coordinator provided
updates to the PI, the Directorate of Special Programmes management and the DPS TWG. The Survey
Coordinator provided secretarial services to the DPS TWG.
2.8 Survey Field Teams

Survey Field Teams were responsible for conducting field operations. There were four field teams, each
equipped with full set of equipment for performing field chest X-rays and field sputum testing. A Local
22
10
Support Team complemented a Core Field Team when they visited the different clusters. During the initial
survey implementation, each Field Team covered approximately 13 clusters. Only two Field Teams were
operational during the last part of the field operations and these covered about six clusters each. A Field
Coordinator headed each team as shown in Figure 12 below.
F IGURE 12: S URVEY F IELD T EAMS
Field Medical Officer
Field Nurse Symptom Interviewer
Field Radiographer Radiography Assistant
Field Survey Coordinator

(Team Leader) Field Laboratory Technician
Field Enumerators
Field Data Supervisor
Field Data Clerk
Field Driver
Field General Hand
2.9 Survey Field Coordinators

As team leaders, Survey Field Coordinators supervised field operations conducted by the Field Teams.
They were responsible for logistical preparations before and during field operations in a cluster as well
as liaising with the Local Support Teams before and after the field operations.
2.10 Local Support Teams

The Local Support Teams were made up of local health care workers, community field workers and local
community stakeholders. The primary functions of the Local Support Teams were to assist in the
logistical preparations for the field operations, mobilising the community before and during field
operations and assisting the Field Teams during actual field activities. This included enumeration of
survey participants, organizing the flow of participants at the survey site, and linking survey participants
to medical care and treatment services as needed. They also assisted with mop-up operations and
transported sputum samples to the nearest laboratory when required.
2.11 External Technical Assistance Group

The External Technical Advisory Group comprised of representatives from technical agencies such as
WHO, KNCV TB Foundation, Centers for Disease Control and Prevention (CDC), Namibia Statistics
Agency, Namibian Institute of Pathology and United States Agency for International Development
(USAID). These stakeholders provided technical assistance whenever required in all aspects of the
design, planning and implementation of the survey as well as analysis and dissemination of the its
findings.
23
11
3. SURVEY METHODS
3.1 Survey design
The Namibian TB DPS was a nationwide, population-based cross-sectional survey conducted from July
2017 to March 2018. The survey was cluster-based to provide national representation of the population.
3.2 Sampling frame and cluster characteristics

Namibia has 14 administrative regions and each region is sub-divided into constituencies (121
constituencies in total). For the purposes of the survey, each constituency was further divided into
enumeration areas (EAs) with defined boundaries. The Namibian Statistics Agency (NSA), using the
Namibia 2011 Population and Housing Census created 4,129 new primary sampling units based on the
EAs, each with approximately 200 households to serve as clusters for the survey. Because each
household was estimated to have 2.5 adults aged 15 years and above, each cluster had approximately
500 adults eligible to participate in the survey.
3.3 Sample size

Assuming the estimated prevalence of TB was 486 per 100,000 as estimated by WHO in 2016, the
desired sample size was calculated to be 34,167 people aged 15 years and above. The calculation was
based on the formula below:
  
k 
2
2 1−
n = 1.96 2  * 1 + (m − 1) 
 d  
   1 −  
Where:
a) n is the estimated sample size
b) π is the presurvey estimate of the prevalence of bacteriologically confirmed pulmonary TB
(486/100,000).
c) Precision (d) = 20% is the required relative precision
d) m is the Cluster size = 500 persons
e) Design effect = 1.39
f) k is the coefficient of inter–cluster variation= 0.4
g) Expected response rate = 80%
With a targeted sample size of 34,167 and a cluster size of 500 eligible adults, the number of clusters
required was 68.
3.4 Sampling strategy

A multistage stratified cluster sampling strategy was followed to select the 68 required clusters out of the
4,129 new sampling units. Stratification was by region and rural-urban selection. All 14 regions were
selected to ensure wide representation and assigned clusters based on the population size. Thereafter,
clusters in each region were divided into rural and urban, and from these, clusters were randomly drawn
from each stratum.
Of the 68 clusters required for the survey, 33 (49%) urban clusters and 35 (51%) rural clusters were
identified.
24
12
3.5 Target population
The target population for this survey comprised all persons (male and female) aged 15 years and above,
residing within the boundary of Namibia, and drawn from the 68 clusters selected according to probability
proportionate to size.
3.5.1 Inclusion and exclusion criteria

National level: The whole country was included in the sampling frame, with all the 4,129 clusters eligible
for sampling.
Cluster level: Any cluster could participate in the survey. Clusters that were not sampled were not visited
for the survey operations but were eligible for piloting of the survey instruments.
Household level: All households within a cluster were selected for participation except those where an
adult 15 years and above could not be interviewed, or where physical interviews could not be conducted
due to inaccessibility of the household during field cluster operations.
Individual level: All individuals 15 years and above who had lived within a household for two weeks or
more prior to household listing and consented to take part in the survey were included. Individuals with a
mental or physical disability were eligible to participate in the survey, as long as they were able to give
consent, or if their guardians gave assent. Individuals residing in congregated facilities such as
correctional facilities, police holding cells, military camps or barracks and school hostels were excluded,
with the exception private households associated with congregate facilities where staff members stayed
with their families.
3.6 Survey preparations

3.6.1 Data collection instruments
Several data collection forms were developed and used during the different stages of the survey. The
forms were converted to electronic format and integrated through a mobile data collection system on
tablets and laptop computers used during the various stages of field operations. Additionally, Picture
Archiving and Communication System (PACS) and Computer Aided Detection for TB (CAD4TB) software
were used to manage and read radiographic images. Barcode scanners were used to identify
participants through their appointment cards as well as identifying specimens. Paper based
questionnaires were made available for use in the field in case of technical failure. Annexures B to O
show copies of the forms used in the survey.
3.6.2 Orientation Workshop for MoHSS representatives

Prior to the survey, several platforms were used to sensitise stakeholders about the survey. A formal
orientation workshop for MoHSS regional and district focal persons took place in May 2017. Induction
was given on the survey protocol as well as the roles and responsibilities of MoHSS focal persons during
the survey.
3.6.3 Training
In preparation for the pilot and field operations, orientation and training were provided to all field teams,
selected local support team members, the central team and the NTLP officers. This took place from May
to mid-July 2017 and covered survey protocol, roles and responsibilities, SOPs, manuals, simulation of
25
13
field activities by all field teams, cluster mapping (demarcation) and the use of Global Positioning System
(GPS) devices.
Training on the assembly and set-up of radiographic equipment was provided by the suppliers of the
equipment to radiographers, radiographic assistants, drivers and general handymen. Radiographers and
medical officers were also trained by a specialist radiologist on X-ray image reading to enhance their
skills and appreciate image quality. The MoHSS and Namibia Radiation Protection Authority (NRPA)
conducted general training on radiation safety and education to the field teams.
In collaboration with the Namibia Institute of Pathology (NIP) Ltd and Analytical Technology & Chemical
Supply (Anatech) (Pty) Ltd, the field laboratory technologists and laboratory assistants were trained on
laboratory safety, specimen collection, handling, processing and shipping, data capturing and
documentation. Furthermore, all technologists were primed on instrument maintenance, quality
assurance and Xpert MTB/RIF result analysis.
The HIV testers and counselors were trained on health safety, point-of-care HIV testing and counselling
based on the National HIV Serial Testing Algorithm. Competency assessment and certification was
conducted by NIP and the MoHSS HIV Testing Services (HTS).
All professional staff on the survey teams were required to be registered with the Health Professions
Councils of Namibia (HPCNA).
3.6.4 Equipment testing and on -site validation

The NRPA inspected and licensed the radiographic equipment as they arrived in Namibia. The Xpert
MTB/RIF instruments were validated by testing 30 known samples on each instrument by the respective
field laboratory technologists. All the laboratory instruments complied with NIP quality assurance
requirements.
3.6.5 Pretesting and Piloting of survey instruments

After training of the survey teams, the survey instruments and procedures were pretested by conducting
mass screening of 1,036 inmates and 38 staff at the Windhoek Correctional Facility. Pre-tests were
carried out on all procedures and instruments that would be used during the survey.
A survey pilot was conducted in July 2017 in one urban and one rural cluster that were not in the survey
sample (in Khomas region), in conditions that were meant to mimic real survey conditions. Survey
procedures and tools were revised from the lessons learned during the pilot. Training on survey
procedures and troubleshooting mechanisms was given to field teams following the revisions. Results
from the pilot survey are not part of this report.
3.6.6 Publicity and awareness campaigns

Community awareness campaigns: Prior to and during the undertaking of the survey, publicity and
awareness campaigns targeting the population were conducted at all levels through various media to
provide information on the survey and to minimize barriers to participation. The campaigns informed the
population about the objectives of the survey, the targeted population, processes and dates for
enumeration and the actual survey activities. Publicity included print media, television, radio, health and
wellness events. Orientation for regional and district focal persons were conducted and was followed with
two pre-survey visits to the communities.
First pre-survey visits: In preparation for the field operations, the central coordinating team, NTLP
officers and field coordinators conducted first pre-survey visits to sensitize the community and local
26
14
leaders. The meeting with local leaders, municipalities and town councils were arranged by the regional
and district focal persons orientated in May 2017. These focal persons further accompanied the team or
arranged for a person familiar with the area and community to accompany the team to these meetings.
Survey objectives and procedures were discussed at these meetings and potential concerns were
addressed in preparation for field operations. As part of the visit, a cluster site was identified and
demarcated.
Second pre-survey visits: Additional sensitization and preparatory visits were conducted by the field
coordinators with the support of the local district and regional health representatives in each of the
clusters. The visits included meeting local stakeholders to finalize logistics leading to field cluster
operations. During the visits, local support teams were recruited and trained. Furthermore, discussions
on the mobilization of local communities and the distribution of survey campaign materials were held.
3.7 Field Procedures

3.7.1 Household listing and enumeration
Household listing: Following demarcation of cluster boundaries, a dedicated team of enumerators listed
all the households identified within the cluster boundaries. Members of listed households were sensitized
on the survey procedures after giving their permission. Head of household or representative was
interviewed.
All household members including children were listed by name, age and sex using an electronic survey
census household questionnaire. In addition, socio-economic information was collected. All listed
households were marked with a survey sticker on the door or at the gate or a location where the sticker
could be visibly seen to avoid a re-visit.
Enumeration: All household members who were eligible to participate in the survey were issued with
appointment cards with a unique ID on a pre-printed barcode and were subsequently invited to visit field
cluster site. The unique ID was used to identify the participant through all field operations and database
records.
3.7.2 Field cluster site operations

Figure 13 below illustrates the flow of survey field activities. Each of the four teams spent a week
stationed in each selected cluster to complete cluster site operations.
Station 1: Reception and Registration

Informed consent process: Upon arrival at the field cluster site, a member of the local support team
conducted a group information session with all potential participants. The visitors were given details on
the survey procedures and given an opportunity to seek clarification if needed. Each eligible participant
was issued with two copies of a paper-based consent form (Annex C). One copy of the consent form was
kept at the site and the second was issued to participants for personal reference. Data clerks captured
the consent in the electronic database.
Verification: Eligibility to participate in the survey was verified based on the appointment card issued,
the verified age and a signed consent form checked for completeness. Data clerks used the participants’
unique barcodes to verify the participants’ demographic information (name, last name, date of birth/age,
residential address and contact details) in the survey database.
27
15
F IGURE 13: T HE FLOW OF FIELD ACTIVITIES DURING THE SURVEY
Station 2: TB screening interview
All eligible participants were screened for TB by a trained symptoms interviewer using the TB symptom-
screening questionnaire (Annex F). Questions were asked in the participant’s preferred language as far
as possible. Participants were considered symptomatic if they had any one or a combination of the
following symptoms: cough, night sweats, loss of weight or fever for two weeks or more. In addition,
questions related to HIV status and treatment were asked. The responses were captured electronically
in the survey field database.
28
16
Station 3: Chest X-ray (CXR)
CXRs were taken using a direct digital radiography system for all participants except pregnant women,
participants who could not stand and those who did not consent for the CXR procedure. The last normal
menstrual period (LNMP) date was sought from all females of child bearing age (up to 50 years) in order
to assess risk for pregnancy. A rapid pregnancy test was performed for participants who were uncertain
of pregnancy. Participants with positive results from the pregnancy test were referred for sputum
collection without a CXR. Survey participants were only allowed to undergo the CXR procedure upon
presentation of a survey appointment card. A radiographer or radiographic assistant obtained consent
from the participant for the CXR. All participants eligible for CXR were provided with an abdominal/pelvic
lead apron during the CXR procedure. Each participant then had a single erect postero-anterior (PA)
chest radiograph taken. The field radiographer processed the image and sent it through the integrated
local PACS for interpretation by the CAD4TB software as well as by the medical officer (MO)
simultaneously. All images were anonymized, stored and backed up on a central PACS cloud storage
with barcodes and cluster names.
The MO read all the CXR images parallel to the CAD4TB software, and these were classified as either
Normal, Abnormal TB-suggestive or Abnormal not TB-suggestive. The CAD4TB assigned a score from
0 to 100 based on likelihood of the image to be compatible with TB, which was then reclassified as
Abnormal if the CAD4TB score was above 60 and Normal if it was below 60.
Sputum eligibility determination
Eligibility for sputum collection was determined through an automated sputum eligibility algorithm within
the survey information system. This included the presence of any of the following symptoms as reported
by the participant; cough, drenching night sweats, fever, unintentional weight loss over a period of two
weeks or longer. In addition, all Abnormal images rendered a participant eligible for sputum collection.
All participants for whom CXR procedure could not be performed or participants who refused to consent
for the CXR procedure were also eligible for sputum collection.
Station 4: In-depth interviews
All participants with TB symptoms, abnormal CXR and every tenth participant from among those with
normal CXR and asymptomatic were eligible for an in-depth interview. A field nurse administered an in-
depth interview questionnaire (Annex K) electronically. This interview assessed the TB symptoms further,
as well as the risk of TB and other diseases.
Station 5: Field laboratory testing
Eligible participants were directed to the laboratory station for verification, then to a sputum collection
area where a poster depicting sputum production and collection instructions were displayed. The field
laboratory technologist or assistant explained the sputum production instructions as per the poster. The
participants were then issued with a 40ml labelled sputum container.
The participant provided a sputum specimen in the specimen container provided. Once the sample was
received, the laboratory staff checked both the quality and quantity of the sputum. The participant was
required to produce at least 4ml of sputum. The ‘first spot sputum’ (Specimen 1) was examined with an
Xpert MTB/RIF test. Each team had two GeneXpert machines mounted onto mobile clinic vans for Xpert
testing by trained laboratory staff. All the Xpert MTB/RIF positive results were given to the MO to interpret
29
17
and refer the affected participant to the local health facility via the local support team. Copies of these
positive results were sent to the central level for the clinical management subgroup.
Sputum eligible participants were then issued with a second labelled sputum container to collect a
‘second spot sputum’ (Specimen 2), which was collected at least an hour after the first specimen. On
receiving specimen 2, a ‘bacteriological TB request form’ was completed indicating the participant’s
details. The TB request form was then packaged with the specimen stored under cold chain conditions
at 2-8OC for transportation to the NIP Windhoek Central Reference Laboratory (WCRL) through the
district laboratory within four days of collection. A shipment log and a thermometer with a small water
tube for temperature monitoring accompanied specimens.
Station 6: HIV testing and counselling services (HTS)
As part of the standard of care for health services in Namibia, provider-initiated counselling and testing
(PITC) for HIV was available to all survey participants using an opt-out approach. HIV Counsellors (CC)
who were part of both local support team and the core field team were responsible for HTS. The MoHSS-
approved HIV test algorithm was followed; SURE CHECK HIV ½ Assay was used for screening for HIV,
Determine HIV ½ Ag/Ab Combo Assay was used as a confirmatory test for positive results, and HIV ½
STAT-PAK™ Assay as the tie-breaker. Participants were referred for re-testing at the nearest health
facility using enzyme linked immunosorbent assay (ELISA) in the event of further discordance in the
results.
Station 7: Reception-out
Participants who went through any of the stations at the cluster site were checked out at this station as
part of systems validation. Participants also handed in appointment cards at this station. Data clerks lastly
verified completion of all eligible stations before participants exited the site.
3.7.3 Mop-up activities

Mop-up activities were carried out to reach people who were eligible to participate in the survey as
identified and invited, but could not attend the cluster site activities. Reasons for the inability to reach the
site included being elderly, pregnant, disabled, forgotten appointment or just unable to travel to the cluster
site due to distance. Eligible participants in this category were transported by the survey team to and
from the cluster site for participation.
Mop-up activities were usually carried out on the fifth and sixth day of screening. However, on a daily
basis depending on the number of participants screened per day, data clerks sent standardized text (bulk)
messages to invited participants reminding them of their appointment as part of on-going follow up
activities.
3.8 Central procedures

3.8.1 Central laboratory procedures
On receiving specimens at the WCRL, temperatures were re-checked, and the specimens checked for
quality, quantity, leakages and labeling. This was recorded on a log sheet.
Sputum specimens that reached the WCRL within seven days from the date of collection were
decontaminated, concentrated and subjected to smear examination and mycobacterial culture. Two
liquid-based cultures (BD MGIT™) were performed for each specimen, followed by rapid identification
using an immunochromatographic assay, the BD TB Identification Test. Where there was a growth of
30
18
mycobacterium tuberculosis, the specimen was further subjected to drug susceptibility testing (DST)
using liquid culture methods.
Specimens that reached the WCRL later than seven days from the date of collection were tested with X-
pert MTB/RIF in the central laboratory. Specimens that could not be processed at the WCRL due to the
specimen load and also to comply with survey timelines were shipped to the National Institute for
Communicable Diseases (NICD) laboratory in South Africa. This is the WCRL’s supranational laboratory
for the same laboratory procedures. Certified staff from the WCRL and NICD performed all X-pert
MTB/RIF, smears and cultures on the survey specimens.
All positive and negative specimens tested at the WCRL were aliquoted in cryovials, frozen and stored
at -80oC.
3.8.2 Central radiologist reading procedures

All CXR images acquired in the field were transmitted electronically to the central PACS cloud for storage
and back-up via the central server. A central radiologist re-read all the abnormal images from the field
MOs and CAD4TB software as well as 10% of all the normal chest radiographs. This was done by
completing an electronic form on the radiologist’s platform on the survey information system. In addition,
the radiologist re-read all the images from participants with bacteriologically positive sputum results.
3.8.3 Decision by the Clinical Management Subgroup

Participants with positive bacteriological results had their information reviewed electronically by the
Clinical Management Subgroup. Headed by a coordinator from the NTLP, this subgroup provided
guidance to field teams on the interpretation of abnormal findings and the management of patients. In
addition, it monitored and ensured adherence to case definitions and determined participants whose
results fulfilled the survey case definitions. Case definitions used during the survey are displayed in Table
1.
T ABLE 1: D EFINITION OF A TB CASE IN THE SURVEY
Xpert Smear Culture or 2nd Radiologist’s Interpretation
MTB/RIF microscopy Xpert MTB/RIF (if conclusion
performed)
+ + - + or - Definite TB case
+ - + + or - Definite TB case
+ - - + Definite TB case
- - + + Definite TB case
- + + + or - Definite TB case
+ + + + or - Definite TB case
- + - + or - Not a TB case (probable
MOTT)
+ - - - Probable TB case
- - + - Probable TB case
- - - + Not a TB case
3.8.4 Management of participants with health needs
a. Management of participants found to have TB

TB positive sputum results were communicated to the district TB and leprosy coordinators (DTLCs) who
ensured that these participants are informed about their results and registered in the TB registers. The
31
19
DTLC ensured that participants who tested TB positive were initiated on appropriate treatment consistent
with the national guidelines for the management of TB. The Field Promoter or Health Extension Worker
(HEW) from the local support team accompanied the identified TB patients to the nearest clinic to ensure
they were enrolled in care and initiated on appropriate treatment. The Field Promoter or HEW noted the
address of the identified TB patients for contact investigation and plans for follow up of patients on
treatment.
Even where cases were identified after the team had left the cluster, the field coordinator still
communicated this to the DTLC for them to trace these participants. The DTLC then communicated with
the local community-based TB care (CBTBC) providers and ensured continued care of patients.
b. Follow-up of participants with symptoms, abnormal CXR and other identified

conditions
Participants who were symptomatic but for whom a TB diagnosis could not be made at the survey site
were assessed by the field MO and referred to the nearest hospital for further management. Additionally,
any participant with abnormal CXR that was not TB but required medical attention was referred by the
field MO to the nearest local senior medical officer with his or her CXR interpretation for appropriate care.
In the case of patients with conditions that required urgent medical attention, the MO in collaboration with
the DTLC or another senior member of the local support team made the necessary transport
arrangements and ensured that the patients attended the nearest health facility.
Participants with symptoms from other chronic conditions such as asthma, chronic obstructive pulmonary
disease, diabetes or hypertension were also referred to health facilities for further examination,
particularly if those conditions are not well controlled.
c. Management of participants who were HIV positive

Participants who disclosed a positive result during symptom interview were asked if they were receiving
antiretroviral treatment (ART). If not, they were offered referral to the local support team for further
management. Participants who tested positive were also offered referral for ART. Confidentiality was
maintained throughout, following the recommendations in the HTS guidelines. HIV results were only
disclosed to the concerned participant in a private environment. Disclosure to partners or any individual
other than a health care worker involved in the management was done with the explicit consent of the
concerned participant. The DTLC liaised with the HTS team to get the HIV results of identified TB patients
and ensure that the results were documented as per national guidelines. After completion of fieldwork in
each cluster, the HIV counsellors followed up all HIV positive participants to ensure they were linked to
care. For all TB/HIV co-infected participants, the DTLC ensured that recommended interventions such
as co-trimoxazole preventive therapy (CPT) and antiretroviral treatment (ART) were followed, consistent
with the national guidelines.
3.9 Post-survey feedback meetings

The field teams facilitated post survey de-brief meetings for each cluster with the District Coordinating
Committee and/or Regional Management Team. The team reported on participants diagnosed with TB
and other medical conditions and linkage to care.
32
20
3.10 Quality assurance
Equipment calibration, maintenance and monitoring procedures were performed as per manufacturer’s
instructions and approved standard operating procedures (SOPs) in the field. Trained field staff
performed the procedures throughout survey activities. The NIP WCRL provided specimens of known
results to each field team which were used as positive and negative internal quality controls (QCs) for
Xpert MTB/RIF tests. These specimens were tested and the results documented for each module on the
Xpert MTB/RIF machine after arriving at the cluster site to ensure proper instrument performance prior
to clinical use and result reporting. Routine internal quality control procedures were followed as outlined
in the NIP SOPs at the WCRL on all the second specimens. All positive culture and Xpert MTB/RIF
specimens and 10% of the negative specimens were stored and shipped for re-testing at the NICD in
South Africa to assess the reproducibility of test results produced by the Namibian WCRL.
For CXR, routine warm-up procedures were followed for all CXR equipment as per the manufacture’s
guidelines. The procedures were done daily before commencement of participant screening. Scheduled
maintenance by the supplier was also performed on all the machines. The central team conducted routine
visits to the cluster sites to ensure compliance to SOPs. All abnormal CXR images and 10% of all normal
CXR were re-read by a radiologist at central level.
The central team was on hand to support field teams remotely and conducted quality assurance visits,
where all aspects of the survey were observed and reviewed in the field with the field teams. This allowed
for troubleshooting and refinement of field activities. In addition, technical consultants from KNCV TB
Foundation and WHO participated in field monitoring visits.
3.11 Data management

All data were handled and managed according to the survey data management manual. All data collected
during the survey is the property of the MoHSS, with the NTLP managing the data on behalf of the
MoHSS. Data management fell under the responsibility of Data Manager on behalf of the NTLP
throughout the survey. Electronic tablets and computers were used for managing electronic forms, while
barcode scanners were used to identify and link entries to the participants’ unique barcode. Data clerks
at cluster site and central level filed paper records.
Household listing and enumeration data was collected using KoBo Toolbox, a free-to-use mobile data
collection system. Data from this system was integrated with a survey specific data management system,
named NAMTBCollect, was developed using PHP programming software, with MySQL as the database
platform and Apache as the webserver. This platform was used for all other field cluster operations as it
possessed special features that enabled full digitalization of the survey processes. The features included
Pop up reception reminders, Bulk SMS feature, Field flow monitoring, Queue Management, Field
Dashboards, Central dashboards, Sputum eligibility algorithm and Eligibility for central re-reading
algorithm and are summarized in Annex Q.
At central server level, NAMTBCollect used Linux operating system, while Windows operating system
was preferred at field level as it was found by most of the field staff to be more user friendly.
Household listing and enumeration data was synchronised daily with the NAMTBCollect. Figure 14
illustrates the synchronizing processes. The central database automatically imported the data with
specific variables of interest and fed to field servers located in the cluster sites. Between the central and
field servers, data was imported/exported and backed up daily. It was imperative that participants were
enumerated 2-3 days prior to field operation activities to allow availability of the listing data at field level
33
21
severs. In addition, integration between the NAMTBCollect platform and field GeneXpert and the PACS
system allowed for availability of Xpert results and embedding of links to CXR images and direct reporting
in the NAMTBCollect system.
A summary of data sources, format, storage, responsibility and security of electronic and hard copy
records is provided in Annex R. Access to the survey database was restricted to the survey Data
Manager, the systems administrator and the Survey Coordinator. It was necessary to share participants’
positive test results for linkage to care. In this case, the participants’ results were shared only with
authorized personnel such as the healthcare workers, DTLCs, HIV counsellors and the clinical
management subgroup.
Four multi-stakeholder workshops were conducted to clean, validate and analyze data. During the
workshops, access to the main dataset was still restricted to authorized personnel only. For analysis, all
personal identifying information such as name, surname and contact details were removed for
anonymization.
F IGURE 14: A N ILLUSTRATION OF THE DATA SYNCHRONIZING PROCESSES
3.12 Statistical analysis for the determination of TB Prevalence estimation

rates
Data collected through mobile electronic forms was anonymized at central level after consolidating into
a comma separated values (csv) spreadsheet for analysis using STATA version 12.1. The main outcome
was bacteriologically confirmed pulmonary TB according to the survey case definition (Table 1: Definition
of a TB case in the survey, section 3.12.3). TB prevalence calculations are presented separately.
Individual level analyses of the prevalence of the outcome of interest were performed using logistic
regression. For the national prevalence, logistic regression with robust standard errors calculated from
34
22
observed between-cluster variability will be used, and the results compared across three models of
logistic regression (Floyd et al., 2013):
• logistic regression with robust standard errors, restricted to survey participants with no imputation of
missing values
• logistic regression with robust standard errors, with missing value imputation for survey non-
participants as well as participants and including all individuals who were eligible for the survey in the
analysis
• logistic regression model with robust standard errors, with missing value imputation for those survey
participants who were eligible for sputum examination but for whom smear and/or culture results were
missing, and inverse probability weighting applied to all survey participants.
Differences in the prevalence between the three models was compared and sensitivity analysis
conducted to cater for the possibility of data missing not at random.
For the association with other variables and risk factors, random-effects logistic regression was
employed. Secondary analysis included analysis of health seeking behaviors and associations between
known risk factors and sociodemographic information.
3.13 Ethical Considerations

Ethics approval: The survey was approved by the MoHSS Ethics Committee in February 2017 (Annex
A). The survey was also approved by the CDC Namibia and Atlanta offices. The WHO gave concurrence
with the survey protocol.
Informed consent: All survey participants were informed about the survey requirements and were
required to submit written informed consent at reception prior to having any screening procedures
performed. All participants aged 15-17 years were required to have a legal guardian present for their
screening visit. The legal guardian was required to co-sign the participant assent. Participants were
allowed to opt out of the survey processes at any point during the cascade without any consequences.
Confidentiality: Participants were issued a unique barcode to facilitate anonymous tracking and
reporting of results. Participants’ barcodes were only used for purposes of case management, patient
notification and linkage to treatment either at field or central level. Participant personal identifiers were
not imported on PACS for CXR re-reading. All members of the field teams signed confidentiality forms
prior to conducting field activities. Access to hard copies of forms and the electronic database was
restricted to authorized personnel. Findings from the survey are presented in aggregate form without
reference to participants’ identifying information.
Radiation protection: The TB screening equipment were inspected and licensed by NRPA. The NRPA
performed random visits to cluster sites to monitor compliance to the radiation management plan (RMP).
Field survey staff members were trained on radiation protection and safety by NRPA before field work
commenced. The CXR screening area was setup so that the X-ray beam was directed away from human
subjects and a minimum distance of five (5) metres from the X-ray station was marked off and treated as
a supervised area. The trucks hosting the X-ray units were lead-lined to minimize exposure of the general
public, survey staff and the environment to radiation. The portable X-ray units were shielded by four (4)
mobile lead shields on each side of the machine in the X-ray area while working in the field or by a double
brick wall when working from a building.
35
23
Lead protection apparel such as lead gowns, lead-apron and thyroid shields as well as lead cap were
provided to each team for protection of participants and survey staff. Radiation warning signs written in
local languages were displayed at the entrance, inside and outside of the trucks and around the portable
machine, and surrounding areas of the cluster site.
A survey participant was only allowed to undergo the X-ray procedure upon presentation of a survey
appointment card. A single PA CXR was performed on participants who provided verbal consent for the
CXR procedure. Pregnant participants were not eligible for the CXR procedure and were therefore not
allowed to have a CXR examination. The radiographers were to collimate the beam and apply the ALARA
principle at all times. This was confirmed with regular quality assurance visits by the central coordination
team.
Infection control: All the field teams were trained on HIV and TB prevention and infection control
procedures prior to field activities. The nurse at the cluster site was assigned to oversee all procedures
related to universal precautions and TB infection control. During sputum collection, the participants were
directed to an isolated open-air environment that was identified by the field team before the field
operations commenced. This area was away from the rest of the participants and made provision for
natural ventilation. Since there were no biosafety cabinets in the mobile laboratories, the sputum
specimens were processed in the open air where there was adequate ventilation. All field medical staff
were provided with personal protective gear that included gloves, lab coats, N95 face respirators and
hand disinfectant for use whenever appropriate.
The field medical staff also cleaned the machines and workstations with an anti-bacterial solution and
disinfected medical devices and equipment in between participants. Each participant was provided with
a T-shirt or a disposable gown to avoid cross-infection during the CXR procedure. The trucks hosting the
mobile X-ray units and Xpert MTB/RIF equipment were equipped with an ultra-violet germicidal irradiation
unit for TB infection control.
All NIP routine waste disposal procedures for sputum containers and TB and HIV testing were applied
during the survey.
3.14 Definitions
Abnormal chest X ray – Presence of any changes or opacities on a chest radiographic picture taken in
the postero-anterior position and includes any of the following descriptions: infiltration, cavitation,
consolidation, fibrosis, pleural effusion, pleural thickening, lymph node enlargement, other unexplained
opacity; or as defined by a positive score/score above the threshold in the CAD4TB chest X-ray reading
software.
Adult – any individual who is 15 years of age or older, having reached or surpassed their 15th birthday
on the day of TB screening during the survey.
Bacteriologically positive – Any demonstration of acid-fast bacilli on smear microscopy, or

demonstration of mycobacterium tuberculosis using either Xpert MTB/RIF or other identification from a
positive mycobacterial culture isolate.
Culture positive specimen – Any sputum specimen reported as having grown mycobacterium
tuberculosis following culture in the laboratory using standard methods.
36
24
Eligible for sputum collection – Any survey participant who has symptoms suggestive of TB (symptom
positive), abnormal chest X-ray, or there was failure to perform a CXR at the time of the visit.
Significant Symptoms - Any symptoms suggestive of TB that had a duration of two weeks or longer.
Household – A group of people, related or unrelated, who live in the same dwelling unit and share or
have a common catering arrangement.
Household member - Any person who has been residing in the household for at least two weeks,
whether present or absent at the time of the listing operation.
New TB case – Any patient diagnosed with active tuberculosis and who, at the time of specimen
collection for survey, had either never received treatment for tuberculosis, or had only received treatment
for tuberculosis for less than four weeks (can be on treatment or not on treatment).
Normal chest X-ray – Absence of any changes or abnormal opacities in the chest cavity on a
radiographic image taken in the postero-anterior position.
Previously treated TB case – Any patient diagnosed with active TB but who, prior to specimen
collection for the survey, had received at least four weeks treatment for TB (can be either on treatment
or not on treatment).
Probable TB case – A survey participant in whom a medical officer has recommended treatment for TB,
even though they do not fulfil the criteria for a definite survey case.
Resident - A household member who has been living in that location for at least two weeks. In areas
with nomadic populations, (Opuwo in Kunene region and Tsumkwe in Otjozondjupa region) participants
will be explicitly asked whether they have previously participated in this survey, in which case they were
excluded.
Smear positive TB case – Any patient, new or previously treated, diagnosed with active TB based on
a positive sputum smear microscopy and is either Xpert positive or has Mycobacterium tuberculosis
detected on culture.
Survey participant – Any eligible individual(s) who had consented to take part in the survey and
underwent either symptom screening and or had a field chest X-ray performed at the field cluster site for
purpose of the TB disease prevalence.
Survey TB case – A survey participant who is eligible for sputum collection (presence of symptoms,
abnormal chest X-ray or failure to perform chest X-ray) and whose sputum is either culture positive with
identification of mycobacterium tuberculosis, or Xpert MTB/RIF positive (mycobacterium tuberculosis
detected), in addition to being smear positive, having an abnormal chest X-ray or symptoms suggestive
of TB (symptom positive).
Symptom positive – Presence of any of cough, night sweats, loss of weight or fever for two weeks or
more.
Xpert positive TB case - Any patient, new or previously treated, diagnosed with active TB based on
detection of mycobacterium tuberculosis by Xpert MTB/RIF.
37
25
4. RESULTS
Field operations took place between July 2017 and March 2018. Data was collected from 68 clusters
across urban and rural clusters in 14 regions.
4.1 Census of survey population

Individuals enumerated at the 15,410 households visited were 56,922, of which 32,776 (57.6%) lived in
rural areas and 18,544 (32.6%) were children under the age of 15. From the enumerated, 38,378 were
aged 15 years and above with 38,353 being resident in listed households for over two weeks. This
qualified them as eligible to participate in the survey.
Table 2 illustrates the enumerated population by sex, age group and eligibility to participate.
T ABLE 2: E LIGIBLE VS I NELIGIBLE SURVEY POPULATION
TOTAL
Ineligible Eligible
(All)
Resident <2weeks
or unknown Age<15Yrs
duration
n % n % n % n
Sex Male 10 0.0% 9,099 0.2% 17,113 0.3% 26,222

Female 15 0.0% 9,445 0.2% 21,240 0.4% 30,700
TOTAL 56,922
Age (years) 0–4 0 0.0% 7,304 0.1% 0 0.0% 7,304
5–14 0 0.0% 11,240 0.2% 0 0.0% 11,240
15–24 7 0.0% 0 0.0% 11,304 0.2% 11,311
25–34 9 0.0% 0 0.0% 9,350 0.2% 9,359
35–44 6 0.0% 0 0.0% 6,889 0.1% 6,895
45–54 1 0.0% 0 0.0% 4,502 0.1% 4,503
55–64 2 0.0% 0 0.0% 2,923 0.1% 2,925
65+ 0 0.0% 0 0.0% 3,152 0.1% 3,152

Unknown 0 0.0% 0 0.0% 233 0.0% 233
TOTAL 56,922
Setting Urban 17 0.0% 6,273 0.1% 17,856 0.3% 24,146
Rural 8 0.0% 12,271 0.2% 20,497 0.4% 32,776
TOTAL 56,922
Region Erongo 0 0.0% 392 0.0% 2,635 0.0% 3,027
Hardap 0 0.0% 829 0.0% 1,663 0.0% 2,492
//Karas 0 0.0% 636 0.0% 1,712 0.0% 2,348
38
26
TOTAL
Ineligible Eligible
(All)
Resident <2weeks
or unknown Age<15Yrs
duration
n % n % n % n
Kavango East 1 0.0% 1,141 0.0% 2,294 0.0% 3,436
Kavango 4 0.0% 1,484 0.0% 1,798 0.0% 3,286

West
Khomas 16 0.0% 1,742 0.0% 5,903 0.1% 7,661

Kunene 0 0.0% 827 0.0% 1,739 0.0% 2,566
Ohangwena 2 0.0% 2,691 0.0% 4,115 0.1% 6,808
Omaheke 0 0.0% 491 0.0% 1,174 0.0% 1,665
Omusati 2 0.0% 2,930 0.1% 4,152 0.1% 7,084
Oshana 0 0.0% 1,569 0.0% 3,513 0.1% 5,082
Oshikoto 0 0.0% 1,885 0.0% 3,601 0.1% 5,486
Otjozondjupa 0 0.0% 1,094 0.0% 2,281 0.0% 3,375
Zambezi 0 0.0% 833 0.0% 1,773 0.0% 2,606
TOTAL 0.0% 18,544 0.3 38,353 0.7% 56,922
The sex and age distribution of the eligible population was almost identical to the enumerated (census)
population since very few adult individuals (n=25 or 0.04%) were ineligible due to residency of less than
2 weeks duration. This is shown in Figure 15.
F IGURE 15: A GE AND SEX DISTRIBUTION OF ENUMERATED AND ELIGIBLE POPULATIONS
39
27
In turn, the age-sex distribution of the enumerated population is very similar to that of the entire Namibian
population in 2016(Namibia Statistics Agency, 2016). This indicates that there was minimal, if any
sampling bias and that the survey population had a similar demographic structure to the country as a
whole.
F IGURE 16: N AMIBIAN POPULATION ESTIMATE , 2016

Namibia population estimate, 2016
Age group
65+
55-64
45-54
35-44
25-34
15-24
5-14
0-4
-15% -10% -5% 0% 5% 10% 15%
% Female % Male
4.2 Prevalence survey cascade
Figure 17 displays a summary of participation at different levels of the survey from enumeration to survey
outcomes indicating losses at each level
4.3 Survey Participation

4.3.1 Participants vs non-participants
Of the 38,353 eligible to participate, 29,523 (76.9%) consented to participation in the survey screening
procedures. Non-participants are eligible individuals who did not complete the symptom screening or
CXR. Of the eligible individuals, 8,533 did not visit the cluster site while 297 visited the cluster site but
declined to participate.
The difference in the age and sex distribution of the participants (Figure 18) compared to the eligible
population suggests that young adult males were less likely to participate and older females were more
likely to participate in the survey.
40
28
F IGURE 17: F LOW CHART DEMONSTRATING SURVEY PARTICIPATION
41
29
F IGURE 18: A GE AND S EX DISTRIBUTION OF PARTICIPANTS RELATIVE TO THE ELIGIBLE POPULATION
Participation varied considerably across the 68 clusters (Figure 19). It ranged between 45.3% and 96.0%
and tended to be higher in rural clusters. Overall, participation rate stood at 76.9%. Average participation
increased over the course of the survey with the exception of the three last clusters in the Khomas region.
F IGURE 19: P ARTICIPATION RATE OF CLUSTER OVER TIME (J ULY 2017 TO M AR 2018)
Of the total eligible to participate, 29,495 (76.9%) underwent symptom and/or chest X-ray screening and
are henceforth referred to as survey participants. The vast majority (94.1%) of the participants underwent
both symptom and chest X-ray screening. Some 1,744 (5.9%) did not receive a chest X-ray screening
42
30
because of pregnancy, immobility, equipment failure or other reasons. Table 3 shows the breakdown of
those eligible by participation status and sex, age, region and setting (rural or urban). Table 4Error!
Reference source not found. further shows the coverage by the different screening methods.
T ABLE 3: P ARTICIPANTS VS NON - PARTICIPANTS AMONG THOSE ELIGIBLE TO PARTICIPATE
Participants (had symptom TOTAL
Non-participants
screening and/or Chest X-ray) (eligible)
N % N % n
Sex Female 4,340 11.3 16,900 44.1 21,240

Male 4,518 11.8 12,595 32.8 17,113
Total 38,353
15–24 3,046 7.9 8,258 21.5 11,304
Age (years) 25–34 2,532 6.6 6,818 17.8 9,350
35–44 1,497 3.9 5,392 14.1 6,889
45–54 825 2.2 3,677 9.6 4,502
55–64 392 1.0 2,531 6.6 2,923
65+ 333 0.9 2,819 7.4 3,152
Unknown 233 0.6 0 0 233
Total 38,353
Stratum Urban 5,678 14.8 12,178 31.8 17,856
Rural 3,180 8.3 17,317 45.2 20,497
Total 38,353
Erongo 974 2.5 1,661 4.3 2,635
Hardap 549 1.4 1,114 2.9 1,663
Region
//Karas 438 1.1 1,274 3.3 1,712
Kavango_East 357 0.9 1,937 5.1 2,294
Kavango_West 283 0.7 1,515 3.0 1,798
Khomas 2,376 6.2 3,527 9.2 5,903
Kunene 192 0.5 1,547 4.0 1,739
Ohangwena 720 1.9 3,395 8.9 4,115
Omaheke 139 0.4 1,035 2.7 1,174
Omusati 449 1.2 3,703 9.7 4,152
Oshana 984 2.6 2,529 6.6 3,513
Oshikoto 469 1.2 3,132 8.2 3,601
Otjozondjupa 404 1.1 1,877 4.9 2,281
Zambezi 524 1.4 1,249 3.3 1,773
Total 38,353
43
31
T ABLE 4: C OVERAGE BY C HEST X-R AY AND S YMPTOMS
Symptom
Chest X-ray screening
screening
Total Eligible n % n %
Sex Male 17,113 12,196 31.8 12,595 32.8
Female 21,240 15,555 40.6 16,899 44.1
Total 38,353 27,751 29,494
Age groups (years) 15–24 11,304 7,716 20.1 8,257 21.5

25–34 9,350 6,310 16.5 6,818 17.8
35–44 6,889 5,071 13.3 5,392 14.1
45–54 4,502 3,552 9.3 3,677 9.6
55–64 2,923 2,452 6.4 2,531 6.6
65+ 3,152 2,650 6.9 2,819 7.4
Unknown 233 0 0 0.0
38,353 27,751 29,494
Setting Urban 17,856 11,649 30.4 12,177 31.7
Rural 20,497 16,102 42.0 17,317 45.2
38,353 27,751 29,494
Region Erongo 2,635 1,602 4.2 1,661 4.3
Hardap 1,663 1,074 2.8 1,114 2.9
//Karas 1,712 1,241 3.2 1,274 3.3
Kavango_East 2,294 1,878 4.9 1,937 5.1
Kavango_West 1,798 1,440 3.8 1,515 4.0
Khomas 5,903 3,377 8.8 3,526 9.2
Kunene 1,739 1,455 3.8 1,547 4.0
Ohangwena 4,115 3,282 8.6 3,395 8.9
Omaheke 1,174 991 2.6 1,035 2.7
Omusati 4,152 3,605 9.4 3,703 9.7
Oshana 3,513 2,334 6.1 2,529 6.6
Oshikoto 3,601 3,050 8.0 3,132 8.2
Otjozondjupa 2,281 1,761 4.6 1,877 4.9
Zambezi 1,773 661 1.7 1,249 3.3
Total 38,353 27,751 29,494
4.4 Screening Results

4.4.1 Symptom Screening
Of all survey participants, 29,494 (100%) underwent symptom screening; only one participant skipped
symptoms screening and went on to have a CXR. Table 5 illustrates those with significant symptoms
(duration of 2 weeks or more, or unknown duration).
44
32
T ABLE 5: S YMPTOM SCREENING RESULTS
Total Night
Cough Weight loss Fever Any symptom
Screened Sweats
n n % n % n % n % n %
Sex Male 12,595 1,496 5.07 914 3.10 920 3.12 600 2.03 2,699 9.15
Female 16,899 1,727 5.86 1,310 4.44 1,168 3.96 932 3.16 3,571 12.11
Total 29,494 3,223 2,224 2,088 1,532 6,270

Age
15–24 8,257 523 1.77 235 0.80 369 1.25 194 0.66 1,001 3.39
(years)
25–34 6,818 610 2.07 476 1.61 524 1.78 307 1.04 1,329 4.51
35–44 5,392 610 2.07 477 1.62 401 1.36 294 1.00 1,215 4.12
45–54 3,677 473 1.60 392 1.33 328 1.11 264 0.90 999 3.39
55–64 2,531 440 1.49 292 0.99 203 0.69 207 0.70 791 2.68
65+ 2,819 567 1.92 352 1.19 263 0.89 266 0.90 935 3.17
Total 29,494 3,223 2,224 2,088 1,532 6,270
Stratum Urban 12,177 1,307 4.43 942 3.19 964 3.27 662 2.24 2,638 8.94
Rural 17,317 1,916 6.50 1,282 4.35 1,124 3.81 870 2.95 3,632 12.31
Total 29,494 3,223 2,224 2,088 1,532 6,270
Region Erongo 1,661 177 0.60 162 0.55 102 0.35 98 0.33 375 1.27
Hardap 1,114 208 0.71 128 0.43 154 0.52 102 0.35 393 1.33
//Karas 1,274 150 0.51 134 0.45 140 0.47 81 0.27 341 1.16
Kavango_East 1,937 138 0.47 95 0.32 142 0.48 89 0.30 312 1.06
Kavango_west 1,515 94 0.32 123 0.42 64 0.22 58 0.20 228 0.77
Khomas 3,526 352 1.19 204 0.69 237 0.80 152 0.52 684 2.32
Kunene 1,547 312 1.06 166 0.56 212 0.72 178 0.60 565 1.92
Ohangwena 3,395 302 1.02 199 0.67 116 0.39 101 0.34 548 1.86
Omaheke 1,035 253 0.86 189 0.64 227 0.77 142 0.48 499 1.69
Omusati 3,703 214 0.73 227 0.77 44 0.15 71 0.24 425 1.44
Oshana 2,529 291 0.99 238 0.81 189 0.64 149 0.51 581 1.97
Oshikoto 3,132 211 0.72 117 0.40 75 0.25 63 0.21 372 1.26
Otjozondjupa 1,877 339 1.15 105 0.36 167 0.57 143 0.48 552 1.87
Zambezi 1,249 182 0.62 137 0.46 219 0.74 105 0.36 395 1.34
Total 29,494 3,223 2,224 2,088 1,532 6,270
4.4.2 Field Chest X-Ray

Of all the participants in the survey, 27,751 (94.1%) had a field CXR performed. A reading by either a
medical officer (MO) or the automated CAD4TB software determined CXR results. Both reading systems
deemed 22,709 CXR images normal, while 1,970 were deemed abnormal by both.
The MO determined 2,003 to be abnormal but these were below the set CAD4TB threshold of 60 (i.e.
normal). From the 2,003 abnormal, 381 were not consistent with TB. Conversely, the CAD4TB
determined 1,069 to be abnormal (above the set threshold of 60) yet these were missed by the MO. In
45
33
all, 5,042 had an abnormal CXR based on either the MO interpretation or CAD4TB. Table 6 shows the
breakdown of participants’ final field CXR results.
T ABLE 6: F IELD C HEST X R AY FINDINGS
TOTAL
Normal Abnormal (of those with an CXR)
n % n % n
Sex Male 9,805 35.3 2,391 8.6 12,196
Female 12,904 46.5 2,651 10.0 15,555
Total 22,709 5,042 27,751
Age (years) 15–24 7,339 26.4 377 1.4 7,716
25–34 5,772 20.8 538 1.9 6,310
35–44 4,218 15.2 853 3.1 5,071
45–54 2,614 9.4 938 3.4 3,552
55–64 1,597 5.8 855 3.1 2,452
65+ 1,169 4.2 1,481 5.3 2,650
Total 22,709 5,042 27,751
Stratum Urban 9,783 35.3 1,866 6.7 11,649
Rural 1,2926 46.6 3,176 11.4 16,102
Total 22,709 5,042 27,751
Erongo 1,382 5.0 220 0.8 1,602
Hardap 737 2.7 337 1.2 1,074
Region
//Karas 1,096 4.0 145 0.5 1,241
Kavango_East 1,578 6.0 300 1.1 1,878
Kavango_West 1,089 3.9 351 1.3 1,440
Khomas 2,805 10.1 572 2.1 3,377
Kunene 1,159 4.2 296 1.1 1,455
Ohangwena 2,676 9.6 606 2.2 3,282
Omaheke 755 2.7 236 1.0 991
Omusati 2,932 10.6 673 2.4 3,605
Oshana 1,879 7.0 455 1.6 2,334
Oshikoto 2,690 10.0 360 1.3 3,050
Otjozondjupa 1,365 4.9 396 1.4 1,761
Zambezi 566 2.0 95 0.3 661
Total 22,709 5,042 27,751
4.4.3 Eligibility for Sputum Collection

Of the 29,495 participants, 10,884 (36.9.0%) were eligible for sputum collection for the following reasons;
• 1,703 had significant symptoms and abnormal field CXR
• 3,339 had abnormal field CXR with no significant symptoms
• 4,114 had significant symptoms but normal field CXR
• 453 had significant symptoms but no field CXR performed and
• 1,275 had no significant symptoms yet were eligible because no field CXR was performed
46
34
4.5 Laboratory examination
4.5.1 Submission of sputum
Of the 10,884 eligible for sputum examination 9,462 (86.9%) submitted at least one sputum specimen for
examination.
• 1,422 (13.1%) sputum eligible participants did not provide sputum
• 8,032 submitted two specimens
• 1,160 submitted only the first specimen
• 270 submitted one specimen that went for central testing (second specimen) without getting the first
specimen tested.
4.5.2 Field laboratory testing

Of the 9,462 participants that submitted sputum, 9,192 had a field Xpert MTB/RIF test.
• 115 had a positive (MTB detected) results
• 9,044 had a negative result
• 33 had no interpretable results (invalid or errors)
Table 7 shows the results of field testing against eligibility for sputum examination
T ABLE 7: S PUTUM ELIGIBILITY AND F IELD X PERT MTB/RIF RESULTS
Field X-pert Result
No specimen
Detected Not detected No result
collected
Field CXR reading N % n % n % n % TOTAL
Normal 3 0.0% 3,426 31.5% 16 0.1% 669 6.1% 4,114
Abnormal 108 1.0% 4,294 39.5% 12 0.1% 628 5.8% 5,042

No CXR taken 4 0.0% 1,324 12.2% 5 0.0% 395 3.6% 1,728
Total 115 1.1% 9,044 83.1% 33 0.3% 1,692 15.5% 10,884
Eligible for sputum examination according to symptoms
Yes 54 0.5% 5,234 48.1% 21 0.2% 961 8.8% 6,270
No 61 0.6% 3,810 35.0% 12 0.1% 731 6.7% 4,614
Total 115 1.1% 9,044 83.1% 33 0.3% 1,692 15.5% 10,884
Eligible for sputum examination according to CXR or symptoms
Yes 113 1.0% 8,068 74.1% 29 0.3% 1,399 12.9% 9,609
Eligible for other
2 0.0% 976 9.0% 4 0.0% 293 2.7% 1,275
reasons
TOTAL 115 1.1% 9,044 83.1% 33 0.3% 1,692 15.5% 10,884
47
35
T ABLE 8: S PUTUM ELIGIBILITY AND C ENTRAL LABORATORY RESULTS
Central X Pert Result Central Culture Results
Not done
Positive
No Sample Negative (not (samples were No sample
Detected Not detected Not done (MTB MOTT Contaminated
Collected detected) collected, no collected
detected)
results)
Field
CXR n % n % n % n % n % n % n % n % n % n %
reading
Normal 0 0.0% 553 5.1% 2,641 24.3% 920 8.5% 7 0.1% 1,628 15.0% 99 0.9% 192 1.8% 1,268 11.7% 920 8.5%
Abnormal 21 0.2% 874 8.0% 3,115 28.6% 1,032 9.5% 48 0.4% 1,773 16.3% 139 1.3% 226 2.1% 1,824 16.8% 1,032 9.5%
Unknown 1 0.0% 319 2.9% 778 7.1% 630 5.8% 1 0.0% 492 4.5% 58 0.5% 67 0.6% 480 4.4% 630 5.8%
Total 22 0.2% 1,746 16.0% 6,534 60.0% 2,582 23.7% 56 0.5% 3,893 35.8% 296 2.7% 485 4.5% 3,572 32.8% 2,582 23.7%
Yes 11 0.1% 855 7.9% 3,991 36.7 1,413 13.0% 31 0.3% 2,433 22.4% 169 1.6% 282 2.6% 1,942 17.8% 1,413 13.0%
No 11 0.1% 891 8.2% 2,543 23.4% 1,169 10.7% 25 0.2% 1,460 13.4% 127 1.2% 203 1.9% 1,630 15.0% 1,169 10.7%
Total 22 0.2% 1,746 16.0% 6,534 60.0% 2,582 23.7% 56 0.5% 3,893 35.8% 296 2.7% 485 4.5% 3,572 32.8% 2,582 23.7%
Eligible for sputum examination according to CXR or symptoms
Yes 22 0.2% 1,500 13.8% 5,980 54.9% 2,107 19.4% 55 0.5% 3,549 32.6% 260 2.4% 437 4.0% 3,201 29.4% 2,107 19.4%
Eligible
for other 0 0.0% 246 2.3% 554 5.1% 475 4.4% 1 0.0% 344 3.2% 36 0.3% 48 0.4% 371 3.4% 475 4.4%
reasons
TOTAL 22 0.2% 1,746 16.0% 6,534 60.0% 2,582 23.7% 56 0.5% 3,893 35.8% 296 2.7% 485 4.5% 3,572 32.8% 2,582 23.7%
48
36
4.5.3 Central laboratory testing
Of the 8,302 participants who had specimens submitted to the central laboratory,
6,493 (78.2%) had either an Xpert MTB/Rif or mycobacterial culture successfully
performed.
• 4,725 had a culture results only, of which 52 were positive (MTB detected)
• 1,763 had an Xpert/MTB/Rif result of which only 18 were positive
• 5 had both culture and Xpert/MTB/Rif results of which four were positive
• Of the 115 who had a positive field Xpert MTB/Rif, 17 had a central Xpert
MTB/Rif and 69 had culture (including the five who had both).
o 9 were central Xpert positive
o 37 were culture positive
o 4 were both central Xpert and culture positive
In all, 74 participants who had either a central Xpert or culture conducted, had a
positive result. Among these, 50 had a positive field Xpert. Table 8 shows
combined results of Xpert and mycobacteria culture. Table 9 further shows the
combined central laboratory results among the sputum eligible participants.
T ABLE 9: S PUTUM ELIGIBILITY AND C OMBINED CENTRAL X PERT AND CULTURE RESULTS
Combined Central result
Positive
Negative
(MTB Not done Not available
(not detected)
detected)
Field
CXR n % n % n % n % TOTAL
reading
Normal 7 0.1% 2,280 20.9% 907 8.3% 920 8.5% 4,114
Abnormal 65 0.6% 2,785 25.6% 1,160 10.7% 1,032 9.5% 5,042
Unknown 2 0.0% 869 8.0% 227 2.1% 630 5.8% 1,728
Total 74 0.7% 5,934 54.5% 2,294 21.1% 2,582 23.7% 10,884
Yes 41 0.4% 3,457 31.8% 1,359 12.5% 1,413 13.0% 6,270
No 33 0.3% 2,477 22.8% 935 8.6% 1,169 10.7% 4,614
Total 74 0.7% 5,934 54.5% 2,294 21.1% 2,582 23.7% 10,884
Eligible for sputum examination according to X-ray or symptoms
Yes 73 0.7% 5,308 89% 2,121 19.5% 2,107 19.4% 9,609
Eligible
for other 1 0.0% 626 11% 173 1.6% 475 4.4% 1,275
reasons
TOTAL 74 0.7% 5,934 100% 2,294 21.1% 2,582 23.7% 10,884
49
37
Of the 8,302 who submitted second sputum specimens, 5,622 had smear
microscopy performed.
• Of all the smear tests performed 35 were positive

o 25 with positive smear results also had a positive central result (Xpert
or culture)
o 10 with positive smear results had a negative central result
Table 10 shows the smear results.

T ABLE 10: S PUTUM ELIGIBILITY AND SMEAR RESULTS
Smear
No sample
Positive Negative Not done
submitted
Field CXR
n % n % n % n % TOTAL
reading
Normal 3 9% 2,194 39% 997 37% 920 36% 4,114
Abnormal 31 89% 2,659 48% 1,320 49% 1,032 40% 5,042
Unknown 1 3% 734 13% 363 14% 630 24% 1,728
Total 35 100% 5,587 100% 2,680 100% 2,582 100% 10,884
Yes 24 69% 3,340 60% 1,493 56% 1,413 55% 6,270
No 11 31% 2,247 40% 1,187 44% 1,169 45% 4,614
Total 35 100% 5,587 100% 2,680 100% 2,582 100% 10,884
Eligible for sputum examination according to X-ray or symptoms
Yes 34 97% 5,064 91% 2,404 90% 2,107 82% 9,609
Eligible for
1 3% 523 9% 276 10% 475 18% 1,275
other reasons
TOTAL 35 100% 5,587 100% 2,680 100% 2,582 100% 10,884
Of the 100 who had a Xpert positive field test and submitted a second specimen,
26 were smear positive, 55 smear negative and 19 had no smear results.
Table 11 shows results of smear microscopy against central bacteriological results.
50
38
T ABLE 11: S MEAR M ICROSCOPY VS CENTRAL CULTURE AND X PERT MTB
Central Culture Central Xpert MTB
Culture Culture No specimen

MOTT Contaminated Not done Detected Not detected No result TOTAL
Positive Negative collected
Smear
n % n % n % n % n % n % n % n % n % n %
grading
1+ 4 7% 0 0% 0 0% 0 0% 1 0% 0 0% 2 9% 0 0% 3 0% 5 0.0%
2+ 5 9% 1 0% 0 0% 0 0% 1 0% 0 0% 2 9% 0 0% 5 0% 7 0.1%
3+ 5 9% 0 0% 2 1% 0 0% 0 0% 0 0% 0 0% 0 0% 7 0% 7 0.1%
Scanty 8 14% 5 0% 2 1% 0 0% 1 0% 0 0% 1 5% 0 0% 15 0% 16 0.1%
Negative 34 61% 3,862 99% 292 99% 484 100% 915 26% 0 0% 17 77% 763 44% 4,802 53% 5587 51.3%
Not done 0 0% 25 1% 0 0% 1 0% 2,654 74% 0 0% 0 0% 983 56% 1,697 19% 2680 24.6%
Not
0 0% 0 0% 0 0% 0 0% 0 0% 2,582 100% 0 0% 0 0% 2,582 28% 2582 23.7%
available
TOTAL 55 100% 3,893 100% 296 100% 485 100% 3572 100% 2,582 100% 22 100% 1,746 100 9,111 100% 10,884 100%
39
T ABLE 12: S MEAR RESULTS AND COMBINED CENTRAL RESULTS
Combined Central result
Not done (Culture or

Positive (MTB detected) Negative (not detected) Specimen not submitted
Xpert) Total
Smear
n % n % n % n % n %
grading
1+ 5 0.0% 0 0.0% 0 0.0% 0 0.0% 5 0.0%
2+ 6 0.1% 1 0.0% 0 0.0% 0 0.0% 7 0.0%
3+ 5 0.0% 2 0.0% 0 0.0% 0 0.0% 7 0.0%
Scanty 9 0.1% 7 0.1% 0 0.0% 0 0.0% 16 0.2%
Negative 49 0.5% 4,916 45.2% 622 5.7% 0 0.0% 5,587 51.3%
Not done 0 0.0% 1,008 9.3% 1,672 15.36% 0 0.0% 2,680 24.6%
Not
available 0 0.0% 0 0.0% 0 0.0% 2,582 23.7% 2,582 23.7%
TOTAL 74 0.7% 5,934 54.5% 2,294 21.1% 2,582 23.7% 10,884 100%
40
4.5.4 Central chest X-ray results
The central radiologist re-read 6,767 (24.3%) CXR images. Of these, 1,751 were deemed normal
by both CAD4TB and field MO readings while 5,016 had an abnormal field reading (by either the
MO or CAD4TB).
• The concordance observed was (65.5%) between the field ad central readings
• Of the 1,796 consistent with TB by the central reading 1,771 had been flagged as abnormal
in the field. Therefore, the sensitivity of the combined approach (MO and CAD4TB reading at
a threshold of 60) for detecting TB-consistent abnormalities was 98.6%.
Table 13 shows the central radiologists` results against the field CXR readings.
T ABLE 13: C ORRESPONDENCE BETWEEN FIELD AND CENTRAL READING OF CHEST X-R AY
Chest X-ray, field reading
CXR central reading Normal Abnormal CXR not taken TOTAL
n % n % n % n
Normal 1,574 42.14% 2,161 57.86 0 0 3,735
Abnormal consistent with TB 25 1.39% 1,771 98.61 0 0 1,796
Abnormal inconsistent with TB 152 12.30% 1,084 87.70 0 0 1,236
Not re-read 20,958 92.21% 26 0.11 1,744 7.67 22,728
TOTAL 22,709 5,042 1,744 29495
4.6 Bacteriologically confirmed prevalent TB Cases

In determining survey cases, the clinical management subgroup reviewed information from 150
participants who were eligible for sputum examination and had positive bacteriological results
against the case definitions.
• 119 were determined to be definite TB cases.
o 5 were already on TB treatment.
• 22 were deemed probable TB cases as they satisfied programmatic requirements for TB
diagnosis but did not satisfy the survey definition
o 2 were already on TB treatment.
• 9 were deemed not TB cases, in addition to 10,734 who did not have positive bacteriological
results.
• 132 other participants were on TB treatment when surveyed, of whom 93 were eligible for
sputum collection.
Table 14 shows the final case outcomes against sputum eligibility criteria.
T ABLE 14: F INAL OUTCOME BY SPUTUM ELIGIBILITY
53
41
Final outcome
Definite TB case Probable TB case Not TB case
Field CXR reading n % n % n % TOTAL
Normal 5 0.0% 6 0.1% 4,103 37.7% 4,114
Abnormal 113 1.0% 12 0.1% 4,917 45.2% 5,042
Unknown 1 0.0% 4 0.0% 1,723 15.8% 1,728
Total 119 1.1% 22 0.2% 10,743 98.7% 10,884
Yes 58 0.5% 15 0.1% 6,197 56.9% 6,270
No 61 0.6% 7 0.1% 4,546 41.8% 4,614
Total 119 1.1% 22 0.2% 10,743 98.7% 10,884
Eligible for sputum examination according to X Ray or symptoms
Yes 118 1.1% 21 0.2% 9,470 87.0% 9,609

Eligible for other
reasons 1 0.0% 1 0.0% 1,273 11.7% 1,275
Total 119 1.1% 22 0.2% 10,743 98.7% 10,884
Table 15 shows the final outcome against sex, age group, setting and region among those who
were eligible for sputum examination
T ABLE 15 C ASE O UTCOME

Case Outcome
Definite TB case Probable TB case Not TB case TOTAL
n % n % n % n
Sex
Male 71 0.7% 9 0.1% 4,457 41.0% 4,537
Female 48 0.4% 13 0.1% 6,286 57.8% 6,347
Total 119 1.1% 22 0.2% 10,743 98.7% 10,884
Age groups (years)
15–24 13 0.1% 3 0.0% 1,729 15.9% 1,745
25–34 19 0.2% 3 0.0% 2,087 19.2% 2,109
35–44 28 0.3% 6 0.1% 1,994 18.3% 2,028
45–54 24 0.2% 5 0.0% 1,637 15.0% 1,666
55–64 17 0.2% 1 0.0% 1,353 12.4% 1,371
65+ 18 0.2% 4 0.0% 1,943 17.9% 1,965
Total 119 1.1% 22 0.2% 10,743 98.7% 10,884
54
42
Case Outcome
Definite TB case Probable TB case Not TB case TOTAL
Stratum
Urban 54 0.5% 6 0.1% 4,174 38.3% 4,234
Rural 65 0.6% 16 0.1% 6,569 60.4% 6,641
Total 119 1.1% 22 0.2% 10,743 98.7% 10,884
Region
Erongo 11 0.1% 0 0.0% 549 5.0% 560
Hardap 7 0.1% 2 0.0% 604 5.5% 613
//Kharas 8 0.1% 1 0.0% 433 4.0% 442
Kavango East 8 0.1% 1 0.0% 559 5.1% 568
Kavango West 0 0.0% 0 0.0% 539 5.0% 539
Khomas 18 0.2% 1 0.0% 1,178 10.8% 1,197
Kunene 10 0.1% 1 0.0% 765 7.0% 776
Ohangwena 8 0.1% 4 0.0% 1,088 10.0% 1,100
Omaheke 7 0.1% 2 0.0% 606 5.6% 615
Omusati 7 0.1% 1 0.0% 1,056 9.7% 1,064
Oshana 10 0.1% 1 0.0% 996 9.2% 1,007
Oshikoto 10 0.1% 3 0.0% 722 6.6% 735
Otjozondjupa 12 0.1% 4 0.0% 834 7.7% 850
Zambezi 3 0.0% 1 0.0% 814 7.5% 818
TOTAL 119 1.1% 22 0.2% 10,743 98.7% 10,884
4.7 Estimating the TB prevalence in Namibia

4.7.1 Working case definition (clinical subgroup decision)
A TB case was defined as either having two positive bacteriological tests (Xpert MTB/RIF and
culture) or having one positive bacteriological test (of Xpert or culture) plus TB suggestive CXR
as read by central radiologist.
A total of 119 cases were confirmed as survey cases after review by the clinical management
subgroup, of which 115 fully met the survey case definition. The other four were declared TB
survey cases based on a single positive bacteriological test (of Xpert or culture) including an
abnormal CXR read by the radiologist although not necessarily consistent with TB, in addition to
other information. For all four, the radiologist had commented that the changes were probably
due to TB. The additional 22 cases that were considered to be probable TB cases as they did not
fit the survey case definition but were still treated as TB cases in health facilities.
Of the 119 survey TB cases, 71 (60%) were male; 65 (55%) were based in rural areas. The
number of cases per cluster ranged from zero to six (Figure 20).
55
43
F IGURE 20: N UMBER OF TB CASES PER CLUSTER
Prevalence was defined as the number of cases per 100 000 population and varied greatly
between the clusters. Figure 21 depicts the TB prevalence rate by cluster, which ranged from 0
per 100,000 to 1302 per 100,000. The mean cluster-level prevalence for this definition was 417.0
(95% CI; 348.4-499.).
F IGURE 21: C LUSTER VARIATION IN THE CLUSTER - LEVEL PULMONARY TB PREVALENCE RATE PER
100,000
4.7.2 Revised case definition
56
44
This was the first national prevalence survey to use field testing with Xpert MTB/RIF, but other
recent national surveys had also incorporated Xpert MTB/RIF in some way or other. While Xpert
MTB/RIF is clearly more sensitive than smear microscopy and is good at identifying TB bacteria,
it may detect fragments of non-active bacteria from old or healed TB. Following a multi-country
data analysis workshop for TB prevalence surveys, a revised case definition had to be considered
to account for the questionable specificity of Xpert MTB/RIF in detecting TB and the need to
standardize the varying case definitions used by different countries.
In the revised case definition, a TB case was one where the culture was positive (confirming m.
tuberculosis) or Xpert MTB/RIF was positive with additional supporting CXR determined as
compatible with active TB by the radiologist. This revised case definition yielded 123 cases (56
on the basis of culture and 67 on the basis of Xpert MTB/RIF and supporting CXR). As shown in
Table 16 the two definitions had a concordance of 99.9%, agreeing on 117 positive cases.
T ABLE 16: I NTERSECTION BETWEEN WORKING AND REVISED CASE DEFINITIONS
Revised definition
Working case definition No Yes Total
No 10,759 6 10,765
Yes 2 117 119
Total 10,761 123 10,884
The revised case definition was used for the purposes of determining the final prevalence
estimates. The cluster level prevalence ranged from 0 per 100,000 to 1344 per 100,000. The
mean cluster-level prevalence using the revised case definition was 431 per 100,000 (95% CI;
361.4-514.3).
F IGURE 22:C LUSTER LEVEL PREVALENCE USING THE REVISED CASE DEFINITION
57
45
4.7.3 Final prevalence estimates
Using the revised case definitions, four methods were used to estimate the prevalence of
bacteriologically confirmed TB among adults in Namibia.
The cluster level estimate determined the prevalence by way of averaging the different prevalence
in the 68 clusters while accounting for inter-cluster size variation by weighting. This method,
however is not very accurate as individuals are not treated independently (unit of analysis being
a cluster).
Model 1 estimate determined the prevalence at individual level using logistic regression and
robust standard errors (SE) to account for cluster variability, giving a figure of 433.7/100,000.
However, this method does not account for participants with missing outcome data. It assumes
that patients who were not eligible for sputum collection and those who did not have sputum
examination who have no pulmonary TB, and hence underestimates the true prevalence. It is,
nevertheless the simplest way to estimate prevalence among those participants who had sputum
examined.
Model 2 estimate determined the prevalence at individual level (444.3/100,000) using logistic
regression and robust standard errors but also with missing value multiple imputation (MI) for
survey non-participants as well as participants, including all individuals who were eligible for the
survey in the analysis. This method gives an estimate more applicable to the eligible population
as it accounts for missing information through imputation. The risk, however, is that the estimates
may be biased by the amount of missing data especially if the missingness is not at random.
Therefore, with large amounts of missing data, there is a risk of misleading estimates.
Model 3 was similar to Model 2 but with missing value imputation for those survey participants
who were eligible for sputum examination for whom sputum results were missing, and inverse
probability weighting (IPW) applied to all survey participants. This method had a much lower
fraction of missing information (FMI) than Model 2 (5.7% vs 19.7%). The smaller amount of
missing data that has to be imputed results in a lower risk of bias from multiple imputation and a
more accurate estimate. The final prevalence estimates are based on Model 3 analysis.
Using the Model 3 estimates, the prevalence of bacteriologically confirmed TB in Namibia in this
survey was 465.2 per 100,000 (95% CI; 340.1-590.3). The prevalence was significantly higher in
males at 643.3 per 100,000, which was 2.1 times that for females (304.4). The difference between
rural and urban prevalence was not significant.
In addition to the prevalence estimates using cluster level analysis and the three models, a
sensitivity analysis was performed which estimated the number of culture positive results had all
those eligible been tested. Among the 10,884 participants who were sputum eligible, 3,949
(36.3%) had sputum specimens tested by culture of which 56 (1.4%) were culture positive. The
sensitivity analysis yielded a result of 108 positive results, which would have given a culture-
based prevalence of 365.8 per 100,000. This result is close to the final result, with overlapping
95% confidence intervals.
The final prevalence of bacteriologically confirmed pulmonary TB disease in Namibia

determined by this survey is 465.2 per 100,000 (95% CI; 340.1-590.3).
58
46
Table 17 shows the prevalence estimates based on the four methods used. The Model 3 results
are considered final.
T ABLE 17: F INAL PREVALENCE ESTIMATES ( PER 100,000 POPULATION )

Cluster level Model 1: Robust Model 2: Robust SE Model 3: MI with
estimates (95% CI) standard error with MI (95% CI) IPW (95% CI)
(95% CI)
Overall point 431.0 (361.2-514.3) 433.7 (340.2-552.9) 444.3 (348.6-540.0) 465.2 (340.1-590.3)
prevalence
Setting
Urban 448.4 (359.4-609.8) 507.3 (313.3-701.3) 498.3 (332.1-664.6) 537.3 (321.6-753.1)
Rural 414.0 (319.3-513.7) 378.1 (270.0-486.3) 389.2 (294.9-483.5) 391.4 (276.9-506.0)
Sex
Male 583.0 (481.4-759.3) 613.4 (412.3-814.4) 615.6 (429.7-801.6) 643.4 (428.6-858.1)
Female 299.8 (227.2-397.8) 300.0 (191.6-408.4) 305.4 (195.8-415.0) 304.4 (196.2-412.7)
Age category
15-24 218.4 (113.1-311.1) 170.7 (52.4-288.9) 174.4 (62.2-286.7) 191.0 (52.8-329.2)
25-34 328.7 (185.0-454.7) 316.7 (135.6-497.7) 342.6 (190.8-494.5) 421.7 (162.5-680.9)
35-44 507.9 (387.0-801.4) 548.6 (309.3-787.8) 597.0 (297.4-896.6) 625.9 (311.1-940.8)
45-54 707.2 (473.6-1037.2) 750.4 (383.5-1117.4) 763.4 (429.5-1097.2) 879.2 (440.2-1318.1)
55-64 668.6 (427.2-1105.3) 713.6 (277.2-1150.1) 769.0 (340.9-1197.1) 705.6 (311.5-1099.7)
65 plus 827.0 (413.7-1042.3) 611.6 (261.7-961.4) 631.6 (298.0-965.3) 623.1 (271.9-974.3)
Regional variations in prevalence

This survey was not powered to statistically determine the differences in prevalence of TB
between the regions. However, regional results are shown below, based on Model 3 estimations.
These should be interpreted within the context of the 95% confidence intervals. Of note are the
wide and often overlapping confidence intervals, presenting difficulties in making any sweeping
conclusions about regional variations in prevalence rates.
59
47
T ABLE 18: R EGIONAL VARIATIONS IN TB PREVALENCE RATES
Prevalence per 95% confidence interval 95% confidence interval
Region
100,000 lower limit per 100,000 upper limit per 100,000
Erongo 742 398 1086
Hardap 952 0* 2113
//Kharas 745 322 1168
Kavango East 373 0* 757
Kavango West 7# 0* 23
Khomas 523 188 859
Kunene 746 535 957
Ohangwena 319 0* 679
Omaheke 866 268 1464
Omusati 192 0* 384
Oshana 368 221 516
Oshikoto 336 49 623
Otjozondjupa 588 0* 1424
Zambezi 225 81 370
Namibia 465 340 590
*lower limit below zero
#No cases were actually found in Kavango West, so this result is only from statistical assumptions
60
48
4.8 HIV Results
4.8.1 HIV status
Of the 29,495 participants, 21,795 (73.9%) reported having been tested previously for HIV.
• 21,408 were willing to share results
o 3,132 (14.6%; 95% CI 14.2 - 15.1) were HIV positive
o 3,074 (82%) were on ARV treatment
Of the participants, 11,256 (38.2%) were tested for HIV on site.

• 259 were HIV positive
• 245 were referred to local support team for HIV management
• 13 who were HIV positive declined to be referred, while one was lost to follow up.
In all, 24,641 (83.5%) of the participants knew their status by end of the survey.
• 3,338 (13.5%; 95%CI 13.1 – 14.0) were HIV positive
Of the 119 survey TB cases, HIV results were known for 99 (83.2%) and 18 (18.2%) were positive.
F IGURE 23: K NOW N HIV STATUS
61
49
4.9 Other findings
4.9.1 Housing
Out of the 29,495 participants, 17,317 (58.7%) were in the rural areas. Among the 119 survey
TB cases, 65 (54.6%) were in the rural areas.
• 13,044 (44.2%) of participants resided in traditional rural dwellings compared to 37.8% of
survey TB cases
• 8,207 (27.8%) participants resided in shacks compared to 37.8% of survey TB cases
• 6,419 (21.8%) of participants resided in detached houses compared to 17.6% of survey
TB cases
F IGURE 24: D ISTRIBUTION OF PARTICIPANTS ACROSS RURAL AND URBAN SETTING
F IGURE 25: T YPE OF HOUSING USED BY PARTICIPANTS VERSUS TB CASES
62
50
4.9.2 Sanitation
There were 17,061 (57.8%) participants with access to piped water supply compared to 47.1% of
survey TB cases.
• 14,852 (50.4%) of participants had no access to toilet facilities, as 51.3% of TB cases
• 9,746 (33.0%) of participants had access to some form of flush toilet, as did (29.4%) of TB
cases.
F IGURE 26: S ANITATION BY ACCESS TO PIPED WATER
F IGURE 27: S ANITATION BY TYPE OF TOILET
63
51
4.9.3 Electricity and household fuel
Household electricity was available to 11,534 (39.1%) of participants and 31.9% of TB cases. This
implies that majority of participants did not have access to electricity.
F IGURE 28: ACCESS TO ELECTRICITY
The majority of participants, amounting to 18,978 (64.3%) and 68.1% of TB cases used wood as
the main source of fuel for cooking. Electricity for cooking was used by 8,829 (29%) participants
compared to 24.4% of TB cases. For household heating 15,760 (53.4%) of participants and 48.7%
of TB cases used wood. Use of electricity for household heating was 22.1% participants and
22.7% of TB cases.
F IGURE 29: M AIN HEATING FUEL
64
52
F IGURE 30: M AIN COOKING FUEL
4.9.4 Source of household income

Of the participants, 13,739 (46.6%) relied on salary as the main source of income as did 40.3%
of TB cases.
• 6,290 (21.3%) lived off pension payments as did 20.2% of the TB cases, while 11.4% of
participants and 14.3% of cases relied on farming.
• In 4,158 (14.1%) of participants’ households, there was no one participating in income
generating activities as in 17.6% of the TB cases’ households.
• 4,015 (13.6%) of participants and 16.0% of cases reported that they have experienced hunger
due to absolute lack of food at least once in the past three months.
4.9.5 Current and Previous TB Treatment

Of the 29,495 participants, 3,030 (10.3%) had been treated before for TB, whereas 27 (22.7%) of
TB cases had been treated for TB before.
In all, 139 (0.5%) survey participants were already on TB treatment while participating in the
survey; only five of these participants satisfied the survey case definition and therefore were
survey TB cases.
Consequently, and of significant note, 95.8% of the survey TB cases were not on treatment when
they came to participate in the survey.
65
53
F IGURE 31: P ARTICIPANTS WHO WERE ON TB T REATMENT BEFORE
F IGURE 32: P ARTICIPANTS CURRENTLY ON TB TREATMENT
4.10 Presumptive TB Cases
There were 23,224 (78%) survey participants who did not report any symptoms suggestive of TB,
the remaining 6270 (21%) participants were found to have symptoms suggestive of TB
(presumptive TB cases).
• Of these, 3571 (57%) males and 2699 (43%) female survey participants had symptoms
suggestive of TB.
• Of the presumptive TB cases, 3632 (58.0%) resided in urban areas versus the 2638 (42.0%)
who were found in rural areas.
66
54
F IGURE 33: P RESUMPTIVE CASES BY SEX
F IGURE 34: P RESUMPTIVE CASES BY SETTING ( URBAN / RURAL )
• The majority, amounting to 4181 (66.6%) of the presumptive cases reported to have no
formal employment.
67
55
F IGURE 35: P RESUMPTIVE TB CASES BY OCCUPATION
• 2736 (43.6%) of the presumptive cases had a salary, while the source of income for the
other 56.2% was from various means such as farming, grants, business and retirement
funds.
F IGURE 36: P RESUMPTIVE TB CASES BY SOURCE OF INCOME
Among the 6270 presumptive TB cases, 4448 (71.0%) had some form of education;
• 1,456 (23.2%) reported to have either had some or completed primary school education.
• 2,025 (32.2) reported to have either had some or completed secondary school education.
• Only 234 (3.73%) of the presumptive TB cases had completed tertiary education.
68
56
• 1,490 (23.7%) of the cases reported not to have any form of education, while 60 (0.95%) did
not report their educational level.
F IGURE 37: P RESUMPTIVE TB CASES BY EDUCATION
F IGURE 38: H EALTH SEEKING BEHAVIOR OF PEOPLE WITH PRESUMPTIVE OR CONFIRMED TB
69
57
5. DISCUSSION
5.1 Survey census
All 68 (100%) clusters that were sampled in all regions participated in the survey. This added to
the overall representativeness of the survey. However, there were significant inter-cluster
variations in the enumerated population, suggesting that cluster population estimates may not
have been as uniform as intended. This was corrected at analysis stage with weighting and basing
the final prevalence estimate on a model that included inverse probability weighting. In addition,
limiting the prevalence rate to a national estimate (and not making subnational estimates) limited
biases that may have resulted from cluster selection. The age-sex distribution of the enumerated
population in the survey was roughly similar to that projected by NSA in 2016, based on the
Namibia Population Census, 2011 adding to the validity of the survey.
Since the survey targeted adults, children aged 0-14 years who constituted about a third of the
population in the households were not included for screening in the survey. In the projected
populations for 2017, children made up 36.5% of the population, yet they constituted 32.6% of
the enumerated population. This difference was statistically significant and may have been as a
result of underreporting of children in the survey enumeration, possibly because household
members and enumeration staff would have understood that this survey was not for children.
5.2 Survey participation

The survey achieved a participation of 86.8% relative to the desired sample size of 34,000, also
increasing the validity of the survey. The sample size had been calculated on the assumption of
an 80% participation. However, true participation rates for TB prevalence surveys are calculated
relative to the population of eligible individuals, which in this case was 38,353, thus the
participation rate of 76.9% is considered as having been achieved. This was slightly lower than
expected and was a result of significantly low participation in urban and affluent areas, where the
population was largely uninterested. In many instances, members of the population were quoted
as citing lack of incentives, having their own private doctors (who could provide TB testing if
required) and more worryingly, TB not being a problem in their area as reasons for their
disinterest. There were also many examples of enumerating teams not even gaining access to
private households in these areas. This occured despite extensive mobilization, awareness
campaigns and mop up activities performed by survey staff. At the time of the household
enumeration visits, some eligible participants were not present; consequently, the survey team
issued appointment cards to the heads of households with an assumption that the absent, but
eligible, participants would be informed of the survey. This may have contributed to some of the
eligible participants not visiting the cluster sites. Participation rates were also much higher in
females than males and this is true in other Namibian surveys. Males are generally breadwinners
in the majority of Namibian households and may not have been available to participate due to
economic activities. In addition, men are generally less likely to participate in health-related
campaigns, owing to differences in health-seeking behavior between adult males and women.
HIV related stigma may have impacted on participation in some areas, as some community
members were quoted conflating TB and HIV testing and stating their discomfort with HIV as a
reason for their reluctance. This was particularly true at the beginning of the survey, until survey
70
58
teams were advised not to openly advertise the presence of HIV testing at the cluster sites and
only offering the HIV test as an opt-in during screening rather than an opt-out. In other instances,
poor participation was noted in areas where the X-ray machine operations were interrupted (due
to technical difficulties), suggesting, as had been suspected before, that having a CXR was indeed
an incentive to participation in those areas. In an interesting development, collection of sputum
for examination was said to be associated with occultism and witchcraft by some communities in
Zambezi Region and may have negatively influenced participation. Overall participation improved
with time as field staff became more confident with survey procedures and the population became
more sensitized through various IEC channels.
Once at the cluster sites, relatively few eligible individuals opted out, with only 297 declining to
give consent, 28 just disappearing after giving consent and one skipping the symptom screening
station to proceed directly to CXR. The use of digital technology (NAMTBCollect) with integrated
form and a queue management system for monitoring the flow of participants through the different
stations minimized the loss of participants between stations. Retention between registration and
symptom screening was 99.99% and retention between symptom screening and the CXR station
was 99.93%. In addition, 99.98% (27,746/27,751) of participants with a CXR had images read by
a medical officer after they were taken while 99.99% (27,747/27,751) of participants had CXR
images read by CAD4TB. 99.98% (3967/3973) of the CXR images read by the MO as abnormal
were re-read remotely by a central radiologist. This was testament to the efficiency of digitalizing
the survey.
5.3 HIV
Because Namibia is a high TB/HIV burden country, it was imperative that this survey includes HIV
testing in the algorithm. The approach finally adopted was opt-in due to realization that stigma
could undercut the overall survey participation. Only 38% of survey participants opted for the HIV
test, of which 2.6% were positive. This is at odds with other prevalence estimates, suggesting a
selection bias among those tested (low HIV risk participants going ahead with the HIV test).
However, if self-reported results are taken into consideration, the overall HIV prevalence estimate
is 13.5% (95%CI:13.1 – 14.0), which is more realistic. In fact, the Namibia Population-based HIV
Impact Assessment (NAMPHIA) conducted in 2017 (around the same time as the TB prevalence
survey) determined the national HIV prevalence to be 12.6% (95%CI: 11.7-13.5) among adults
15 to 64 years of age. The 95% confidence intervals overlap in both surveys, suggesting similarity
of findings. Almost three quarters of participants reported having been tested for HIV previously,
suggesting a relatively high penetration of HIV testing availability in the community. This however
is lower than the desired target of 90%. The 82% of the self-reported who were on ART is also
lower than the finding in NAMPHIA (96.4%).
5.4 Chest X-ray

This survey provided an opportunity to use the CAD4TB software in the field screening activities.
Even though the MO was blinded to the CAD4TB scores, there was 89.9% concordance for
distinguishing between abnormal and normal CXR images at CAD4TB = 60 threshold. Since
sputum eligibility was determined by CXR abnormality from either the MO or CAD4TB reading,
this combination ensured high sensitivity, minimizing missed abnormalities. In addition, medical
officers were recommended to “over-read” abnormalities i.e. err on the side of there being
71
59
abnormalities even when unsure, in order to ensure this high sensitivity. However, participants
aged less than 16 years did not benefit from this dual CXR reading as the CAD4TB system would
routinely assign a negative two (-2) score to all those under 16 years due to an inbuilt error
algorithm. This affected 367 (1.3%) of participants. Also, 1,744 (6%) participants did not have a
CXR performed. The reasons for this were non-consenting to CXR, equipment failure, inability to
stand for PA CXR, pregnancy or for other reasons. Equipment failure was often unpredictable
and affected 692 (39%) of those who did not have a CXR performed. However, this was rare as
it only occurred in nine clusters, with the worst affected being Salambala in Zambezi, where 492
participants could not have a CXR performed and all were thus eligible for sputum examination.
The radiologist re-reading at central level was considered the gold standard for this survey. Even
though a low concordance of 65.5% was observed between the field and central reading, this
should not be viewed as a problem. The suggested over-reading by the field MO and the
sensitivity of CAD4TB allowed more cases to be picked up in the field at the cost of specificity. A
sensitivity rate of 98.6% was confirmed between field versus central radiologist readings, with
only 1.4% of the TB compatible abnormal CXR being missed in the field.
5.5 Sputum testing

Due to the automated algorithm within the NAMTBCollect, 100% of participants were assigned
the correct sputum eligibility. In clusters were CXR machines were not working, all participants
were deemed sputum eligible. The automation also ensured that 9.6% of those not eligible for
sputum collection had an in-depth interview, which was a positive achievement considering the
intention was to randomly assign 10%.
Of the participants eligible to provide sputum specimen, 1,422 did not provide a sample as some
participants opted out at this stage or had insufficient sputum volumes. It was not always possible
to verify these reasons in the field or during analysis. A significant number of participants (270)
inexplicably submitted only the second specimen for processing. This may have been due to mix-
up of documentation at the field sites. This observation particularly affected one team, where the
laboratory workers had a tendency to write manually on paper, then transferring information to
the electronic platform later during the day, as opposed to real-time electronic capture. The 1,160
participants who could only provide the first specimen and not the second were reportedly
unwilling to wait at the site to provide the second specimen. In this survey, the majority of the
positive cases were detected using the field GeneXpert testing.
Only 78.2% of those participants who submitted a second sputum specimen had successful
testing with culture and/or Xpert. This relatively low rate was as a result of high rejection rate and
other logistical challenges in the central laboratory. Non-compliance to laboratory SOPs
especially at the beginning of the survey resulted in inadequate specimens and/or empty bottles
reaching the laboratory. The use of parafilm on all specimen collection jars was not consistently
observed due to procurement delays. This contributed to specimen leakages and insufficient
volumes observed at the central laboratory. An unexpected limitation of the capacity to perform
culture at the central laboratory resulted in delays in processing specimens, thus leading to
potential loss of viability of the stored specimens. A decision was made late into the survey to
subject specimens that had been stored for longer than seven days to molecular testing with Xpert
MTB/RIF given its high sensitivity in detecting MTB bacilli. Although this decision may seem to
72
60
have threatened the overall sensitivity, the fact that many of the bacilli stored may had already
lost viability meant that this was possibly the only way to salvage the sensitivity of the survey.
However, the specificity of the procedures may have been threatened, given the false positive
tendency of Xpert MTB/RIF in some previously treated patients.
The performance of central Xpert MTB/RIF on some 21% of the second sputum specimens that
were centrally tested did not significantly affect the yield of central testing. The positivity rate
between mycobacteria culture and Xpert MTB/RIF among those with a positive field Xpert result
was 63.1% (41/65) and 76.5% (13/17) respectively, which was not statistically different.
Not all the specimens were subjected to direct microscopy (DM) at central laboratory because
most specimens tested with Xpert/RIF did not have routine DM performed. Only after the survey
staff requested DM were the specimens subjected to both Xpert MTB/Rif and DM. Of the 74
bacteriological confirmed cases at the central laboratory, 25 had positive smear results.
To determine whether the inability to perform cultures on the majority of eligible participants
prejudiced the survey, a sensitivity analysis was performed. This analysis estimated the number
of positive cultures there would have been had all those eligible for sputum testing submitted
specimens for culture completion. The principal reason cultures were not performed was due to
a failure to produce a second sputum after the first sputum was used for the onsite testing using
GeneXpert. It is, therefore, likely that those that did not have sputum specimens tested for TB
have a lower likelihood of having pulmonary TB. Without pulmonary TB, it would have a more
difficult to produce a viable specimen. This sensitivity analysis applied the rate of TB culture
positive among those with culture done by strata of GeneXpert results. Thus, it assumed that the
proportion of specimens that were culture positive given a GeneXpert result is the same for those
with specimens available for culture as those without. The resulting number of positive cultures
we would expect to have if all cultures were performed on all sputum eligible participants is 108.
This number is very close to the total number of cases identified using the case definition.
5.6 TB Prevalence
The prevalence of bacteriologically confirmed pulmonary TB in participants ≥ 15 years in Namibia
is 465.2 per 100 000 (95% CI, 340 - 590). Due to the strict case definition, several participants
with clinically treatable TB were considered probable cases and were excluded, although they
received care in health facilities. The majority of these probable cases had only one
bacteriological result with no additional confirmatory results available. This could mean that the
prevalence of TB using the less strict everyday case definition is more than the estimate provided
in this survey.
Although more females participated, higher TB prevalence was observed in males. Men are more
than twice as likely to have bacteriologically confirmed TB than women (p<0,01; OR 2.1, 95% CI
1.4 -3.0). This is supported by findings in many low and middle-income countries, where the
pooled male to female ratio of bacteriologically confirmed TB from 56 studies was 2.2 (95% CI;
1.92-2.54).(Horton et al., 2016) These results point towards a TB epidemic that disproportionately
affects men, rendering men a high-risk group. In addition, males remain infectious for longer and
are primary drivers of TB as most TB cases (in children, women and other men) are as a result
of infection by a man.(Dodd et al., 2015) There was no statistically significant difference between
73
61
prevalence found in urban versus rural areas. In the final analysis, age-group differentiation did
not seem to be a statistically significant factor in determining the prevalence of TB. Regional
differences are not presented as the survey aimed to estimate the prevalence at national level.
The prevalence of TB in Namibia is high, and it is within the estimates previously made by the
World Health Organisation. This means that the country continues to be a high TB-burden
country. At the time of releasing this report, similar surveys are underway in neighbouring
Botswana, South Africa, Eswatini, Lesotho and Mozambique. The results will give a more
complete picture of the prevalence of TB in the Southern Africa region.
T ABLE 19: P REVALENCE OF TB AS DETERMINED BY NATIONWIDE SURVEYS IN SELECTED COUNTRIES
Country Prevalence of TB (per 95% confidence Year of
100,0000) intervals estimate
Namibia 465.2 340 - 590 2018
Zambia 638 502 - 774 2013

Zimbabwe 344 270 - 420 2014
Tanzania 293 228 - 358 2012
Kenya 558 455 - 667 2014
Uganda 401 292 - 509 2015
Nigeria 318 225-412 2012
Gambia 212 152 - 272 2013
Ethiopia 277 208 - 347 2011
Myanmar 437 358 - 533 2010
Viet Nam 307 249 - 366 2007
Pakistan 321 229 - 373 2010
F IGURE 39: S TATUS OF TB PREVALENCE SURVEYS IN 2018
74
62
5.7 Limitations of the survey
• The first limitation of this survey was that it was conducted among adults, thus excluding
children. Although the reasons for this are justified, and related to the ease with which
bacteriologically positive TB can be demonstrated in adults, this approach may perpetuate
the gap in understanding the burden of childhood TB. Therefore, the findings from this
survey may not be extrapolated to children, unless certain assumptions are made.
• The survey, by its nature, did not determine the burden of bacteriologically negative and
extrapulmonary TB. It is known that a significant proportion of TB cases are
extrapulmonary and bacteriologically negative, but these cases are diagnosed clinically
and are usually difficult to prove. Therefore, estimation of the true burden of TB (all forms)
will have to apply certain assumptions regarding extrapulmonary and bacteriologically
negative TB.
• This survey was not powered to determine prevalence of TB at subnational level, and
therefore the results may not be used to make conclusions on differences in TB prevalence
rates between regions or other geographical areas.
• A small proportion of the Namibian population was sampled in this survey and, although
the sample is thought to be largely representative, there could be findings that apply more
to the sampled group than the whole population. An example could be the low participation
rate in the affluent communities, skewing other findings towards the less affluent, such as
income, housing, sanitation and even the prevalence of symptoms and TB.
• This survey only tested a third of participants for HIV. That means, for the large part, HIV
results were self-reported, and that can be associated with inaccurate findings.
• Only 36% of eligible participants had a successful culture preformed; this may raise
pertinent questions about the survey possibly missing cases. The sensitivity analysis
reported earlier, goes some way to address this concern.
• Operational limitations including bureaucratic and procurement delays resulted in rushing
of survey procedures at times, and logistical interruptions in the field at others.
75
63
6. PROGRAMMATIC IMPLICATIONS AND
RECOMMENDATIONS
Based on the survey results, the following recommendations are made for future strategic
planning and programmatic implementation.
• Since children aged 0-14 years were excluded from eligible participants due to the category
used (15 years and above) to define adults, the NTLP and MoHSS should consider alternative
ways of estimating the burden of disease among children.
• Given that males generally have a higher incidence of TB than females, yet are less likely to
participate in public campaigns as demonstrated in this survey, innovative strategies should
be introduced to specifically target males as a key population for measuring burden of disease,
particularly the young adult males.
• The survey demonstrated that males do indeed have higher prevalence of TB than females,
which is consistent with programmatic data and other surveys. Therefore, the MoHSS should
devise interventions targeted at reducing the risk of TB, detecting and treating TB in the male
population.
• The very high proportion of survey TB cases not on treatment (95.8%) is only a tip of the
iceberg, suggesting that many TB patients in Namibia are undiagnosed and untreated.
Therefore, the country should invest in strategies to find and treat missing TB patients.
• The difficulties experienced in recruiting participants from urban and affluent areas appeared
related to certain misconceptions about TB and HIV, something which was supported by
anecdotal reports from community statements. Health education campaigns should be
devised that target particularly these communities, such as by using social media platforms.
Knowledge, attitudes and practice assessments for these communities may further inform the
interventions.
• Given the high (89.9%) concordance between CAD4TB and MO’s reading of CXR images in
the field, the MoHSS may consider using CAD4TB as a more cost-effective method for TB
screening of CXRs whenever a TB survey or similar campaign is being done. In addition, long
term application of CAD4TB in high throughput screening settings such as among PLHIV and
staff screening should be considered. The scale-up of direct digital radiography use with tele-
radiology will reduce turnaround times, facilitate easier reading of CXRs, easier sharing of
images, easier storage (minimizing space), lower workload and cut costs in the medium to
long term.
• Since the majority of positive cases were detected in the field through the use of field Xpert,
the first time such a venture has been implemented in Namibia, the MoHSS should introduce
the use of field Xpert testing for active case finding programmes and consider installing some
GeneXpert equipment in some of its mobile outreach clinic vans. Furthermore, where logistical
challenges (transport, storage, testing capacity) may impact on the quality of specimens for
mycobacterial cultures for TB, resorting to molecular testing with Xpert MTB/Rif should be
considered as an alternative.
• The efficiency and time-saving demonstrated by using integrated digital system with real time
monitoring of procedures makes a case for all future surveys and routine practice to adopt
similar technology. The MoHSS should strongly consider real time mobile data collection
systems in all future survey as opposed to paper-based systems.
76
64
7. ANNEXURES
7.1 Annex A: MoHSS ethics approval letter
77
65
78
66
7.2 Annex B: Information sheet for consent
Participant information for the Namibia Tuberculosis Disease Prevalence Survey
Dear participant:
My name is ……………….………………... from the Ministry of Health and Social Services.
You are invited to take part in a survey to find out how many people have tuberculosis (TB) in
Namibia. You are living in the area that has been selected to participate in the survey, therefore
you and all other adults in this area, have been selected. If you agree to participate in the survey,
the following procedure will be taken:
We will ask you to come to a survey station, located at

……………………………………………………, where our staff will ask you few questions
regarding symptoms for TB and perform an X-ray. The X-Ray will show if you have any lung
disorder. If you do not have any symptoms and there are no abnormalities on the X-Ray, then you
will be free to leave the station.
If you have specific symptoms and/or chest X-Ray abnormality, a nurse who will also ask you to
provide two sputum samples will interview you. These sputum samples will only be used for the
TB tests in the laboratory. If TB germs are found in the sputum, you will be given treatment for
TB. If you have other problems, a doctor who is part of the team will advise you accordingly and
may refer you to receive further attention.
If you are interested, we will also be offering HIV testing at the survey station. If you willing to be
tested, and are found to be HIV positive, you will be referred for appropriate care and free
treatment. You do not have to agree to the HIV testing to participate in the survey. You can still
participate in the tuberculosis survey without testing for HIV.
The benefit for you of participating is that you will receive assistance for disease conditions you
might have. Your participation will also provide information that will help the Ministry of Health and
Social Services to improve health services for everyone in the country.
The risks of participation are minimal. You will require a few hours to be at the survey station for
the interviews and examination. The x-Ray procedure is generally safe and precautions will be
taken to prevent potential harm to some cells in your body. You may feel some discomfort when
providing sputum samples, but our staff will try to make the process as easy as possible.
All results will be kept confidential and your name will only be used to assist us to contact you
regarding the care you might need. Participation in this survey is voluntary. If you choose not to
participate, it will not affect in any way the provision of health services to you. You can withdraw
yourself from the survey at any moment.
We will highly appreciate your participation in the survey.
If you have any question please contact the Principal Investigator at this telephone number:
79
67
7.4 Annex C: Participant Consent F orm
I have read/understood the Information Sheet concerning the Namibia Tuberculosis Disease
Prevalence Survey.
I have had the opportunity to ask questions about the survey and the questions that I have asked
have been answered to my satisfaction.
I now understand what will be required of me and what procedures I will have to go through during
this survey.
I understand that I may withdraw from this survey at any time without giving a reason and
withdrawal will not affect my usual care and treatment.
I consent voluntarily to participate in this survey.
Signature / thumb impression: …………………………... Date: ………………………….
Name………………………. of………………………. participant………………………….
Witness Signature / thumb impression: …………….……... Date: …………………………...
Name……………………………of…….………………witness: ……………………………...
FOR INDIVIDUALS AGED 15 TO 18 YEARS OLD, USE CONSENT BELOW:
Ask consent from the parent or legal guardian identified as responsible for the individual
before asking the adolescent for his/her consent.
Enrol into survey only if BOTH the parent (or guardian) and the adolescent consent to
participating.
Signature / thumb impression (participant <18 years) ………………………………... Date:

………………………….
Name………………………. of………………………. participant…………………………….
Parent or Legal Guardian of Signature / thumb impression: ……………...Date: ……………………
Name……………………………of…….………………witness: ……………………………...
80
68
7.5 Annex D: Namibia TB DPS: Enumeration/ Household Listing Form 01 (F01)
1 Date of Enumeration
2 Team
3 Enumerator code
4 Region
5 District Link to region
6 Constituency Link to region

7 Cluster number Auto fill cluster number where there is only one cluster per constituency; Link to
constituency
8 Type of location Urban-Formal Urban-Informal Rural Commercial Rural Communal
9 Common name of location
10 GPS coordinates for household Latitude Longitude
Household number
Household interviewed? Yes No (refuse) If no close form and proceed to net household
11 Household Address Street name, Street number, Erf number
12
13
14 Surname of Person being Interviewed
15 First Name of Person being Interviewed
16 Is this the person being interviewed?
17 Are you the head of this household? Yes NO If yes, skip to question 19
18 If not, how are you Spouse Son Daughter Son in- Daughter-in- Father Mother Other Domestic Other Non- Don't Know
related to the head Law Law Relative Worker relative
of household?
Main language Afrikaans Damara English Herero Kwangali Lozi Oshiwambo San Other (specify)
spoken in the nama
household
19 Total number of individuals in this household Determines how many household members can be entered in questions 22-32 (inclusive of respondent)
(including respondent)
20 Total number of adults 15 years and older (including respondent)
69
81
21 Total number of children 14 years and younger
Section: Individual Household members details
List the names of household members as follows (including person being interviewed) Based on number selected in question 19
22 23 24 25 26 27 28 29 30 31 32 33
Surnam First Name of What is the What is Is (name) How Contact Is Ability to If not, Appointment If yes, Date of Time of appointment
e of Person being Date of birth the Age Male or long phone (name) travel to specify card issued Appointment appointment
Person Interviewed of (Name) (if (Name) Female has number an Adult cluster reason card barcode
being known) (name) of (>15y) or site for
Intervie M or F been (name) a child inability
wed living in (<15y)? (Yes) or to travel
this (No) to site
house
hold?
Start with the next person if household has more than one member, in the Additional form for individual household members
Validation check for Total adults Calculate total number of adults based on question 27, compare to total given in question 20; if numbers different,
prompt enumerator to verify question 20
Calculated number of children Calculate total number of children based on question 27, compare to total given in question 21; if numbers
Validation check for Total children different, prompt enumerator to verify question 21
Household Characteristics
Does your household have the follow amenities?
34 Electricity? Yes NO
35 Television? Yes NO
36 Fixed telephone line? Yes NO
37 Computer/laptop? Yes NO
38 Motor vehicle / car? Yes NO
70 82
39 Access to internet Yes NO
40 Radio/CD cassette player? Yes NO
41 Piped (running) water Yes NO
42 What is the Main Piped into Piped to Public tap Tube Protecte Protected Rainwater Bott Unprotected well Unprotected Tanker Other
source of dwelling yard/plot /standpipe well or d well spring led spring truck /cart
drinking water borehol wate with open
e r drum
43 What is the Main Flush/pour Flush/pour Flush/pour Ventilated Pit latrine Composting No facility /bush Bucket Hanging toilet/ Other
type of toilet flush to piped flush to flush to pit improved pit with slab toilet /field hanging latrine
facilities sewer septic tank latrine (VIP) latrine
system
44 Is main toilet facilities shared or not shared? Shared Not shared
45 Main type of fuel Electricity LPG/ natural gas/ Kerosene Charco Wood Animal Oth No food cooked in If No food cooked in household, skip to
used for cooking? biogas al dung er, household question 47
46 Where is cooking taking In the house In a separate building Outdoors No food cooked in the household Other
place for the household?
47 What is the Main type of fuel used for keeping Nothing Electricity Liquefied Kerosene/ Charcoal Wood Other
warm inside the house during winter petroleum gas paraffin
48 What is the main Farming/ Business Wages and Old-age Cash Retirement Orphan' Disability Other
household source of agriculture activities non- salaries pension remittance fund s grant grant
income farming
49 How many members of this household participated in economic activities (including any Number must be less than or equal to total number of household
paid work) in the last 3 months members
50 What is the average total household income per month?
51 In the last 3 months, did it happen even once that you or any member of the household experienced hunger because there was Yes NO
no food to eat?
52 Did your household have to rely Relief food (free food Reducing number Borrowing cash (cash loan Sale of Sending Other
on any of the following in the last from government and of meals or food - borrowing with interest, assets household
18 months? other bodies) in-take borrowing from friends, members away
etc.),
53 What kind of Detached Semi- Apartment/ flat Guest Part commercial/ Traditional Mobile home Single Improvised Other
house/dwelling do house detached/ flat industrial dwelling (caravan, tent) quarte housing unit
you live in? townhouse r (shack)
54 How many sleeping rooms does your household have?
55 Total number of appointment cards issued Count the number of Appointment cards issued and compare with number of adults
71
7.6 Annex E: Namibia TB DPS: Registration Form 5 (F5)
56 Interview date
57 Team
58 Data clerk code
59 Participant barcode Auto populate Scan the participant barcode at the back of the Appointment card
Check if there are other household members that were also enumerated and ask the participant where they are and when they will visit the cluster site and kindly request
the participant to remind other members to visit the site
60 Participant surname Auto populate
61 Participant first names Auto populate
62 Gender/sex Auto populate
63 Date of birth Auto populate
64 Age Auto populate
65 Do any of these fields need correcting? Yes No
If any field need correction kindly proceed and correct field as per participants advise
66 Correct Participant surname
67 Correct Participant first names
68 Correct Gender/sex Male Female
69 Correct Date of birth Limit year range from 1907 to 2018
70 Correct Age Limit range from 0 to 110
71 Is the Consent form signed? Yes No If no, prompt that patients can be offered an HIV test but will not have study bar code and will not be registered in
survey data
72 Is this the correct appointment Yes No Yes if enumeration question 33 equals registration question 56; No
date? if enumeration question 33 not equal to registration question 56
72
84
73 Interview date
74 Team
75 Interviewer code
76 Participant barcode
77 Participant surname
78 Participant first names
79 Gender/sex Male Female
80 Age This field will Auto populate kindly verify with participant if correct, if not correct send back to Registration
81 Are you coughing? Yes No If no, skip to question 83
82 If yes, for how long? Less than 1 week 1 week 2 weeks Greater than 2 weeks Unknown
83 Are you having a fever? (feeling abnormally hot and/or cold) Yes No If no, skip to question 85
85 Have you recently lost weight unintentionally? Yes No If no, skip to question 87
87 Are you having drenching night sweats? Yes No If no, skip to question 89
90 Are you on TB treatment right now? Yes No
91 Have you been on treatment for TB before? Yes No If no, skip to question 93
92 If Yes, how many times? Must be greater than 0
7.7 Annex F: Namibia TB DPS: Symptom interview Form 6 (F6)
73
93 Have you ever been tested for HIV? Yes No If no, skip to question 99
94 When were your last tested done? <3 months 3-6 months 1-2 years 3 and more years
95 If Yes, are you willing to share your results? Yes No If no, skip to question 99
96 What was your last HIV result? Positive Negative Unknown If negative or unknown, skip to question 99
97 If positive, are you receiving treatment for HIV? Yes No If yes, form is complete
98 If not, would you like to be referred to receive treatment for HIV Yes NO Flag to refer to HIV section after CXR and If answered no, form is complete
lab procedures
99 Would you like to be tested for HIV today Yes NO If Patient is willing to get tested. Flag to refer to HIV section after CXR and Form is complete
lab procedures
86
74
7.8 Annex G: Namibia TB DPS: Chest X-Ray Form 7 (F7)
100 Interview date
102 Team
103 Radiographer code
106 Gender/sex Male Female This field will Auto populate kindly verify with participant if correct, if not correct send back to
Registration
107 Age This field will Auto populate kindly verify with participant if correct, if not correct send
back to Registration
108 Is participant female of child Yes No If no, skip to Yes, if age is between 15 and 49 (inclusive) and sex
bearing age? question 113 is female; No if otherwise
109 Do you know your last date of menstrual period? Yes No If no, skip to question 111
110 What was the date of If date is more than 30 days ago or unknown, go to question 111 Limit year range from 1920
last menstrual period to 2018
If date is 30 days ago or less, skip to question 113;
111 Can you please provide me with a urine Test performed Test refused Only, if not known or If test is declined, skip to
sample for a pregnancy test more than 30 days ago question 113
112 If performed, what is the result of pregnancy test Positive Negative Undetermined
113 Is this participant eligible Yes NO No if question 111 is test refused or if question 112 is If no, skip to question
for CXR? positive or undetermined; Yes if otherwise 115
75
114 Do you consent to having a chest X-ray performed on you? Yes NO If no then Form is complete
115 CXR performed Ye N No if question 113 is no or if question 114 is no If yes then Form is complete, if No proceed
s O to 116
116 If not, why Pregnant Cannot Refused to Equipment Other If question 112 is positive or Form is complete
CXR was not stand for P- consent for failure undetermined, then set to "Pregnant";
performed A X-ray an X-ray if question 114 is no, then set to
"Refused to consent for an X-ray"
76
7.9 Annex H: Namibia TB DPS: Medical Officer Form 8 (F8)
117 Date
118 Team
119 Medical officer code
121 Participant gender/sex Male Female
122 Participant age This field will Auto populate kindly verify with participant if correct, if not correct send back to Registration
123 CXR performed Yes NO If no, prompt that participant data should not be at this station (e.g., no CXR to read)
124 CXR screening result Normal Abnormal TB-suspect Abnormal-other Unknown/not interpretable
290 CXR pattern Normal Consolidatio Cavitation Nodules Mass Reticular Fibro Calcification Pleural Paratracheal Only show if "Abnormal TB
Right lung field n opacities sis thickening, and/or mediastinal suspect" or "Abnormal -other" is
& pleura Pleural lymph node selected in question 124.
effusion enlargement, If normal is selected here, disable
Other all options
291 CXR pattern Normal Consolidatio Cavitation Nodules Mass Reticular Fibro Calcification Pleural Paratracheal Only show if "Abnormal TB
Left lung field n opacities sis thickening, and/or mediastinal suspect" or "Abnormal -other" is
& pleura Pleural lymph node selected in question 124.
effusion enlargement, If normal is selected here, disable
Other all options
292 CXR other Normal heart & Cardiomediastinal Musculoskeletal Only show if "Abnormal -other" is selected in question 124.
abnormality bones abnormality abnormality If normal is selected here, disable all options
293 CXR proposed TB Other Other Neopla Trauma Conge Cardiac Vascular Degenerati Other Only show if "Abnormal TB suspect" or "Abnormal -
diagnostic infection inflammator sm nital disorde disorder ve disorder other" is selected in question 124.If normal is
category y disorder abnorm r selected here, disable all options
ality
294 If Other proposed diagnosis, specify Only show if 'Other' is selected above
295 Is medical referral required on the basis of the CXR? Yes No If Yes, participant must be seen and assessed by medical officer
77
7.10 Annex I: Namibia TB DPS: CAD4TB Form 9 (F9)
125 Date
126 Team
127 Radiographer code
Name
Surname
130 Age
131 CXR performed Yes No If no, prompt that participant data should not be at this station (e.g.,
no CXR to read)
132 CAD4TB serial number
133 CAD4TB score
134 CAD4TB reading TB-suspect, Not TB-suspect
78
7.11 Annex J: Namibia TB DPS: Eligibility for sputum collection Form 10 (F10)
135 Interview date
136 Team
137 Lab technician code

141 Gender/sex Auto populate This field will Auto populate kindly verify with participant if correct, if not correct send back to Registration
142 Age Auto populate This field will Auto populate kindly verify with participant if correct, if not correct send back to Registration
143 Eligibility for sputum collection Yes No Yes if ANY of the following:
1. question 81 in symptom form is yes (Greater than 2 weeks)
2. question 84 in symptom form is 2 weeks, Greater than 2 weeks, or Unknown
5. question 115 in chest x-ray form is no6. question 124 in medical officer form is TB-suspect
7. question 134 in CAD4TB form is TB-suspect
No if otherwise
144 Is the individual randomly selected (every ten person) for the in-depth interview and sputum Yes NO If question 143 is no, select every tenth person for the in-depth
collection interview and sputum collection
145 Prompt for direction to next station • Direct to sputum collection station" if question 143 is yes; "
• Direct to in-depth interview station" if question 144 is yes; "
• Direct to HIV testing station" if question 114 is no”
79
91
7.12 Annex K: Namibia TB DPS: In-depth Interview Form 11 (F11)
146 Interview date
147 Team
148 Nurse code
150 Cellphone Number
What is your Marital status Never Married Married Living together Divorce/separated Widowed
What is your highest level of education No education Some Completed Some Completed More than Don't know
obtained? primary primary secondary secondary secondary
What is the main language that you speak at home

89 What is your occupation, that is, what kind of Professional/technical/man Clerical, Sales and Skilled Unskilled Agriculture None Other
work do you mainly do agerial services manual manual
153 Age
154 Have you ever been on treatment for TB before? Yes No If no, skip to question 161 Yes if question 91 in symptom form is yes; otherwise no
155 If yes, how many times? Set number equal to question 92 on symptom form
156 Date of first TB treatment Limit year range from 1907 to 2018
157 Date of second TB Treatment Limit year range from 1907 to 2018
158 Date of third TB Treatment Limit year range from 1907 to 2018z
159 Date of fourth TB Treatment Limit year range from 1907 to 2018
160 Date of fifth TB Treatment Limit year range from 1907 to 2018
161 During the symptom screen, you mentioned that you had experience the Coughing, Fever Recent unintentional weight Drenching night None
following: loss sweats
Should only be able to answer this question if question 81 in symptom form is yes or question 161 in in-depth interview form is yes to any symptom. If None in 161 skip to question 172
Are these symptoms still correct? Yes NO If no, please correct below for each symptom:
If yes skip to question 166
80
162 Correct coughing status Yes No
163 Correct fever status Yes No
164 Correct recent unintentional weight loss status Yes No
165 Correct drenching night sweats status Yes No
Have you experienced any of these additional symptoms? Yes No If no, skip to question 172
166 Are you coughing up blood? Yes NO If no, skip to question 168
167 If yes, for how long have you been coughing blood? Less than 1 week 1 week 2 weeks Greater than 2 weeks Unknown
168 Do you have chest pain? Yes No If no, skip to question 170
169 If yes for how long have you had chest pain Less than 1 week 1 week 2 weeks Greater than 2 weeks Unknown
170 Do you have abnormal swellings or lymph node enlargement? Yes No If no, skip to question 172
171 If yes, for how long have you had these swellings? Less than 1 week 1 week 2 weeks Greater than 2 weeks Unknown
172 Do you have any other symptoms? Yes No If no, skip to question 175
173 If yes, what symptoms are these?
174 How long have you had those symptoms? Less than 1 week 1 week 2 weeks Greater than 2 weeks Unknown
Regarding the current symptoms mentioned in 173:
This section (questions 175-188) should only be answered if any symptoms were If questions 81, 83, 85, and 87 from symptom form and questions 162, 163, 164, 165, 166, 168, 170, and
mentioned 172 from in-depth interview form are all no, skip to question 189
175 Regarding the current symptoms mentioned 173: Have you Yes No Should only be able to answer if If no, skip to question 187
consulted anyone for help regarding the current symptoms? they have listed any symptoms
176 If yes, who did you consult Local Local Local district Traditional Faith Intermediate or Private Private Pharmacy Ot
first? clinic health hospital healer healer central hospital doctor clinic/ho he
centre spital r
177 Before today, did you submit a sputum sample for current symptoms? Yes No If no, skip to question 179
178 If Yes, what was the result Negative for TB Positive for TB Not sure, If result not given Skip to question 181
179 If you did not submit sputum, why not? None was Could not Could not get in to Did not consider it No sputum Other If not equal to other, skip to
requested produce the clinic/hospital important container question 181
sputum provided
180 If other, specify
181 Regarding the current symptoms mentioned 173: were you asked to have a chest X-ray? Yes No If no, skip to question 183
81
182 If yes, did you have the X-ray taken? Yes No If yes, skip to question 185
183 If you did not have an X-ray, None was Could not get to where No money Did not consider Other If not equal to other, skip to question 185
why not? requested, the X-ray machine was for X-ray, it important
184 If other, specify
185 Regarding the current symptoms mentioned 173: Did you get medication for the current symptoms? Yes No If no, skip to question 189
186 If you did, does the medication make you feel better? Yes No Skip to question 189
187 Regarding the current symptoms mentioned 173: If Could not get to a No money to Already on Did not Symptoms Other If not equal to other, skip to
you did not seek help for the current symptoms why health facility seek care treatment consider it were not question 189
not? important that bad
188 If other reason, specify
189 Do you suffer from any Asthma Heart High blood HIV HIV Physical Diabetes Chronic Other, None If none selected, cannot select any
known chronic conditions? disease pressure on not on disability obstructive others (but can select more than
(hypertension ART ARV, pulmonary one if none not selected)
), disease
(including
chronic
bronchitis
emphysem
a
190 Do you smoke tobacco products (cigarettes, pipe)? Yes No If no, skip to question 192
191 If yes, how much do you smoke? Daily Weekly Monthly Less than monthly
Unknown
192 Do you drink alcoholic beverages? Yes No If no, skip to question 194
193 If yes, how many days have you consumed alcohol in the past two weeks? 0 1-2 3-4, 5+, Don't know
194 Weight (kg)
195 Height (centimeters-no decimals)
196 Mid-upper arm circumference (centimeters)
82 94
7.13 Annex L: Namibia TB DPS: Field Bacteriological Examination Form 12 (F12)
197 Date
198 Team
199 Lab technologist/assistant code
204 Age
Was Specimen 1 received Yes NO If no, skip to question 209
206 Description of Specimen 1 Bloody Mucoid Purulent, Yellowish Greenish , Other
207 Volume of Specimen 1 (ml)
205 Is Xpert MTB/RIF performed on Specimen 1? Yes NO If no, skip to question 209
208 Xpert result of specimen 1 Detected - R resistant Not detected Indeterminate

209 Was Specimen 2 received Yes NO If no, skip to question 214
210 Description of Specimen 2 Bloody Mucoid Purulent, Yellowish Greenish , Other
211 Volume of Specimen 2 (ml)
212 Was specimen 2 forwarded to NIP Yes NO If no, form is complete
213 If so, date forwarded Limit years to 2017 and 2018
214 Requisition number (barcode)
83
95
7.14 Annex M: Namibia TB DPS: HIV Testing Form 13 (F13)
215 Interview date
216 Team
217 Data clerk code
219 Participant gender/sex
220 Participant age
221 HIV test performed Yes NO If no, form is complete
222 HIV test result Positive Negative Indeterminate If negative, form is complete
223 If positive, has the participant been referred Yes NO If yes, enter the Page reference Form is complete
for care number from the HIV register
84
7.15 Annex N: HIV Follow-Up Form
NAMIBIA TB DISEASE PREVALENCE SURVEY 2017, DATA COLLECTION FORMS

Post-cluster follow-up Form 18 (F18)
Question number Variable name
Follow up of Newly diagnosed TB cases during cluster visit

Field counselor to complete this form. This form must only display those participants that:
(1) Has a positive HIV result: HIV_test_result (F13_HIV_test_result) = Positive, Indeterminate
(2) Has chronically condition related to HIV in the in-depth interview form where: F11_chronic_conditions = HIV on ART or F11_chronic_conditions = HIV not on ARV,
This form must display selected participants in Red and once the Field counselor click on the barcode of the participant, a Form with participants details (see below) must pop up, that
allow the Field counselor to complete questions ??????
Once populated and saved the participants, the participants must display Green
290 F01_Barcode_# Participant barcode
291 F05_surname_#_corrected Participant surname
292 F05_name_#_corrected Participant first names

293 F05_Sex_#_corrected Participant gender/sex
294 F05_Age_#_corrected Participant age
295 F01_Region Region
296 F01_District District
297 F13_HIV_referred_care If positive, has the participant been referred for care
70A F05_Phone_# Contact phone number of household member
297a F13_Facility_refered_too Name of Institution/Facility referred too for HIV care
297b F13_Name_HW Name of Health worker/assistant
297c F13_Surname_HW Surname of Health worker/assistant
297c F13_Phone_HW Phone number of Health Worker/assistant

297e F20_comment_HIV_Link Comment on status of participants link to care
297f Follow up date Date

298 F20_ART_number ART number of participants
299 F20_health_care_facility Where is health care facility for treatment

299a Facility received date Date when participant was received for care
300 F20_Treatment_started Date treatment started
300a Comment Comment
85 97
7.16 Annex O: Namibia TB DPS: Data collection form for Central Radiologist
Radiologist to complete this form:

This form must only display those participants that has a
(1) X-ray performed (F07_CXR_performed) = Yes and
(2) X-ray results by MO (F08_CXR_result) = Abnormal all,
(3) F09_CAD4TB_reading by radiographer = Above threshold or TB-suspect and
(4) 10% of participant by cluster with (1) Normal X-ray by radiographer where X-ray results (F08_CXR_result) = Normal and (2) Normal CAD4TB reading by radiographer where F09_CAD4TB_reading
= below threshold or Normal/Not TB-suspect and
(5) 10% of participants not eligible for sputum collection where Question 143 (F10_sputum_eligibility) = No
(6) All participants where GeneXpert results is positive but X-ray result is Normal: F12_Sputum_1_Xpert_Result = Detected - R sensitive or Detected - R resistant or Detected R-Indeterminate or Error
but X-ray and X-ray results (F08_CXR_result) = Normal and (2) Normal CAD4TB reading by radiographer where F09_CAD4TB_reading = below threshold or Normal/Not TB-suspect
This form must display selected participants in Red and once the radiologist click on the barcode the Thirona Image must appear with a Form that allow the radiologist to complete questions 231-235.
Once populated and saved the participants, the participants must display green
Post-cluster follow-up
224 F15_Radioligist_date Date date Auto Yes

populate
current
date
226 F15_Radioligist_code Radiologist's select_one Yes userna link to
code a_b me userna
me
227 F01_Barcode_# Participant Auto Yes Link to chest x-
barcode populat ray form
e
Radiologist 228 F05_Sex_#_corrected Participant Male Femal Yes Link to chest x-
Record final gender/sex e ray form
results on all 229 F05_Age_#_corrected Participant age Auto Yes Link to chest x-
abnormal populate ray form
CXR and 10 230 F15_CXR_performed CXR Yes No Yes Link to chest x- If no, prompt that participant data should not be at
% normal performed ray form, this station (e.g., no CXR to read)
CXR for question 115
quality 231 F15_CXR_Screening_ CXR Normal Abnorm Abnormal- Unknown not
assurance Result radiologist , al TB- other interpretable
screening suspect
result
231A F15_CXR_survey_con CXR N = AD-NS = ADS-NA = ADS-NTB ADS-TB = significant significant – ADS-U = significant
clusion radiologist Norm abnormality abnormalit = abnormality – no active not abnormalit unclassified
survey al detected – y detected abnormalit detected, disease tuberculosis y detected
conclusio not y detected significant –
n significant tuberculosis
(1) if Normal in 231 then only normal must be available in 231A
(2) if not normal in 231 then Normal is not suppose to appear in 231A
(3) if Normal is selected in 231A then finish allow save and close
86
98
232 F15_CX CXR select Acti Vascu Degen Ol Traum Congenital Cardiac Probable Other Neoplas Other Other
R_Diag Radiologi _multi ve lar erative d a, abnormality disorder TB infectio m, inflammat
nostic st ple TB disord disord TB n ory
proposed a_b er er , disorder
diagnosti
c
category
Only show if any "AD- abnormality detected" or "ADS-abnormality detected, significant)" is selected in question 231A.
If normal is selected in 231A , disable all options
233 F15_CXR_Diagnostic If Other proposed text Only show if 'Other' is selected in 232
_other Radiologist diagnosis,
specify
234 F15_CXR_radiologist_ CXR radiologist's text only show if 231A is not Normal
diagnosis diagnosis
235 F15_CXR_follow-up Is follow-up required on select_one Yes No If Yes, participant must be followed up by the clinical
required the basis of this CXR? yes_no management subgroup
87
7.17 Annex P: List of SOPs for the survey
▪ Household listing procedure

▪ SOP for obtaining informed consent
▪ Clinical management SOPs
o TB symptom screening
o In-depth interview
o Managing participants with abnormal symptoms and or chest X-ray (CXR)
o Managing confirmed TB patients
o Managing participants with no symptoms
o Managing participants with HIV
▪ Logistics management SOPs
o Assets management
o Fleet and transportation
o Inventory management
o Setting up of field operations
o Mop-up exercise
▪ Radiology SOPs for
o CXR at field level
o CXR at central level
o Interpretation of CXR at field level
o Installing the x-ray equipment
o De-installation of the CXR equipment
o Radiation protection in the field
o Calculation of the 10th participant (manual)
▪ Laboratory SOPs
o Bench decontamination
o Sample collection and transportation
o Xpert MTB/RIF operations in the field
o Pregnancy urine dip stick test
o Rapid HIV test (Sure check, Determine, Stat-pak)
o Central laboratory SOPs for:
▪ receiving and handling of TB samples
▪ ZN and Auramine staining techniques
▪ MGIT culture, LPA and DST 1 and 2
Manuals:
▪ Field work and data enumeration manual

▪ Data management manual
▪ Manufacturers manual
100
88
7.18 Annex Q: NamTBCollect Special features
▪ Pop up reception reminders: It instructed participants who came to the site, to remind their
eligible house hold members of their appointments to the cluster site.
▪ Bulk SMS feature: This module was only available to the Systems Administrator whereby
SMSes were generated to remind participants of their appointments at the field operation site.
▪ Field flow monitoring: This was used to manage the flow of participants for data consistency.
The system would prohibit participants from skipping eligible stations and would also not allow
non-eligible participants to proceed to stations not applicable to them.
▪ Queue Management: This system was used to control flow of participants. The staff were
able to identify participants on the waiting list and how long they had been waiting to be served
at each station. This assisted the field team to prioritize participants who had waited longer
than others.
▪ Field Dashboards: These allowed field staff to track participants progress and flow through
the cluster site operations in real time.
▪ Central dashboards: These dashboards received live data from the field. The dashboard
allowed central coordinators and the Data Manager to keep track of field proceedings, thus
enabling early detection of errors with early intervention to improve quality data collection.
▪ Sputum eligibility algorithm: An automated algorithm within NAMTBCollect database
determined sputum eligibility. The algorithm imported data from two screening stations
(Radiography and symptoms screening).
▪ Eligibility for central re-reading algorithm: Eligibility for central re-reading was
automatically determined within the system. All participants with an abnormal CXR, and 10%
of all normal CXR with no positive symptoms within a cluster were exported to the radiologist’s
re-reading platform.
101
89
7.19 Annex R: Summary of data sources, storage and security
Data source Format Data storage Responsible Data security
Namibia Master Electronic database & Central, Field NSA Lockable cabinet
Sampling Frame paper (maps of each
cluster in print with Maps to be kept by the
electronic GPS Field coordinator.
reference)
Household census Electronic (SQL format) Field (cluster Enumerators (Collection) HTTS and SSL
questionnaire houses) inscription
Data manager (central)
Household census Electronic Field Enumerators (collection) Passwords protected

register
Survey participant Paper Field Enumerator and Card holder

/appointment card Household participant
Issue in duplicate
Survey participant Paper Cluster site (cluster Data Clerk Lockable cabinets
register site) reception
Symptom Electronic Cluster site reception Data clerk Password protected

screening form
Chest X-ray form Electronic Cluster site X-ray Radiologist Password Protected
unit
Sputum & in-depth Paper Cluster site HCW (nurse) Lockable cabinet
interview register
Laboratory forms Electronic Cluster site lab unit HCW (nurse) & Lab Daily (hourly) back up
and offsite storage
In-depth interview Electronic Cluster site HCW Password protected

questionnaire (unique ID)
Laboratory results Electronic & paper Cluster site lab unit Data manager and Lab Password protected,
technician filling and lockable
cabinet
Sputum log Paper Cluster site lab unit Data clerk Lockable cabinets,
HIV testing Paper Cluster site HCW Unique ID, Lockable

register cabinet
Counsellor
Post-survey Paper Cluster site within DTLC Lockable

follow-up form district
Survey server Electronic (online and Central level Data manager/ IT Password protected,
offline) specialist backup
102
90
7.20 Annex S: Lists of participants and their roles
CENTRAL COORDINATING TEAM

Name Role
Irish Goroh Survey Coordinator/Manager
Cornelius Malungah Logistics Coordinator
Israel Tjizake Data Manager
Willem Hinawike Paulus Radiography Coordinator
Petrus Katota Laboratory Coordinator
Matias Iita Systems Administrator
Hilya Ashipala Central Data Clerk
Mateus Iiyambo Central Data Clerk
NTLP LEADS
Dr Farai Mavhunga Principal investigator
Dr Nunurai Ruswa Technical focal point & clinical coordinator
Helena Mungunda Administrative focal point
SPECIALIST SERVICES
Dr Edward Fynn Central radiologist
Hosea Kambonde System developer
Dr Jane Nabongo Ong'ango Technical consultant
Nico Kalisvaart Data management consultant
Dr Jens Levy Epidemiologist
FIELD COORDINATORS FIELD NURSES
Lahja Shikongo Paulus Alice Jantjies
Christencia Dirks Ndawedwa Michael Hauwanga
Frieda Van Der Byl Thomas Sakaria
Martha Henok Jessy Shau
Emmanuel Amwaama Frieda Nambuli
FIELD LABORATORY TECHNICIANS FIELD RADIOGRAPHERS
Pendapala Shiyuka Emilia Pienaar
Helalia Ndishishi Noëlle Mouton
Audrey Strauss Julia Ashipembe
Johanna Elmarie Gaweses Declencia Brunette Meyer
FIELD RADIOGRAPHIC ASSISTANTS FIELD DATA CLERKS
Monica Amutenya Salom Erasmus
Elina Emvula Olivia Mwanyekange
Hyppolite Shikukutu Lucia Sakaria
103
91
Marie Francine Malanda Gift Katjiku
FIELD CENSUS ENUMERATORS Vaino Shivolo
Haitange Amupolo Hendrick Herman
Kaveuana Katjimune Alfeus Shekunyenge
Christophine Kahee Elizabeth Shigwedha
Katji Paulus Maghumbo FIED INTERVIEWERS
Ruth Halweendo Thelma Mukwaso
Justina Nangolo Raukinen Katshuna
Martha Iilonga Benyamin Shikesho
Immanuel Alombola Arno Norich
Neville-Nash Uhongora Gertrude Aindongo
Demetrie Kanime Debora Simon
Ndjiviro Muvangua Precious Mutumba
Iina-Maria Shiweva Selma Kuuvilwa
Teopolina Nghipunya HIV TESTING COUNSELLORS
Razaro Sikote Hilja Shifotoka
Vincent Khutze (Late) David Nghikelwa
Muchila John Lutombi Gottfried Vallentinus
FIELD DRIVERS Gabriel Nepembe
Freddie Muyamba Believeme Augustus
Berumilu Paulus Mutemwa Edward Muronga
Johannes Nakare Helena Ndinelao Frans
Hans Helmut Garoeb Bertha Nantinda
Elia Dillu Auguste Mupupa
Echley Daniels Drusilla Hoeses
Julius Ndikwetepo Rosetha Ntomfuthi Khobetsi
Herold Kavezepa Rosa Filomina Queebira
Moses Mweshihala Petrus FIELD GENERAL HAND
Nehemia Shikonde Joao Luzendu
Jesaja Shigwedha Bernhard Iitula
Samuel Namwiha Eunice Lweenya
Samuel Kaavara
104
92
4.10.1 Participants: First data cl eaning workshop
Dates: (27 May – 2 June 2018)
Name Surname Designation Organization
Irish Goroh Survey Manger UNDP
Willem H Paulus Radiography Coordinator UNDP
Harriet R Kagoya M&E Officer KNCV
Helena Mungunda TB-HIV Officer NTLP
Charné Feris Occupational Therapist NTLP
Pinehas Iipinge ACSM NTLP
Petrus Katota Lab Coordinator UNDP
Nunurai Ruswa PMDT Coordinator NTLP
Matias Iita Systems Administrator UNDP
Abbas Zezai Country Director KNCV
Anita Beukes Lab Advisor CDC
Olga Afrikanner MoHSS
Edward Fynn MoHSS
Israel Tjizake Data Manager UNDP
Eben Kahitu NSA
Farai Mavhunga Chief Medical Officer NTLP
Nicolette Bloodstaan MoHSS
Aune Shikongo NIP
Beanetha Bayer Senior Health Programmes Officer NTLP
Mary Brantuo WHO
Costa Ndumba PMU
Imelda Katjau NTLP
Hosea Kambonde IMarketing consultants
Sikota Zeko MoHSS Research Ethics
Mateus Iyambo Data Clerk UNDP
Hilya Ashipala Data Clerk UNDP
Vaara Katjiuanjo NTLP
Nico Kalisvaart* KNCV
*Attended virtually to provide backstopping support
4.10.2 Participants: Second data cleaning workshop

Dates: 01 – 06 July 2018
Willem Paulus Radiography Coordinator UNDP
Harriet Kagoya M&E Officer KNCV
105
93
Edward Fynn MoHSS
Eben Kahitu NSA
Farai Mavhunga Chief Medical Officer NTLP
Nicolette Bloodstaan MoHSS
Aune Shikongo NIP
Benetha Bayer Senior Health Programmes Officer NTLP
Costa Ndumba PMU
Imelda Katjau NTLP
Hosea Kambonde IMarketing consultants
Vaara Katjiuanjo NTLP
Nico Kalisvaart Data Manager KNCV
4.10.3 Participants: Third Data cleaning workshop

Dates: 25 - 27 July 2018
Willem Paulus Radiography Coordinator UNDP
Harriet Kagoya M&E Officer KNCV
Eben Kahitu NSA
Aune Shikongo NIP
Nandjebo Ndahafa NTLP
Nico Kalisvaart Data Manager KNCV
Rosamunde Amutenya M &E Officer NTLP
4.10.4 Participants: Data analysis workshop

Dates: 13 – 17 Aug 2018
Irish Goroh Survey Manager UNDP
106
94
Edward Fynn MoHSS
Eben Kahitu NSA
Paheye Kambinda MoHSS
Aune Shikongo NIP
Albertina Thomas Chief Health Programmes Officer NTLP
Julia Amukwaya NTLP
Nandjebo Ndahafa NTLP
Jens Levy KNCV
4.10.5 Participants: Report writing workshop

Dates: 03-07 September 2018
Rosamunde Amutenya HPO NTLP
Ndahafa Nandjebo SHPO NTLP
Paheye Kambinda Chief Radiographer MoHSS
Anita Beukes Lab Advisor CDC
107
95
REFERENCES
Dodd, P. J. et al. (2015) ‘Age- and Sex-Specific Social Contact Patterns and Incidence of
Mycobacterium tuberculosis Infection’, American Journal of Epidemiology. Narnia, 183(2), p.
kwv160. doi: 10.1093/aje/kwv160.
Floyd, S. et al. (2013) ‘Analysis of tuberculosis prevalence surveys: new guidance on best-
practice methods’, Emerging Themes in Epidemiology. BioMed Central, 10(1), p. 10. doi:
10.1186/1742-7622-10-10.
Horton, K. C. et al. (2016) ‘Sex Differences in Tuberculosis Burden and Notifications in Low- and
Middle-Income Countries: A Systematic Review and Meta-analysis’, PLOS Medicine. Edited by
J. Z. Metcalfe. Public Library of Science, 13(9), p. e1002119. doi: 10.1371/journal.pmed.1002119.
ICAP, MoHSS and CDC (2018) Namibia Population-based HIV Impact Assessment (Preliminary
report). Windhoek.
Namibia Statistics Agency (2016) ‘Namibia Inter-censal Demographic Survey 2016 Report’, pp.
1–136.
National Planning Commission (2015) Poverty and Deprivation in Namibia.
National Planning Commission (2018) ‘Status of the Namibian Economy’, (March), pp. 9–10.
Available at: https://www.npc.gov.na/?wpfb_dl=315.
NSA (2013) Demographic Health Survey, Namibia. Windhoek and Rockville. Available at:
https://dhsprogram.com/pubs/pdf/FR298/FR298.pdf.
NSA (2014) Namibia Population Projections 2011-2041. Windhoek.
World Bank Group (2018) Namibia Country Profile. Available at:
https://databank.worldbank.org/embed-int/CountryProfile/id/b450fd57 (Accessed: 12 March
2019).
World Health Organization (2017) Global Tuberculosis Report 2017. Geneva. doi:
WHO/HTM/TB/2017.23.
108
96
97
100

Namibia TB Prevalence Survey Report 2019

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Namibia TB Prevalence Survey Report 2019

Uploaded by

Copyright:

Available Formats

1

NAMIBIA TUBERCULOSIS DISEASE PREVALENCE SURVEY REPORT 2019

Table 1: Definition of a TB case in the survey ................................................................. 19

Executive Director: Ministry of Health & Social Services

ACSM Advocacy, communication and social mobilisation

AFB Acid-fast bacilli

ART Antiretroviral therapy

BD-MGIT Becton Dickinson’s mycobacteria growth indicator tube

CAD4TB Computer Aided Detection for TB

CBTBC Community-based TB care

CDC United States Centers for Disease Control and Prevention

CHPO Chief Health Programmes Officer

CHW Community health worker

CNR Case notification rate

CPT Cotrimoxazole prophylactic therapy

CSV Comma-separated values

CXR Chest X-ray

DCC District Coordination Committee

DOT Directly-observed treatment

DPS Disease Prevalence Survey

DRS (anti-tuberculous) Drug resistance survey

DSP Directorate of Special Programmes

DST Drug susceptibility testing

DTLC District Tuberculosis and Leprosy Coordinator

ELISA Enzyme-linked immunosorbent assay

FMI Fraction of missing information

GDP Gross domestic product

GNI Gross national income

GPS Global Positioning System

GRN Government of the Republic of Namibia

HCT HIV counselling and testing

HEW Heath Extension Workers

HIV Human immunodeficiency virus

HPCNA Health Professions Councils of Namibia

HTS HIV Testing Services

IEC Information, Education and Communication

IPW Inverse probability weighting

KNCV Koninklijke Nederlandse Centrale Vereniging (Royal Netherlands Tuberculosis

LED Light emitting diode

LTFU Lost to follow-up

LIS Laboratory information system

MDG Millennium development Goals

MDR-TB Multi-drug-resistant tuberculosis

MoHSS Ministry of Health and Social Services

MOTT Mycobacteria other than tuberculosis

MTB/RIF Mycobacterium tuberculosis / Rifampicin

MTP-I First Medium-Term strategic Plan (for TB)

MTP-II Second Medium-Term strategic Plan (for TB and leprosy)

MTP-III Third Medium-Term strategic Plan (for TB and leprosy)

MySQL My-Structured Query Language

NAMPHIA Namibia Population-based HIV Impact Assessment

NGO Non-governmental organisation

NICD National Institute for Communicable Diseases (South Africa)

NRPA Namibia Radiation Protection Authority

NSC National Steering Committee (for TB and Leprosy)

NSP New smear-positive

NTLP National Tuberculosis and Leprosy Programme

PACS Picture archiving and communication system

PHC Primary health care

PHP Hypertext Preprocessor

PITC Provider initiated counseling and testing (for HIV)

PLHIV People Living with HIV

PTB pulmonary tuberculosis