Global DOTS Expansion: how are we doing? Mario C. Raviglione Stop TB World Health Organization 3rd DOTS Expansion W. G. Meeting 5-6 October 2002 Montreal, Canada

This Talk will... Review where we are today in DOTS expansion efforts Propose a framework for identifying solutions to reach the 2005 targets Assess the main constraints in countries based on day-1 discussions World Health Organization

The Burden of Tuberculosis, 2002 1.8 million deaths 98% of these deaths in the developing world About 230,000 deaths due to TB/HIV 8.2 million new cases, 80% in 22 high-burden countries Multi-drug resistance (MDRTB) present in 63 of 72 countries surveyed in 1994-1999 and important in some The global burden of tuberculosis is truly enormous with some 1.9 million deaths per year according to the most detailed country-based analysis yet carried out and reported last year by the surveillance and monitoring unit of WHO's Communicable Disease Operational and Epidemiological Research Unit. Some 380,000 of these deaths occur in HIV infected individuals largely, but not solely, in Africa. And 98% of these deaths occur in the developing world. Staggeringly, for a disease many of us believed would disappear in our lifetime, TB is estimated to be the commonest cause of death of young women worldwide. Worse still, but at the same time providing cause for hope, these deaths are preventable. However, persistent poor practice in many countries is raising the spectre of multi-drug resistant (MDR) TB. This form of TB, if it became widely established, would make the control of the disease beyond the financial capacity of many countries. World Health Organization 3

History of DOTS expansion 1991: WHA establishes the 70/85 targets for 2000 1993: TB as a global emergency 1994: New TB control framework 1995: DOTS launched as a brand 1996: Global monitoring established 1998: London committee assesses constraints 1998: StopTB Partnership launched 2000: Amsterdam declaration; targets in 2005; DEWG 2001: GDEP and GDF launched 2001: GPSTB and Washington Commitment (+GFATM) World Health Organization

The WHO TB Control Strategy (DOTS) Government commitment to TB control Diagnosis by smear microscopy mostly on self-reporting symptomatic patients Standardised SCC with DOT Efficient system of drug supply Efficient recording and reporting system with assessment of treatment results World Health Organization

DOTS Expansion 1990-2000: rapid and impressive Total number of countries 200 DOTS launched 148 150 127 119 Number of countries New Framework 107 99 100 73 50 19 10 16 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Year Global Tuberculosis Control. WHO Report 2002. WHO/CDS/TB/2002.295 World Health Organization

Implementation of DOTS, 2000 Implementation in < 10% of pop Not implementing DOTS Implementation in 10 to 90% of pop Low incidence non-DOTS country Implementation in > 90% of pop No report The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2001

TB Control Status of 210 Countries (%), 2000 DOTS, DOTS, pilot phase expansion phase 4% 21% Non-DOTS, high incidence 16% No report 11% DOTS, full coverage Non-DOTS, 45% low incidence 3% World Health Organization

DOTS Coverage by WHO Region, 2000 67 % 49 % 17 % 65 % 68 % 65 % Whole population Population under DOTS World Health Organization

Treatment Outcomes by WHO Region: DOTS vs. non-DOTS 1999 Cohort Treated successfully Not treated successfully Not evaluated World Health Organization

Progress in Treatment Success under DOTS Global Results, 1994 - 2000 84 81 77% 78.5 78.4 78.3 80.2 Treatment Success Rates % Years World Health Organization

Progress in Global Case Detection under DOTS, 1995-2001 45 ss+ cases detected under DOTS all estimated ss+ cases 30% 30 Case detection rate (%) 15 11% 1995 1996 1997 1998 1999 2000 2001 Global Tuberculosis Control. WHO Report 2002. WHO/CDS/TB/2002.295 World Health Organization

Projected DOTS Case Detection 80 WHO target 70% 70 60 accelerated progress: 50 target 2005 40 Cases notified under DOTS (%) 30 DOTS begins 1991 average rate of 20 progress: 10 target 2013 1990 1995 2000 2005 2010 2015 Year World Health Organization

Global Case Detection & Cure: Take-home Message... 70% (148/210) of countries adopted DOTS and 55% of global population accessing DOTS Average cure rate stable at 80% under DOTS and <40% elsewhere 27% infectious cases detected under DOTS - x2.5 from 11% in 1995, but far from target Compared to 1999, an extra 152,000 SS+ cases reported under DOTS: if 330,000 yearly, 70% of cases under DOTS in 2005 World Health Organization

Progress in TB Control, high-burden Countries, 1999-2000 100 China TARGET ZONE Brazil Cambodia 90 Philippines Viet Nam India Myanmar 80 Bangladesh Nigeria Kenya Tanzania Pakistan Ethiopia Zimbabwe 70 South Africa Thailand DRCongo Mozambique 60 Russia Uganda Treatment success (%) 50 Indonesia Afghanistan 40 30 20 10 10 20 30 40 50 60 70 80 90 100 DOTS detection rate (%)

DOTS Expansion in India increased 25-fold over the past 3.5 Years Population covered 45% of the population now has access to the RNTCP RNTCP India, May 2002 World Health Organization

Is DOTS geographical Coverage all that counts? Evidence that DOTS geographical coverage may be paralleled by a similar increase in case detection, but below the target curve At maximum DOTS coverage, case detection seems to remain below the target level (70%) in most settings Dye C, Watt C , Bleed D, Williams B. Tuberculosis 2002 in press World Health Organization

Conclusions of this Analysis The current trend is such that the detection target may not be reached until 2013 Even if geographical coverage of 100% is achieved in the near future, the 70% detection target may not be achievable What DOTS currently does is to guarantee high cure rates and detection of the “easier” cases. However, additional interventions are necessary to increase case detection/notification New case finding methods and improved surveillance are crucial World Health Organization

Where are the missing Cases? At home, if DOTS programmes not accessible Missed, if DOTS programmes do not suspect/diagnose Missed, if DOTS programmes do not notify In prisons, if un-linked In other public health systems, if un-linked In non-DOTS programmes, if R&R do not exist In the private sector, if it remains un-linked World Health Organization

How to recruit the missing Cases? 1. Widen access to DOTS Governmental health services Patients’ constraints 2. Improve quality of DOTS Increase suspicion, diagnostic capacity and notifications 3. Enlist all care providers to deliver DOTS: Other MOH facilities Non-MOH governmental systems and services Private sector: Private practitioners, NGOs, Academia, etc World Health Organization

Actions necessary to maximise Recruitment of Cases under DOTS 1. Government Expand coverage to 100% and ensure access Improve quality of DOTS delivery Enlist all other MOH and non-MOH care providers Support all partners in their contribution to TB control 2. Others not governmental People and communities: social movements and support NGOS: care and IEC Private sector: care World Health Organization

Some principles on how to act… First, the non-negotiable principle: governments carry the responsibility to pursue their WHA targets. They are central to TB control and must provide their people with 100% DOTS coverage Second, all non-governmental action needs to be supported by governments, especially where governments cannot do it alone and partners need to be enlisted Third, all entry points are good to achieve the targets and should be exploited in parallel, rather than in sequence: at 3 years before the target date, it is not business as usual World Health Organization

Countries in need of political will, new policy, donor coordination Afghanistan: re-build health system Brazil: DOTS coverage of all States Nigeria: DOTS coverage of all States Pakistan: DOTS coverage of all Provinces Russia: DOTS coverage in all Oblasts World Health Organization

Countries concerned with access to DOTS DR Congo: difficult areas, IEC, community care Ethiopia: need to increase services and staff Tanzania: integration PC and communities, IEC Uganda: community care expansion, IEC World Health Organization

Countries concerned with quality of DOTS services South Africa: HRC, training, IEC Mozambique: training, IEC, need to increase services and staff Zimbabwe: training and community care World Health Organization

Countries needing wider engagement of all HC providers Bangladesh: NGOs, traditional healers, IEC China: hospital system, advocacy in Provinces India, Thailand, Indonesia : private sector, hospitals and urban control Kenya: integration PC and private sector Myanmar: hospitals and NGOs Philippines: private sector, training Provinces Cambodia and Vietnam: primary care, prisons World Health Organization

Summary Latest information (2000) Treatment success increasing (84% of 85%) DOTS case detection increasing slowly (30% of 70%) Quality DOTS Expansion is top priority of governments to achieve full geographical coverage Full DOTS coverage in public health services does not seem sufficient to achieve detection target and all partners must be enlisted to contribute Additional approaches are necessary to increase case detection: e.g., involve communities; social mobilisation and people IEC; improve primary care; integrate hospital, prison, army and urban systems; engage private sector sensu lato World Health Organization

Specifically, the DEWG should ensure that: Country assessments are conducted on request followed by planning of interventions The Lab Subgroup improves diagnosis The PPM and PAL Subgroups identify solutions There is a funded plan for Human Resources The STB-CB assists with building commitment The GFATM finances country plans World Health Organization

DOTS Results in TB Incidence Decline The Success Story of Peru, 1980-2000 220 DOTS 1990 200 case finding 180 160 Pulmonary TB cases/100,000 140 DOTS implementation and expansion, instead, have excellent outcomes. In Peru, DOTS expansion has meant a decline in TB incidence by 6% per year during the past decade. 120 PTB falling at 6%/yr 100 1980 1985 1990 1995 2000 World Health Organization

TB Deaths prevented in China 60 deaths averted 59 000 56% 50 30 000 47% 26 000 37% 40 percentage 30 20 10 case fatality case fatality deaths averted (-programme) (+programme) World Health Organization

The Success Story of the Philippines: Cure Target reached, Detection Target closer 87% 88% 71% 57% 48% 20% NTP Philippines, July 2002 World Health Organization

The Success Story of Cuba, 1962-2001 Hospital Self-adm. DOT 12/18 Full DOT 35% drop in GDP Definition change SCC RMP Cases Deaths Source: Ministry of Health, Cuba