Global DOTS Expansion: will we reach the Targets? Mario C. Raviglione Stop TB World Health Organization 33rd IUATLD World Conference 6-10 October 2002 Montreal, Canada

This Talk will... Describe what these famous targets are Review where we are today Speculate on where we are likely to be in 2005 and on what needs to be done now World Health Organization

44th World Health Assembly, 1991 Resolution WHA 44.8 To intensify collaboration with Member States in strenghtening NTPs in order to improve case finding and treatment and attain a global target of : 1 - Curing 85% of SS+ patients by 2000 and 2 - Detecting 70% of such cases by 2000 World Health Organization

Other Targets Okinawa G8 Summit, 2000 Millennium Development Goals to reduce TB prevalence and mortality by 50% in 2010 Millennium Development Goals to have halved by 2015, and begun to reverse, the incidence of……TB World Health Organization

Rationale for the 70/85 Targets: Prevalence of SS+ cases (basic incidence 100 SS+ per 100,000) From Styblo K. Long-term evaluation of modern TB control programmes, WHO unpublished document, 1991 World Health Organization

Short History of the WHA Targets 1991 WHA Resolution 1995 CARG calls for knowledge of status 1996 New M&S system in place with results available 2000 WHA Resolution (WHA 53) to postpone to 2005 World Health Organization

A Slide from the Past - CARG 1996: Progress Towards Year 2000 Targets Status in 1996 WHO Global TB Programme 1996

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

DOTS Coverage by WHO Region, 2000 67 % 49 % 17 % 65 % 68 % 65 % Whole population Population under DOTS 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 60% of global population accessing DOTS Average cure rate under DOTS almost reaching target (84%); <40% elsewhere 30% infectious cases detected under DOTS - x3 from 11% in 1995, but far from target 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 in most settings Dye C, Watt C , Bleed D, Williams B. Tuberculosis 2002 in press World Health Organization

Growth of DOTS coverage and case detection in India 50 25 40 20 30 15 DOTS coverage (%) Smear-positive case detection under DOTS (%) 20 10 10 5 1995 1996 1997 1998 1999 2000 2001 1995 1996 1997 1998 1999 2000 2001

Growth of DOTS coverage and case detection in Philippines 100 60 50 80 40 60 DOTS coverage (%) Smear-positive case detection under DOTS (%) 30 40 20 20 10 1995 1996 1997 1998 1999 2000 2001 1995 1996 1997 1998 1999 2000 2001

CASE DETECTION IS PROPORTIONAL TO COVERAGE DURING DOTS EXPANSION

Case Detection is proportional to DOTS Coverage in 5/6 Regions World Health Organization

Conclusions of this Analysis The current trend is such that the detection target may not be reached in 2005 Even if geographical coverage of 100% is achieved in the near future, the 70% detection target may not be achievable w/o a comprehensive approach What DOTS currently does is to guarantee high cure rates and detection of the “accessible” 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? DOTS Notifications Estimated incidence DOTS Detection Rate = Denominator too large Numerator too small World Health Organization

Is the Denominator too large? (= are we overestimating Incidence?) Methodological errors in WHO’s estimates? But….all estimates point in the same direction (Murray et al. 1991, Sudre et al. 1992, Dolin et al. 1994, Dye et al 1999) There is no obvious systematic error, as some countries are achieving the targets World Health Organization

Is the Numerator too small? (= are we truly missing Cases?) DOTS programmes not accessible DOTS programmes not able to suspect/diagnose DOTS programmes not notifying Prison programmes un-linked Other public health systems un-linked Non-DOTS programmes not diagnosing/notifying Private sector un-linked World Health Organization

Conclusions Latest information (2000) Treatment success under DOTS excellent (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 in all countries 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

How to reach our Targets? Intensify expansion of DOTS through a coordinated GDEP, well financed and resourced Evaluate country-specific constraints and address them one-by-one through new interventions Improve primary services to maximise case finding Integrate management and information systems of other health programmes (hospitals, prisons, army) Engage the private health sector in TB control efforts World Health Organization