1. 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

2. 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

3. 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 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

4. 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

5. 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

6. 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 WHO/CDS/TB/
World Health Organization

7. 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

8. 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

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

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

11. Progress in Treatment Success under DOTS Global Results, 1994 - 200084 81
77%
78.5
78.4
78.3
80.2
Treatment Success Rates %
Years
World Health Organization

12. Progress in Global Case Detection under DOTS, 1995-200145
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 WHO/CDS/TB/
World Health Organization

13. Projected DOTS Case Detection80
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

14. 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

15. 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 (%)

16. 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

17. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. DOTS Results in TB Incidence Decline
The Success Story of Peru,
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

31. TB Deaths prevented in China60
deaths averted % 50 % % 40
percentage 30 20 10
case fatality
case fatality
deaths averted
(-programme)
(+programme)
World Health Organization

32. 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

33. 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