1. 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

2. 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

3. 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

4. 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

5. 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From Styblo K. Long-term evaluation of modern TB control programmes, WHO unpublished document, 1991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

6. 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

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

8. 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

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

10. 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

11. 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

12. 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

13. 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

14. 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 (%)

15. 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

16. 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

17. Growth of DOTS coverage and case detection in India50 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

18. 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

19. CASE DETECTION IS PROPORTIONAL TO COVERAGE DURING DOTS EXPANSION

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

22. 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

23. Where are the missing Cases?
DOTS Notifications
Estimated incidence
DOTS Detection Rate =
Denominator too large
Numerator too small
World Health Organization

24. 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

25. 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

26. 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

27. 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