Monitoring Outcomes in TB Control Summary...Monitoring Outcomes in TB Control Summary Dan Bleed, WHO...
Transcript of Monitoring Outcomes in TB Control Summary...Monitoring Outcomes in TB Control Summary Dan Bleed, WHO...
Monitoring Outcomes in TB Control
Summary
Dan Bleed, WHO Stop TB Geneva2nd consultation on macroeconomics and health
Working group 1, 28 Oct 2003
• Selected operational (outcome)indicators that dovetail with ourbrand-name strategy.
• Indicators available and used atall levels in std fashion
• Routine data lean, useful forclinical decisions, programmemonitoring, and epi interpretation
WHO global reports on TB control, 1997-2003
TB monitoring at global/regional level
Typically reflect 85% of the world’s countries, 95% of the world’s pop.
Www.who.int/gtb
Incidence Rate<10 (19)10 to 24 (31)25 to 49 (41)50 to 99 (35)100 to 299 (50)300 or More (25)
Estimated TB Incidence Rate, 2002
TB monitoring at global/regional level (cont.)New TB cases 8.6m (138/100K)Deaths from TB (inc HIV) 1.8m (28/100K)Prevalence HIV in new adult cases 12%Prevalence MDR in new cases 3.2%
Regional trends (AFR)
050
100150200250300350400
1980 1985 1990 1995 2000
Stan
dard
ized
cas
e no
tific
aito
n ra
teTB monitoring at global/regional level (cont.)
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50
100
150
200
250
300
1980 1985 1990 1995 2000
Stan
dard
ized
cas
e no
tific
atio
n ra
teRegional trends (FSU countries)
TB monitoring at global/regional level (cont.)
World Health Assembly 1991Targets for 2005:
• 70% case detection• 85% cure
MDG “impact” targets for 2015:• Halve TB prevalence and TB deaths
Tracking global targets...TB monitoring at global/regional level (cont.)
High treatment success in DOTS areas
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10
20
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90
100
1995 1996 1997 1998 1999 2000 2001
Trea
tmen
t suc
cess
(%)
DOTS smear+non DOTS smear+target 85%
Progress towards 70% case detection
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10
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1990 1995 2000 2005 2010 2015
Year
Cas
e de
tect
ion
rate
(%
) Target 70%
Smear+ cases DOTS
All smear+ cases
Forecast 2002: 1.4m smear+ = 37% DDR
Progress towards the 70/85 targets
Zimbabwe
Viet Nam
Tanzania
Uganda
Thailand
South AfricaRussia
Philippines
Pakistan
NigeriaMyanmar
MozambiqueKenya
Indonesia India
Ethiopia
DR Congo
ChinaCambodia
Brazil
Bangladesh
Afghanistan
40
50
60
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0 20 40 60 80 100
DOTS detection rate (%)
Trea
tmen
t suc
cess
(%)
WHA 1991 targets for 2005:• 70% case detection• 85% cure
MDG “impact” targets for 2015:• Halve TB prevalence and TB deaths
…but also because of the monitoring systemsestablished within countries.
Global / regional TB monitoring is possible becausewe have clear indicators and targets at globallevel...
• Definition of case types on 3 axes (history,site, smear). Cannot be compromised.• Maintenance of a district-level individualpatient register (managerial tool).• Collection of follow-up data on each courseof treatment over 6-9 months of treatment --smears plus 100% final outcome of eachcourse.• Cohort analysis of treatment success, i.e.,patients grouped by period of diagnosis.
The WHO/IUATLD-recommended monitoringsystem for national TB control programmes:
Quarterly reporting forms
Mutually exclusive
Q2Q1 2003Q4 2002 Q3Cured
Cohort AnalysisQ4 2003
FailedCured
CuredCured
DiedDefaulted
Defaulted
TransferredCured
Cured
Performed here
Reasons for successful national implementation ofTB monitoring systems:
A. TB control is very vertical Health workers are TB-dedicated ?
B. TB control has the most money Salaries are better? Equipment too?
C. TB control is easierSputum collection / smear microscopy easy?6-mo follow-through easy ?
D. None of the above
Answer: D
…because the national TB monitoringsystem has following features:
• Case definitions have clinical relevance (assignment ofregimens, outcomes of regimens, e.g., default)
• Treatment outcome = immediate indicator of programmeoutcome. Relevant and motivating to all levels.
• Cross-referenced data sources (TB register, Lab) are usefulfor supervision. (TB coordinator can verify data, look atcase-finding effort (Nb suspects, Distribution of case types)
• TB register has managerial relevance (estimating supplies)
• Fall in deaths (rapid), fall in incidence (slower) and rise inave age gives insight to Epi picture, ulimately show impact.
Is TB incidence really falling in Oman?
0.000
0.005
0.010
0.015
0.020
0.025
1980 1985 1990 1995 2000 2005
Smea
r+ c
ases
/slid
es
exam
ined
050100150200250300350400450
Smea
r+ c
ases
or
smea
rs e
xam
ined
mean rate decline 9%/yr
Smear+ case detection depends on number of slides examined/patient
2030405060708090
100
1.6 1.8 2.0 2.2 2.4 2.6 2.8 3.0 3.2 3.4Slides examined/patient
Smea
r+/a
ll pu
lmon
ary
Distribution of case types vis-a-visnormal benchmarks.
Three Syrian provinces report low proportions of smear-positive cases
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20
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A D H I K L M R RD S SW T ZProvince
Smea
r+/p
ulm
onar
y ca
ses
Impact of improved TB control in Peru: deaths averted
0
5000
10000
15000
20000
87 88 89 90 91 92 93 94 95 96 97 98 99
Estim
ated
num
ber o
f dea
ths
otherdefaulteduntreated
DOTS 1991
Dynamics of pulmonary TB in Peru 1980-2000
100
120
140
160
180
200
220
1980 1985 1990 1995 2000
Pulm
onar
y TB
cas
es/1
00,0
00 DOTS 1990
PTB falling at 6%/yr
case finding
DOTS
• Government commitment to TB control
• Diagnosis by smear microscopy mostly on self-reporting symptomatic patients
• Standardised Short-course Treatment (SCC) withdirect observation (DOT)
• Efficient system of drug supply
• Efficient recording and reporting system withassessment of treatment results
The internationally-recommended TB control strategy
THE END
Summary
Dan Bleed, WHO Stop TB Geneva2nd consultation on macroeconomics and health
Working group 1, 28 Oct 2003
• Selected operational (outcome)indicators that dovetail with ourbrand-name strategy.
• Indicators available and used atall levels
• Routine data lean, useful forclinical decisions, programmemonitoring, and epi interpretation
HC+L
HC
HCHC+L
DHOHosp
.
Supervision, R&R
LAB, Treatment Smear prep,Treatment
LAB, Treatment
District in IndonesiaPublic Preventive Services Public Curative Services
DOTS reduces prevalence of TB by 37% over a decade in China
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50
100
150
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250
1990 2000
Prev
alen
ce c
ultu
re+
TB/1
00,0
00
DOTSOther
Why are TB cases “undetected”?
estimated TB cases
all true TB cases
cases presentingto health facilities
cases presenting topublic health facilities
cases presenting toDOTS facilities
cases correctlydiagnosed by DOTS
facilities
diagnosed casesreported by DOTS
facilities
FrameworkandEvidence base