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.)

0

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

0

10

20

30

40

50

60

70

80

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

0

10

20

30

40

50

60

70

80

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

70

80

90

100

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

0

20

40

60

80

100

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

0

50

100

150

200

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