strategic information and the control of tuberculosis brian williams and chris dye tb programme,...
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Strategic Information and the Control of Tuberculosis
Brian Williams and Chris Dye
TB programme,Monitoring and Evaluation, WHO
Cure
Detect
Dynamical models
70%
85%
DOTS
MDGs
Ext. pul.
Smear +
Culture +
Incidence
Prevalence
Programme data
Surveys
Data Epi Programmes Policy
5%p.a.
MDR
HIV
Four questions
• Where should donors invest?
• If ‘DOTS don’t do it’ what does?
• What will ARV drugs do for TB?
• How can we monitor progress?
Estimated TB cases, 2000 Corbett et al. Archives of
Internal Medicine 2003
Estimated TB Incidence Rates, 2000
25 to 49
50 to 99
100 to 299
< 10
10 to 24
300 or more
No Estimate
per 100 000 population
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
0–1010–2425–4950–99100–299300+No data
Estimated TB incidence vs HIV prevalence
in high burden countries
0
400
800
1200
1600
0.0 0.1 0.2 0.3 0.4
HIV prevalence, adults 15-49 years
Est
imat
ed a
nn
ual
TB
in
cid
ence
(per
100
K a
du
lts,
199
9)
HIV prevalence increases by 1%TB incidence increases by 26/100k/yrEveryone had HIV, TB incidence would be 3%/yr
Four questions
• Where should donors invest?
• If DOTS don’t do it what does?
• What will ARV drugs do for TB?
• How can we monitor progress?
0
100
200
300
400
500
600
700
1980 1990 2000
TB
not
ifica
tion/
100k
0.00
0.05
0.10
0.15
HIV
pre
vale
nce
NairobiMansoer and Kutwa
0
100
200
300
400
500
600
700
1980 1990 2000
TB
not
ifica
tion/
100k
0.00
0.05
0.10
0.15
HIV
pre
vale
nce
NairobiMarum and Chebet
0
100
200
300
400
500
600
700
1980 1990 2000
TB
not
ifica
tion/
100k
0.00
0.05
0.10
0.15
HIV
pre
vale
nce
Nairobi
6 yr
DOTS plus…
• TB preventive therapy (Malawi)? • TB mass treatment (South
Africa)?• Behaviour change (Uganda)?• Condoms (Thailand)?• ART (Brazil)?• Prophylactic ART?
Impact of inteventions on TB casesT
B in
cide
nce/
100k
/yr
800
600
400
200
0
.Baseline
ARV 80%
TLTI (6 m)
TLTI (life)
ARV 100%
TB detect.
TB cure
HIV incid
Base line:CDR = 50%CR = 70%Interventions:10% increase
1980 2000 2020 2040 Year
Currie et al. AIDS 2003
PT (6 mo.)
PT (life)
Four questions
• Where should donors invest?
• If DOTS don’t do it what does?
• What will ARV drugs do for TB?
• How can we monitor progress?
0.00
0.05
0.10
0.15
1985 1990 1995 2000
Ann
ual i
ncid
ence
in A
IDS
cas
es
Pulmonary TB
Disseminated TB
Mono Dual Triple therapy
TB among AIDS patients in Brazil
www.aids.gov.br/boletim/bol_htm/boletim.htm
0.000
0.001
0.002
0.003
0.004
0 5 10 15 20
Years since HIV infection
Relative TB incidence800
700600
500
400
300200
100
0
CD4+ cell counts at start of therapy (100s/l)
1.00.90.80.70.60.50.40.30.20.10.0
800
700
600
500
400
300
200
100
0
Coveragecompliance
0.0 0.2
0.2 0.4
0.4 0.6
CD
4+ c
ell
cou
nt
at
sta
rt o
f A
RVa
Reduction in the life-time risk of TB among HIV positive people
Williams & Dye Science
Four questions
• Where should donors invest?
• If DOTS don’t do it what does?
• What will ARV drugs do for TB?
• How can we monitor progress?
Is TB incidence falling in Morocco?
0
10
20
30
40
50
60
70
1980 1985 1990 1995 2000 2005 2010 2015
Inci
den
ce r
ate/
100,
000
po
pu
lati
on
Is TB incidence falling in Morocco?
0
10
20
30
40
50
60
70
1980 1985 1990 1995 2000 2005 2010 2015
Inci
den
ce r
ate/
100,
000
po
pu
lati
on
on 1994 age-structure
on aging population
3.8% p.a.
Aging cases say that it is
35
37
39
41
43
45
1980 1985 1990 1995 2000
Ave
rag
e ag
e ca
ses
(yr)
Pulmonary TB falling fastest in children than in Morocco
0
2
4
6
8
10
12
0 20 40 60 80
Age (years)
Dec
line
in p
ulm
on
ary
TB
(%
per
cap
ita/
yr)
average rate decline 3.8%/yr
Four answers• TB investment? 22 high burden countries;
especially those where AIDS is high.
• What might work? Find and cure (better DOTS); refer TB patients for ARV; cut HIV transmission.
• What will ARVs do for TB? Reduce TB in late stage HIV; little impact on overall transmission
• Monitoring? Draw on unused local programme data, surveys, expertise and knowledge.
Stategic decision making needs...
Strategic dataCurrently national, aggregated data; local disaggregatged data; surveys; etc.
Understand the epidemiologyGood models to explain and predict; refinements for HIV
Test impactImpact of DOTS programmes; investigate context; monitoring part of treatment.
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