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Strategic Information and the Control of Tuberculosis Brian Williams and Chris Dye TB programme, Monitoring and Evaluati

Strategic Information and the Control of Tuberculosis Brian Williams and Chris Dye TB programme, Monitoring and Evaluation, WHO. Data. Epi. Programmes. Policy. 70%. Detect. Prevalence. DOTS. Smear +. Programme data. Dynamical models. MDR. Culture +. Ext. pul. Surveys. 5%p.a. .

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Strategic Information and the Control of Tuberculosis Brian Williams and Chris Dye TB programme, Monitoring and Evaluati

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  1. Strategic Information and the Control of Tuberculosis Brian Williams and Chris Dye TB programme, Monitoring and Evaluation, WHO

  2. Data Epi Programmes Policy 70% Detect Prevalence DOTS Smear + Programme data Dynamical models MDR Culture + Ext. pul. Surveys 5%p.a. 85% MDGs Cure HIV Incidence

  3. 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?

  4. Estimated TB cases, 2000 Corbett et al. Archives of Internal Medicine 2003

  5. Estimated TB Incidence Rates, 2000 per 100 000 population < 10 10 to 24 25 to 49 50 to 99 100 to 299 300 or more No Estimate 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 0–10 10–24 25–49 50–99 100–299 300+ No data

  6. Estimated TB incidence vs HIV prevalence in high burden countries 1600 1200 Estimated annual TB incidence (per 100K adults, 1999) 800 400 HIV prevalence increases by 1% TB incidence increases by 26/100k/yr Everyone had HIV, TB incidence would be 3%/yr 0 0.0 0.1 0.2 0.3 0.4 HIV prevalence, adults 15-49 years

  7. 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?

  8. Mansoer and Kutwa Nairobi

  9. Marum and Chebet Nairobi

  10. Nairobi 6 yr

  11. DOTS plus… • TB preventive therapy (Malawi)? • TB mass treatment (South Africa)? • Behaviour change (Uganda)? • Condoms (Thailand)? • ART (Brazil)? • Prophylactic ART?

  12. Impact of inteventions on TB cases Baseline ARV 80% TLTI (6 m) TLTI (life) ARV 100% TB detect. TB cure HIV incid . 800 600 400 200 0 TB incidence/100k/yr Base line: CDR = 50% CR = 70% Interventions: 10% increase 1980 2000 2020 2040 Year PT (6 mo.) PT (life) Currie et al. AIDS 2003

  13. 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?

  14. Mono Dual Triple therapy TB among AIDS patients in Brazil Pulmonary TB Disseminated TB www.aids.gov.br/boletim/bol_htm/boletim.htm

  15. CD4+ cell counts at start of therapy (100s/l) 0 100 200 300 400 Relative TB incidence 500 600 700 800 Years since HIV infection

  16. Reduction in the life-time risk of TB among HIV positive people Williams & Dye Science

  17. 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?

  18. Is TB incidence falling in Morocco? 70 60 50 40 population Incidence rate/100,000 30 20 10 0 1980 1985 1990 1995 2000 2005 2010 2015

  19. Is TB incidence falling in Morocco? 70 60 50 on aging population 40 population Incidence rate/100,000 30 on 1994 age-structure 20 3.8% p.a. 10 0 1980 1985 1990 1995 2000 2005 2010 2015

  20. 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.

  21. Stategic decision making needs... Strategic data Currently national, aggregated data; local disaggregatged data; surveys; etc. Understand the epidemiology Good models to explain and predict; refinements for HIV Test impact Impact of DOTS programmes; investigate context; monitoring part of treatment.

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