DOTS Expansion: Monitoring Drugs

Leopold Blanc

TBS, Stop TBWHO, Communicable Diseases

Global monitoring examples

Monitoring drugs

Indicators for TuberculosisImpact: change in epidemiological profile

(special studies)

Number of smear-positive cases per 100,000 population (prevalence/incidence)

Number of deaths from TB (all forms) per 100,000 population annually (mortality)

per 100 000 pop

<10 (20)10 to 24 (32)25 to 49 (37)50 to 99 (38)100 to 299 (52)300 or more (29)no estimate (3)

Estimated Global Incidence 2000

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

DOTS results in TB incidence decline. The Case of Peru

100

120

140

160

180

200

220

1980 1985 1990 1995 2000

TB

cas

es/1

00,0

00

DOTS 1990

PTB falling at 6% per year

case finding

0

10

20

30

40

50

60%

Case Fatality (–Program)

Case Fatality(+Program)

Deaths Averted

Deaths averted59, 000 56%30, 000 47%26, 000 37%

TB Deaths Prevented in ChinaTB Deaths Prevented in China

World Health OrganizationWorld Health Organization

Indicators for Tuberculosis

Coverage/Outcomes (routinely collected)At national/intermediate/district level

Proportion of all treatment units implementing DOTS (DOTS coverage: 100%)

Proportion of smear-positive TB cases registered under DOTS successfully treated (treatment success rate: 85%)

Proportion of all estimated new smear-positive TB cases detected under DOTS (ratio of detection: 70%)

Projected Case Detection Under DOTSWithout accelerated expansion, World Health Assembly

targets will be reached in 2013.

0

10

20

30

40

50

60

70

80

1990 1995 2000 2005 2010 2015

Cas

es n

oti

fied

un

der

DO

TS

(%

)

Average rate of progress:target 2013

Accelerated progress:target 2005

WHO target 70%

DOTS begins 1991

DOTS Progress in 22 High-burden Countries, 1999–2000

10

20

30

40

50

60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100

DOTS Detection Rate (%)

Tre

atm

ent

Suc

cess

(%

)

Uganda

DRCongo

Kenya Tanzania

Vietnam

MyanmarBangladeshIndia

Philippines

Indonesia

China

EthiopiaNigeria

South AfricaThailand

Cambodia TARGET ZONEBrazil

Zimbabwe

Mozambique

Afghanistan

Russia

Pakistan

Source: Global Tuberculosis Control. WHO Report 2002. WHO/CDS/TB/2002.295.

Indicators for TuberculosisProcess/outputs (examples)

Financial - Proportion of total financial requirements for DOTS implementation/expansion

available; proportion from government - Proportion of implementation units with adequate budget for DOTS components

Diagnosis - Proportion of respiratory symptomatics examined by smear examination - Proportion of units with adequate cross-check results in QA system

Treatment - Regimens: proportion of patients receiving standard regimens - Case management: proportion of all cases receiving adequate supervision in

intensive phase

Drugs: Workshop discussion

Monitoring - Proportion of units with adequate supervision and monitoring - Proportion of units submitting accurate, complete, and timely reports

Indicators for TuberculosisManagement of drugs (examples)

Drug policy/registration

Procurement

Distribution

Use of drugs

Quality control

Drug Policy/Registration

Percentage of TB drugs that are registered in the country

Average number of days to register or re-register TB drugs after they arrive in country

Percentage of TB treatment facilities that have the national guidelines for treatment of TB

Procurement

Average lead time to receive approvals for an order of TB drugs

Average lead time for suppliers to fulfill contracts

Average time required to clear shipments of TB drugs from the port of entry for the last three procurements

Costs of TB drugs as percentage of costs of GDF

Distribution

Average percentage of time out-of-stock for a set of TB drugs at central level and at treatment facility

Average percentage of a set of unexpired TB drugs available in MOH storage and treatment facilities

Average percentage of stock records that correspond with physical counts for a set of TB drugs at central level and in treatment facilities

Drug Use

Percentage of new smear-positive patients with pulmonary TB who were prescribed drugs and dosage according to national guidelines

Percentage of TB patients who could describe how the prescribed medication should be used

Percentage of prescribed TB drugs actually dispensed

Percentage of drug retail outlets where rifampicin and streptomycin were available without prescription

Quality Control

Percentage of TB drug samples that failed quality-control testing out of the total number of TB drug samples tested

Total number of quality problems reported during the year by storerooms, prescribers, dispensing personnel, and patients