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Special Communication |

Evolution of Tuberculosis Control and Prospects for Reducing Tuberculosis Incidence, Prevalence, and Deaths Globally

Christopher Dye, DPhil; Catherine J. Watt, DPhil; Daniel M. Bleed, MD; S. Mehran Hosseini, MD; Mario C. Raviglione, MD
JAMA. 2005;293(22):2767-2775. doi:10.1001/jama.293.22.2767.
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Context The United Nations Millennium Development Goals (MDGs) are stimulating more rigorous evaluations of the impact of DOTS (the WHO-recommended approach to tuberculosis control based on 5 essential elements) and other possible strategies for tuberculosis (TB) control.

Objective To evaluate the prospects for detecting 70% of new sputum smear–positive cases and successfully treating 85% of these by the end of 2005, for reducing TB incidence, and for halving TB prevalence and deaths globally between 1990 and 2015, as specified by the MDGs.

Data Sources TB case notifications (1980-2003) from DOTS and non-DOTS programs and cohort treatment outcomes (1994-2002) reported annually to the World Health Organization (WHO) by up to 200 countries, TB death registrations, and prevalence surveys of infection and disease.

Study Selection Case notification series that reflect trends in incidence, treatment outcomes from DOTS cohorts, death statistics from countries with WHO-validated vital registration systems, and national prevalence surveys of infection and disease.

Data Extraction Case reports, treatment outcomes, prevalence surveys, and death registrations from WHO's global TB database covering 1990-2003 to estimate TB incidence, prevalence, and death rates through 2015 for 9 epidemiologically different world regions.

Data Synthesis TB incidence increased globally in 2003, but incidence, prevalence, and death rates were approximately stable or decreased in 7 of 9 regions. The exceptions were regions of Africa with low (<4% in adults 15-49 years) and high rates (≥4%) of HIV infection. The global detection rate of new smear-positive cases by DOTS programs increased from 11% in 1995 to 45% in 2003 (with the lowest case-detection rates in Eastern Europe and the highest rates in the Western Pacific) and could reach 60% by 2005. More than 17 million patients were treated in DOTS programs between 1994 and 2003, with overall treatment success rates more than 80% since 1998. In 2003, overall reported treatment success was 82%, with much variation among regions. The highest rates were reported in the Western Pacific region (89%) and lowest rates in African countries with high and low HIV infection rates (71% and 74%, respectively), in established market economies (77%), and in Eastern Europe (75%). To halve the prevalence rate by 2015, TB control programs must reach global targets for detection (70%) and treatment success (85%) and also reduce the incidence rate by at least 2% annually. To halve the death rate, incidence must decrease more steeply, by at least 5% to 6% annually.

Conclusion Reduction of TB incidence, prevalence, and deaths by 2015 could be achieved in most of the world, but the challenge will be greatest in Africa and Eastern Europe.

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Figure 1. Trajectories of the Tuberculosis Epidemic for 9 Epidemiologically Different Regions of the World
Graphic Jump Location

Points mark trends in incidence rates, derived from case notifications for 1990-2003. Dashed lines project incidence rates beyond 2003 to 2015. The 2 panels separate regions with estimated incidence rates above (A) or below (B) the global average in 1990 (solid line). Groupings of countries are based on the World Health Organization (WHO) regions of Africa, which is subdivided into countries with high human immunodeficiency virus (HIV) infection rates (≥4% in adults aged 15-49 years in 2003) and those with low HIV rates (<4%), Central Europe, Eastern Europe (former Soviet countries plus Bulgaria and Romania), Eastern Mediterranean, established market economies (all 30 Organization for Economic Cooperation and Development countries, except Mexico, Slovakia, and Turkey, plus Singapore), Latin America, Southeast Asia, and Western Pacific. The countries in each region are listed in full elsewhere.15 Lines were fitted by nonlinear least squares regression to the notification data for countries within regions, and the fitted lines aggregated to generate the regional trend. Aggregation of fits to country data explains why regional trends do not always look smooth.

Figure 2. Estimated Progress Toward the Target of 70% Smear-Positive Case Detection by DOTS Programs According to 3 Scenarios
Graphic Jump Location

Lines show the measured progress from 1995-2003 (solid)15 and 3 scenarios leading up to Millennium Development Goals target year 2015. The baseline scenario assumes that the increase in case detection in each of 9 regions will proceed at the average rate measured for 1995-2003 and that no region will attain a case detection rate greater than 70%. The optimistic scenario assumes that the 70% target will be reached in all regions no later than 2005. The pessimistic scenario assumes that the case detection rate will not exceed 50% in any region by 2015. Discontinuities in these trajectories arise because the case detection rate in each region is assumed to stop abruptly at the maximum permitted under each scenario.

Figure 3. Treatment Success Rates, 1994-2002
Graphic Jump Location

Progress toward the Millennium Development Goals target of 85% treatment success globally and for the 22 highest-incidence countries that account for about 80% of all new cases each year. The number of sputum smear–positive patients registered for treatment globally by DOTS programs increased from 224 416 in 1994 to 1 422 075 in 2002.

Figure 4. Expected Impact of the DOTS Strategy
Graphic Jump Location

A, Tuberculosis prevalence rates. B, Tuberculosis mortality rates globally. Solid lines show the consequences of implementing the scenarios in Figure 2. The dashed lines show the expected reductions in prevalence and death rates in the baseline scenario for the world excluding Africa (countries with low and high HIV rates) and Eastern Europe. CDR indicates the case detection rate by DOTS programs. Horizontal dotted lines mark the position of the Millennium Development Goals (MDGs) targets for prevalence and deaths, to be reached by 2015. Discontinuities in the trends arise for the reason given in Figure 2.



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