Dye C, Garnett G P, Sleeman K, Williams B G
Global Tuberculosis Programme, WHO, Geneva, Switzerland.
Lancet. 1998 Dec 12;352(9144):1886-91. doi: 10.1016/s0140-6736(98)03199-7.
WHO advocates the use of directly observed treatment with a short-course drug regimen as part of the DOTS strategy, but the potential effect of this strategy worldwide has not been investigated.
We developed an age-structured mathematical model to explore the characteristics of tuberculosis control under DOTS, and to forecast the effect of improved case finding and cure on tuberculosis epidemics for each of the six WHO regions.
In countries where the incidence of tuberculosis is stable and HIV-1 absent, a control programme that reaches the WHO targets of 70% case detection and 85% cure would reduce the incidence rate by 11% (range 8-12) per year and the death rate by 12% (9-13) per year. If tuberculosis has been in decline for some years, the same case detection and cure rates would have a smaller effect on incidence. DOTS saves a greater proportion of deaths than cases, and this difference is bigger in the presence of HIV-1. HIV-1 epidemics cause an increase in tuberculosis incidence, but do not substantially reduce the preventable proportion of cases and deaths. Without greater effort to control tuberculosis, the annual incidence of the disease is expected to increase by 41% (21-61) between 1998 and 2020 (from 7.4 million to 10.6 million cases per year). Achievement of WHO targets by 2010 would prevent 23% (15-30) or 48 million cases by 2020.
The potential effect of chemotherapy (delivered as DOTS) on tuberculosis is greater in many developing countries now than it was in developed countries 50 years ago. To exploit this potential, case detection and cure rates urgently need to be improved in the main endemic areas.
世界卫生组织提倡将直接观察下的短程药物治疗作为综合直接观察短程化疗策略的一部分，但该策略在全球的潜在效果尚未得到研究。
我们建立了一个年龄结构数学模型，以探讨综合直接观察短程化疗策略下的结核病控制特征，并预测改善病例发现和治愈对世界卫生组织六个区域中每个区域结核病流行情况的影响。
在结核病发病率稳定且无人类免疫缺陷病毒1型（HIV-1）的国家，一个达到世界卫生组织70%病例发现率和85%治愈率目标的控制项目将使发病率每年降低11%（范围为8%-12%），死亡率每年降低12%（9%-13%）。如果结核病已经下降了若干年，相同的病例发现率和治愈率对发病率的影响会较小。综合直接观察短程化疗策略挽救的死亡比例高于病例比例，在存在HIV-1的情况下这种差异更大。HIV-1流行导致结核病发病率上升，但并未大幅降低病例和死亡的可预防比例。如果不加大控制结核病的力度，预计在1998年至2020年间该疾病的年发病率将增加41%（21%-61%）（从每年740万例增至1060万例）。到2010年实现世界卫生组织的目标将在2020年预防23%（15%-30%）即4800万例病例。
现在化疗（以综合直接观察短程化疗的形式实施）对许多发展中国家结核病的潜在效果比50年前对发达国家的效果更大。为了挖掘这一潜力，主要流行地区迫切需要提高病例发现率和治愈率。
