Guia Tuberculose WHO 2

8/6/2019 Guia Tuberculose WHO 2

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he World Health Organization (WHO) has published

an annual report on global control o tuberculosis(B) every year since 1997. Te main purpose o the

report is to provide a comprehensive and up-to-date

assessment o the B epidemic and progress made in B

care and control at global, regional and country levels.

Progress towards global targets set or 2015 is given par-

ticular attention. Te target included in the Millennium

Development Goals (MDGs) is that B incidence should

be alling by 2015. Te Stop B Partnership has set two

additional targets, which are to halve rates o prevalence

and mortality by 2015 compared with their levels in

1990. Collectively, the WHOs Stop B Strategy and the

Stop B Partnerships Global Plan to Stop B have setout how the 2015 targets can be achieved.

Tis fteenth annual report1 contains more up-to-

date inormation than any previous report in the series,

ollowing earlier data collection and the completion o

the production cycle within a calendar year.

Te estimates o the global burden o disease caused

by B in 2009 are as ollows: 9.4 million incident cases

(range, 8.9 million9.9 million), 14 million prevalent

cases (range, 12 million16 million), 1.3 million deaths

among HIV-negative people (range, 1.2 million1.5 mil-

lion) and 0.38 million deaths among HIV-positive people(range, 0.32 million0.45 million). Most cases were in

the South-East Asia, Arican and Western Pacifc regions

(35%, 30% and 20%, respectively). An estimated 1113%

o incident cases were HIV-positive; the Arican Region

accounted or approximately 80% o these cases.

Tere were 5.8 million notifed cases o B in 2009,

equivalent to a case detection rate (CDR, defned as the

proportion o incident cases that were notifed) o 63%

(range, 6067%), up rom 61% in 2008. O the 2.6 mil-

lion patients with sputum smear-positive pulmonary B

in the 2008 cohort, 86% were successully treated.

New and compelling data rom 15 countries show that

eorts by national B programmes (NPs) to engage all

care providers in B control (termed public-private mix,

or PPM) can be a particularly eective way to increase

the CDR. In areas where PPM was implemented, non-

NP providers accounted or around one-fth to one-

third o total notifcations in 2009.

In 2009, 26% o B patients knew their HIV status

(up rom 22% in 2008), including 53% o patients in

the Arican Region. A total o 300 000 HIV-positive B

patients were enrolled on co-trimoxazole preventive

therapy, and almost 140 000 were enrolled on antiret-roviral therapy (75% and 37% respectively o those who

tested HIV-positive). o prevent B, almost 80 000 peo-

ple living with HIV were provided with isoniazid preven-tive therapy. Tis is an increase rom previous years, but

still represents less than 1% o the estimated number o

people living with HIV worldwide.

Among B patients notifed in 2009, an estimated

250 000 (range, 230 000270 000) had multidrug-

resistant B (MDR-B). O these, slightly more than

30 000 (12%) were diagnosed with MDR-B and notifed.

Diagnosis and treatment o MDR-B need to be rapidly

expanded.

Funding or B control continues to increase and will

reach almost US$ 5 billion in 2011. Tere is considerable

variation in what countries spend on a per patient basis(US$ 1000), and the extent to which coun-

tries rely on domestic or external sources o unds. Com-

pared with the unding requirements estimated in the

Global Plan, the unding gap is approximately US$ 1 bil-

lion in 2011. Given the scale-up o interventions set out

in the plan, this could increase to US$ 3 billion by 2015

without intensifed eorts to mobilize more resources.

Incidence rates are alling globally and in fve o

WHOs six regions (the exception is the South-East Asia

Region, where the incidence rate is stable). I these trends

are sustained, the MDG target will be achieved. Mortal-ity rates at global level ell by around 35% between 1990

and 2009, and the target o a 50% reduction by 2015

could be achieved i the current rate o decline is sus-

tained. At the regional level, the mortality target could

be achieved in fve o WHOs six regions; the exception

is the Arican Region (although rates o mortality are

alling). Prevalence is alling globally and in all six WHO

regions. Te target o halving the 1990 prevalence rate

by 2015 appears out o reach at global level, but could be

achieved in three o six regions: the Region o the Ameri-

cas, the Eastern Mediterranean Region and the Western

Pacifc Region.

Reductions in the burden o disease achieved to date

ollow 15 years o intensive eorts to improve B care

and control. Between 1995 and 2009, a total o 41 mil-

lion B patients were successully treated in DOS pro-

grammes, and up to 6 million lives were saved including

2 mill ion among women and children. Looking orwards,

the Stop B Partnership launched an updated version o

the Global Plan to Stop B in October 2010, or the years

20112015. In the fve years that remain until the tar-

get year o 2015, intensifed eorts are needed to plan,

fnance and implement the Stop B Strategy, accordingto the updated targets included in this plan. Tis could

save at least one million lives per year.1 wo reports were published in 2009. Te and

sections o this report explain why this was necessary.


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he World Health Organization (WHO) has published

an annual report on global control o tuberculosis(B) every year since 1997. Te main purpose o the

report is to provide a comprehensive and up-to-date

assessment o the B epidemic and progress made in B

care and control at global, regional and country levels.

Tis fteenth annual report1 contains more up-to-date

inormation than any previous report in the series, ol-

lowing earlier data collection and the completion o the

production cycle within a calendar year.

Te main part o the report is structured in eight

major sections, as ollows:

Methods. Tis section explains how the data used toproduce the report are collected, reviewed and ana-

lysed.

Te global burden of disease caused by B in

2009. Tis section presents estimates o incidence,

prevalence and mortality (absolute numbers and

rates) at global, regional and country levels in 2009.

Global targets, the WHO Stop B Strategy and

the Global Plan to Stop B. Tis section defnes

the global targets or B control that have been set

or 2015, as part o the Millennium Development

Goals (MDGs) and by the Stop B Partnership. It then

describes the main components o the Stop B Strat-egy and the Stop B Partnerships Global Plan to Stop

B, which in combination have set out how the global

targets can be achieved.

Progress in implementing the Stop B Strat-

egy and the Global Plan to Stop B. Tis section

includes analysis o case notifcations, treatment out-

comes, case detection rates (or all orms o B), the

contribution o publicprivate mix (PPM) initiatives

to case notifcations, implementation o collabora-

tive B/HIV activities and the management o drug-

resistant B. It also eatures the topic o humanresource development and provides an update about

the work o the Global Laboratory Initiative, whose

goal is to strengthen laboratories worldwide.

Financing for B control. Recent trends in und-

ing or B control, including comparisons with the

unding requirements estimated in the Global Plan,

are presented and discussed. Recent successes in

strengthening planning and budgeting or B control

using the WHO B planning and budgeting tool are

showcased.

Progress towards the 2015 targets. Tis section

analyses trends in rates o B incidence, prevalence

and mortality rom 1990 to 2009, and assesses wheth-

er the 2015 targets can be achieved at global, regional

and country levels.

Improving measurement of the burden of disease

caused by B. Tis section summarizes progress at

country level in strengthening surveillance (o cases

and deaths) and implementing surveys o the preva-

lence o B disease, in the context o the policies and

recommendations o the WHO Global ask Force on

B Impact Measurement. Conclusions. Tis fnal section draws together the

main fndings and recommendations in the report.

explains the methods that were used to produce

estimates o disease burden. contains summary

tables that provide global, regional and country-specifc

data or the main indicators o interest.

or all countries are available online at www.

who.int/tb/data; their content is advertised in .

1 wo reports were published in 2009. Te frst report (March) includ-

ed key indicators up to and including 2007 (or example, estimates

o disease burden and case notifcations). Te second report (pub-

lished on the web in December) included key indicators up to and

including 2008. wo reports were produced in one year in anticipa-

tion o a dierent production cycle in which reports would always

contain data up to and including the previous calendar year.


3/43

or the 2010 round o data collection, WHO updated

the orms that were used in 2009. Te main changewas that questions on surveillance o MDR-B, which

had previously been asked through a separate data col-

lection eort, were integrated into the global B data

collection orm. As in 2009, two versions o the orm

were developed (a long orm and a short orm). Te short

orm was adapted or use in high-income countries (that

is, countries with a gross national income per capita o

US$ 12 196 in 2009, as defned by the World Bank) and/

or low-incidence countries (defned as countries with an

incidence rate o


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provides details about the methods used to

produce estimates o the disease burden caused by B

(measured as incidence, prevalence and mortality).

In line with the methods explained in this annex, the

results provided in the main text o the report and in

are presented as best, low and high estimates.

When the term range is used ater a best estimate in

the main text o the report, the lower and higher num-

bers correspond to the 2.5th and 97.5th centiles o the

outcome distributions produced by simulations. Tese

are distinct rom 95% confdence intervals, which are

estimated directly rom observed, empirical data.


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tinues to increase slightly rom year to year, as slow

reductions in incidence rates per capita (see )continue to be outweighed by increases in population.

Estimates o the number o cases broken down by age

and sex have been prepared by an expert group2 as part o

1 Te range is t he uncertainty interva l that corresponds to the 2.5th and 97.5th centiles o the outcome distributions produced by simulations.

See also and .2 Tis expert group is convened by the WHO Global ask Force on B Impact Measurement. See also o this report.

n 2009, there were an estimated 9.4 million incidentcases (range, 8.9 million9.9 million)1 o B glo-

bally (equivalent to 137 cases per 100 000 population)

(, ). Te absolute number o cases con-


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024

2549

5099

100299

300

No estimate

Estimated new TB

cases (all forms) per100 000 population

04

519

2049

50

No estimate

HIV prevalencein new TB cases,all ages (%)


7/43

an update to the Global Burden o Disease study.1 Tese

indicate that women2 account or an estimated 3.3 mil-

lion cases (range, 3.1 million3.5 million), equivalent to

35% o all cases.

Estimates o the numbers o B cases among women

and children need to be improved through more report-

ing and more analysis o notifcation data disaggregatedby age and sex.

Most o the estimated number o cases in 2009

occurred in Asia (55%) and Arica (30%);3 smaller pro-

portions o cases occurred in the Eastern Mediterranean

Region (7%), the European Region (4%) and the Region o

the Americas (3%). Te 22 HBCs that have received par-

ticular attention at the global level since 2000 account

or 81% o all estimated cases worldwide (). Te

fve countries with the largest number o incident cases

in 2009 were India (1.62.4 million), China (1.11.5 mil-

lion), South Arica (0.400.59 million), Nigeria (0.37

0.55 million) and Indonesia (0.350.52 million). India

alone accounts or an estimated one fth (21%) o all B

cases worldwide, and China and India combined account

or 35%.

O the 9.4 million incident cases in 2009, an estimated

1.01.2 million (1113%) were HIV-positive, with a best

estimate o 1.1 million (12%) (, ). Tese

numbers are slightly lower than those reported in pre-

vious years, reecting better estimates (based on more

direct measurements as documented in ) as well

as reductions in HIV prevalence in the general popula-

tion. O these HIV-positive B cases, approximately 80%were in the Arican Region.

Tere were an estimated 14 million prevalent cases

(range, 12 million16 million) o B in 2009 (),

equivalent to 200 cases per 100 000 population. As

explained in , prevalence is a robust indicator

o the burden o disease caused by B when it is directly

measured in a nationwide survey. When survey data are

not available, it is dicult to estimate its absolute level

and trend. In those countries where surveys are done

and repeated at periodic intervals (see ), esti-

mates o the prevalence o B and trends in rates o B

prevalence will improve.

In 2009, an estimated 1.3 million deaths (range, 1.2 mil-

lion1.5 million) occurred among HIV-negative cases

o B ( ), including 0.38 million deaths (range,

0.3 million0.5 million) among women. Tis is equiva-

lent to 20 deaths per 100 000 population. In addition,

there were an estimated 0.4 million deaths (range,

0.32 million0.45 million) among incident B cases

that were HIV-positive (data not shown); these deaths

are classifed as HIV deaths in the 10th revision o the

International Classifcation o Diseases (ICD-10). Tus

in total, approximately 1.7 million people died o B in

2009. Te number o B deaths per 100 000 population

among HIV-negative people plus the estimated number

o B deaths among HIV-positive people equates to a

best estimate o 26 deaths per 100 000 population.

Tere were an estimated 440 000 cases o multi-drug

resistant B (MDR-B) in 2008 (range, 390 000

510 000).4 Te 27 countries (15 in the European Region)

that account or 86% o all such cases have been termed

the 27 high MDR-B burden countries (see also ). Te our countries that had the largest number o

estimated cases o MDR-B in absolute terms in 2008

were China (100 000; range, 79 000120 000), India

(99 000; range, 79 000120 000), the Russian Federa-

tion (38 000; range, 30 00045 000) and South Arica

(13 000; range 10 00016 000). By July 2010, 58 coun-

tries and territories had reported at least one case o

extensively drug-resistant B (XDR-B).5

1 Tis study is an update to Lopez AD et al. Global burden of disease

and risk factors. New York, Oxord University Press and Te World

Bank, 2006.2 Defned as emales aged 15 years old.3 Asia here means the WHO regions o South-East Asia and the West-

ern Pacifc. Arica means the WHO Arican Region.4 Te latest estimates are or 2008, as published in March 2010 in:

Multidrug and extensively dr ug-resistant B (M/XDR-B): 2010 global

report on surveillance and response. Geneva, World Health Organiza-

tion, 2010 (WHO/HM/B/2010.3). Figures have not been updat-

ed or this report.5 XDR-B is defned as resistance to isoniazid and riampicin (i.e.

MDR-B) plus resistance to a uoroquinolone and, at least, one

second-line injectable agent (amikacin, kanamycin and /or capreo-

mycin).


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lobal targets or reducing the burden o diseasecaused by B have been set or 2015 and 2050

(). Currently, most attention is given to the tar-

gets set or 2015. Te target set within the context o

the MDGs is to halt and reverse the incidence o B by

2015. Te additional targets set by the Stop B Partner-

ship are to halve B prevalence and death rates by 2015,

compared with their levels in 1990.

Te Stop B Strategy1 is the approach recommended by

WHO to reduce the burden o B in line with global tar-

gets set or 2015. Te strategy is summarized in .

Te six major components o the strategy are: (i) pursue

high-quality DOS expansion and enhancement; (ii)

address B/HIV, MDR-B, and the needs o poor and

vulnerable populations; (iii) contribute to health-system

strengthening based on primary health care; (iv) engage

all care providers; (v) empower people with B, and com-

munities through partnership; and (vi) enable and pro-

mote research.

Achievements in B control in the years ollowing

implementation o DOS and the Stop B Strategy, andprospects or the urther gains that could be made up to

2015, are highlighted in .

Te Stop B Partnerships Global Plan to Stop B, 2006

2015,2 was launched in January 2006. It set out the scale

at which the interventions included in the Stop B Strat-

egy need to be implemented to achieve the 2015 targets.

In 2010, as the mid-point o the original 10-year plan

approached, the plan was updated. Tis updated ver-

sion o the plan, which covers the fve years rom 2011

to 2015, includes an updated set o targets.3 Te majortargets or 2015 in this updated plan have been defned

as ollows:

diagnosis, notifcation and treatment o approximate-

ly 7 million cases;

a treatment success rate among sputum smear-

positive cases o 90%;

HIV testing o 100% o B patients;

enrolment o 100% o HIV-positive B patients on

co-trimoxazole preventive therapy (CP) and antiret-

roviral therapy (AR);

provision o isoniazid preventive therapy (IP) to a llpeople living with HIV who are attending HIV care

services and are considered eligible or IP;

testing o 100% o previously treated B patients or

MDR-B, as well as testing o any new B patients

considered at high risk o having MDR-B (estimated

globally at around 20% o all new B patients);

enrolment o all patients with a confrmed diagnosis

o MDR-B on treatment consistent with internation-

al guidelines;

mobilization o US$ 7 billion per year to fnance

implementation o the Stop B Strategy, plus aroundUS$ 1.3 billion per year or research and development

related to new drugs, new diagnostics and new vac-

cines.

1 Te Stop B Strategy: building on and enhancing DOS to meet the B-

related Millennium Development Goals. Geneva, World Health Organ-

ization, 2006 (WHO/HM/B/2006.368).2

Te Global Plan to Stop B, 20062015: actions for life towards a worldfree of tuberculosis. Geneva, World Health Organization, 2006

(WHO/HM/SB/2006.35).3 Te Global Plan to Stop B, 20112015. Geneva, World Health Organ-

ization, 2010 (WHO/HM/SB/2010.2).


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his section examines the latest data on implementa-

tion o the Stop B Strategy, and compares progresswith the targets included in the Global Plan to Stop B,

20112015 where applicable. Te frst three topics cov-

ered are case notifcations, treatment success rates or

sputum smear-positive B patients and case detection

rates or all orms o B. Tese all illustrate progress in

implementing DOS the oundation o the Stop B

Strategy. Te ourth topic is the engagement o the ull

range o care providers in B control (component 4 o

the strategy) through PPM. Such engagement is essen-

tial to ensure high levels o case detection and treatment

success. Te next two sections cover collaborative B/

HIV activities and the diagnosis and treatment o drug-resistant B, both o which all under component 2 o

the Stop B Strategy.

Boxes are used to eature our topics laboratory

strengthening, HRD, strengthened surveillance and

rational use o anti-B medicines. All our topics are

closely related to health-system strengthening (compo-

nent 3 o the Stop B Strategy) as well as DOS and the

engagement o all care providers. ACSM, community B

care and research (components 5 and 6 o the strategy)

are not discussed because there are limitations in theavailable data. In uture, additional eorts to compile

better data on these topics will be needed. Te data that

are currently available as well as data or all other topics

covered in the 2010 data collection orm can be viewed

and downloaded on the WHO web site (www.who.int/tb/

data).

In 2009, 5.8 million cases o B (new cases and relapse

cases) were notifed to NPs, including 2.6 million new

cases o sputum smear-positive pulmonary B, 2.0 mil-

lion new cases o sputum smear-negative pulmonary B(including cases or which smear status was unknown),

0.9 million new cases o extrapulmonary B and 0.3 mil-

lion relapse cases ().1

Among pulmonary cases, 57% o global notifcations

were sputum smear-positive. Among the 22 HBCs, the

percentage o notifed cases o pulmonary B that were

sputum smear-positive was relatively low in Zimbabwe

(29%), the Russian Federation (31%), Pakistan (42%),

1 No distinction is made between DOS and non-DOS programmes. Tis is because by 2007, virtual ly all (more than 99%) notifed cases were

reported to WHO as treated in DOS programmes. Since 2009, the WHO data collection orm has made no d istinction between notifcations

in DOS and non-DOS programmes.


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Myanmar (45%), Kenya (46%) and Ethiopia (46%). A

comparatively high proportion o notifed cases were

sputum smear-positive in Bangladesh (81%), the Demo-

cratic Republic o the Congo (85%) and Viet Nam (73%).

Globally, the rate o treatment success or new sputum

smear-positive cases o pulmonary B who were treated

in the 2008 cohort was 86% (). Tis is the sec-

ond successive year that the target o 85% (frst set in

1991) has been exceeded globally. O the 22 HBCs, 13

reached the 85% target. Tis included Kenya and the

United Republic o anzania, demonstrating that coun-

tries in which there is a high prevalence o HIV among

B patients are able to achieve this target. Among WHO

regions, three met or exceeded the 85% target: the East-

ern Mediterranean Region, the South-East Asia Region

and the Western Pacifc Region. Te treatment success

rate was 80% in the Arican Region, 77% in the Region

o the Americas and 66% in the European Region (where

death and ailure rates are comparatively high). Eorts

to increase treatment success rates are warranted in

these regions, especially the European Region.

Te case detection rate (CDR)1 has been a much-used

indicator o national progress in B control since the

mid-1990s. For a given country, it is calculated as the

number o notifed cases o B in one year divided by the

number o estimated incident cases o B in the same

year, and expressed as a percentage. Te considerable

attention given to the CDR was in line with the two prin-

cipal global targets (case detection and treatment suc-

cess rates) set or B control during the period 1991 to

2005. Te targets o reaching a CDR o 70% and a treat-

1 Te CDR is actually a ratio rather than a rate, but the term rate

has become standard terminology in this context o this indicator.


12/43


13/43

ment success rate o 85% among sputum smear-positive

cases o pulmonary B by 2000 were set by the Forty-

ourth World Health Assembly in 1991, with the target

year subsequently reset to 2005.

Given uncertainty in estimates o B incidence, this

report places less emphasis on the CDR, compared with

past reports (and this will be true o uture reports on

global B control as well). In particular, this report (or

the frst time in the series o reports published since

1997) does not include estimates o the CDR or sputum

smear-positive cases o pulmonary B ().Te best estimate o the CDR o all orms o B in 2009

was 63% (range, 6067%) (). Te highest rates o

case detection in 2009 are estimated to be in the Euro-

pean Region (best estimate 80%; range, 7485%) and

the Region o the Americas (best estimate 79%; range,

7485%), ollowed by the Western Pacifc Region (best

estimate 70%; range, 6478%). Te Arican Region has

the lowest estimated rate o case detection (best esti-

mate 50%; range, 4853%). Among the HBCs, the high-

est rates o case detection in 2009 are estimated to be in

Brazil, the Russian Federation, South Arica, Kenya, the

United Republic o anzania and China; the lowest rate

is in Nigeria.

While estimated rates o B incidence are allingslowly, notifcation rates are increasing in the Arican

Region and (particularly since around the year 2000)

the Eastern Mediterranean and South-East Asia regions,


14/43

indicating that case detection is improving (see

in ). In the Western Pacifc Region, notif-

cations increased sharply between 2002 and 2006, but

have since stabilized; here, patterns are strongly inu-

enced by China, which accounts or almost 70% o inci-

dent cases in this region ().

Despite diculties with estimating the case detection

rate (, ), eorts to increase the percentage

o B cases that are diagnosed and treated according to

international guidelines are clearly o major importance.

Tis will be necessary to move towards the 7 million

notifcations targeted in the Global Plan or 2015 (and

eventually, to achieve early detection o all cases).

Tere are three main reasons why incident cases o B

may not be notifed (see also , ). Teseare:

Cases are diagnosed but not reported. For people

in this category, strengthening surveillance systems,

establishing links with the ull range o health-care

providers and stronger enorcement o legislation

regarding notifcation o cases (where this is mandat-

ed by law) will help.

Cases seek care but are not diagnosed. For people

in this category, better diagnostic capacity is needed.

Tis could mean better laboratory capacity as well as

more knowledgeable and better trained sta, espe-

cially in peripheral-level health-care acilities.

Cases do not seek care. For people in this category,

reasons could include not recognizing any symptoms

o B and/or no access (fnancial and/or geographi-

cal) to health-care services. o reach cases in this

category, health systems need to be strengthened sothat basic health-care services are available to more

people, and fnancial barriers to diagnosis (and subse-

quently treatment) need to be mitigated or removed.


15/43

A case study rom China, which i llustrates how strength-

ening surveillance can lead to increased notifcations

o B cases and an increase in the CDR, is provided in

. Engagement o all care providers is discussed

in the next section. Strengthening o laboratory capac-

ity and human resource development are discussed in

and , respectively.

In many countries, one o the best ways to increase case

detection is or NPs to establish collaboration with theull range o health-care providers. Tis is component 4

o the Stop B Strategy (), and its two subcompo-

nents are:

involvement o all public, voluntary, corporate and

private providers through Public-Private Mix (PPM)

approaches; and

promotion o the International Standards or uber-

culosis Care through PPM initiatives.

Eorts to engage all care providers through PPM initia-

tives, beyond those which all under the direct respon-

sibility o the NP (termed non-NP providers in this

report), are being introduced and scaled up in many

countries. Unortunately, demonstrating this progress

is not always possible. First, it requires that systematic

recording and reporting o the source o reerral and

place o B treatment is being done. Second, it requires

that data reported at the local level are aggregated, ana-

lysed and reported at the national level.1 Oten, one or

both conditions are not yet met.

Despite this recording and reporting challenge, sub-

stantial progress in engaging non-NP care provid-

ers through PPM can be documented or an increasing

number o countries. New and compelling data compiled

rom 15 countries (including nine HBCs) in 2010, which

demonstrate the major contribution that PPM can make

to case notifcations, are summarized in . Inthese 15 countries, the contribution o PPM initiatives

typically ranges rom between about one fth to one

third o total notifcations, in the geographical areas in

which PPM has been implemented. Tis has been accom-

panied by maintenance o high rates o treatment suc-

cess (data not shown).

As also il lustrated in , NPs have used a vari-

ety o approaches to engage non-NP care providers,

according to the local context. Tese include incentive-

based schemes or individual and institutional providers

in India and Myanmar; a web-based system or man-

datory reporting o B cases by all providers in China

1 WHO recommends that the source o reerral and the place o treat-

ment should be routinely recorded and reported.


16/43

(); and reimbursement or B care delivered by pri-

vate providers through health insurance, when care con-

orms with agreed-upon standards, in the Philippines. It

is also noticeable that countries have prioritized dier-ent types o care providers. Tis includes pharmacies in

Cambodia, private hospitals in Nigeria, public hospitals

in China and Indonesia, social security organizations in

Mexico and prison services in Kazakhstan.

In general, only a small proportion o targeted care

providers collaborate actively with NPs and contribute

to B case notifcations in most countries. For this rea-

son, it is not surprising that NPs oten give frst priority

to engaging institutional providers with whom estab-

lishing collaborative links may be less demanding and,

or a given amount o eort, will yield a higher numbero notifcations. At the same time, involving ront-line

health workers such as community-based inormal pro-

viders, private practitioners and pharmacies who are

oten the frst point o contact or people with symp-

toms o B can help to reduce diagnostic delays and

the out-o-pocket expenditures o B patients. For these

reasons, scaling up PPM, in phases i not at once, should

aim to systematically map and engage all relevant care

providers in B care and control.

Collaborative B/HIV activities are essential to ensurethat HIV-positive B patients are identifed and treated

appropriately, and to prevent B in HIV-positive people.1

Tese activities include establishing mechanisms or col-

laboration between B and HIV programmes; inection

control in health-care and congregate settings; HIV test-

ing o B patients and or those B patients inected

with HIV CP and AR; and intensifed B case-fndingamong people living with HIV ollowed by IP or those

without active B. esting B patients or HIV and pro-

viding CP or HIV-positive B patients are typically the

responsibility o NPs; national HIV programmes are

usually responsible or initiating intensifed case-fnding

among HIV-positive people and provision o IP to those

without active B. Provision o AR to HIV-positive B

patients is oten the responsibility o national HIV pro-

grammes, but may also be done by NPs. When NPs do

not provide AR directly, they are responsible or reer-

ring HIV-positive B patients to AR services.Further progress in implementing collaborative B/

HIV activities was made in 2009, which consolidated the

achievements documented in previous reports. Just over

1.6 million B patients knew their HIV status in 2009

(26% o notifed cases), up rom 1.4 million in 2008 (

). Te highest rates o HIV testing were reported

in the European Region, the Arican Region and the

Region o the Americas, where 86%, 53% and 41% o B

patients knew their HIV status, respectively ().

In 55 countries, at least 75% o B patients knew their

HIV status, including 16 Arican countries (

), up rom 50 countries in total and 11 in the Arican

1 Interim policy on collaborative B/HIV activities. Geneva, World

Health Organization, 2004 (WHO/HM/B/2004.330; WHO/

HM/HIV/2004.1).


17/43

0

1

2

3

4

5

6

7

200392

(43%)

200484

(47%)

2005131

(81%)

2006146

(90%)

2007169

(98%)

2008167

(98%)

2009143

(98%)

4.2% 3.2%8.5%

12%

20% 22%26%

Cases

(millions

)

014

1549

5074

75

No data

Percentage of notifiedTB cases with knownHIV status


18/43

Region in 2008. Te number o HIV-positive B patients

enrolled on CP and AR has been increasing in recent

years, especially since 2005 (). By 2009, almost

300 000 HIV-positive B patients were started on CP

and almost 140 000 were enrolled on AR. Almost 80%

o B patients who were known to be HIV-positive were

started on CP and almost 40% were enrolled on AR( , ). Further eorts are needed to

reach the Global Plan target o starting 100% o HIV-

positive B patients on both CP and AR by 2015.

Screening or B among HIV-positive people and

providing IP to those without active B have steadily

increased, particularly since 2007 (, ).

In 2009, 1.7 million HIV-positive people were screened

or B and close to 80 000 o those without active B

were enrolled on IP. Te numbers screened are equiva-

lent to about one third o the people living with HIV who

are on AR, about 10% o the people living with HIV who

are estimated to be in need o AR and about 5% o the

estimated total number o HIV-positive people world-

wide. Te numbers started on IP are less than 1% o the

estimated number o people living with HIV. Intensifed

eorts are needed to approach the Global Plan target o

providing IP to all those attending HIV care services

who are eligible or it by 2015.

Globally, just over 30 000 cases o MDR-B were noti-

fed to WHO in 2009, mostly by European countries and

South Arica (, ). Tis represents 12%o the estimated number o cases o MDR-B among all

notifed cases o pulmonary B in 2009 (). Coun-

try plans suggest that, overall, the numbers o patients

diagnosed with MDR-B and started on treatment will

almost double in 2010 and 2011, compared with 2009

( ). Substantial increases in the numbers o

patients diagnosed with MDR-B and started on treat-

ment are expected in the three countries where the esti-

mated number o cases is highest: China, India and the

Russian Federation ().

Tere has been an impressive increase in the share

o notifed cases enrolled on treatment in projects or

programmes approved by the Green Light Committee

(GLC), in which patients are known to be receiving treat-

ment according to international guidelines. Te number

reached around 11 000 in 2009, and is expected to rise

to over 30 000 in 2011 (approximately 60% o all noti-

fcations o MDR-B that are projected by countries in

that year). Tis remains a small raction o the estimated

number o B patients who have MDR-B (eighth col-

umn rom right, ). Much more rapid expansion

o diagnosis and treatment within and outside projects

and programmes approved by the GLC is needed toapproach the targets or MDR-B that are included in

the Global Plan ().

National data on treatment outcomes among cohorts

Num

bero

fTBpatients(

thousan

ds

)

2003 2004 2005 2006 2007 2008 2009

0

100

200

300

400

500

Tested HIV-positive

CPT

ART

Percentageo

fHIV

-pos

itive

TBpatients

0

20

40

60

80

100

200327 (30%)

200424 (29%)

200539 (53%)

200655 (64%)

200773 (92%)

200886 (93%)

200963 (75%)

CPT

Percentageo

fHIV

-posi

tive

TBpatients

ART

200347 (9%)

200424 (25%)

200547 (55%)

200669 (64%)

200793 (85%)

2008109 (96%)

200989 (80%)

0

20

40

60

80

100


19/43

Num

bero

fpeop

lescreene

d(thous

an

ds

)

200514 (35%)

200644 (49%)

200772 (59%)

200882 (66%)

200978 (71%)

0

400

800

1200

1600

2000

0.6%1.0%

2.0%

4.4%

5.2%

Percentageo

fHIV

-pos

itivepeop

le

withoutact

ive

TB

200510 (21%)

200625 (26%)

200742 (44%)

200843 (51%)

200941 (48%)

0

0.1

0.2

0.3

0.4

Num

bero

fpatients

(thousan

ds

)

0

10

20

30

40

50

60

2005(100)

2006(107)

2007(110)

2008(128)

2009(91)

2010(83)

2011(74)

1923

30 29 31

5052non-GLC

GLC

Notified Projected

Num

bero

fpatients

(thousan

ds

)

2007 2008 2009 2010 2011 2012 2013 2014 20150

50

100

150

200

250

300


20/43


21/43

%o

fnewcasesteste

d

AFR(15)

AMR(16)

EMR(11)

EURb

(42)SEAR(3)

WPR(11)

Total(98)

AFR(22)

AMR(15)

EMR(10)

EURb

(40)SEAR(6)

WPR(11)

Total(104)

0

10

20

30

40

0

10

20

30

40

%o

fre-t

reatmentcasesteste

d

o at least 200 patients are currently limited to nine

countries: Brazil, Kazakhstan, Peru, the Philippines, the

Republic o Moldova, Romania, South Arica, urkey and

Uzbekistan (). Rates o treatment success are

variable, ranging rom below 40% to almost 80%. High

rates o deault are a common problem (with a median

value o 17%).One o the most important constraints to rapid expan-

sion o diagnostic and treatment services or MDR-B is

laboratory capacity. Without greater capacity to diagnose

MDR-B, the number o cases diagnosed and treated will

remain low. Diagnostic testing or drug susceptibility, or

DS, among new cases o B remains almost entirely

confned to the European Region and the Region o the

Americas ( ). Even in these regions, however,

the percentage o previously treated patients who were

tested or drug resistance was less than 40%, ar below

the target o testing all previously treated patients by

2015 that is included in the Global Plan.

Recent eorts to strengthen laboratory services,

under the umbrella o the Global Laboratory Initiative,

are highlighted in .

While eorts to improve the diagnosis and treatment

o MDR-B are urgently needed, the existence o MDR-B

and XDR-B also highlights the paramount importance

o preserving the ecacy o the ew anti-B medicines

currently used in B treatment ().

Limiting the number o cases o MDR-B (and drug-

susceptible B) also requires that proper measures or

inection control are in place. Tese measures includepersonal protection (or example, masks), administra-

tive controls (or example, in waiting areas or people

attending outpatient services) and environmental meas-

ures such as ventilation systems. Te best indicator to

assess the quality o inection control is the ratio o the

notifcation rate o B among health-care workers to

the notifcation rate among the general population. Tis

ratio should be approximately 1. Te data required to

calculate this indicator are requested on the WHO data

collection orm, but to date the availability o reliable

data is limited. Collection and reporting o data on this

indicator need to be improved.

A total o 64 countries reported that training related

to inection control was done in 2009. For 35 countries,

this included training in tertiary (reerral) hospitals.

Among 80 countries that provided data, 55 (69%) report-

ed having a ocal point or inection control related to B

in at least one o their tertiary hospitals. O 75 countries

that provided data, 36 (48%) had perormed an assess-

ment o the status o inection control or B in at least

part o their network o tertiary hospitals in 2009.

Percentageo

fco

hort

Kazakhstan(1609)

Turkey(240)

Philippines(296)

Perub

(670)Uzbekistan

(330)Republic

of Moldova(254)

Brazil(406)

SouthAfrica(3815)

Romania(707)

0

10

20

30

40

50

60

70

80

90

100

Successfully treated Died Failed Defaulted Not evaluated


22/43

Peru

Haiti Senegal

Cte dIvoireCameroonDR Congo

Zambia

SwazilandLesotho

DjiboutiEthiopiaUgandaKenyaUR Tanzania

India

BangladeshMyanmarViet NamIndonesia

KazakhstanUzbekistanKyrgyzstanTajikistanAzerbaijan

BelarusRepublic of MoldovaGeorgia

2009: 6 countries

2010: 18 countries

2011: 3 countries

EXPAND-TBrecipient countries


23/43


24/43


25/43

he unding available or B control in the 22 HBCshas increased year-on-year since 2002, with the

exception o a small dip in 2009, and is expected to reach

US$ 3.0 billion in 2011 (, ,

). Most o this unding has been used to support DOS

implementation, although the share or MDR-B (mostly

accounted or by unding in the Russian Federation and

South Arica) has increased since 2007 (). Te

relatively small amount o unding reported or collabo-

rative B/HIV activities reects the act that unding

or most o these interventions is channelled through

national HIV programmes and nongovernmental organ-

izations rather than via NPs. National governments

are the largest source o unding (), account-

ing or 85% o total expected unding in 2011. Financing

rom the Global Fund has become increasingly impor-

tant since 2004, and is expected to reach US$ 327 mil-

lion in 2011 (a 10% increase compared with 2010). Other

donor unding is expected to amount to approximately

US$ 100 million in 2011. In absolute terms, 61% o the

unding expected in 2011 is accounted or by just two

countries: the Russian Federation and South Arica (

).

Despite increases in unding and nine completedrounds o proposals1 to the Global Fund, NPs continue

to report unding gaps ( ). Since 2007, these

gaps have been in the range o US$ 0.30.5 billion per

year. In 2011, unding gaps are anticipated or all com-

ponents o the Stop B Strategy, including or DOS (the

basic package that underpins the Stop B Strategy). In

some countries, there are still unding gaps or supplies

o frst-line anti-B drugs.

rends in unding or the 22 HBCs as a whole conceal

important variations among countries (,

, ). Both NP budgets and unding o NPs

have been increasing in most countries; the exceptions

include Kenya, Indonesia and Mozambique, where und-

ing has allen since 2008 (). Funding has been

closest to keeping pace with increases in NP budgets

in Brazil, China, India, the Philippines and the Russian

Federation. In contrast, unding gaps have persisted in

most Arican countries as well as Cambodia, Myanmar

and Pakistan. In 2011, the Russian Federation, Tailand,

Brazil, South Arica, China, the Philippines and Viet Nam

will rely primarily on domestic unding (including loans

rom development banks). In other HBCs, there is much

greater reliance on donor unding, ranging rom around

1.5 1.6

1.92.0

2.2

2.52.6

2.5

2.83.0

Unknowna

Global Fund

Grants (excludingGlobal Fund)

Loans

Government,general health-care services(excluding loans)

Government,NTP budget(excluding loans)

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

US$billions

(constant2010

US$)b

0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

US$billions

(constant2010

US$)b

2002 2003 2004 2005 2006 2007 2008 2009 2010 20110

0.5

1.0

1.5

2.0

2.5

3.0

3.5

1.5 1.6

1.92.0

2.2

2.52.6

2.5

2.83.0

General health-care services:MDR-TBa

General health-care services:DOTSa

OR/surveys/other

PPM/PAL/ACSM/CBC

TB/HIV

MDR-TB

DOTS

1 Te frst round was completed in 2003. Round 9 was completed

(including decisions on which proposals would be approved or

unding) in 2009.


26/43

153

411

310

472

270

337

OR/surveys

ACSM/CBC/PPM/PAL

TB/HIV

MDR-TB

DOTS, excludingfirst-line drugs

DOTS, first-linedrugs

US$m

illions

(constant2010

US$)b

0

100

200

300

400

500

2006 2007 2008 2009 2010 2011

1.5 1.6

1.9 2.0

2.2

2.52.6

2.5

2.8

3.0

RussianFederation

South Africa

China

India

Brazil

All other HBCs

US$billions

(constant2010

US$)a

0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011


27/43

22 HBCs Afghanistan Bangladesh Brazil Cambodia

China DR Congo Ethiopia India Indonesia

Kenya Mozambique Myanmar Nigeria Pakistan

Philippines Russian Federation South Africa Thailand Uganda

UR Tanzania Viet Nam Zimbabwe

6

34

2002 2005 2008 2011

30

21

9

20

2002 2005 2008 2011

13

13

2002 2005 2008 2011

18

10

2

21

14

434343 1258

1227

704

1286

273

273258

413

2

23

2002 2005 2008 2011

20

4

5

46

38

12

3

32

31

1

21

14

8

7

63

2002 2005 2008 2011

47

52

37

28

54

35

5

88

50

394

239

208

19

64

8

64

6

39

31

39

45

147

112

112

12

94

71

45

931

28192536

2248

0

21

5

5

9

45

25

25

17

64

59

63

3

38

14

36

US$m

illions

(constant2010

U

S$)b

NTP budget

Available funding

8


28/43

40% o available unding in India to more than 90% o

available unding in the Democratic Republic o the Con-

go ().

Tere is also considerable variation in the estimated

cost per patient treated according to the DOS strat-

egy (). Tis ranges rom under US$ 100 (in

Bangladesh, India, Myanmar, Pakistan and Zimbabwe)

to around US$ 750 in Tailand, US$ 10001500 in Bra-zil and South Arica and more than US$ 7 500 in the

Russian Federation. In most HBCs, the cost per patient

treated under DOS is around US$ 150400. As shown

in , variation in the cost per patient treated

is clearly related to income levels (or example, Brazil

and South Arica are upper-middle income countries,

where prices or inputs such as NP sta and hospi-

tal care are higher than in low-income countries). Te

major reason why the Russian Federation is an outlier

is the model o care used: high costs are associated with

a policy o lengthy hospitalization o B patients with-

in an extensive network o B hospitals and sanatoria.A urther explanation or variation in costs appears to

be the scale at which treatment is provided. Te coun-

tries with relatively low costs or their income level (or

example, Bangladesh, China, India, Indonesia and the

Philippines) are also the countries where the total num-

bers o patients treated are highest (as shown by the size

o the circles in ). A similar pattern exists or

the cost per patient successully treated, which combines

inormation about both costs and eectiveness (

).1 Tis analysis is or the 22 HBCs and a subset o 85 other countries

that are among the 149 countries considered in the Global Plan. Te

total unding available in the group o 107 countries or which datawere available was adjusted upwards according to the raction o

cases or which they accounted, to allow direct comparison with the

group o 149 countries considered in the Global Plan. Te Global

Plan excludes high-income countries.

Besides the 22 HBCs, 81 other countries have reported

fnancial data to WHO since 2006 that allow assessment

o trends in unding or B control. Combined, these 103

countries account or 96% o the worlds notifed cases

o B. Funding or B control has grown rom US$ 3.9

billion in 2006 to a projected US$ 4.7 billion in 2011

(, ). As in HBCs, the largest shareo unding is or DOS implementation; an increasing

amount is or MDR-B. National governments account

or 86% o the unding expected in 2011, ollowed by

the Global Fund (US$ 513 million, or 11% o total und-

ing) and then by grants rom donors besides the Global

Fund (US$ 101 million, or 2%). Loans rom development

banks account or the remaining 1% o total unding. Te

unding gaps reported by these 103 countries amount to

US$ 0.6 billion in 2010 and US$ 0.3 billion in 2011 (

).

A comparison o the unding available in the coun-

tries that reported fnancial data with the unding

requirements set out in the Global Plan is provided, by

region and or the period 20112015, in .1

Overall, unding alls short o the requirements o the

Global Plan. Te gap is approximately US$ 1 billion in

2011. Given the scale-up o interventions set out in the

plan, this could increase to US$ 3 billion by 2015 with-

out intensifed eorts to mobilize more resources.

Internal sources

Government, NTP budget(excluding loans)

Government, generalhealth-care services(excluding loans)

Loans

External sources


Global Fund

% of total available funding

DR Congo

Bangladesh

Zimbabwe

Myanmar

Uganda

Cambodia

UR Tanzania

Afghanistan

Ethiopia

Nigeria

Mozambique

Pakistan

Kenya

Indonesia

IndiaViet Nam

Philippines

China

South Africa

Brazil

Thailand

Russian Federation

0 10 20 30 40 50 60 70 80 90 100


29/43

Cost

per

DOTSpatienttreate

d(logarithm

icsca

le)

GNI per capita (logarithmic scale)

4

6

8

10

5 6 7 8 9

R2=0.58

AFGHANISTAN

BANGLADESH

BRAZIL

CHINA

DR CONGO

ETHIOPIAINDONESIA

INDIA

KENYA

CAMBODIA

MYANMAR

UR TANZANIA NIGERIA

PAKISTAN

PHILIPPINES

RUSSIAN FEDERATION

THAILAND

UGANDA

VIET NAM

SOUTH AFRICA

185

44

1204

203169139

164

83

164

250

52

346

92

241

7678

756

222

140

334

1186

86ZIMBABWE

MOZAMBIQUE 227

R2=0.55

Costpersmear-pos

itivepatientsuccess

fully

treate

d(logarithm

icsca

le)

GNI per capita (logarithmic scale)

4

6

8

10

5 6 7 8 9

12 939

117

194212

194

247

47

198181

154

311

1662

90

171

1341

858

232

192

9175

438

AFGHANISTAN

BANGLADESH

BRAZIL

CHINA

DR CONGO

ETHIOPIAINDONESIA

INDIA

KENYACAMBODIA

MYANMAR

UR TANZANIA

NIGERIA

PAKISTAN

PHILIPPINES

RUSSIAN FEDERATION

THAILAND

UGANDAVIET NAM

SOUTH AFRICA

ZIMBABWE

MOZAMBIQUE 367


30/43

Te quality o fnancial data reported to WHO has stead-

ily improved since data were frst collected in 2002. At

the same time, reported budgets and expenditures are

not always consistent rom one year to the next; assess-

ments o the unding required particularly or newer

components o B control (such as management odrug-resistant B) can appear too low (or, less oten,

too high); and persistent unding gaps indicate a need to

strengthen resource mobilization eorts based on con-

Gap

Unknownc

Global Fund


Loans

Government,general health-care services(excluding loans)

Government,NTP budget(excluding loans)

US$billions

(constant2010

US$)b

0

1

2

3

4

5

6

2006 2007 2008 2009 2010 2011

4.0

4.6

5.05.3

5.1 5.0

US$billions

(constant201

0US$)b

0

1

2

3

4

5

6

4.0

4.65.0

5.35.1 5.0

Gap

General health-care services:MDR-TB

General health-care services:DOTS

OR/surveys/other

PPM/PAL/ACSM/CBC

TB/HIV

MDR-TB

DOTS

2006 2007 2008 2009 2010 2011

vincing plans and well-justifed budgets. Te WHO B

planning and budgeting tool was developed in 2006, to

assist with the development o comprehensive plans and

budgets or all relevant components o B control. When

completed, one advantage o the tool is that it automati-

cally summarizes NP budgets and sources o unding

in the ormat requested on the annual WHO B data col-

lection orm. Successes in using the tool to help with thedevelopment and budgeting o strategic plans in Bang-

ladesh, Cambodia and Mongolia between mid-2009 and

mid-2010 are highlighted in .

Europeb,c Rest of the Worldb Worldb

0

2000

4000

6000

8000

10 000

US$millions(nominal)

2010 2015 2010 2015 2010 2015

Available Needed

Total

DOTS

MDR-TBd

Laboratories

TB/HIV


31/43

US$m

illions

General health-care services

Other

MDR-TB

Programmemanagementand supervision

HRD: Staff,technicalassistance andtraining

First-line drugsImprovingdiagnosis

0

10

20

30

40

50

60

70

2011 2012 2013 2014 2015


32/43

rogress made towards achieving the impact targets

set or 2015 to halt and reverse the incidence o Bby 2015 (MDG arget 6.c), and to halve prevalence and

mortality rates compared with a baseline o 1990 (the

targets set by the Stop B Partnership) is illustrated

at the global level in and at the regional level

in , and .1 Progress in

achieving reductions in incidence and mortality is shown

or each o the 22 HBCs in and .

Globally, rates o incidence, prevalence and mortality

are all declining (). Incidence rates are alling

slowly, at around 1% per year, ollowing a peak at just

over 140 cases per 100 000 population in 2004. I cur-

rent trends are sustained, then MDG arget 6.c will beachieved. Mortality rates have allen by one third since

1990, and prevalence rates are also in decline. Projec-

tions suggest that the target o halving mortality by

2015 compared with 1990 could be achieved at global

level. Te target o halving the prevalence rate appears

out o reach. It should be noted, however, that there is

more uncertainty about trends in prevalence, compared

with trends in mortality (see also ).

Regionally, incidence rates are declining in fve o

WHOs six regions (). Te exception is the

South-East Asia Region (where the incidence rate is sta-ble), largely explained by apparent stability in the B

incidence rate in India. Further evaluation o trends

in the disease burden in India is needed, and has been

Rateper100000popu

lation

140

120

100

80

60

40

20

0

35

30

25

20

15

10

5

0

300

250

200

150

100

50

0

1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 20151990 1995 2000 2005

Incidence and notifications Mortality Prevalence

planned or early 2011. Among the fve regions where

incidence rates are alling, the rate o decline varies romless than 1% per year in the Eastern Mediterranean and

European regions to around 2% per year in the Arican

Region (since 2004) and 4% per year in the Region o

the Americas. As also illustrated in , notifca-

tions are closest to estimated incidence in the Region o

the Americas and the European Region, indicating that

the highest rates o case detection are achieved in these

regions (see also ). As incidence alls slowly,

notifcations are increasing in the Arican Region and

(particularly since 2000) in the Eastern Mediterranean

and South-East Asia regions, indicating improving rates

o case detection. In the Western Pacifc Region, notif-cations increased sharply between 2002 and 2006, but

have since stabilized; here, patterns are strongly inu-

enced by China, which accounts or almost 70% o inci-

dent cases in this region ().

Te latest assessment or the 22 HBCs suggests that

incidence rates are alling or stable in all countries

except South Arica (). rends in incidence

rates are assumed to be stable in Aghanistan, Bangla-

desh, India, Indonesia, Myanmar and Pakistan, in the

absence o convincing evidence to the contrary (

). Te stability in B incidence rates in India (whichaccounts or 61% o cases in this region) as well as Bang-

ladesh, Indonesia and Myanmar explains the at trend

in estimated incidence in the South-East Asia Region.

1 See in o this report or defnitions o the globaltargets or B control.


33/43

1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 20151990 1995 2000 2005 2010 2015

500

400

300

200

100

0

400

300

200

100

0

Rateper100000popu

lation

400

300

200

100

0

120

100

80

60

40

20

0

120

100

80

60

40

20

0

600

500

400

300

200

100

0

Africa The Americas Eastern Mediterranean

Europe South-East Asia Western Pacific



1990 1995 2000 2005 1990 1995 2000 2005 1990 1995 2000 2005

140

120

100

80

60

40

20

0

300

200

100

0

60

50

40

30

20

10

0

60

50

40

30

20

10

0

200

150

100

50

0

150

100

50

0

Rateper100000popu

lation


34/43

1990 1995 2000 2005 2010 2015

Rate

per100000popu

lation

60

50

40

30

20

10

0

15

10

5

0

10

8

6

4

2

0

60

50

40

30

20

10

0

40

30

20

10

0

40

30

20

10

0

1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015



In most o the HBCs, notifcations have been getting

closer to estimated incidence in recent years, notably in

Aghanistan, Bangladesh, Cambodia, China, Indonesia,

Pakistan, South Arica and the United Republic o an-

zania ().

Prevalence rates are alling in all six WHO regions (

). Te most impressive progress is in the Region

o the Americas, where the Stop B Partnerships targeto halving the 1990 prevalence rate has been achieved.

Projections suggest that the Western Pacifc and Eastern

Mediterranean regions are on track to achieve the target

by 2015, and the European Region could get close. On

current projections, the Arican and South-East Asian

regions will not achieve the target.

Mortality rates (excluding B deaths among HIV-

positive people) are alling in all six WHO regions. Te

best progress towards the 2015 target o halving the

1990 mortality rate is in the Region o the Americas and

the Western Pacifc Region, both o which appear to have

achieved the target already. Te Eastern Mediterranean,

European and South-East Asia regions are close to reach-

ing the target, and could do so beore 2015. In the Ari-

can Region, achieving the target appears out-o-reach,

ollowing a major increase in B incidence and mortality

rates associated with the HIV epidemic throughout the

1990s and up to around 2004.

Among the 22 HBCs, mortality rates appear to be

alling with the possible exception o Aghanistan and

Uganda ( ). Even allowing or uncertainty in

these estimates, our countries reached the target o

halving the 1990 mortality rate by 2009 (Brazil, Cam-bodia, China and the United Republic o anzania), and

six additional countries (India, Indonesia, Kenya, Myan-

mar, Pakistan and the Russian Federation) have a good

chance o doing so by 2015. In the other HBCs, current

orecasts suggest that the target may not be achieved.

Te reductions in mortality associated with progress

to date in implementing the DOS strategy (19952006)

and its successor, the Stop B Strategy (launched in

2006) have saved millions o lives since 1995, and con-

tinued implementation could save millions more in the

years up to 2015 ().1 From 1995 to 2009, 49

1 Tese results are based on the ollowing manuscript: Glaziou P et

al. Lives saved by tuberculosis control and prospects or achiev-

ing the 2015 global target or reductions in tuberculosis mortality

(submitted or publication in May 2010).


35/43

1 99 0 1 99 5 2 00 0 2 00 5 1 99 0 1 99 5 2 00 0 2 00 5

1 990 1 995 2 000 2 005 19 90 19 95 200 0 200 5 1 990 1 995 20 00 20 05

050

100

150

200

250

0

200

400

600

800

0

50

100

150

200

0

100

200

300

0

50

100

150

0

50

100

150

200

250

0

50

100

150

200

250

300

0

100

200

300

400

0

100

200

300

400

500

0

100200

300

400

500

0

50

100

150

200

250

0

100

200

300

400

0

100200

300

400

500

0

200

400

600

800

0

100

200

300

400

500

0

100200

300

400

500

0

50

100

1501000

1000

0

50

100

150

200

250

0

50

100

150

200

250

300

0

20

40

60

80

100

120

0

200

400

600

0

50

100

150

Rateper1

00000popu

lation

Afghanistan Bangladesh Brazil Cambodia China

DR Congo Ethiopia India Indonesia Kenya

Mozambique Myanmar Nigeria Pakistan Philippines

Russian Federation South Africa Thailand Uganda UR Tanzania

Viet Nam Zimbabwe

million patients were treated, o whom 41 million were

successully treated in DOS programmes, saving up to 6

million l ives. Tis includes approximately 2 mil lion lives

saved among women and children. From 2010 to 2015,

a urther 5 million lives could be saved i current eorts

and levels o achievement in B control are sustained,

including around 2 million women and children. With

expansion o treatment or MDR-B and interventionssuch as AR or HIV-positive B patients in the period

20112015, as set out in the Global Plan, even more lives

could be saved.


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0

20

40

60

80

0

20

40

60

80

100

120

0

20

40

60

80

0

10

20

30

40

50

60

0

1020

30

40

50

60

70

0

2040

60

80

100

120

0

20

40

60

80

100

0

50

100

150

200

0

20

40

60

80

0

20

40

6080

100

0

5

10

15

0

10

20

30

40

70

0

20

4060

80

0

10

20

30

40

0

50

100

150

200

0

20

40

60

80

0

20

4060

80

120

0

50

100

150

0

10

20

30

40

0

10

20

30

40

50

60

0

10

20

30

40

50

60

0

10

20

30

40

1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015

1 990 1995 2000 2005 201 0 2015 1 990 1995 2000 2005 201 0 2015 1 990 1995 2000 2005 201 0 2015

100

50

60

100

Rateper100000popu

lation

Afghanistan Bangladesh Brazil Cambodia China

DR Congo Ethiopia India Indonesia Kenya

Mozambique Myanmar Nigeria Pakistan Philippines

Russian Federation South Africa Thailand Uganda UR Tanzania

Viet Nam Zimbabwe

Annua

lnum

bero

flivessave

d(millions

)

0.0

0.2

0.4

0.6

0.8

1.0

0.05

0.00

0.05

0.10

0.15

0.20

0.25

0.0

0.2

0.4

0.6

0.8

1.0

1.2

2000 2005 2010 2015

HIV-negative

HIV-positive

Total


37/43

stimates o B incidence, prevalence and mortality

and their trend (presented in and in ) are based on the best available data and

analytical methods. Methods were updated in 2009 ol-

lowing 18 months o work by an expert group convened

under the umbrella o the WHO Global ask Force on

B Impact Measurement.1 Improvements to methods

(ull details are provided in ) include systematic

documentation o expert opinion and how this has been

used in estimates o the burden o disease caused by B,

simplifcation o models,2 updates to parameter values

based on the results o systematic reviews, much greater

use o mortality data rom vital registration systems (89

countries or the analyses presented in this report, uprom three in the years up to 2008) and systematic docu-

mentation o uncertainty.

Despite this progress, estimates o the disease burden

need to be urther improved in the period up to 2015

(and beyond) using better surveillance systems, more

extensive and in-depth analysis o available surveil-

lance and programmatic data, and additional survey

data. For example, with the exception o Eritrea in 2005,

the last nationwide and population-based surveys o

the prevalence o B disease in the Arican Region were

undertaken between 1957 and 1961; only around 10%o B-attributable deaths (in HIV-negative people) are

recorded in vital registration systems and reported to

WHO; and most notifcation systems are recording only

around 5070% o estimated cases.

Besides its work on reviewing and updating the meth-

ods that are used to produce estimates o the burden o

disease caused by B, the WHO Global ask Force on B

Impact Measurement is thus making concerted eorts

to support countries to pursue two other major strategic

tracks o work (ull details are available in a recent WHO

Policy Paper3). Tese are:

Surveys o the prevalence o B disease, with particu-

lar attention to 21 global ocus countries (

). Tese surveys should be carried out according to

WHO guidelines and related ask Force recommenda-

tions;

Strengthening surveillance o cases and deaths

through notifcation and vital registration systems.

Te ultimate goal is or B incidence and mortality

to be measured directly rom these systems. Te ask

Force has defned a conceptual ramework or this

work () and related tools to help countries

to implement it in practice.

As o mid-2010, all o the countries in the South-East

Asia and Western Pacifc regions where prevalence sur-

veys are recommended (Bangladesh, Cambodia, China,

Indonesia, Myanmar, the Philippines, Tailand and VietNam) were on track with survey implementation. Bangla-

desh (2008), the Philippines (2007) and Viet Nam (2007)

recently completed surveys, and subsequent surveys are

planned close to 2015. Te most notable successes in

2009/2010 among Asian countries were the completion

o nationwide surveys in Myanmar (in April 2010; see

) and China (in July 2010). Te results o these

surveys will be o major importance or gaining a better

understanding o the burden o disease (both countries)

and the impact o B control in the past two decades (in

China, ollowing previous surveys in 1990 and 2000).

Looking orwards, a survey will be implemented inCambodia in 2011, ollowing a previous survey in 2002.

Tis will allow assessment o the impact o B control

since 2002 i.e. the years since DOS was implemented. A

survey is in the advanced stages o preparation in Tai-

land, and in Indonesia a ollow-up to the 2004 survey is

planned or 2013 or 2014.

In the Eastern Mediterranean Region, Pakistan

secured ull unding or a survey in 2008, but security

concerns and other actors that aect feld operations

may preclude implementation.

Te greatest challenge in terms o implementation oprevalence surveys is in the Arican Region. Nonetheless,

considerable progress was made during 2009 and 2010.

As o July 2010, fve countries were in a strong position to

start surveys in late 2010 or early 2011 (Ethiopia, Ghana,

Nigeria, Rwanda and the United Republic o anzania).

Preparations were relatively advanced in Kenya, Malawi,

Uganda, Zambia and South Arica, although unding

gaps remained a major bottleneck in Kenya (dependent

on the approval o unding rom a Round 9 grant rom

the Global Fund), Uganda (where reprogramming o Glo-

bal Fund grants is needed) and Zambia (where ull und-

ing had been secured but the subsequent suspension o

a Global Fund grant now impedes progress). Intensive

eorts are needed to ensure that countries planning sur-

veys in 2010 and 2011 are able to do so successully.

In 2009 and 2010, there was substantial progress in

1 For urther details, see the ask Force web site at: http://www.

who.int/tb/advisory_bodies/impact_measurement_taskorce/en/

index.html. Te review is also the basis or the B component o

the orthcoming update to the Global Burden o Disease, due or

publication in 2010.2 For example, some parameter values are now estimated only at glo-

bal level or or regions, rather than or each country individually.3 B impact measurement: policy and recommendations for how to assess

the epidemiological burden of B and the impact of B control . Gene-

va, World Health Organization, 2009 (Stop B policy paper no. 2;

WHO/HM/B/2009.416).


38/43


39/43

analysing surveillance and programmatic data, with

analyses used to develop recommendations or how

surveillance systems need to be strengthened and to

produce updated estimates o disease burden. Regional

workshops to apply the ask Force ramework () or systematic assessment o surveillance data were

held in the Eastern Mediterranean, European, South-

East Asia and Western Pacifc regions and the Region

o the Americas. Country missions in which the rame-

work was applied were undertaken in the Philippines,

the United Republic o anzania and Viet Nam. By July

2010, these workshops and country missions had cov-

ered a total o 70 countries ( ). A workshop

or 17 countries in the Arican Region is scheduled or

December 2010.

An important conclusion rom workshops and country

missions was that there is an urgent need to strengthen

vital registration systems, to allow better measurement

o mortality ( ). Tere is also an urgent need to

introduce electronic recording and reporting systems,

without which it is dicult or impossible to adequately

assess many aspects o data quality. Examples o aspects

o data quality that are dicult or impossible to assess

without case-based and electronic reporting systems

include the extent to which misclassifcations and dupli-

cations exist. In addition, the availability o electronic

data, stored in well-managed relational databases (not

Excel spreadsheets), greatly acilitates data analysis.More widespread adoption o updated recommendations

on recording and reporting is also required (or example,

to ensure availability o data disaggregated by HIV sta-

tus and source o reerral).

An example o experience with implementing a case-

based and electronic recording and reporting system

(rom China) in provided in.

Besides improving estimates o the disease burden

caused by B, better data rom surveys and surveillance

combined with better analysis o these data should be o

great value in identiying where and why cases are not

being detected. In turn, fndings should help to identiy

which components o the Stop B Strategy need to be

introduced or scaled-up to improve B control. Examples

rom Cambodia, Myanmar and Viet Nam are highlighted

in the second edition o WHOs guidelines on surveys o

the prevalence o B disease.1

1 Te second edition o these guidelines (ollowing publication o

the frst edition in 2007) has been produced as a major collabora-tive eort among technical and fnancial part ners and lead survey

investigators rom Asian and Arican countries. Te guidelines

were in the late stages o preparation at the time this report went

to press, with publication expected beore the end o 2010.


40/43


41/43


42/43

his section summarizes the main conclusions that can

be drawn rom the fndings included in this report.It also draws together the main recommendations that

appear in the report, in the orm o a Box ().

Te global burden o B is alling slowly. Incidence

rates have been declining since 2004 at the global lev-

el, and i this trend is sustained, MDG arget 6.c will

be achieved worldwide. Five o WHOs six regions are

also on track to achieve this target (the exception is

the South-East Asia Region, where the incidence rate

is stable). Mortality rates at global level ell by around

35% between 1990 and 2009, and the target o a 50%

reduction by 2015 could be achieved i the current rate

o decline is sustained. At the regional level, the mortal-ity target could be achieved in fve o WHOs six regions;

the exception is the Arican Region (although rates o

mortality are alling in this region). Prevalence is all-

ing globally and in all six WHO regions. However, the

target o halving 1990 prevalence rates by 2015 maynot be reached at global level. Tree regions are on track

to achieve this target: the Region o the Americas, the

Eastern Mediterranean Region and the Western Pacifc

Region.

Reductions in the disease burden achieved to date ol-

low 15 years o intensive eorts at country level to imple-

ment the DOS strategy (19952005) and its successor,

the Stop B Strategy (launched in 2006). Between 1995

and 2009, a cumulative total o 41 million B patients

were successully treated in DOS programmes, and up

to 6 million lives were saved. Te treatment success rate

achieved in DOS cohorts worldwide has now exceededthe global target o 85% or two successive years.

Although increasing numbers o B cases have access

to high-quality treatment or B as well as access to


43/43

related interventions such as AR, much more remains

to be done. More than one-third o incident B cases are

not reported as treated in DOS programmes, around

90% o patients with MDR-B are not being diagnosed

and treated according to international guidelines, many

HIV-positive B cases do not know their HIV status and

most o the HIV-positive B patients who do know theirHIV status are not yet being provided with AR. Fund-

ing gaps remain large at more than US$ 1 billion per

year, despite increases in unding over the past decade

and substantial fnancing rom the Global Fund in many

countries.

Looking orwards, the Stop B Partnership launched

an updated version o the Global Plan to Stop B in

October 2010, or the years 20112015. In the fve

years that remain until the target year o 2015, intensi-

fed eorts to plan, fnance and implement the Stop B

Strategy, according to the updated targets included in

the Global Plan, are needed. Tis could save a cumulativetotal o 5 million lives, including 2 million women and

children.

Documents

Guia Tuberculose WHO 2