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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.
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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 (%)
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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.
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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,
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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.
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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.
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(); 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).
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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
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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
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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
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%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
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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
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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.
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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
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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
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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
Grants (excludingGlobal Fund)
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
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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
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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
Grants (excludingGlobal 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$millions(nominal)
2010 2015 2010 2015 2010 2015
Available Needed
Total
DOTS
MDR-TBd
Laboratories
TB/HIV
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US$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
-
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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.
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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
Europe South-East Asia Western Pacific
Africa The Americas Eastern Mediterranean
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
-
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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
Africa The Americas Eastern Mediterranean
Europe South-East Asia Western Pacific
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).
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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
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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).
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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.
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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
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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.