TUBERCULOSIS CONTROL SAARC REGION

Transcription

1 TUBERCULOSIS CONTROL SAARC REGION Update 2013 SAARC Tuberculosis and HIV/AIDS Centre

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3 TUBERCULOSIS CONTROL SAARC REGION Update 2013 SAARC Tuberculosis and HIV/AIDS Centre [STAC] (Thimi, Bhaktapur), P.O.Box No. 9517, Kathmandu, Nepal. Tel: , , fax: Website:

4 SAARC TB & HIV/AIDS CENTER 2013 All rights reserved. Publications of the SAARC TB & HIV/AIDS CENTER are available on the STAC web site ( SAARC TB & HIV/AIDS CENTER, Thimi, Bhaktapur, Nepal (tel.: ; fax: ; All reasonable precautions have been taken by the SAARC TB & HIV/AIDS CENTER to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the SAARC TB & HIV/AIDS CENTER be liable for damages arising from its use. Printed in Nepal

5 Foreword Tuberculosis remains a public health problem in the world despite the availability of extremely effective treatment regimens. Moreover, multi drug resistant TB and HIV are emerging threats for tuberculosis control. The SAARC region continues to make a considerable contribution to the global efforts towards the elimination of TB Control. This is the eleventh Report on Tuberculosis Situation of the SAARC Region and it is an update of the previous one. It includes information on population coverage by DOTS, case detection and treatment outcome of eight member countries of SAARC and challenges ahead. This report has been prepared on the basis of information collected from member countries during the year 2013 and by reviewing other documents including Global TB Control Report WHO, In this report, DOTS coverage and case detection rates are on the basis of 2012 data and treatment outcome is for the 2011 cohort. Some latest information available from country reports is also highlighted. This report indicates that remarkable progress in TB control has been made in this region since the introduction of DOTS strategy. Major challenges are however there in control of TB, such as sustaining quality in diagnosis and case management, improving the quality of implementation and making it more accessible to people in order to increase case detection, strengthening human resources in terms of numbers and technical capacity, strengthening laboratory network and improving EQA and supervision, establishing effective coordination between NTP and NACP and tackling migration & cross border issues. Documentation of achievements from implemented activities is essential for future planning and moving the program forward. Dissemination of such information is also important for the inspiration of the TB control programs and others working for control of TB. I am confident that this document Tuberculosis Control SAARC Region, Update will serve these purposes. I would like to thank the program managers and experts within SAARC member countries, who have generated and shared the epidemiological data and facts utilized in this report. We look forward to your continued collaboration in our joint efforts to broaden the partnership for control of tuberculosis in the SAARC region. Dr. Kashi Kant Jha Director, STAC

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7 Contents Title Foreword Abbreviation Executive Summary Page No. i iii 1. SITUATION OF TUBERCULOSIS Introduction of SAARC 1.2 SAARC TB and HIV/AIDS Centre (STAC) 1.3 Goals, Targets and Indicators for TB Control 1.4 The Stop TB Strategy 1.5 Global TB Epidemiology 1.6 TB/HIV Co-infections 1.7 TB Mortality 2. PROGRESS IN TB CONTROL IN SAARC REGION DOTS Coverage 2.2 TB Epidemiology in SAARC Region 2.3 Notifications, Case Detections and treatment Success 2.4 MDR TB 2.5 New Smear Positive TB Case 3. PROGRESS WITH TB CONTROL IN SAARC MEMBER STATES Afghanistan Bangladesh Bhutan India Maldives Nepal Pakistan Sri-Lanka 4. TB/HIV CO-INFECTION REFERENCES 67

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9 Abbreviations ACSM : Advocacy, Communication and Social Mobilization AIDS : Acquired Immuno - Deficiency Syndrome APHI : Afghan Public Health Institute ART : Antiretroviral Treatment ARTI : Annual Risk of Tuberculosis Infection BCG : Bacille-Calmette-Guérin BPHS : Basic Package of Health Services CB : Community-Based CBCI : Catholic Bishop Conference of India CDR : Case Detection Rate CHC : Community Health Centers CPT : Co-trimoxazole Preventive Therapy DDG : Deputy Director General, DGHS : Directorate General of Health Services DMIS : Drug Management Information System DOTS : Directly Observed Treatment Short course DRS : Drug Resistance Survey EP : Extra-Pulmonary EPHS : Essential Package of Health Services EQA : External Quality Assurance FDCs : Fixed-Dose Combination Drugs GDF : Global Drug Facility GENETUP : German Nepal Tuberculosis Project GLC : Green Light Committee GoIRA : Government of Islamic Republic of Afghanistan HBCs : High-Burden Countries HIV : Human Immunodeficiency Virus HRD : Human Resources Development HRM : Human Resource Management ICD : International Classification of Diseases IEC : Information, Education and Communication IGMH : Indira Gandhi Memorial Hospital IPT : Isoniazid Preventive Therapy JICA : Japan International Cooperation Agency LPA : Line Probe Assay M&E : Monitoring and Evaluation MBDC : Mycobacterial Disease Control MDGs : Millennium Development Goals

10 MDR : Multi Drug Resistance MoH : Ministry of Health MoPH : Ministry of Public Health NATA : Nepal Anti Tuberculosis Association NIDCH : National Institute of Disease and Chest Hospital NPTCCD : National Programme for Tuberculosis Control and Chest Diseases NRHM : National Rural Health Mission NSP : National Strategic Plan NSS : New Sputum Smear NTC : National Tuberculosis Centre NTI : National Tuberculosis Institute NTP : National Tuberculosis Programme NTRL : National TB Reference laboratory PAL : Practical Approach to Lung Health PHCC : Primary Health Care Centre PHCs : Primary Health Centers PHIs : Public Health Inspectors PHL : Public Health Laboratory PHS : Public Health Services PLHIV : People Living with HIV PMDT : Programmatic Management of Drug-Resistant Tuberculosis PMU : Programme Management Unit PPD : Purified Protein Derivative PPM : Public-private Mix PPs : Private Practitioners RNTCP : Revised National TB Control Programme SAARC : South Asian Association for Regional Cooperation SCC : Short Course Chemotherapy SLDs : Second Line Drugs SNRL : Supranational Reference Laboratory SOPs : Standard Operating Procedures STAC : SAARC TB and HIV/AIDS Centre TB : Tuberculosis ToT : Training of Trainers UHCs : Upazila Health Complexes VCCT : Voluntary Counseling and Testing Centre WHO : World Health Organization XDR : Extensively Drug-Resistant Tuberculosis

11 Executive Summary This is the eleventh Report on tuberculosis (TB) situation of SAARC Region which is being published by SAARC Tuberculosis and HIV/AIDS Centre (STAC) in a series that started in The main purpose of the report is to provide a comprehensive and up-to-date assessment of the TB epidemic and progress made in TB care and control at Global, SAARC Region and Member States level. The incidence has been falling globally achieving the Millennium Development Goal target. Of estimated 8.6 million new cases of TB (122 per population), 6.1 million cases were notified in 2012 of which 2.6 million were New Smear-Positive TB cases. There were an estimated 12 million prevalent cases in 2012 (169 cases per population) globally. An estimated people developed MDR-TB and there were an estimated deaths from MDR-TB. A total of TB patients eligible for MDR-TB treatment were detected in 2012, out of which people with confirmed MDR-TB. A total of approximately 1.3 million people died of TB in 2012 and among them 0.94 million deaths were from TB among HIV-negative people and an additional 0.32 million deaths from TB among people who were HIV-positive. The SAARC region, with an estimated incidence of 3.1 million TB cases, carries 37% of the global burden of TB out of which 1.7 million are estimated to be sputum smear positive infectious cases. Four of the eight Member Countries in the Region are among the 22 high burden countries (Afghanistan, Bangladesh, India and Pakistan) together notified 97% of the region. India alone accounted close to three fourth of all notifications in the SAARC region. The case detection rate in the region is 53 % in the year And out of the sputum smearpositive pulmonary TB in the Region 89% were successfully treated among the 2011 cohort. A total 81,786 estimated cases of MDR-TB among notified cases were notified in 2012 in the SAARC region, of which 39% were new pulmonary cases and 61% were previously treated cases. However, were total confirmed cases of MDR-TB which is (23.36%) of total estimated cases of MDR-TB among notified cases. As the large number of HIV infected persons are in the SAARC Region particularly in India, Bangladesh and Pakistan with high rates of TB transmission and the presence of high TB

12 prevalence, the HIV epidemic could have significant implications on TB control in the Region. Collaborative TB/HIV activities are critical in order to ensure that HIV positive TB patients are identified and treated and also to prevent active TB disease in latently infected HIV positive people. HIV testing for TB patients is a critical entry point for both treatment and prevention. There was a significant progress in offering HIV testing for TB patients between 2002 and 2012 as health care providers initiated the provider initiated HIV testing for newly diagnosed TB patients. All the SAARC Member States have developed their strategic plans for expansion of TB/HIV collaborative activities and are in the expansion mode. Some SAARC Member States have made significant progress in TB/HIV collaboration, while some are slow on this component. All the Member States have initiated management of MDR-TB under the National TB Control Programme. While, all the SAARC Member States have initiated management of MDR-TB under the National TB Control Programme, one of the most important constraints to rapid expansion of diagnostic and treatment services for MDR-TB identified by all the SAARC Member States, is laboratory capacity. Constraints in availability and retention of adequately trained human resources, is one of the major concerns of all the SAARC Member States.

13 1. SITUATION OF TUBERCULOSIS 1.1 Introduction of SAARC The South Asian Association for Regional Cooperation (SAARC) established on 8 th December 1985 comprises of Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka. SAARC is a manifestation of the determination of the people of South Asia to work together towards finding solutions to their common problems in a spirit of friendship, trust and understanding and to create an order based on mutual respect, equity and shared benefits. The SAARC Secretariat is supported by different regional centers established in Member States to promote regional cooperation. Among them, SAARC TB and HIV/AIDS Centre is one of the regional centers which is located in Nepal. 1.2 SAARC TB and HIV/AIDS Centre (STAC) Background The Heads of State or Government of Member Countries of SAARC at their Fifth Summit held in Male on November 1990 decided to establish SAARC Tuberculosis Centre in Nepal. The Centre was established in 1992 to work for control and prevention of Tuberculosis in the Region. Considering the role played by the centre through its activities on TB/HIV co-infection, the centre was renamed as SAARC Tuberculosis and HIV/AIDS Centre by the Thirty-first Session of Standing Committee of SAARC held in Dhaka on November 9-10, 2005 (during the Thirteen SAARC Summit) to work for prevention and control of TB and HIV/AIDS in the SAARC Region by coordinating the efforts of the National Tuberculosis Control Programme and National AIDS Control Programme of the Member States, with the following vision, mission, goal and objective Vision SAARC TB and HIV/AIDS Centre be the leading institute to support and guide SAARC Member States to make the Region free of TB and HIV/AIDS Mission The Mission of the SAARC TB and HIV/AIDS Centre is to support the efforts of National TB and HIV/AIDS Control Programmes through evidence based policy guidance, coordination and technical support. TUBERCULOSIS CONTROL SAARC 1

14 1.2.4 Goal The goal of the SAARC TB and HIV/AIDS Centre is to minimize the mortality and morbidity due to TB and HIV/AIDS in the Region and to minimize the transmission of both infections until TB and HIV/AIDS cease to be major public health problems in the SAARC Region Objective To work for prevention and control of TB and HIV/AIDS in the SAARC Region by coordinating the efforts of the National TB and National HIV/AIDS Control Programmes of the SAARC Member States Role of STAC One of the main functions of this centre is to collect, collate, analyze and disseminate relevant information in the field of TB and HIV/AIDS in the Region. In this regard, the Centre has been preparing and publishing annual SAARC Regional epidemiological reports on TB and HIV/AIDS for all the Member States and other stakeholders working in the field of TB and HIV/AIDS. Based on this information, progress in achieving Millennium Development Goals (MDGs) in relation to TB and HIV/AIDS in the SAARC Member States can be monitored. In all the Member States, the Government together with its partners from the public and private sectors is committed to further intensify the DOTS programme in order to sustain the achieved success to reach the MDG-related TB control targets. The New Stop TB strategy embraces the fundamentals of TB control originally framed as DOTS, but extends beyond the TB control (DOTS) activities into other key areas. These include the well-known problems of multi-drug resistant TB or MDR-TB (and now also extensive drug resistance TB, XDR-TB) and of TB associated with HIV/ AIDS. The Global Plan of the Stop TB Partnership details the scale at which the six components of the STOP-TB strategy should be implemented in order to achieve the global targets. 1.3 Goals, targets and indicators for TB control The recently recommended approach of the World Health Organization to TB care and control is the Stop TB Strategy, launched in This strategy was linked to new global targets for reductions in TB cases and deaths that were set for 2015 as part of the Millennium Development Goals (MDGs) and by the Stop TB Partnership. The targets are that TB incidence should be falling by 2015 (MDG Target 6.c) and that 2 TUBERCULOSIS CONTROL SAARC

15 prevalence and death rates should be halved compared with their levels in The outcome targets to achieve a case detection rate of new smear-positive cases of at least 70% and to reach a treatment success rate of at least 85% for such cases were first established by the WHA in Within the MDG framework, these indicators were defined as the proportion of cases detected and cured under DOTS. The ultimate goal of eliminating TB, defined as the occurrence of less than 1 case per million populations per year by 2050, was set by the Stop TB Partnership. The TB Control Programmes focuses on the five principal indicators that are used to measure the impact and outcomes of TB control: incidence, prevalence and deaths (impact indicators) and case detection and treatment success rates (outcome indicators). MILLENNIUM DEVELOPMENT GOALS (MDGs) SET FOR 2015 GOAL 6: COMBAT HIV/AIDS, MALARIA AND OTHER DISEASES Target 6.c: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases Indicator 6.9: Incidence, prevalence and death rates associated with Tuberculosis. Indicator 6.10: Proportion of Tuberculosis cases detected and cured under directly observed treatment short course STOP TB PARTNERSHIP TARGETS, SET FOR 2015 AND 2050 By 2015: Reduce prevalence and death rates by 50%, compared with their levels in By 2050: Eliminate TB as a public health problem (defined as a global incidence of active TB of less than one case per 1 million population per year) 1.4 The Stop TB Strategy The Stop TB Strategy is the approach recommended by WHO to reduce the burden of TB in line with global targets set for The six major components of the strategy are: (i) pursue high-quality DOTS expansion and enhancement; (ii) address TB/HIV, MDR-TB, and the needs of poor and vulnerable populations; (iii) contribute to healthsystem strengthening based on primary health care; (iv) engage all care providers; (v) empower people with TB, and communities through partnership; and (vi) enable and promote research. The strategy is summarized below: TUBERCULOSIS CONTROL SAARC 3

16 The Stop TB Strategy at a glance VISION GOAL A TB-Free World To dramatically reduce the global burden of TB by 2015 in line with the Millennium Development Goals and the Stop TB Partnership targets. OBJECTIVES Achieve universal access to high-quality care for all people with TB. Reduce the human suffering and socioeconomic burden associated with TB. Protect vulnerable populations from TB, TB/HIV and drug resistant TB Support development of new tools and enable their timely and effective use Protect and promote human rights in TB prevention, care and control TARGETS MDG 6, Target 6.c: Halt and begin to reverse the incidence of TB by 2015 Targets linked to the MDGs and endorsed by the Stop TB partnership COMPONENTS OF STOP TB STRATEGY 1. Pursue high-quality DOTS expansion and enhancement a) Secure political commitment, with adequate and sustained financing b) Ensure early case detection, and diagnosis through quality-assured bacteriology c) Provide standardized treatment with supervision, and patient support d) Ensure effective drug supply and management e) Monitor and evaluate performance and impact 2. Address TB/HIV, MDR-TB, and the needs of poor and vulnerable populations a) Scale-up collaborative TB/HIV activities b) Scale-up prevention and management of multi-drug-resistant TB (MDR-TB) c) Address the needs of TB contacts and of poor and vulnerable populations 3. Contribute to health system strengthening based on primary health care a. Help improve health policies, human resource development, financing, supplies, service delivery, and information b. Strengthening infection control in health services, other congregate settings and households c. Upgrade laboratory networks, and implement the Practical Approach to Lung Health 4 TUBERCULOSIS CONTROL SAARC

17 d. Adapt successful approaches from other fields and sectors, and foster action on the social determinants of health 4. Engage all care providers a. Involve all public, voluntary, corporate and private providers through public-private Mix (PPM) approaches b. Promote use of the international Standards for Tuberculosis Care 5. Empower people with TB, and communities through partnership a. Pursue advocacy, communication and social mobilization b. Foster community participation in TB care, prevention and health promotion c. Promote use of the Patients Charter for Tuberculosis Care 6. Enable and promote research a. Conduct programme-based operational research b. Advocate for and participate in research to develop new diagnostics, drugs and vaccines 1.5. GLOBAL TB EPIDEMIOLOGY Global Epidemiology: Globally, Tuberculosis is still a major public health problem. As per WHO Global Report 2013, there were an estimated 8.6 million incident cases of TB and 1.3 million people died from the disease ( deaths among people who were HIV-negative and among people who were HIV-positive) in Among these deaths there were approximately from MDR-TB, a relatively high total compared with incident cases of MDR-TB worldwide in Although most TB cases and deaths occur among men, the burden of disease is high among women. In 2012, an estimated women died from TB ( among HIV-negative women and among HIV-positive women). There were also an estimated TB deaths among HIV-negative children (estimates of HIVassociated mortality are not yet available). The South-East Asia and Western Pacific Regions collectively accounted for 58% of the world s TB cases in The African Region had approximately one quarter of the world s cases, and the highest rates of cases and deaths relative to population (255 TUBERCULOSIS CONTROL SAARC 5

18 incident cases per on average, more than double the global average of 122). India and China had the largest number of cases (26% and 12% of the global total, respectively). South Africa and Swaziland had the highest incidence rate per capita (about 1 new case for every 100 people each year) Incidence of TB In 2012, there were an estimated 8.6 million incident cases of TB (range, 8.3 million 9.0 million) globally, equivalent to 122 cases per population. Most of the estimated number of cases in 2012 occurred in Asia (58%) and the African Region (27%) smaller proportions of cases occurred in the Eastern Mediterranean Region (8%), the European Region (4%) and the Region of the Americas (3%) as per WHO Global Report The five countries with the largest number of incident cases in 2012 were India (2.0 million 2.4 million), China (0.9 million 1.1 million), South Africa (0.4 million 0.6 million), Indonesia (0.4 million 0.5 million) and Pakistan (0.3 million 0.5 million). Of the 8.6 million incident cases, an estimated 0.5 million were children and 2.9 million (range, million) occurred among women. The 8.6 million incident TB cases in 2012 included 1.0 million 1.2 million (12 14%) among people living with HIV, with a best estimate of 1.1 million (13%). The proportion of TB cases co-infected with HIV was highest in countries in the African Region. Overall, 37% of TB cases were estimated to be co-infected with HIV in this region, which accounted for 75% of TB cases among people living with HIV worldwide. The best estimate is that there were new cases of MDR-TB worldwide in This total includes cases of primary and acquired MDR-TB Prevalence of TB The prevalence of bacteriologically confirmed pulmonary TB can be directly measured in nationwide population-based surveys using sample sizes of around people. Survey results can be used to produce a national estimate of TB prevalence that includes all forms of TB. There were an estimated 12 million prevalent cases (range, 11 million 13 million) of TB in This is equivalent to 169 cases per population. By 2012, the prevalence rate had fallen 37% globally since Current forecasts suggest that the Stop TB Partnership target of halving TB prevalence by 2015 compared with a baseline of 1990 will not be met worldwide. 6 TUBERCULOSIS CONTROL SAARC

19 1.5.4 TB Mortality There were an estimated 1.3 million TB deaths in These deaths included among women and among children. There were approximately deaths from MDR-TB (range, ). Approximately 75% of total TB deaths occurred in the African and South-East Asia Regions in 2012 (both including and excluding TB deaths among HIV-positive people). India and South Africa accounted for about one-third of global TB deaths. The number of TB deaths per population averaged 13 globally in 2012 and 17.6 when TB deaths among HIVpositive people are included. Globally, mortality rates (excluding deaths among HIV-positive people) have fallen by 45% since 1990; the current forecast suggests that the Stop TB Partnership target of a 50% reduction in TB mortality by 2015 compared with a baseline of 1990 will be achieved. Mortality rates are declining in all six WHO regions. The 2015 target has already been surpassed in the Region of the Americas (since 2004) and the Western Pacific Region (since 2002), and may have been reached in the Eastern Mediterranean Region. Among the other three regions, the South-East Asia Region appears best placed to achieve the target. Mortality rates appear to be falling in most of the 22 HBCs, although there is considerable uncertainty about the level of and trends in mortality in some countries MDR-TB Globally in 2012, there were an estimated (range: ) new cases of MDR-TB and there were an estimated (range: ) MDR-TB cases among notified TB patients. Globally, 3.6% of new TB cases and 20.2% of previously treated cases are estimated to have MDR-TB. These estimates are essentially unchanged from Case Detection Rate The best estimate of the CDR for all forms of TB globally in 2012 was 66% (range, 64 69%), up from 53 59% in 2005 and 38 43% in 1995 the year in which the DOTS strategy began to be introduced and expanded. The highest CDRs in 2012 were estimated to be in the Region of the Americas (best estimate 79%; range, 74 85%), the Western Pacific Region (best estimate 81%; range, 75 89%) and the European Region (best estimate 74%; range, 70 79%). The other regions had estimated CDRs in the range of 55 71%, with best estimates of around 60%. All regions have improved their estimated CDRs since the mid-1990s, with improvements particularly evident since Among the 22 HBCs, the highest rates of case detection in 2012 were TUBERCULOSIS CONTROL SAARC 7

20 estimated to be in Brazil, China, Kenya, the Philippines and the Russian Federation. The lowest rates, with best estimates of around 50%, were in Afghanistan, Bangladesh, the Democratic Republic of the Congo, Mozambique, Nigeria and Zimbabwe. 1.6 TB/HIV Co-infection In 2012, 1.1 million (13%) of 8.6 million people who developed TB worldwide were HIV-positive. The African Region accounted for 75% of the estimated number of HIVpositive incident TB cases. The number of people dying from HIV-associated TB has been falling since However, there were still deaths from HIV-associated TB in 2012 and further efforts are needed to reduce this burden. Globally, 80% of HIV-positive TB patients were provided with co-trimoxazole preventive therapy (CPT), a level similar to recent years in In 2012, 4.1 million people enrolled in HIV care were reported to have been screened for TB, up from 3.5 million in Of the reported 1.6 million people newly enrolled in HIV care in 2012, almost were provided with isoniazid preventive therapy (IPT). Coverage needs to be increased, since about 50% of those newly enrolled in HIV case and screened for TB are likely to be eligible for IPT. Table 01: Global Epidemiological Burden of TB (2012) S. No. Indicators Estimated Number(rates) 1 Population 7.05 billion 2 Estimated Incidence 8.6 million (122 cases/ ) 3 Estimated Prevalence 12 million (169 cases/ ) 4 CDR of all form of TB 66% (64 69 %) 5 Treatment Success Rate (2011 cohort) 87% 6 Cases Enrolled on MDR-TB Treatment Estimated Deaths Due to TB 1.3 million (13 cases/ ) 8 HIV Positive in incident TB cases 1.1 million 8 TUBERCULOSIS CONTROL SAARC

21 Table 02: Global Estimated Incidence and Notified New Cases of TB (2012) WHO Regions Estimated Incidence (in thousands) Total Notified Smear- Positive New Retreatment New and % new Smear Negative/ Unknown Extra Pulmonary Relapse Retreatment Excl. Relapse Relapse pulmonary case smear positive Africa Region Region of Americas Eastern Mediterranean Region European Region South East Asia Region Western Pacific Region Global Source: Global TB Report WHO, 2013 TUBERCULOSIS CONTROL SAARC 9

22 Figure 01: Global Estimated TB Incidence Rates, 2012 Source: Global TB Report WHO, 2013 Figure 02: Global trends in estimated rates of TB incidence, prevalence and mortality. Left: Global trends in estimated incidence rate including HIV-positive TB (green) and estimated incidence rate of HIV-positive TB (red). Centre and right: Trends in estimated TB prevalence and mortality rates and forecast TB prevalence and mortality rates The horizontal dashed lines represent the stop TB Partnership targets of a 50% reduction in prevalence and mortality rates by 2015 compared with Shaded area represents uncertainty bands. Mortality excludes TB deaths among HIV-positive people. Source: Global TB Report WHO, TUBERCULOSIS CONTROL SAARC

23 Figure 03: Treatment Outcomes among New Smear Positive Cases 2011 Cohort 7% 2% 4% 4% 4% 80% Cured Treatment completed Treatment failed Defaulted Died Not evaluated Source: Global TB Report WHO, 2013 In 2011, the treatment success rate continued to be high at 87% among all new TB cases. Of which 80% cured and 7% treatment completed. However, 2% failed, 4% default & died and 4% were not evaluated. Figure 04: Trend of Treatment Success and Case Detection rate ( ) Source: Global TB Report WHO, 2013 Figure 04 shows the trend of treatment success rate and case detection rate. Both the rates are in increasing trend from 1995 and remain steady from The case detection rate was 66 % in 2012 and treatment success was 87% in TUBERCULOSIS CONTROL SAARC 11

24 2. PROGRESS IN TB CONTROL IN SAARC REGION This chapter provides analysis of the compiled country reports on the numbers of TB cases registered in 2012 and reporting on the treatment outcomes of patients registered in 2011 for the SAARC Member States. 2.1 DOTS Coverage A remarkable progress has been made for DOTS since its inception in 1993 in SAARC Region. By 1997 all Member States started DOTS strategy for TB control. DOTS coverage within SAARC region has steadily increased since Population coverage in 1997 was 11%, since then it has been increasing and reached 99% in 2006 and since 2007 it is 100%. 2.2 TB Epidemiology in SAARC region The SAARC region, with an estimated annual incidence of 3.1 million TB cases, carries 37% of the global burden of TB incidence. Four of the eight Member Countries in the Region are among the 22 high burden countries, with India accounting for 27 % of the world s TB cases. Among 3.1 million incident TB cases, 1.7 million are notified new and relapse cases. Table 03: Estimates of the burden of diseases caused by TB in the SAARC Region 2012 Prevalence Mortality (Excluding Country Population Incidence (Including HIV) HIV) ('000) Number Number Number ('000) Rate* ('000)* Rate* ('000) Rate* Afghanistan b Bangladesh c Bhutan a India b Maldives a Nepal b Pakistan c Sri Lanka a Total a Data & Report sent by Member States, NTP, b Annual Report of NTP, c Global TB Report WHO, 2013 * Rates are per population 12 TUBERCULOSIS CONTROL SAARC

25 2.3 Notification, Case Detections and Treatment Success A total 1, 693, 306 cases were notified in 2012 in the SAARC region, of which 51% were new sputum smear positive cases. Overall case detection rate in the region in 2012 for all types of TB cases is 53 % and treatment success rate of 89%. (Table 04) Table 04: Case detection (2012) and Treatment outcomes, New Smear - Positive cases (2011), SAARC Region Country Population ('000) Incidence Number ('000) Notified New and Relapse Case Detection Rate (%) Rate* Number Percent a Data & Report sent by Member States, NTP, b Annual Report of NTP, c Global TB Report WHO, 2013 * Rates are per population Cure Rate Treatment Outcome (%) Treatment Completed Treatment Success Afghanistan b N/A N/A 91 Bangladesh c Bhutan a India b Maldives a N/A N/A 57 Nepal b Pakistan c Sri Lanka a N/A N/A 87 Total TUBERCULOSIS CONTROL SAARC 13

26 2.4 MDR - TB Table 05: Testing for MDR - TB and number of confirmed cases of MDR - TB in the SAARC Region, 2012 Estimated cases of MDR-TB among Notified Total confirmed Country cases of MDR- New Pulmonary Cases Previously treated cases Total TB Afghanistan Bangladesh Bhutan India Maldives Nepal Pakistan Sri Lanka Regional A total 81,786 estimated cases of MDR-TB among notified cases were notified in 2012 in the SAARC region, of which 39% were new pulmonary cases and 61% were previously treated cases. However, were total confirmed cases of MDR-TB which is (23.36%) of total estimated cases of MDR-TB among notified cases (Table 05). 2.5 New Smear Positive TB Cases Figure 05: Distribution of notified New Smear Positive TB Cases in SAARC Member States, 2012 Nepal 1.71 Maldives 0.01 Pakistan Sri Lanka 0.49 Afghanistan 1.51% Bangladesh Bhutan 0.05 India TUBERCULOSIS CONTROL SAARC

27 Four of the 22 countries with the highest burden of TB namely Afghanistan, India, Bangladesh and Pakistan together notified new smear positive cases, which represent 97.7 % of total new smear positive cases notified in the Region. India alone accounted close to three fourth (71.5%) of all notifications in the SAARC region. (Figure 5) Figure 06: Progress in TB Control in SAARC Region ( ) Source: Global TB Report WHO, 2013 & SAARC Tuberculosis Updates Figure 06 shows the overall progress in tuberculosis control in the region. It depicts that there is remarkable progress in DOTS coverage which has already been reached 100% since Regarding treatment success, the target is achieved since In 2012, case detection rate for all types of TB cases is 53%. TUBERCULOSIS CONTROL SAARC 15

28 Table 06: Global vs. SAARC Region on TB Indicators 2012 TB Control Indicators Global SAARC % of Global Estimated Population 7.05 billion 1.65 billion 23 Estimated Incidence Estimated Prevalence 8.6 million (122 cases/ ) 12 million (169 cases/ ) 3.1 million (193 cases/ ) 4.6 million (282 cases/ ) New all types TB Cases notified 6.0 million 1.7 million 28 New SS +ve TB Cases notified 2.5 million 0.88 million 35 Case Detection Rate all forms of TB 66 % 53 % - Treatment Success Rate (2011 cohort) 87 % 89 % - Case Enrolled on MDR-TB Treatment Estimated Deaths Due to TB 1.3million (13 cases/ ) 0.4 million (25 cases/ ) HIV Positive in incident TB cases 1.1 million 0.1 million 9 Source: Global TB Report WHO, 2013, Report sent by Member States & Annual Reports of NTP of Member States Figure 07: SAARC trends in estimated rates of TB incidence, prevalence and mortality. Left: SAARC trends in estimated incidence rate including HIV-positive TB (green) and estimated incidence rate of HIV-positive TB (red). Centre and right: Trends in estimated TB prevalence and mortality rates and forecast TB prevalence and mortality rates The horizontal dashed lines represent the stop TB Partnership targets of a 50% reduction in prevalence and mortality rates by 2015 compared with Shaded area represents uncertainty bands. Mortality excludes TB deaths among HIV-positive people. Incidence Prevalence Mortality Data Source: Global TB Report WHO, TUBERCULOSIS CONTROL SAARC

29 In the SAARC region, the incidence rate was relatively stable from 1990 up to around 2001, and then started to fall (Figure 07), achieving the MDG target ahead of the 2015 deadline. Between 2011 and 2012, the rate of decline was 2%. There were an estimated 4.6 million prevalent cases of TB in 2012, equivalent to 282 cases per population. By 2012, the prevalence rate had fallen 44% in the SAARC region since Current forecasts suggest that the Stop TB Partnership target of halving TB prevalence by 2015 compared with a base line of 1990 will not meet in all the Member States. In the SAARC region, mortality rates (excluding deaths among HIV-positive people) have fallen by 42% since 1990, the current forecast suggests that the Stop TB Partnership target of a 50% reduction in TB mortality by 2015 compared with a base line of 1990 will be achieved (Figure 07). Mortality rates are declining in all eight Member States. TUBERCULOSIS CONTROL SAARC 17

30 3. PROGRESS WITH TB CONTROL IN SAARC MEMBER STATES Afghanistan Bangladesh Bhutan India Maldives Nepal Pakistan Sri Lanka 18 TUBERCULOSIS CONTROL SAARC

31 Afghanistan Islamic Republic of Afghanistan is one of the eight countries of the SAARC Region. Afghanistan is a land-locked country, surrounded by Pakistan, Iran, Turkmenistan, Uzbekistan, Tajikistan and China. The land area is 652,225 square kilometers. In Afghanistan, the province is governed by a Governor. Afghanistan consists of 34 provinces and 364 districts. Population of Afghanistan was 30 million in Introduction The National Tuberculosis Control Program (NTP) was established in 1954 by Ministry of Public Health (MoPH)/Government of Islamic Republic of Afghanistan (GoIRA), with technical and financial supports of World Health Organization(WHO). In 1997 NTP, in collaboration with World Health Organization (WHO) and other TB partners, adopted the Directly Observed Treatment Short course (DOTS) strategy. But actual implementation of this strategy initiated only in 2002 when, the formation of a new Afghan government, Transitional Government of Afghanistan, came to power. TB control program services have been integrated into BPHS for primary health care and EPHS for secondary health care which were the priority public health services in this country. The TB services rapidly expanded after involvement of BPHS and EPHS implementers. In early 2003, the first National Strategic Plan (NSP) for TB Control ( ) was drafted and the global targets of 70% case detection of new sputum smear positive cases and 85% treatment success were adopted as the national goals. Second National Strategic Plan was developed in 2006 for next 5 years ( ). In 2008 this plan was revised in line with Millennium Development Goals (MDGs) and Global Stop TB Partnership Strategy. The targets of this revised plan were for 5 years starting from 2009 onward. In 2012, NTP developed its fourth plan for the years The mission of the NTP is to reduce the impact of TB as a public health problem in the country. Since 2002, under the new Afghan government, the NTP has taken major blows to improve its managerial and technical capacity as well as in securing external technical assistance and resources in order to implement the DOTS strategy. Resultantly TB care and TUBERCULOSIS CONTROL SAARC 19

32 Afghanistan control services are delivered free of charge to the population as covered by the BPHS and EPHS. The strategy of NTP for prevention of tuberculosis is early detection and treatment of all TB cases. TB sputum smear microscopy is the main tool for detection of infectious cases. NTP has been using the 8 months TB treatment regimen till 2012 and has planned gradually shifting to the 6 months regimen which will be implemented in all provinces after April To achieve the strategic objectives, currently NTP has a network of health professional at central, and at provincial levels. The NTP staffs at different levels of the programs are responsible for proper implementation of TB control activities, based on the scope of their work across the country. TB Epidemiology WHO estimated approximately 61,000 all types of TB cases occurred in year 2012 with incidence of (189/ 100,000) population. The prevalence of TB is around 110,000 cases (351/ 100,000 pop per year) and mortality is 13,000 (39/ 100,000). Incidence of MDR-TB is estimated as 6.3% among both new and re-treated cases. The incidence of Multi-Drug Resistant (MDR) TB is derived from a sub national drug resistance survey conducted in six provinces of Afghanistan during As per WHO estimates around 1100 MDR-TB cases are present in the country but there were totally 64 cases were notified as MDR-TB by end of Total number of diagnosed TB cases starting from 2001 till 2012 is Total cases were detected in 2012 (highest annual TB case notification so far in last decade). The progress is commendable because in 2001 only 9,581 cases were detected and from that point onwards, the trends shows increasing pattern except in 2008 and 2009 where a slight decline was seen in notified numbers as compared to previous year (2007). From 2010 onward, again the trends are upward. During 2012, all type of TB cases and of NNS+ TB cases have been notified. New Smear positive pulmonary TB cases constituted 45% of pulmonary TB cases. Extra pulmonary TB cases constituted 23% a, new smear negative constituted 16%, other previously treated 2%, new pulmonary SS not done 9% and 4% were re-treatment of all cases. Continuously, there have been variations in TB distribution by age and gender. There exists high incidence among people aged 15 to 44, with the highest incidence among the most productive age group of years old. While Children under 15 make 40% of total general 20 TUBERCULOSIS CONTROL SAARC

33 Afghanistan population in the country, where notified TB cases less than 15 years consists of about 10 % of all TB cases in More female cases (particularly, aged 15 to 45 years old) compared to males were seen with TB infection. The proportion of notified female TB cases are 62%, while male are 38%. Major Achievements Drug management unit of NTP quarterly updates TB drug situation including current inventory of TB drugs and lab-consumables. MDT drugs received and supplied for 2012 and middle of Procurement of laboratory consumables by financial support of WHO. Totally 135 HIV+ Patients received IPT. PPM has been expanded to 9 Provinces (Kabul, Nangarhar, Herat, Balkh, Paktia, Khost, Ghazni, Laghman, and Jawzjan). Operational research for clinical culture conducted National and sub national QRM guidelines was develop and applied Situational analysis of Management of Pediatric TB in Provincial and District Hospitals of Afghanistan Training Modules and SOPs for all level of health staff are available PPM practical guideline was developed ACSM strategy was finalized and translated to local languages Challenges Delay in procurement of anti TB drug and laboratory consumable through Global drug facility. Insufficient Budget for TB/HIV Collaborative Activities. Limited numbers of VCCT Centers. Capacity building of HRD s Staff on Human Resource Management. Improving quality of training. Low awareness about TB among communities, especially rural areas. Weak coordination between NTP, research institutions and APHI. New Initiatives More than 111 public and private health facilities (including hospitals) are providing services in Kabul city. Introducing new diagnostic tools & technology TUBERCULOSIS CONTROL SAARC 21

34 Afghanistan Future Plans Program decentralization Community Based DOTS introduction Regular TB task force & PHCC meetings Development of consolidated work plan Introducing new lab diagnostic tools/technology & Expanding EQA Coverage Strengthening HRM, operational research and M&E. Revision, development and implementation of tools and documents for quality DOTS implementation Expanding MDR management to main cities (Regions) Figure 08: Number of TB case notified (all types) by year Figure 09: Percentage of treatment outcomes among New smear positive cases (2011) 1% 2% 2% 3% 4% 88% Cured Treatment completed Failed Defaulted Died Not evaluated Source: Annual Tuberculosis Report, Afghanistan, 2012 Source: Global TB Report WHO, 2013& Annual Tuberculosis Report, Afghanistan, 2012 Figure10: NSS+ Distribution by Age and Gender 2012 Figure 11: Case detection rate (all forms) and Treatment success rate for NSP cases ( ) Source: Annual Tuberculosis Report, Afghanistan, 2012 Source: Global TB Report WHO, 2013& Annual Tuberculosis Report, Afghanistan, TUBERCULOSIS CONTROL SAARC

35 Afghanistan Epidemiology, 2012 Population Source: Annual Tuberculosis Report, Afghanistan, 2012 Epidemiological burden 30 million Incidence ( all cases/ pop/yr ) 189 Prevalence of TB ( all cases / pop) 351 Mortality ( Deaths/ pop) 39 Surveillance and DOTS implementation DOTS Case detection rate ( all types % ) 48 DOTS treatment success rate ( NSS+ % ) 91 Laboratory Services Number of laboratories performing smear microscopy 600 National / Provincial reference Lab Implementation of EQA Collaborative TB/HIV activities National policy of counseling and testing TB patients for HIV National surveillance system of HIV infection in TB patients Started testing on trail basis Started Present Ongoing TUBERCULOSIS CONTROL SAARC 23

36 BANGLADESH People s Republic of Bangladesh is one of the Member States of the SAARC Region. It is a coastal country in South Asia. It shares the land borders with India and Myanmar and has an irregular coastline of Bay of Bengal to the south. It has six divisions and these divisions in turn are divided into 64 districts or Zila. The total area of the country is 147,570 km 2. Population of Bangladesh is 155 million and it is one of the most densely populated countries in the world. Introduction Tuberculosis (TB) is a major public health problem in Bangladesh since long. In 1965, tuberculosis services were mainly curative and based in TB clinics and TB hospitals. TB services were expanded to 124 upazila health complexes (UHCs) during the Second Health and Population Plan ( ), and were operationally integrated with leprosy during the Third Health and Population Plan ( ) under the Mycobacterial Disease Control (MBDC) unit of the Directorate General of Health Services (DGHS). The revised NTP adopted the DOTS strategy during the Fourth Population and Health Plan ( ) under the project "Further Development of TB and Leprosy Control Services". The NTP started its field implementation in November 1993 in four thanas (upazilas) and progressively expanded to cover all upazilas by mid In July 1998, the NTP was integrated into the Communicable Disease Control component of the Essential Services Package under the Health and Population Sector Program (HNPSP) and NTP is recognized as a priority in HNPSP. The Government of Bangladesh, together with its many and diverse partners from the public and private sectors, is committed to further intensify the DOTS program in order to sustain the achieved success and to reach the TB control targets linked to the Millennium Development Goals (MDGs). 24 TUBERCULOSIS CONTROL SAARC

37 BANGLADESH TB Epidemiology Tuberculosis is a major public health problem in Bangladesh and it ranks sixth among countries with the highest burdens of TB. The estimated prevalence and incidence rates of all forms of tuberculosis were respectively 434 and 225 per population in Treatment success rate among new smear-positive cases is steadily 92% for the cohort of patients registered since 2006, including 2011 cohort. Data from previous drug resistance surveys indicate low levels of MDRTB. Isolated surveys indicated that MDR-TB rates among newly diagnosed cases range between 0.4% and 3% and among previously treated cases, between 3% and 15.4%. A limited survey of drug susceptibility among patients failing retreatment regimens showed that 88% had MDR-TB. A nationally representative population-based survey was completed in 2011 to assess the magnitude of drug resistance nationwide; results will be available in HIV prevalence in the adult general population is low (less than 1%) in Bangladesh except for injecting drug users, among whom a recent survey revealed an HIV prevalence of 7%. This has raised concerns regarding the potential for transmission of HIV to other population groups. National TB HIV operational guidelines were developed in While a national TB HIV committee is now functional, collaboration between the National AIDS and STI programme and national TB programme for TB HIV activities needs to be strengthened. A limited number of NGOs provide HIV counselling, prevention and care for TB HIV coinfected individuals. Capacity building for wider implementation of TB HIV interventions started in 2009 and is ongoing. The number of TB patients tested in 2011 for HIV was 1900 among the total TB patients notified and all TB HIV co-infected patients detected (53) started ART and CPT. Major Achievements The first national drug resistance survey (DRS) completed MDR-TB guidelines revised and updated; MDR-TB management piloted successfully in NIDCH and scaled up to one more site in Chittagong; Guidelines for community-based MDR-TB finalized and piloted in four sites of four districts with implementation support by the partner (TB CARE II); TUBERCULOSIS CONTROL SAARC 25

38 BANGLADESH Upgrading and renovation of NTRL at NIDCH, Dhaka completed; Piloting of e-tb manager initiated in six sites and expanded to twenty more sites in 2012; PAL guidelines finalized and two batches of ToT conducted in Sept 2012; Childhood TB guidelines published and ToT conducted in 2012; TB infection control operational guidelines published; The training manuals for Gene X-pert developed and twelve Gene X-pert machines installed in different sites in Line probe assay (LPA) and liquid culture installed and functionalized in SAARC Regional Training of Trainers for Microbiologist Major Challenges: Ensuring uninterrupted supply of drug and logistics; Scaling up the management of DR-TB and community PMDT; Further scaling up and strengthening private-public collaborative interventions; Strengthening linkages with the national AIDS and STI programme for TB HIV; Quality control and sustaining the quality of DOTS ; Strengthening system for diagnosis of smear-negative, extra pulmonary and child TB cases. Reaching hard-to-reach population in islands and different marshy lands. Planned Activities Establishment of the regional reference laboratories at Khulna and Sylhet for culture and drug susceptibility testing in a phase-wise manner The second national TB prevalence survey planned in Phase-wise expansion of TB HIV collaborative activities Developing capacity for wider implementation of TB HIV, MDR-TB and PPM DOTS interventions; Further expanding private-public collaborative activities Strengthening the procurement and supply management system; Strengthening supervision and monitoring; 26 TUBERCULOSIS CONTROL SAARC