TUBERCULOSIS CONTROL SAARC REGION

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2 TUBERCULOSIS CONTROL SAARC REGION UPDATE 2009 SAARC Tuberculosis & HIV/AIDS Centre (STAC) (Thimi, Bhaktapur), P. O. Box No. 9517, Kathmandu, Nepal. Tel: , , Fax: Website:

3 Foreword Tuberculosis continues to be a public health problem in the world despite the availability of highly effective treatment regimens. More over multi drug resistant TB and HIV are looming threats for tuberculosis control. This is the seventh annual report on TB situation in 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 2008 (and early part of the year 2009) and reviewing other documents including WHO Report 2009 on Global TB Control. In this report, DOTS coverage and case detection rates are on the basis of 2008 data and treatment outcome is for the 2007 cohort. But some latest information available from country reports is also highlighted. This report suggests 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 issue. Documentation of achievements from implemented activities is essential for future planning and moving the programme forward. Dissemination of such information is also important for the inspiration of the TB control programmes and others working for control of TB. I am confident that this document Tuberculosis in the SAARC Region, an Update 2009 will serve these purposes. I would like to thank the Epidemiologists and experts within SAARC member countries and WHO, who have generated and shared the epidemiological data and facts utilized for this report. Finally, I appreciate the sincere efforts of STAC staff members for publication of this document. We look forward to your comments and suggestions, and continued collaboration in our joint efforts to broaden the partnership for control of tuberculosis in the SAARC region. Dr. Kashi Kant Jha Director, STAC

4 Contents Title Page No. Foreword List of Tables List of Figures Abbreviations and Acronyms Tuberculosis in the SAARC Region Introduction 1 2. Goals, target and Indicators for TB Control 1 3. Global Situation of TB 2 4. Situation of Tuberculosis Control in South East Asia 6 5. Epidemiology of TB in SAARC Region 6 6. Situation of Tuberculosis Control in SAARC Region 9 7. Magnitude of the MDR_TB Problem-Global MDR-TB Problem in SAARC Region 11 Progress in TB Control in SAARC Region DOTS Coverage 14 2 Notification, Case Detections and Treatment Success 15 Progress with TB Control in SAARC Member States Afghanistan 19 Bangladesh 23 Bhutan 27 India 31 Maldives 37 Nepal 43 Pakistan 49 Sri-Lanka 53 STAC s Support for TB Control in the region 59

5 List of Tables No. Title Page No. 1 Millennium Development Goals 1 2 Global Epidemiological Burden of TB 4 3 Global Estimated incidence of all forms of TB, Case notifications, Case Detection (under DOTS) and DOTS Coverage, Estimates of TB disease incidence, prevalence and mortality in the SAARC region Estimates of MRD-TB among all TB cases and smear positive cases on SAARC Regions 13 6 Adoption of DOTS by SAARC Member States 14 7 Case detection (2008) and Treatment outcome (2007), SAARC Region 15 8 Global vs SAARC Region on TB Indicators 16 9 TB Notification for 2008, Maldives 38 List of Figures No. Title Page No. 1 Estimated number of new TB cases, by country, Trends in estimated Prevalence & Incidence of all forms of TB and Mortality : ( ) 3 3 Trend of Global Epidemiological Burden of TB ( ) 5 4 Global Trend of Case detection rate & Treatment Success Rate ( ) 5 5 Estimated incidence of all forms of TB in WHO Region, Trends in estimated prevalence, incidence and mortality, SAARC region, Estimated prevalence rates for all forms of TB, SAARC region, 1990, 2001, 2004 & Estimated incidence of all forms of TB, SAARC region, 1990, 2001, 2004 & Estimated mortality rates of all forms of TB, SAARC region, 1990, 2001, 2004 & DOTS Coverage in SAARC Region, Case detection Rate 2008 and Treatment Success Rate, Distribution of notified New Smear positive TB cases in SAARC Member States, Progress in TB control in SAARC Region 16 Afghanistan 14 DOTS coverage and Case detection ( ) Case Notification by type of patients, Sex distribution of Different Types of notified TB cases in

6 No. Title Page No. 17 Treatment outcome for New Smear Positive cases: 2007 cohort Treatment success and Case detection rate ( ) 22 Bangladesh 19 Progress in DOTS implementation and Case detection under DOTS Case Notification by type of patients, 2008 (n=151,186) Treatment outcome of new smear positive cases registered in Trends in Treatment Success Rates, cohorts 25 Bhutan 23 Case notification by type of Patients, New Smear Positive cases by age and gender, Sex distribution among different types of registered TB patients: Cases register by treatment category Treatment outcome among New Smear positive cases: 2007 cohort Trend of Case detection & Treatment Success rate 30 India 29 Country accounting for the global incidence of TB Rapid Scale-up of RNTCP Coverage Cases registered by Type of TB patients: Treatment outcome of New Smear Positive cases : 2007 cohort Trend of case detection rate & Treatment success rate- 35 Maldives 34 Trend of Case detection and Cure rate ( ) Case notification by type of Patients, New Smear Positive cases by age and gender, 2008: Sex distribution among different types of registered TB patients, Cases registered by treatment category Treatment outcome among New Smear positive cases: 2007 cohort 41 Nepal 40 Trends of DOTS expansion in Nepal (2001- July 08) Case Finding Trend since Adoption of DOTS ( ) Case notification by type of patients,

7 No. Title Page No. 43 Gender Distribution among different types of notified TB cases Treatment outcomes of New Smear positive cases registered in Trend of Case Detection Rate & Treatment success Cases Registered by treatment category Treatment Outcomes of MDR TB Patients (160) till Result of Multi Drug Resistance (MDR) Surveillance, Pakistan 49 Government Funding for TB Control Programme Population Covered by DOTS Case notification by Type of patients, Gender Distribution among different types of notified TB cases Cases registered by Treatment Category, Treatment outcomes of New Smear positive cases registered in Trend of Case Detection Rate & Treatment success 52 Sri Lanka 56 Case Notification by type of patients, 2008 (n=9390) Gender Distribution among different types of notified TB cases New smear positive Cases by Age and Sex, Cases registered by Treatment Category, Treatment outcome of New Smear Positive cases: 2007 cohort Trend of Case detection and treatment success rate 56

8 Abbreviations and Acronyms AFB ARTI BCG BRAC BPHS CBO CDR DDR DFB DOT DOTS DRS DST DTC EQA ESP FDC GFATM GLC HBCs H.E. HIV/AIDS HR ICTC I/NGO IEC IGMH IUATLD MDG MDR MoH Acid Fast Bacillus Annual Risk of Tuberculosis Infection Bacillus Calmette Gurine Bangladesh Rural Advancement Committee Basic Public Health Services Community Based Organization Case Detection Rate DOTS Detection Rate Damien Foundation Bangladesh Directly Observed Treatment Directly Observed Treatment Short-course Drug Resistance Surveillance Drug Susceptibility Test District Tuberculosis Centre External Quality Assurance Essential Services Package Fixed Dose Combinations Global Fund for AIDS, TB and Malaria Green light Committee High burden Countries His Excellency Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome Human Resource Integrated Counseling and Testing Centres International Non Governmental Organization Information, Education and Communication Indira Gandhi Memorial Hospital International Union Against Tuberculosis Lung Diseases Millennium Development Goals Multi Drug Resistance Ministry of Health

9 MoPH NACO NACP NATA NGO No. NPTCCD NRL NTI NTP P.O. PLWHA/PLHA TSR Ministry of Health and Population National AIDS Control Organization National AIDS Control Programme Nepal Anti-TB Association Non Governmental Organization Number National Programme for Tuberculosis Control and Chest Diseases National Reference Laboratory National Tuberculosis Institute National Tuberculosis Programme Post Office People Living With HIV/AIDS Treatment Sucess Rate

10 Tuberculosis in the SAARC Region - An Update Introduction SAARC (South Asian Association for Regional Cooperation) is an association for 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 comprises of Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka. SAARC Tuberculosis and HIV/AIDS Centre (STAC) is a Regional Centre of SAARC, located in Kathmandu, Nepal. The Centre was established in The initial mandate of the centre was to work for prevention and control of TB & HIV related TB in the Region by coordinating the efforts of the National Tuberculosis Control Programs of the Member States. Later on, its mandate has been extended to work for prevention & control of HIV/AIDS and TB/HIV co infection in the Region. Accordingly, the centre has been working since 2005 for prevention and control of TB and HIV/AIDS in the Region. 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 control in the Region and elsewhere. In this regard, the Centre has been preparing and publishing annual SAARC Regional epidemiological reports on TB and HIV/AIDS for dissemination to all Member States and other stakeholders working in the field of TB and HIV/AIDS. Based on this information, progress towards Millennium Development Goals (MDGs) in relation to TB and HIV/AIDS in the SAARC Member States can be monitored. In all Member States, the Government together with its many and diverse partners from the public and private sectors, is committed to further intensify the DOTS programme in order to sustain the achieved success and to reach the MDGrelated TB control goal and targets. Table 1 : Millennium Development Goals Goal 6 Target 8 Indicator 23 Indicator 24 To combat HIV/AIDS, malaria and other diseases To have halted by 2015, and begun to reverse the spread (incidence) of malaria and other major diseases Prevalence and death rates associated with tuberculosis : Halve TB death and prevalence by 2015 (compared to 1990) Proportion of tuberculosis cases detected and cured under DOTS: 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) and of TB associated with the Human Immunodeficiency Virus (HIV). The Global Plan of the Stop TB Partnership details the scale at which the six components of the strategy should be implemented if the global targets are to be achieved. 2. Goals, targets and indicators for TB control The global targets and indicators for TB control were developed within the framework of the MDGs by the Stop TB Partnership and the WHA. The impact targets are to halt and begin to reverse the incidence of TB by 2015 and to reduce by 50% prevalence and mortality rates by 2015 relative to 1990 levels. TUBERCULOSIS CONTROL SAARC REGION UPDATE

11 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 World Health Assembly in Within the MDGs framework, these indicators were defined as the proportion of cases detected and cured under DOTS. The ultimate goal of eliminating TB, defined as occurrence of less than 1 case per million population 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). Stop TB Partnership targets By 2005 : At least 70% of people with sputum smear positive TB will be diagnosed (i.e. under the DOTS strategy), and at least 85% successfully treated. The target of a case detection rate of at least 70% and a treatment success rate of at least 85% were first set by the World Health Assembly of WHO in By 2015 : The global burden of TB (per capita prevalence and death rates) will be reduced by 50% relative to 1990 levels. By 2050 : The global incidence of active TB will be less than 1 case per million population per year 3. Global Situation of TB With nearly two billion people (one third of the World s population) harbouring latent infection, TB is a global threat. Based on surveillance and survey data, WHO estimates that 9.27 million new cases of TB occurred in 2007 (139 per population), compared with 9.24 million new cases (140 per population) in Of these 9.27 million new cases, an estimated 44% or 4.1 million (61 per population) were new smear positive cases. Figure 1 : Estimated number of new TB cases, by country, TUBERCULOSIS CONTROL SAARC REGION UPDATE 2009

12 Asia (South-East Asia and Western pacific regions) accounts for 55% of global cases, and Africa accounts for 31%; the other regions account for relatively small fractions of global cases. 22 high burden countries (HBCs) collectively account for 80% of TB cases globally. Among the 9.27 million incident cases of TB in 2007, an estimated 1.37 million (14.8%) were HIV-positive. The African Region accounted for most (79%) of HIV-positive TB cases, followed by the South-East Asia Region (mainly India) with 11% of total cases. There were an estimated 13.7 million prevalent cases in 2007 (206 per population), a slight decrease from An estimated 1.32 million HIV-negative people (19.7 per population) died from TB in 2007, and there were an additional (0.45 million) TB deaths among HIV-positive people. Deaths from TB among HIV-positive people account for 23% of the estimated 2 million HIV deaths that occurred in 2007 There were an estimated 0.5 million ( ) cases of Multi-drug Resistant TB (MDR-TB) cases in Of these, were among new cases (3.1% of all new cases) and were among cases that had been previously treated for TB (19% of all previously treated cases). Of the incident cases of MDR-TB in 2007, (68%) were smearpositive. Globally, just under cases of MDR-TB were notified to WHO in 2007, mostly by European countries and South Africa. This was 8.5% of the estimated global total of smear-positive cases of MDR-TB. Of the notified cases, 3681 were started on treatment in projects or programmes approved by the Green Light Committee (GLC), and are thus known to be receiving treatment according to international guidelines. This is equivalent to 1% of the estimated global total of smear-positive cases of MDR-TB. Although the total number of incident cases of TB is increasing in absolute terms globally as a result of population growth, the three major indicators of impact incidence, prevalence and mortality rates per population are falling globally.(figure 2) Prevalence rate is falling at a faster rate than TB incidence. If verified by further monitoring, MDG target 6.c was met globally by 2005 (incidence rates peaked in 2004), and in five of six WHO regions (the exception being the European Region, where rates are approximately stable). If these trends are sustained globally, the incidence of tuberculosis should be halted and reversed well before 2015.The targets to halve prevalence and death rates by 2015 compared with 1990, set by the Stop TB Partnership, are more demanding. Based on trends for last five years, it indicates that the Stop TB Partnership targets of halving prevalence and death rates by 2015 compared to 1990 could be achieved in South East Asia, Western Pacific and Eastern Mediterranean, regions of Americas. Figure 2 : Trends in estimated Prevalence & Incidence of all forms of TB and Mortality : ( ) TUBERCULOSIS CONTROL SAARC REGION UPDATE

13 5.6 million New and relapse cases were notified in 2007, of which 2.6 million (46%) were new smear-positive cases. Of these notifications, 5.5 million (99%) were from DOTS programmes, including 2.6 million (47%) new smear positive cases. A total of 37.3 million new and relapse cases, and 18.1 million new smear-positive cases, were notified by DOTS programmes in the 13 years between 1995 and Of 2.55 million notifications (99.2% of total notifications in DOTS areas and 98.3% of all notifications), 1.65 million were male and 0.9 million were female, giving a male: female ratio of 1.1:8. The case detection rate of new smear-positive cases under DOTS (that is, the percentage of estimated incident cases that were notified and treated in DOTS programmes) was 63%, a small increase from 62% in 2006 but still 7% short of the target of 70% first set for 2000 by the World Health Assembly (WHA) in The target was met in 74 countries and in two regions the Region of the Americas (73%) and the Western Pacific Region (77%). The South-East Asia Region (69%) almost met the target. Table 2: Global Epidemiological Burden of TB Indicators 2007 Population 6.6 billion Prevalent TB cases 13.7 Million (206/100,000) Estimated New TB Cases 9.27 Million (139/100,000) Estimated New smear +ve cases 4.1 Million CDR of New smear +ve Cases (DOTS) 63 % Treatment success rate (2006 cohort) 85 % Estimated MDR-TB cases 0.5 Million Death due to TB 1.32 Million Death due to TB and HIV infection 0.46 million HIV Prevalence in incident TB cases 1.37 Million (14.8 %) Source: WHO Global TB Report, 2009 Table 3 : Global Estimated incidence of all forms of TB, Case notifications, Case Detection (under DOTS) and DOTS Coverage, 2007 WHO Regions Estimated incidence of all forms of TB (Number 1000s) Notification of New Sputum Smear positive(dots) Case detection rate (DOTS)% Pop. Covered by DOTS % African Region Region of Americas Eastern Mediterranean Region European Region South East Asia Region Western Pacific Region Global Source: WHO Global TB Report, TUBERCULOSIS CONTROL SAARC REGION UPDATE 2009

14 The 196 countries reporting to WHO in 2008 notified 5.6 million new and relapse cases, of which 2.6 million (46%) were new smear positive cases. In 2007, DOTS programme detected new smear positive cases, out of an estimated 4.1 million new smear positive cases, giving a case detection rate of 63%. (Table 3) Figure 3 : Trend of Global Epidemiological Burden of TB ( ) Cases per population Figure 3 shows that the number of new TB cases per capita is falling slowly, where as the number of new sputum positive TB cases per capita is fluctuating before 2006 and decreased to 60 per population in Figure 4: Global Trend of Case detection rate & Treatment Success Rate ( ) Figure 4 shows that there is a small increase of case detection rate from a figure of 61% in 2006 to 63% in 2007, following a slow and linear increase between 1995 and 2002 and a more rapid increase from 49% to 61 % between 2003 and According to global report this improvement that occurred between 2002 and 2007 was attributable mostly to increases in the numbers of new smear positive cases reported in the Eastern Mediterranean, South East Asia and Western Pacific regions. The Western Pacific region had the highest (77%) and the African region had the lowest case detection rate (47%). There is a gradual improvement in treatment success rate and it reached to global target in 2006 and continued in Reaching the case detection target at global level requires greater efforts to detect and treat cases in all regions, using the range of interventions and approaches defined in the stop TB strategy. TUBERCULOSIS CONTROL SAARC REGION UPDATE

15 4. Situation of Tuberculosis Control in South East Asia Countries in the South-East Asia Region have continued to make steady progress with TB control. The Region still accounts for the highest numbers of TB patients globally, carrying over 34% of the world s TB burden. (Figure 5) The South-East Asia Region, with an estimated 4.88 million prevalent cases and an annual incidence of 3.17 million TB cases, carries one-third of the global burden of TB. Five of the 11 Member countries in the Region are among the 22 high-burden countries, with India accounting for over 20% of the world s cases. Over 2 million TB patients are being registered for treatment by National programmes every year, of whom over 85% are successfully treated, averting at least deaths from TB every year. As a result, the Region is already demonstrating a slow but steady decline in TB incidence rates. By the end of 2007, five countries in the Region have achieved the global target for case detection and eight countries achieved treatment success target. As a result, the overall Regional case detection rate was near to 70% in 2007 and the treatment success rate for the 2006 cohort of new smear-positive patients was 87%. All countries are implementing the New Stop TB Strategy launched in In the region India, Myanmar, Nepal and Thailand have the highest rates of TB/HIV co-infection. Six countries have reported data on drug resistance since 1994, namely, India, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand. Based on these reports, MDR-TB in the South East Asian Region is estimated at 2.8% among new cases, and 18.8% among previously treated cases. TB control: Progress and Plans for implementing the New Stop TB strategy was an agenda item which resulted in a resolution at the 60th Regional Committee in The resolution called on Member countries to ensure that necessary steps are taken to fully implement national plans for TB control, incorporating all elements of the Stop TB strategy, in order to achieve the TB targets set under the Millennium Development Goals by Figure 5 : Estimated incidence of all forms of TB in WHO Regions, 2007 Source: Global Tuberculosis Control Surveillance, Planning, Financing, WHO, Geneva, Epidemiology of TB in SAARC region The SAARC region, with an estimated 4.4 million prevalent cases and an annual incidence of 2.7 million TB cases, carries 29.3% of the global burden of TB. Four of the eight Member Countries in the Region are among the 22 high burden countries, with India accounting for 21 % of the world s cases. Among estimated 2.7 million TB cases, 1.2 million are sputum smear positive cases which are infectious for the community. Though there was progress in TB control after introduction of DOTS strategy in the Region, the disease still claims more than lives each year. 6 TUBERCULOSIS CONTROL SAARC REGION UPDATE 2009

16 Table 4 : Estimates of TB disease incidence, prevalence and mortality in the SAARC region 2007 Country Population in thousand Estimated Incidence All types Rate per lakh pop Estimated Incidence New sputum smear +ve. Rate per lakh pop. Estimated Prevalence All types Rate Estimated death rate per lakh pop.- all forms of TB Afghanistan Bangladesh Bhutan India Maldives Nepal Pakistan Sri Lanka Total (Source: Global tuberculosis control 2009, WHO) Table 4 shows the estimated TB incidence, prevalence and mortality rates for Member countries in the SAAARC Region for The TB control in the Region is affected by the availability of quality and coverage of various TB control interventions, population demographics, socio-economic standards, HIV and emerging drug resistant TB cases. Figure 6 : Trends in estimated prevalence, incidence and mortality, SAARC region, (Source: Global tuberculosis control 2009, WHO) Figure 6 shows the overall trends in the estimated prevalence, incidence and mortality rates per population in the region as a whole, between 1990 and The estimated prevalence, incidence as well as mortality are falling slowly since This trend needs to be maintained to achieve MDG goals. TUBERCULOSIS CONTROL SAARC REGION UPDATE

17 TB disease incidence, prevalence and mortality The prevalence and incidence surveys are important as they provide accurate estimations of the burden of disease in countries. There are still uncertainties about the current estimates for TB disease prevalence, incidence and mortality rates in individual member countries in the Region. This requires strengthening of all aspects of the TB surveillance system, focusing on quality data entry, compilation and reporting. There were an estimated 4.4 million prevalent cases in Figure 7 shows the estimated prevalence rates in the 8 Member countries of the region comparing the rates between 1990, 2001, 2004 and Figure 7 : Estimated prevalence rates for all forms of TB, SAARC region, 1990, 2001, 2004 & 2007 Figure 8 : Estimated incidence of all forms of TB, SAARC region, 1990, 2001, 2004 & 2007 Cases per population Cases per population Figure 8 shows the estimated incidence rate of all forms of TB in the 8 Member countries of the region comparing the rates between 1990, 2001, 2004 and There are indications of decrease in Bangladesh, Bhutan, Maldives and Nepal, whereas in remaining other member countries it shows no change. 8 TUBERCULOSIS CONTROL SAARC REGION UPDATE 2009

18 Figure 9 : Estimated mortality rates of all forms of TB, SAARC region, 1990, 2001, 2004 & 2007 Cases per population Figure 9 shows the estimated mortality rate of all forms of TB in the 8 Member countries of the region comparing the rates between 1990, 2001, 2004 and There are indications of decrease in all member countries except in Afghanistan and Bhutan, where in it shows fluctuations. 6. Situation of Tuberculosis Control in SAARC Region Tuberculosis is one of the major public health problems in the SAARC Region with immense socio-economic impacts. About 50% of the adult population of this Region has already been infected with Mycobacterium tuberculosis and is at risk of developing tuberculosis disease. In the year 2008, a total 1.9 million all types of TB cases were notified (129/100000). This represents 75.3 % of the 2.6 million estimated incident cases; the 0.8 million new smear positive cases notified (55/100000) account for 72.0 % of the 1.1 million estimates. According to the estimate, SAARC Region was bearing 29.86% of the total global new sputum smear positive cases with 22.9 % of population share in India, Bangladesh, Pakistan and Afghanistan are occupying the 1 st, 6 th, 8 th and 22 nd positions in the list of 22 high burden countries (HBCs) {according to estimated incidence (absolute number) of TB,.2007} with India having the highest (21.2 %) global absolute burden of TB in These 4 SAARC nations account for 28.6 % of the global absolute burden of TB. By adopting DOTS strategy, the Region has made remarkable progress in TB control. In the year 2008, SAARC Region covered 100% of its population with DOTS. In the region in 2008, 72.0 % of the total estimated new smear positive cases were detected. Hence, the region achieved the global target of case detection. The Region also achieved the target of 85% (now 90.7%) treatment success rate for new smear positive cases initiated on treatment. Major challenges however remain for control of TB, such as Sustaining quality in diagnosis and case management Expanding DOTS services in private sector and hard to reach areas Strengthening human resources in terms of numbers and technical capacity Strengthening laboratory network and improving EQA and supervision Building infrastructure and technical capacity for culture and DST for management of MDR TB TUBERCULOSIS CONTROL SAARC REGION UPDATE

19 Establishing effective coordination between NTP and NACP Tackling the issues for tuberculosis arising due to migration & cross border, mobility of populations. References: 1. NTP, country reports of WHO, Report 2009, Global Tuberculosis Control. Epidemiology, Strategy, Financing. 3. Tuberculosis in the South East Asia region, 2009, WHO 4. Tuberculosis in SAARC region, an update 2008, SAARC TB and HIV/AIDS Center, 7. Magnitude of the MDR-TB problem-global 1 The fourth WHO/IUATLD global report on anti tuberculosis drug resistance surveillance has documented that many areas of the world face endemic and epidemic MDR-TB, and in some areas resistance is alarmingly high. Global Estimates Based on drug resistance information from 114 countries and 2 SARs of China reporting as well as nine other epidemiological factors, it is estimated that (95% CIs, ) cases of MDR-TB emerged in China and India carry approximately 50% of the global burden of MDR-TB and the Russian Federation a further 7%. The total number of MDR TB cases estimated to have occurred in 2006 among newly diagnosed TB cases was or 3.1% (95% CIs ), among previously treated cases was or 19.3% ( 95% CIs ) and among total incident TB cases was 4.8% (95% CIs ). Some countries of the former Soviet Union, provinces in China reported the highest proportions of resistance, while Western Europe, followed by countries in Africa, reported the lowest proportions of MDR-TB. It is important to note at least one country in all six WHO regions has reported >3.0% MDR-TB among new cases. Based on information gathered throughout the global project, the most recent data available from 114 countries and 2 SARs of China was weighted by the population in areas surveyed. The data represent TB cases, and gave the following results for global population weighted proportion of resistance among: New cases Any resistance 17.0% (95% confidence levels, CIs, ) isoniazid resistance 10.3% (95% CIs, ) MDR 2.9% (95% CIs, ) Previously treated cases Any resistance 35.0% (95% CIs, ) isoniazid resistance 27.7% (95% CIs, ) MDR-TB 15.3% (95% CIs, ) All TB cases Any resistance 20.0% (95% CIs, ) isoniazid resistance 13.3% (95% CIs, ) MDR-TB 5.3% (95% CIs, ). The most recent estimates suggest that there were cases of MDR-TB in 2007, accounting for 85% of all cases. By the end of 2008, 55 countries and territories had reported at least one case of XDR TB. 10 TUBERCULOSIS CONTROL SAARC REGION UPDATE 2009

20 Among TB cases tested for drug susceptibility in 2007, cases of MDR-TB were diagnosed and notified.although there is evidence that notifications are increasing, the number of MDR-TB cases notified in 2007 represented only 6% of the 0.5 million cases estimated to exist worldwide (and 9% of estimated cases of smear positive MDR-TB). In 2007, the patients were treated in GLC approved projects representing 0.7% of estimated MDR-TB cases. By the end of 2008, a total of 134 projects in 60 countries covering a cumulative total of approximately patients had been approved by the GLC, among them 6 countries were in South East Asia region. For the South East Asia region, MDR-TB prevalence is estimated as 2.8% (95% CIs, ) among new cases and 18.8% (95% CIs, ) among previously treated cases. Based on the available information, it is estimated that there were 149,698 incident MDR-TB cases in the region in 2006, with 74% of these cases estimated to be in India. 8. MDR-TB problem in SAARC region Afghanistan Percentage of MDR in new TB cases was 3.4% and among previously treated TB cases was 37% 1. BANGLADESH There is no national data on drug resistance at the National level. The estimated levels of MDR-TB in the country are 3.6% among newly diagnosed and 19.3% among previously treated patients 1. Isolated surveys have indicated that MDR- TB rates among newly diagnosed cases range between 0.2% and 3% and among previously treated cases, between 3% and 15.4% respectively. A survey of drug susceptibility among patients failing category II regimens has been conducted, supported by the supra national reference laboratory at Antwerp. The survey showed that 88% of Category II failures, had MDR TB. MDR-TB management is ongoing in an area where TB control services are supported by Damien Foundation, as well as at the National TB Control Programme, and also at the National Institute of Diseases of Chest and Hospital, Dhaka, which is the GLC approved DOTS Plus site under the national programme supported by Global fund.(march 2008) BHUTAN According to the drug sensitivity testing pattern ( ) under National Tuberculosis Control Program, in Bhutan there were 71 MDR-TB patients registered since 2001, among them 30 are cured, 8 died and I failed. 6 patients had completed the treatment. 5 INDIA Drug resistant tuberculosis has frequently been encountered in India and its presence has been known virtually from the time anti-tuberculosis drugs were introduced for the treatment of TB. It is estimated that 110,132 (80, ,801) MDR-TB cases emerged in India in 2006, representing over 20% of the global burden. (WHO-March 2008) DOTS Plus services for the management of MDR-TB patients have been rolled out in the states of Gujarat and Maharashtra in March, 2007 and in Andhra Pradesh in Oct 2008 under the National Programme. Delhi, Haryana, Kerala and West Bengal have initiated the identification of MDR suspects and will roll out the treatment services shortly. RNTCP report 2009 shows that 1496 MDR-TB suspects were subjected to culture and DST, among them 308 MDR TB cases were detected and 190 cases were registered for Cat IV treatment. Several small surveys conducted across the country have shown the prevalence rates of MDR-TB in the country at around 3% among new cases and 12% among retreatment cases. A large scale population based survey in the states of Gujarat and Maharastra has also indicated similar resistance levels. Available information suggests that the proportion of MDR-TB is relatively low in India. However, this translates into large absolute number of cases with an estimated annual incidence of 111,000 cases of MDR-TB. 6 TUBERCULOSIS CONTROL SAARC REGION UPDATE

21 MALDIVES Facilities for mycobacterium culture are available at the Indira Gandhi Memorial hospital in Male. Five patients who failed category 2 regimens had done culture and DST at Tuberculosis Research Centre in Chennai and second line regimen drugs for these patients have been procured on a case by case basis by the programme. 7 NEPAL As part of the IUATLD/WHO Global Surveillance programme NTP conducts repeated national surveys of drug resistance among newly registered TB cases. This surveillance report showed that the prevalence of MDR-TB among New TB cases in 1996/97-1.2%, 1998/99-3.6%, 2001/02 1.3% and the latest survey conducted during shows 2.9% and among previously treated cases 11.7%. 8 DOTS Plus programme for treatment of Multi Drug Resistant TB (MDR-TB) started at 5 main centers and 16 sub-centers in September By the mid July 2008, 10 treatment centers and 34 sub-centers were offering MDR TB treatment and follow up services. Nepal was the first country in the SAARC region to introduce DOTS-Plus, integrating it with the NTP. By 2008 NTP registered 494 MDR TB cases for treatment. The largest number of MDR TB cases registered belongs to failures of CAT 2 (89%) followed by CAT I failures with culture and DST confirmed MDR TB (5.8%). 8 PAKISTAN Preparation for registration of MDR-TB patients is in progress. 9 Percentage of estimated MDR-TB in new TB cases was 3.4% and among previously treated TB cases was 36.5% 1 SRI-LANKA The estimated MDR-TB patients are 299 (2.3% of all TB cases). According to available data on MDR TB from the National Reference Laboratory, as all the specimens from the whole country are processed there, in years ( ) the total No. of MDR patients detected by the central laboratory is 48. Out of these 48 patients, the new cases were 12 & retreatment cases were The new survey data available from Sri-Lanka is showing exceptionally low proportion of resistance. 1 MDR-TB is diagnosed at the central reference laboratory and patients are treated primarily at one referral hospital, though other hospitals also manage these cases. The SAARC region is home of four TB high burden countries. Though resistance in the region is moderate the overall burden of MDR-TB is considerable. Important progress has been made throughout the region in initiating MDR-TB treatment. All countries have identified laboratory capacity as the major constraint to scaling up MDR-TB diagnosis and treatment. Expanding laboratory capacity for quality assured culture and drug susceptibility testing for both first and second-line drugs in the countries of the Region both for better surveillance and to diagnose and treat these cases is an urgent priority. The other concern is that unless MDR-TB management develops rapidly in the public sector an increasing number of MDR-TB cases will be managed by the unregulated private sector, which lacks capacity to ensure compliance of treatment for long duration. Based on anti-tuberculosis drug resistance information from WHO Global TB information, 2009, the number of MDR TB among all cases and smear positive cases, percentage of MDR among new and retreatment cases is shown in table below:. 12 TUBERCULOSIS CONTROL SAARC REGION UPDATE 2009

22 Table 5 : Estimates of MDR-TB among all TB cases and new smear positive cases in SAARC Member States Country % of New % of Retreatment MDR-TB 2007 all cases Number among smear positive Afghanistan Bangladesh Bhutan India Maldives Nepal Pakistan Sri Lanka Total References : 1. The WHO/IUATLD Global Project on Anti tuberculosis Drug Resistance. Surveillance. ANTI-TUBERCULOSIS DRUG RESISTANCE IN THE WORLD, Fourth Global Report, WHO, WHO Global Tuberculosis Control 2009, Epidemiology, Strategy, Financing 3. Drug resistant Tuberculosis in the South East Asia region., March 2008, Regional Office for South East Asia, New Delhi 4. Operational Manual for the Management of MDR-TB-DOTS- PLUS pilot Project Bangladesh, 5. Bhutan-Country presentation in SAARC Programme Managers meeting at Maldives, on May RNTCP status report, India National Strategic Plan for Tuberculosis Control , Ministry of Health, Maldives 8. Annual report of National Tuberculosis centre, Nepal, 2006/07 9. NTP Pakistan report, Sri Lanka-Country presentation in Second workshop to develop Regional Guidelines for Treatment of MDR-TB & third Meeting of Lab Directors from 9 Reference Laboratories in SAARC Region at Bhutan. TUBERCULOSIS CONTROL SAARC REGION UPDATE

23 Progress in TB Control in SAARC Region This chapter reviews the progresses made in TB control in SAARC Member States. It provides an analysis of the compiled country reports on the numbers of TB cases registered in 2008 and reporting on the treatment outcomes of patients registered in DOTS Coverage Globally the total number of countries implementing Directly Observed Treatment Short-course (DOTS) has increased steadily from 1995 to 2003, and has since remained stable at around 180 countries. All 22 HBCs have had DOTS programmes since 2000, many of which have been established for much longer. 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. Table 6 : Adoption of DOTS by SAARC Member States Country Year of adopting DOTS strategy Afghanistan 1997 Bangladesh 1993 Bhutan 1996 India 1997 Maldives 1994 Nepal 1996 Pakistan 1995 Sri Lanka 1994 DOTS coverage within SAARC region has steadily increased since Population coverage in 1997 was 11%, since then it has been increasing and reached 99.5% in 2006 and 100% in 2007 and in (Figure 10) Figure 10: DOTS Coverage in SAARC Region, TUBERCULOSIS CONTROL SAARC REGION UPDATE 2009

24 2. Notifications, Case Detections and treatment Success Table 7 : Case detection (2008) and Treatment outcome (2007), SAARC Region Estimated Notified Case Detection Rate (%) Treatment outcome (%) Country Population All types New sputum smear +ve. All types New sputum smear +ve. All types New sputum smear +ve Cure Rate Treatment Completed Treatment Success Afghanistan , Bangladesh Bhutan 660, India 1,147,700, Maldives 298, NA NA Nepal Pakistan 167,671, Sri Lanka 20,517, Total 1,532,912, Source : NTP Reports 2008, from SAARC Member States A total cases (all types) were notified in 2008 in this region, of which 43% were new sputum smear positive cases. The case detection rate for new smear positive is 72.0% for 2008 for this region. Overall case detection rate in the region in 2008 for all type of TB cases is 75.0 %.( Table 7) In 2008, all member countries met the targets of case detection rate and treatment success (Figure 11). Figure 11 : Case detection Rate 2008 and Treatment Success Rate, 2007 Note : TSR of Maldives of 2006 Case Detection Rate of New SS +ve TUBERCULOSIS CONTROL SAARC REGION UPDATE

25 Figure 12 : Distribution of notifi ed New Smear positive TB cases in SAARC Member States, 2008 Four of the 22 countries with the highest burden of TB namely India, Bangladesh, Pakistan and Afghanistan together notified new smear positive cases, which represent 97.6 % of total new smear positive cases notified in the Region. India alone accounted close to three fourth (72.05%) of all notifications in the SAARC region and continues to account for almost one fifth of the global burden of TB. (figure 12) Figure 13 : Progress in TB control in SAARC Region Fig 13 shows the overall progress in tuberculosis control in the region. It depicts that there is remarkable progress in DOTS coverage and reached to100% in Regarding treatment success, the target is achieved since In 2008 case detection rate reached 72.0%. Table 8 : Global vs SAARC Region on TB Indicators TB Control Indicators Global 2006/07 SAARC 2007/08 Estimated Population New SS +ve TB Cases notified New all types of TB Cases notified DOTS Coverage (% ) New SS +ve Case Detection Rate (%) Treatment Success Rate (%) TUBERCULOSIS CONTROL SAARC REGION UPDATE 2009

26 Progress with TB Control in SAARC Member States Afghanistan Bangladesh Bhutan India Maldives Nepal Pakistan Sri Lanka TUBERCULOSIS CONTROL SAARC REGION UPDATE

27 18 TUBERCULOSIS CONTROL SAARC REGION UPDATE 2009

28 Afghanistan In Afghanistan, Tuberculosis (TB) is one of the main public health problems. Afghanistan ranks 22nd on the list of 22 High- Burden TB countries in the world. Despite political instability and limited resources, the National TB Control Programme (NTCP) Afghanistan has managed to provide high quality TB treatment to greater numbers of patients each year for the past decade. In 1997, Ministry of Population and Health (MOPH) in collaboration with WHO and other NGO s, adopted the Directly Observed Treatment Short course (DOTS) strategy. By the end of 2002, the country reported 38 percent DOTS coverage. With increased support, improved regional coordination, and greater collaboration between private providers and communities, DOTS coverage reached 100 percent in In early 2003, the first National Strategic Plan for TB Control was drafted and the global targets of 70% case detection and 85% treatment success by 2005 were adopted by the MOPH as the national goals of the 3-year DOTS strategy and now TB control is the top priority of Public Health. DOTS centers have increased from 30 in 2001 to 1031 in 2008 all over the country. The Case Notification Trend has also increased from 9581 cases in 2001 to cases in The treatment success continues to be high, averaging 88 to 89 percent over the past four years, higher than the WHO global target of 85 percent. Surveillance and Epidemiology, 2008 Population (Thousands) million Epidemiological burden Incidence (all cases/ pop/yr) Incidence (ss+/ pop/yr) - 76 Prevalence rate (all cases/ pop) Mortality rate (TB Cases/100000pop/yr) - 30 Surveillance and DOTS implementation DOTS Case detection rate (all types %) - 74 DOTS case detection rate (new ss+, %) - 73 DOTS treatment success (new ss+, %) - 89 Laboratory services Number of laboratories performing smear microscopy National Tuberculosis Reference Lab - 1 Collaborative TB/HIV activities National policy of counseling and testing TB patients for HIV - drafted National surveillance system of HIV infection in TB patients - planned Source: NTP report of Afghanistan, 2009 TUBERCULOSIS CONTROL SAARC REGION UPDATE

29 Ministry of Public Health delivers health services impartially and without any form of discrimination to the needy people of Afghanistan in all corners of the country through the Basic Package of Health Services (BPHS) and the Essential Package of Health Services delivery systems, funded through a grant with WHO and implemented by international and national NGOs. Figure 14 : DOTS coverage and Case detection ( ) DOTS Coverage consistently improved and reached global target in 2006(Figure 14) and case detection rate improved and reached 73% in 2008.Hence global target of case detection also reached in Figure 15 : Case Notifi cation by type of patients, 2008 Among 28,301 TB cases notified, 46 % new smear positive, 28% new smear negative and 22 % new extra-pulmonary. Only 4% were relapse cases. (Figure 15) 20 TUBERCULOSIS CONTROL SAARC REGION UPDATE 2009

30 Figure 16 : Sex distribution of Different Types of notifi ed TB cases in 2008 In all types of notified TB cases, female cases are found to be notified more than male. Within New smear positive groups, females occupy 68% and males occupy only 32%. (Fig 16) Figure 17 : Treatment outcome for New Smear Positive cases: 2007 cohort Treatment outcomes of 2007 Cohort: cured 85%, treatment completed 5%, died 2% and failure 1%. (Fig 17) TUBERCULOSIS CONTROL SAARC REGION UPDATE

31 Figure 18 : Treatment success and Case detection rate ( ) In comparing treatment success and case detection rate, treatment success is maintained above the targeted 85% and was 89% in 2007; also case detection rate was consistently improving and reached 73% in (Fig 18) Challenges : Increasing government funding, TB is considered as one of the top health priorities, nonetheless government funding makes up only 0.3% of the NTP budget for 2007, leaving TB control heavily dependent on international funding. Scaling up the collaboration with BPHS partners by developing collaborative mechanisms and providing TB specific technical assistance, anti TB drugs and laboratory reagents Strengthening the NTP central unit, and defining a clear policy for staffing and training. Planned activities : Improve quality of TB services through continuous monitoring and evaluation of TB control activities, supervision, training/ retraining and community involvement. Strengthening and monitoring of TB contact investigation activities within TB control services Ensure appropriate and efficient coordination with and among the various partners through the interagency Coordination Committee Response to MDR-TB and TB/HIV Co-infection References : 1. National Tuberculosis Control Programme Afghanistan, Annual report NTP, Afghanistan report, TUBERCULOSIS CONTROL SAARC REGION UPDATE 2009