GLOBAL TUBERCULOSIS REPORT

Transcription

1 GLOBAL TUBERCULOSIS REPORT 217

2 GLOBAL TUBERCULOSIS REPORT 217

3 Globl tuberculosis report 217 ISBN World Helth Orgniztion 217 Some rights reserved. This work is vilble under the Cretive Commons Attribution-NonCommercil-ShreAlike 3. IGO licence (CC BY-NC-SA 3. IGO; Under the terms of this licence, you my copy, redistribute nd dpt the work for non-commercil purposes, provided the work is ppropritely cited, s indicted below. In ny use of this work, there should be no suggestion tht WHO endorses ny specific orgniztion, products or services. The use of the WHO logo is not permitted. If you dpt the work, then you must license your work under the sme or equivlent Cretive Commons licence. If you crete trnsltion of this work, you should dd the following disclimer long with the suggested cittion: This trnsltion ws not creted by the World Helth Orgniztion (WHO). WHO is not responsible for the content or ccurcy of this trnsltion. The originl English edition shll be the binding nd uthentic edition. Any medition relting to disputes rising under the licence shll be conducted in ccordnce with the medition rules of the World Intellectul Property Orgniztion. Suggested cittion. Globl tuberculosis report 217. Genev: World Helth Orgniztion; 217. Licence: CC BY-NC- SA 3. IGO. Ctloguing-in-Publiction (CIP) dt. CIP dt re vilble t Sles, rights nd licensing. To purchse WHO publictions, see To submit requests for commercil use nd queries on rights nd licensing, see Third-prty mterils. If you wish to reuse mteril from this work tht is ttributed to third prty, such s tbles, figures or imges, it is your responsibility to determine whether permission is needed for tht reuse nd to obtin permission from the copyright holder. The risk of clims resulting from infringement of ny third-prty-owned component in the work rests solely with the user. Generl disclimers. The designtions employed nd the presenttion of the mteril in this publiction do not imply the expression of ny opinion whtsoever on the prt of WHO concerning the legl sttus of ny country, territory, city or re or of its uthorities, or concerning the delimittion of its frontiers or boundries. Dotted nd dshed lines on mps represent pproximte border lines for which there my not yet be full greement. The mention of specific compnies or of certin mnufcturers products does not imply tht they re endorsed or recommended by WHO in preference to others of similr nture tht re not mentioned. Errors nd omissions excepted, the nmes of proprietry products re distinguished by initil cpitl letters. All resonble precutions hve been tken by WHO to verify the informtion contined in this publiction. However, the published mteril is being distributed without wrrnty of ny kind, either expressed or implied. The responsibility for the interprettion nd use of the mteril lies with the reder. In no event shll WHO be lible for dmges rising from its use. Designed by minimum grphics Cover designed by Irwin Lw Printed in Frnce WHO/HTM/TB/217.23

4 Contents Abbrevitions iv Acknowledgements v Executive Summry 1 Chpter 1. Introduction 5 Chpter 2. The Sustinble Development Gols nd the End TB Strtegy 7 Chpter 3. TB disese burden 21 Chpter 4. Dignosis nd tretment: TB, HIV-ssocited TB nd drug-resistnt TB 63 Chpter 5. TB prevention services 97 Chpter 6. Finncing for TB prevention, dignosis nd tretment 17 Chpter 7. Universl helth coverge, socil protection nd socil determinnts 123 Chpter 8. TB reserch nd development 137 Annexes 1. The WHO globl TB dtbse Country profiles for 3 high TB burden countries Regionl nd globl profiles TB burden estimtes, notifictions nd tretment outcomes 227 GLOBAL TUBERCULOSIS REPORT 217 iii

5 Abbrevitions DSM AIDS ART BCG BRICS CFR CHOICE CI CRS DST EBA EECA FIND GAF GDP Globl Fund HBC HIV IGRA IHME ctive TB drug-sfety monitoring nd mngement cquired immunodeficiency syndrome ntiretrovirl therpy bcille Clmette-Guérin Brzil, Russin Federtion, Indi, Chin nd South Afric cse ftlity rtio CHOosing Interventions tht re Cost-Effective (WHO) confidence intervl creditor reporting system drug susceptibility testing erly bctericidl ctivity Estern Europe nd Centrl Asi Foundtion for Innovtive New Dignostics Globl Action Frmework for TB Reserch gross domestic product The Globl Fund to Fight AIDS, Tuberculosis nd Mlri high-burden country humn immunodeficiency virus interferon gmm relese ssy Institute of Helth Metrics nd Evlution NCD NFC NHI NTP OECD OIE OOP PEPFAR PMDT P:N PPM RR-TB SDG SHA SMS SPARKS SRL TB TBTC TDR noncommunicble disese ner-field communiction ntionl helth insurnce ntionl TB progrmme Orgnistion for Economic Co-opertion nd Development World Orgnistion for Animl Helth out-of-pocket President s Emergency Pln For AIDS Relief progrmmtic mngement of drug-resistnt TB prevlence to notifiction (rtio) public-public nd public-privte mix rifmpicin-resistnt TB Sustinble Development Gol System of Helth Accounts short messge service Socil Protection Action Reserch & Knowledge Shring suprntionl reference lbortory tuberculosis TB Tril Consortium Specil Progrmme for Reserch nd Trining in Tropicl Diseses ILO Interntionl Lbour Orgniztion TNF tumour necrosis fctor LED light-emitting diode TPP trget product profile LMIC low- nd middle-income country TST tuberculin skin test LPA line probe ssy UHC universl helth coverge LTBI ltent TB infection UN United Ntions MAMS-TB multi-rm, multi-stge TB UNAIDS Joint United Ntions Progrmme on HIV/AIDS MDG Millennium Development Gol UNICEF United Ntions Children s Fund MDR/RR-TB MDR-TB M:F MoH MOLISA multidrug-resistnt TB or rifmpicin-resistnt (but isonizid-susceptible) TB multidrug-resistnt TB, defined s resistnce to rifmpicin nd isonizid mle to femle (rtio) ministry of helth Ministry of Lbour Invlids nd Socil Affirs (Viet Nm) US USAID VICTORY VR WHO WRD XDR-TB United Sttes US Agency for Interntionl Development Viet Nm Integrted Center for TB nd Respirology Reserch vitl registrtion World Helth Orgniztion WHO-recommended rpid dignostic extensively drug-resistnt TB iv GLOBAL TUBERCULOSIS REPORT 217

6 Acknowledgements This globl TB report ws produced by core tem of 2 people: Lur Anderson, Annbel Bddeley, Ann Den, Hnnh Monic Dis, Dennis Flzon, Ktherine Floyd, Inés Grci Ben, Nebit Gebreselssie, Christopher Gilpin, Philippe Glziou, Yohhei Hmd, Avinsh Knchr, Irwin Lw, Christin Lienhrdt, Andrew Sirok, Chrlmbos Sismnidis, Hzim Timimi, Wyne vn Gemert, Din Weil nd Mtteo Zignol. The tem ws led by Ktherine Floyd. Overll guidnce ws provided by the Director of the Globl TB Progrmme, Mrio Rviglione. The dt collection forms (long nd short versions) were developed by Philippe Glziou nd Hzim Timimi, with input from stff throughout the WHO Globl TB Progrmme. Hzim Timimi led nd orgnized ll spects of dt mngement. The review nd follow-up of dt ws done by tem of reviewers tht included Annbel Bddeley, Ann Den, Dennis Flzon, Inés Grcí Ben, Mede Gegi, Yohhei Hmd, Thoms Joseph, Avinsh Knchr, Tomáš Mts, Linh Nguyen, Andre Pntoj, Andrew Sirok, Hzim Timimi, Mukund Uplekr, Wyne vn Gemert nd Mtteo Zignol. Dt for the Europen Region were collected nd vlidted jointly by the WHO Regionl Office for Europe nd the Europen Centre for Disese Prevention nd Control (ECDC); we thnk in prticulr Encrn Gimenez, Vhur Hollo nd Csb Ködmön from ECDC for providing vlidted dt files nd Andrei Ddu from the WHO Regionl Office for Europe for his substntil contribution to follow-up nd vlidtion of dt for ll Europen countries. UNAIDS mnged the process of dt collection from ntionl AIDS progrmmes nd provided ccess to their TB/HIV dtset. Review nd vlidtion of TB/ HIV dt ws undertken in collbortion with UNAIDS stff. Mny people contributed to the nlyses, preprtion of figures nd tbles, nd writing required for the min chpters of the report. The Executive Summry, Chpter 1 (Introduction) nd Chpter 2 (The Sustinble Development Gols nd the End TB Strtegy) were prepred by Ktherine Floyd. Chpter 3 (TB disese burden) ws prepred by Ann Den, Ktherine Floyd, Philippe Glziou, Irwin Lw, Chrlmbos Sismnidis nd Mtteo Zignol, with contributions from Lur Anderson nd Peter Dodd. The writing of Chpter 4 (Dignosis nd tretment of TB, HIV-ssocited TB nd drug-resistnt TB) ws led by Dennis Flzon nd Wyne vn Gemert, with support from Ktherine Floyd nd Mtteo Zignol, nd the preprtion of figures nd tbles ws led by Hzim Timimi; other chpter contributors included Lur Anderson, Annbel Bddeley, Hnnh Monic Dis, Yohhei Hmd, Thoms Joseph, Avinsh Knchr, Irwin Lw, Andrew Sirok, Chrlmbos Sismnidis nd Mukund Uplekr. Chpter 5 (TB prevention services) ws prepred by Yohhei Hmd, Avinsh Knchr nd Hileyesus Gethun, with contributions from Annbel Bddeley, Ktherine Floyd nd Mtteo Zignol. Chpter 6 (Finncing for TB prevention, dignosis nd tretment) ws prepred by Ktherine Floyd, Inés Grci Ben nd Andrew Sirok. The production of Chpter 7 (Universl helth coverge, socil protection nd socil determinnts) ws led by Din Weil, with contributions from Mrzi Clvi, Amy Collins, Inés Grci Ben, Ktherine Floyd, Philippe Glziou, Mry Antonette Remonte, Andrew Sirok, Krin Stenberg, Mukund Uplekr nd Rjendr Ydv. Chpter 8 (TB reserch nd development) ws prepred by Christin Lienhrdt, Nebit Gebreselssie nd Christopher Gilpin, with support from Ktherine Floyd nd Krin Weyer nd contributions to specific components of chpter content from Dennis Flzon, Priy Shete nd Din Weil. Irwin Lw coordinted the finliztion of figures nd tbles for ll chpters nd subsequent review of proofs, ws the focl point for communictions with the grphic designer nd designed the report cover. The report tem is grteful to vrious internl nd externl reviewers for their useful comments nd suggestions on dvnced drfts of the min chpters of the report. Prticulr thnks re due to Colin Mthers for his review of Chpter 3; to Jesus Mri Grci Cllej nd Stvinder Singh for their reviews of Chpter 4 nd Chpter 5; to Cllum Brindley nd Odd Hnssen for their reviews of finncing estimtes relted to universl helth coverge included in Chpter 7; nd to Dniel Cirillo, Jonthn Dniels, Cludi Denkinger, Brbr Lughon, Din Rozendl, Mel Spigelmn nd Jennifer Woolley for their reviews of Chpter 8. Annex 1, which provides n overview of the globl TB dtbse, ws written by Hzim Timimi. The country profiles tht pper in Annex 2, the regionl profiles tht pper in Annex 3 nd the detiled tbles showing dt for key indictors for ll countries in the ltest yer for which informtion is vilble (Annex 4) were lso prepred by Hzim Timimi. For Annex 2, Ktherine Floyd, Irwin Lw nd Andrew Sirok gve input to the design nd content of the pges on indictors in the Sustinble Development Gols tht re ssocited with TB incidence. The preprtion of the online technicl ppendix tht explins the methods used to estimte the burden of disese cused by TB ws GLOBAL TUBERCULOSIS REPORT 217 v

7 led by Philippe Glziou, with contributions from Peter Dodd, Chrlmbos Sismnidis nd Mtteo Zignol. We thnk Vlérie Robert in the Globl TB Progrmme s monitoring nd evlution unit for impeccble dministrtive support, Doris M Ft from the WHO Mortlity nd Burden of Disese tem for providing dt extrcted from the WHO Mortlity Dtbse tht were used to estimte TB mortlity mong HIV-negtive people, Kthryn Bistline for providing supplementry finncil dt for South Afric, Hps Toure for providing ntionl helth ccount dt tht were not vilble in the Globl Helth Observtory, nd Julin Dher nd Mry Mhy (UNAIDS) for providing epidemiologicl dt tht were used to estimte HIV-ssocited TB incidence nd mortlity. The entire report ws edited by Hilry Cdmn, who we thnk for her excellent work. We lso thnk Sue Hobbs for her outstnding work on the design nd lyout of this report. Her contribution, s lwys, ws very highly pprecited. This yer, we re prticulrly pprecitive of her work on Annex 2, notbly the new content (compred with previous editions of the report) on indictors in the Sustinble Development Gols tht re ssocited with TB incidence. The principl source of finncil support for WHO s work on globl TB monitoring nd evlution is the United Sttes Agency for Interntionl Development (USAID), without which it would be impossible to produce the Globl Tuberculosis Report. Production of the report ws lso supported by the governments of Jpn nd the Republic of Kore. We cknowledge with grtitude their support. In ddition to the core report tem nd those mentioned bove, the report benefited from the input of mny stff working in WHO regionl nd country offices nd hundreds of people working for ntionl TB progrmmes or within ntionl surveillnce systems who contributed to the reporting of dt nd to the review of report mteril prior to publiction. These people re listed below, orgnized by WHO region. We thnk them ll for their invluble contribution nd collbortion, without which this report could not hve been produced. Among the WHO stff not lredy mentioned bove, we thnk in prticulr Edith Alrcon, Mohmed Abdul Aziz, Smih Bghddi, Msoud Dr, Mirth Del Grndo, Khurshid Alm Hyder, Dniel Kibug, Dinnuy Kombte- Noudjo, Rfel López Olrte, Prth Prtim Mndl, André Ndongosieme, Nobu Nishikiori nd Wilfred Nkhom for their contribution to dt collection nd vlidtion, nd review nd clernce of report mteril by countries in dvnce of publiction. WHO stff in Regionl nd Country Offices WHO Africn Region Boubcr Abdel Aziz, Abdoulye Mrim Bïss, Esther Aceng-Dokotum, Hrur Admu, Inácio Alvreng, Smuel Herms Andrinriso, Jvier Armburu Gurd, Cludin Augusto d Cruz, Ayodele Awe, Nyé Bh, Mrie Ctherine Broun, Bbou Bzie, Sirimn Cmr, Lstone Chitembo, Dvi Kokou Mwule, Ev De Crvlho, Ndell Dikhte, Noel Djemdji, Sithembile Dlmini-Nqeketo, Ismel Hssen Endris, Louis Gnd, Boingotlo Gsennelwe, Crolin Crdoso d Silv Gomes, Kss Hilu, Ptrick Hzngwe, Télesphore Hounsou, Jen Irgen, Moses Jeuronlon, Michel Jose, Khelifi Houri, Dniel Kibug, Hillry Kipruto, Dinnuy Kombte-Noudjo, Aristide Désiré Komngoy Nzonzo, Angel Ktherine Lo Seone, Shrmil Lreef-Jh, Leonrd Mbemb, Richrd Mbumb Ngimbi, Nkteko Mkhondo, Jules Mugbo Semhore, Christine Musnhu, Ahmd NssuriI, André Ndongosieme, Denise Nkezimn, Wilfred Nkhom, Nicols Nkiere, Abel Nkolo, Ghisline Nkone Asseko, Ishmel Nysulu, Smuel Ogiri, Dniel Olusoti, Amos Omoniyi, Hermnn Ongouo, Philip Onyebujoh, Chijioke Oskwe, Felici Owusu-Antwi, Philip Ptrobs, Richrd Oleko Rehn, Neem Gideon Simkoko, Susn Zimb-Tembo, Addislem Tefer, Dest Tiruneh, Trore Tieble, Hubert Wng, Addislem Yilm, Assefsh Zehie. WHO Region of the Americs Zohr Abkouk, Edith Alrcon, Pedro Avedillo, Dvid Chvrri, Betriz Cohenc, Mirth Del Grndo, Mrcos Espinl, Hrry Geffrrd, Mssimo Ghidinelli, Guillermo Gonzlvez, Percy Hlkyer, Frnklin Hernndez, Reynold Hewitt, Sndr Jones, Ptrice Lwrence, Frncisco Leon Brvo, Rfel Lopez Olrte, Wilmer Mrquino, Fbio Moherdui, Romeo Montoy, Alin Perez, Enrique Perez, Soledd Pérez, Jen Mrie Rwngbwob, Hns Sls, Roberto Slvtell, Alb Lidi Sánchez, Angel Roberto Sempertegui, Ktrin Smith, Alfonso Tenorio, Jorge Victori, Mrcelo Vil, Kthryn Vogel Johnston. WHO Estern Mediterrnen Region Mohmed Abdel Aziz, Mohmmd Aloudl, Smih Bghddi, Mi Eltigny Mohmmed, Hni Husseiny, Sindni Ireneus Sebit, Qutbuddin Kkr. WHO Europen Region Nikit Afnsyev, Silviu Ciobnu, Alexey Bobrik, Cssndr Butu, Andrei Ddu, Msoud Dr, Soudeh Eshni, Jmshid Gdoev, Gyne Ghuksyn, Ogty Gozlov, Vitcheslv Grnkov, Nino Mmulshvili, Myrt Sriyev, Jvhir Suleymnov, Szbolcs Szigeti, Gzmend Zhuri, Mrtin vn den Boom; nd temporry dvisors: An Ciobnu, Arksi Hovhnnesyn, Inn Motrich. vi GLOBAL TUBERCULOSIS REPORT 217

8 WHO South-Est Asi Region Mohmmd Akhtr, Vikrunness Begum, Vineet Bhti, Mri Regin Christin, Anupm Hzrik, Md Khurshid Alm Hyder, Nvrtnsingm Jnkn, Setiwn Jti Lksono, Subhsh Lkhe, Prth Prtim Mndl, Sundri Mse, Hyng Song, Ikushi Onozki, Shushil Dev Pnt, Mlik Prmr, Rnjni Rmchndrn, Md Kmr Rezwn, Mukt Shrm, Achuthn Nir Sreenivs, Ddng Supriydi, Ugyen Wngchuk. WHO Western Pcific Region Shll Ahmdov, Lepiti Hnsell, Tuhid Islm, Nrntuy Jdmb, Nobuyuki Nishikiori, Fukushi Morishit, Ktsunori Osug, Khnh Phm, Klpeshsinh Rhevr, Richrd Rehn, Fbio Scno, Jcques Sebert, Ynni Sun, Thipphsone Vixysouk, Qung Hieu Vu, Rjendr-Prsd Ydv, Subhsh Ydv, Lungten Wngchuk. Ntionl respondents who contributed to reporting nd verifiction of dt WHO Africn Region Abderrmne Abdelrhim Brk, Jen Louis Aben Foe, Felix Kwmi Afutu, Sofine Alihlss, Arlindo Tomás do Amrl, Rosmunde Amuteny, Séverin Angonou, Younouss Assoumni, Agnès Pscline Audzghe, Aw Boubcr, Bllé Boubkr, Adm Mrie Bngour, Jorge Noel Brreto, Wilfried Bekou, Ari Berhne, Frnk Ade Bonsu, Evngelist Chiskitw, Adjim Combry, Ftou Tiépé Coulibly Adjobi, Abdoulye Dillo, Adm Dillo, Ambrosio Disdidi, Themb Dlmini, Sicelo Dlmini, Antoine De Pdoue Etoundi Evoun, Alfred Etwom, Jun Eyene Acuresil, Ykhokh Fll, Lelis Fekdu, Lynd Fory, Gilberto Frot, Hervé Gilds Gndo, Evriste Gsn, Abu George, Belineh Girm, Amnuel Hdgu, Boukoulmé Hing, Aou Him Oumrou Hinikoye, Smi Hmmdi, Nii Hnson-Nortey, Georges Hermn, Adm Jllow, Jorge Jone, Clr Chol Kspo, Michel Ksw, Jmes Holim Ktt, Kenyerere Henry Shdreck, Dedeh Kesselly, Botshelo Tebogo Kgwdir, Mureen Kimenye, Désiré Aristide Komngoy Nzonzo, Bkry Konte, Ptrick Konwloh, Jcquemin Koukou Koukou, Joseph Oluwtoyin Kuye, Adebol Lwnson, Gertrude Ly, Llng Bridget Mm, Jocelyn Mhoumbou, Lerole Dvid Mmetj, Ivn Mnhiç, Tseliso Isc Mrt, Snele Msuku, Fri Mvhung, Bongiwe Mhlng, Ptrick Migmbi, Jum John Hssen Mogg, Sidin Mohmed Ahmed, Louine Renee Berndette Morel, Jmes Upile Mpung, Frnk Rwbinumi Mugbe, Betrice Mutyob, Lindiwe Mvusi, Aboubcr Mzembb, Fulgence Ndyikengurukiye, Deus Ndikumgenge, Thddée Ndikumn, Norbert Ndjek, Fith Ngri, Antoine Ngoulou, Emmnuel Nkiligi, Godwin Ohis, Frnck Hrdin Okemb-Okombi, Oumr Abdelhdi, Emile Rkotondrmmnn, Mrtin Rkotonjnhry, Thto Rleting, Mrie Edwige Rznmnn, Aduli Gomes Rodrigues, Aibn Ronoh, Mohmmed Fezul Rujeedw, Agbenyegn Smey, Chrles Sndy, Kebb Snneh, Mrie Srr Diouf, Chil Sylvi Simwnz, Nichols Sizib, Rhw Tekle, Keit Mrime Tieb Trore, Thusoyone Titi Tsholofelo. WHO Region of the Americs Srit Aguirre Grcí, Shluddin Ahmed, Edwin Aizpuru, Xochil Alemán de Cruz, Mirin Alvrez, Aish Andrewin, Denise Arkki-Snchez, Chris Archibld, Sndr Ariz, Crmen Arry Girond, Arriet Pessolno Fernndo, Norm Letici Artiles Mill, Crlos Alberto Mrcos Ayl Lun, Wiedjipreksh Blesr, Ptrici Brtholomy, Dorothe Bergen Weichselberger, Mrí Bermúdez, Tmr Bobb, Eulynis Brown, Mrtín Cstellnos Joy, Ronld Cedeño, Shwn Chrles, Gemm Chery, Krolyn Chong, Eric Commiesie, Mriel Contrer, Yren Cruz, Crlos Vitl Cruz Lesge, Ofeli Cuevs, Clr De l Cruz, Nild de Romero, Mercedes Espñ Cedeño, Sntigo Fdul, Hugo Fernndez, Cecili Figuero Benites, Gret Frnco, Victor Gllnt, Julio Gry Rmos, Izzy Gerstenbluth, Normn Gil, Mrgrit Godoy, Roscio Gomez, Nrd Gonzlez Rincon, Betriz Gutiérrez, Yskr Hlbi, Dorothe Hzel, Mri Henry, Tni Herrer, Olg Joglr, Din Khn, Sybil Mrbel Knowles Smith, Adm Lnger, Athelene Linton, Cludi Lleren, Mrth López, Eugene Mduro, Andre Mldondo Svedr, Mrvin Mnznero, Belkys Mrcelino, Luz Mrin Duque, Antonio Mrrero Figuero, M. de Lourdes Mrtínez, Zeidy Mt Azofeif, Sergio Mulen, Timothy McLughlin- Munroe, Angelic Medin, Mry Mercedes, Monic Mez, Leilwti Mohmmed, Jeetendr Mohnlll, Ernesto Moreno Nrnjo, Frncis Morey, Willy Morose, Ver Nestor, Alice Neymour, Andrés Oyol, Cheryl Peek-Bll, Toms Portillo Esquivel, Ird Potter, Robert Prtt, Mnohr Singh Rjmnickm, Norm Lucreci Rmirez Sgstume, Andres Rincón, Cielo Rios, Juli Ros Mri Rios Vidl, Feros Roche, Mri Rodriguez, Dvid Rodríguez, Mrcel Rojs, Myrin Román, Kti Romero, Rfel Rosles, Arelisbel Ruiz Guido, Wlimer Slzr, Hild Mrí Slzr Bolños, Mritz Smyo Peláez, Krl Mrí Sánchez Mendoz, Nestor Segovi, Nicol Skyers, Guido Sliv, Dnilo Solno Cstro, Ntli Sos, Din Sotto, Deborh Stijnberg, Lourdes Surez Alvrez, Jckurlyn Sutton, Michelle Trotmn, Clrisse Tsng, Meliss Vldez, Dniel Vázquez, Jun Victori, Iynn Wellington, Smuel Willims, Jennifer Wilson. WHO Estern Mediterrnen Region Trig Abdll Abdllrhim, Mohmmd Abouzeid, Khwj Leeq Ahmd, Ahmdi Shhnz, Nmtullh Ahmdzdh, Al Hmdn Khlood, Al Sidi Ftmh, Ftm Al Yqoubi, Bdr Albri, Abdulbri Al-Hmmdi, Abdulltif Al-Khl, Nd Almrzouqi, GLOBAL TUBERCULOSIS REPORT 217 vii

9 Ebrhim Al-Romihi, Esm Al-Sberi, Lyth Al-Slihi, Kifh Alshqeldi, Smir Amin, Wgdy Amin, Bhnsy Smir, Ibrhim Bdwn, Mohmed Belkhl, Ahmed Dmiereih, Mohmed Furjni, Aml Gll, Dhikryet Gmr, Assi Hissm Mohmed, Rft Hkeem, Hw Hssn Guessod, Slm Hudi, Swsn Jourieh, Rzi Kniz Ftim, Abdulhmeed Kshkry, Nsir Mhmood Khn, Syed Mhmoudi, Mulhm Mustf, Nsehi Mhshid, Mh Nsereldeen, Yssir Piro, Ndi Sbrh, Mulhm Sleh, Mohmmd Khlid Seddiq, Mohmmed Sghir, Mohemmed Tben, Him Ycoub. WHO Europen Region Ntvn Alikhnov, Ekkehrdt Altpeter, Srh Anderson, Yelen Arbuzov, Trude Mrgrete Arnesen, Zz Avlini, Velimir Bereš, Snježn Brčklo, Rikke Bruun de Neergrd, Ros Cno Portero, Aysoltn Chryev, Dniel Chemtob, Domnic Ion Chiotn, Nico Ciorn, Thierry Comolet, Andrei Corlotenu, Vleriu Crudu, Vlerij Edit Dvidviciene, Hyk Dvtyn, Ptrick de Smet, Gerrd de Vries, Irène Demuth, Rquel Durte, Mlden Duronjić, Lnfrnco Fttorini, Len Fiebig, Viktor Gsimov, Mjlind Gjocj, Biljn Grbvčević, Genndy Gurevich, Jen-Pul Guthmnn, Wlter Hs, Armen Hyrpetyn, Peter Helbling, Uršk Hribr, Ilievsk Poposk Biljn, Zhumgli Ismilov, Srh Jckson, Jerker Jonsson, Erhn Kbskl, Abdylt Kdyrov, Ourni Klkouni, Dzmitry Klimuk, Mri Korzeniewsk-Koseł, Kovcs Gbor, Meve Llor, Yn Levin, Nino Lomtdze, Irin Lucenko, Stevn Lucic, Ekterin Mliukov, Lilii Msiuk, Donik Mem, Violet MIhilovic Vucinic, Dce Mihlovsk, Vldimir Milnov, Uch Nnv, Ntli Nizov, Mihel Obrovc, Jon O Donnell, Anlit Pce Ascik, Clr Plm Jordn, Nrgiz Prpiev, Victori Petric, Sbine Pfeiffer, Asyliddin Rdzhbov, Gbriele Rinldi, Jerôme Robert, Kzimierz Roszkowski-Śliż, Elen Scchini, Gerrd Scheiden, Dniel Schmid, Anit Seglin, Firuze Shripov, Aleksndr Simunovic, Erik Slump, Hnn Soini, Ivn Solovic, Irin Sorok, Alexnder Spin, Victor Spinu, Sergey Sterlikov, Mj Stosic, Petr Svetin, Petr Svetin Sorli, Tgizde Sevinj, Shhnoz Usmnov, Tonk Vrlev, Irin Vsilyev, Piret Viiklepp, Vlentin Vilc, Jiri Wllenfels, Mryse Wnlin, Pierre Weicherding, Aysegul Yildirim, Mj Zkosk, Istvn Zsrnoczy, Hsn Žutić. WHO South-Est Asi Region Nzis Arefin Ski, Knthi Ariyrthne, Abdul Hmeed, Aminth Aroosh, Si Thu Aung, Rtn Bhdur Bhttri, Tong Chol Choe, Yullit Evrini Yuzwr, Devesh Gupt, Rouseli Hq, Chndim Hemchndr, Sirinph Jittimnee, Suksont Jittimnee, Phlin Kmolwt, Ahmdul Hsn Khn, Myo Su Kyi, Constntino Lopes, Shmim Mnnn, Pronb Kumr Modk, Md. Mojibur Rhmn, Nirup Pllewtte, Jmyng Pem, Chewng Rinzin, Sulistyo SKM, Asik Sury, Phurp Tenzin, Jnk Thilkertne, Shrt Chndr Verm, Dhmmik Vidngm. WHO Western Pcific Region Zirwtul Adilh Aziz, Pul Ai, Rfidh Bhrudin, Mohmed Nim bin Abdul Kdir, Urnchineg Borgil, Srh Brown-Ah Ku, Ris Bukbuk, Chi-kuen Chn, Nou Chnly, Phonenly Chittmny, Cho Kyung Sook, Chou Kuok Hei, Nese Ituso Conwy, Alice Cuenc, Enkhmndkh Dnjd, Jne Dowbobo, Du Xin, Mo Tn Eng, Jck Ekiek Myleen, Sen Fni, Florence Flment, Jocelyn Flores-Cbrles, Ludovic Floury, Louise Fonu, Ann Mrie Celin Grfin, Donn Me Gviol, Neti Hermn, Dniel Houillon, Noel Itogo, Kng He-Young, Seiy Kto, Khin Mr Kyi Win, Chi-chiu Leung, Liz Lopez, Ngoc-Phuong Luu, Alice Mnlo, John Ryn McLne, Mei Jin, Glori Mendiol, Kuniki Miyke, Binh Ho Nguyen, Viet Nhung Nguyen, Connie Olikong, Pkr Won Seo, Penitni Sosi, Mrcelin Rbulimn, Asmh Rzli, Reiher Berek, Mohd Rotpi Abdullh, Bernrd Rouchon, Lmek Sle, Temilo Seono, Tieng Sivnn, Phnnsinh Sylvnh, Shunji Tkkur, Edwin Tngro, Kyw Thu, Alfred Tongnibei, Kzuhiro Uchimur, Frnk Underwood, Wng Lixi, Yee Tng Wng, Justin Wong, Zhng Hui. viii GLOBAL TUBERCULOSIS REPORT 217

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11 LEAVE NO ONE BEHIND UNITE TO END TB

12 Executive Summry The purpose of WHO s Globl Tuberculosis Report is to provide comprehensive nd up-to-dte ssessment of the TB epidemic nd of progress in cre nd prevention t globl, regionl nd country levels. 1 This is done in the context of recommended globl TB strtegies nd ssocited trgets, nd broder development gols. For the period , these re WHO s End TB Strtegy nd the United Ntions (UN) Sustinble Development Gols (SDGs), which shre common im: to end the globl TB epidemic. Specific trgets set in the End TB Strtegy include 9% reduction in TB deths nd n 8% reduction in TB incidence (new cses per yer) by 23, compred with 215. Achieving these trgets requires provision of TB cre nd prevention within the broder context of universl helth coverge, multisectorl ction to ddress the socil nd economic determinnts nd consequences of TB, nd technologicl brekthroughs by 225 so tht incidence cn fll fster thn rtes chieved historiclly. Overll, the ltest picture is one of still high burden of disese, nd progress tht is not fst enough to rech trgets or to mke mjor hedwy in closing persistent gps. TB is the ninth leding cuse of deth worldwide nd the leding cuse from single infectious gent, rnking bove HIV/AIDS. In 216, there were n estimted 1.3 million TB deths mong HIV-negtive people (down from 1.7 million in 2) nd n dditionl 374 deths mong HIV-positive people. 2 An estimted 1.4 million people fell ill with TB in 216: 9% were dults, 65% were mle, 1% were people living with HIV (74% in Afric) nd 56% were in five countries: Indi, Indonesi, Chin, the Philippines nd Pkistn. 3 Drug-resistnt TB is continuing thret. In 216, there were 6 new cses with resistnce to rifmpicin (RR- TB), the most effective first-line drug, of which 49 hd multidrug-resistnt TB (MDR-TB). 4 Almost hlf (47%) of these cses were in Indi, Chin nd the Russin Federtion. 3 Globlly, the TB mortlity rte is flling t bout 3% per yer. TB incidence is flling t bout 2% per yer nd 16% of TB cses die from the disese; by 22, these figures need to improve to 4 5% per yer nd 1%, respectively, to rech the first (22) milestones of the End TB Strtegy. Most deths from TB could be prevented with erly dignosis nd pproprite tretment. Millions of people re dignosed nd successfully treted for TB ech yer, verting millions of deths (53 million 2 216), but there re still lrge gps in detection nd tretment. In 216, 6.3 million new cses of TB were reported (up from 6.1 million in 215), equivlent to 61% of the estimted incidence of 1.4 million; the ltest tretment outcome dt show globl tretment success rte of 83%, similr to recent yers. There were reported cses of HIV-positive TB (46% of the estimted incidence), of whom 85% were on ntiretrovirl therpy (ART). A totl of people were strted on tretment for drug-resistnt TB, smll increse from in 215 but only 22% of the estimted incidence; tretment success remins low, t 54% globlly. Mking lrge inrods into these gps requires progress in prticulr subset of high TB burden countries. Ten countries ccounted for 76% of the totl gp between TB incidence nd reported cses; the top three were Indi (25%), Indonesi (16%) nd Nigeri (8%). 5 Ten countries ccounted for 75% of the incidence-tretment enrolment gp for drug-resistnt TB; Indi nd Chin ccounted for 39% of the globl gp. 6 Most of the gps relted to HIV-ssocited TB were in the WHO Africn Region. TB preventive tretment is expnding, especilly in the two priority risk groups of people living with HIV nd children under 5. However, most people eligible for TB preventive tretment re not ccessing it. Finncing for TB cre nd prevention hs been incresing for more thn 1 yers, but funding gps still exist (US$ 2.3 billion in 217). Totl helth spending lso flls short of the resources needed to chieve universl helth coverge. Closing these gps requires more resources from both domestic sources (especilly in middle-income countries) nd inter ntionl donors (especilly in low-income countries). Broder influences on the TB epidemic include levels of poverty, HIV infection, undernutrition nd smoking. Most high TB burden countries hve mjor chllenges hed to rech SDG trgets relted to these nd other determinnts. The pipelines for new dignostics, drugs, tretment regimens nd vccines re progressing, but slowly. Incresed invest ment in reserch nd development is needed for there to be ny chnce of chieving the technologicl brekthroughs needed by 225. The WHO Globl Ministeril Conference on ending TB in the SDG er in November 217 nd the first UN Generl Assembly high-level meeting on TB in 218 provide historic opportunity to glvnize the politicl commitment needed to step up the bttle ginst TB nd put the world nd individul countries on the pth to ending the TB epidemic. GLOBAL TUBERCULOSIS REPORT 217 1

13 Additionl highlights from the report Introduction The min dt sources for the report re nnul rounds of globl TB dt collection implemented by WHO s Globl TB Progrmme since 1995 nd dtbses mintined by other WHO deprtments, UNAIDS nd the World Bnk. In WHO s 217 round of globl TB dt collection, 21 countries nd territories tht ccount for over 99% of the world s popultion nd TB cses reported dt. The SDGs nd the End TB Strtegy The first milestones of the End TB Strtegy re set for 22. They re 35% reduction in TB deths nd 2% reduction in TB incidence, compred with levels in 215; nd tht no TB ptients nd their households should fce ctstrophic costs s result of TB disese. Monitoring of TB-specific indictors is well estblished t globl nd ntionl levels. For exmple, stndrdized monitoring of notifictions of TB cses nd their tretment outcomes t globl nd ntionl levels hs been in plce since 1995, nd estimtes of TB incidence nd mortlity hve been published nnully by WHO for more thn decde. In 217, WHO hs developed TB-SDG monitoring frmework of 14 indictors tht re ssocited with TB incidence, under seven SDGs. There re seven indictors under SDG 3 (helth nd well-being): coverge of essentil helth services; percentge of totl helth expenditures tht re out-of-pocket; helth expenditure per cpit; HIV prevlence; prevlence of smoking; prevlence of dibetes; nd prevlence of lcohol use disorder. The other seven indictors, linked to SDGs 1, 2, 7, 8, 1 nd 11, re: proportion of the popultion living below the interntionl poverty line; proportion of the popultion covered by socil protection floors/systems; prevlence of undernourishment; proportion of the popultion with primry relince on clen fuels nd technology; gross domestic product (GDP) per cpit; Gini index for income inequlity; nd proportion of the urbn popultion living in slums. TB disese burden Most of the estimted number of incident cses in 216 occurred in the WHO South-Est Asi Region (45%), the WHO Africn Region (25%) nd the WHO Western Pcific Region (17%); smller proportions of cses occurred in the WHO Estern Mediterrnen Region (7%), the WHO Europen Region (3%) nd the WHO Region of the Americs (3%). The nnul number of incident TB cses reltive to popultion size vried widely mong countries in 216, from under 1 per 1 popultion in most high-income countries to 15 3 in most of the 3 high TB burden countries, nd bove 5 in few countries including the Democrtic People s Republic of Kore, Lesotho, Mozmbique, the Philippines nd South Afric. Regionlly, the fstest decline in TB incidence is in the WHO Europen Region (4.6% from 215 to 216). The decline since 21 hs exceeded 4% per yer in severl high TB burden countries, including Ethiopi, Keny, Lesotho, Nmibi, the Russin Federtion, the United Republic of Tnzni, Zmbi nd Zimbbwe. About 82% of TB deths mong HIV-negtive people occurred in the WHO Africn Region nd the WHO South-Est Asi Region in 216; these regions ccounted for 85% of the combined totl of TB deths in HIV-negtive nd HIV-positive people. Indi ccounted for 33% of globl TB deths mong HIV-negtive people, nd for 26% of the combined totl of TB deths in HIV-negtive nd HIV-positive people. Globlly, the TB mortlity rte (per 1 popultion) fell by 37% between 2 nd 216. Regionlly, the fstest declines in the TB mortlity rte re in the WHO Europen Region nd the WHO Western Pcific Region (6.% nd 4.6% per yer, respectively, since 21). Globlly in 216, n estimted 4.1% (95% confidence intervl [CI]: %) of new cses nd 19% (95% CI: %) of previously treted cses hd MDR/RR-TB. Ntionl notifiction nd vitl registrtions systems need to be strengthened towrds the gol of direct mesurement of TB incidence nd mortlity in ll countries. Ntionl TB prevlence surveys provide n interim pproch to directly mesuring the burden of TB disese in n importnt subset of high TB burden countries. Dignosis nd tretment: TB, HIV-ssocited TB nd drug-resistnt TB Most of the globl increse in notifictions of new TB cses since 213 is explined by 37% increse in Indi The globl mle:femle (M:F) rtio for notifictions ws 1.7. Results from ntionl TB prevlence surveys of dults show higher M:F rtios, indicting tht notifiction dt understte the shre of the TB burden ccounted for by men in some countries. Globlly, children (ged <15 yers) ccounted for 6.9% of the new TB cses tht were notified in 216. In 216, coverge of testing for rifmpicin resistnce ws 33% for new TB ptients nd 6% for previously treted TB ptients, nd 41% overll (up from 31% in 215). Globlly in 216, 57% of notified TB ptients hd documented HIV test result, up from 55% in 215. In the WHO Africn Region, where the burden of HIV-ssocited TB is highest, 82% of TB ptients hd documented HIV test result (up from 81% in 215). The tretment success rte for HIV-ssocited TB (215 cohort) ws 78% nd for extensively drug-resistnt TB (XDR- TB) (214 cohort) it ws 3%. At lest 35 countries hve introduced shorter regimens for tretment of MDR/RR-TB. As prt of efforts to improve outcomes for MDR/XDR-TB, 89 countries nd territories hd strted using bedquiline nd 54 hd used delmnid by June GLOBAL TUBERCULOSIS REPORT 217

14 TB prevention services The number of children ged under 5 yers who were reported to hve been strted on TB preventive tretment incresed by 85% between 215 nd 216 (from to ), but ws still only 13% of the 1.3 million estimted to be eligible. A totl of people newly enrolled in HIV cre were strted on TB preventive tretment in 216, bsed on dt from 6 countries. As in previous yers, South Afric ccounted for the lrgest shre of the totl (41%), followed by Mozmbique, Zimbbwe nd Mlwi. However, of the 3 high TB/HIV burden countries, 18 did not report ny provision of preventive tretment in 216. In the 12 high TB/HIV burden countries tht did report dt, coverge rnged from 2.4% in Indonesi to 73% in Zimbbwe. In Keny, dt on the number of people newly enrolled in HIV cre who were strted on TB preventive tretment in 216 were not vilble. However, TB preventive tretment ws provided to totl of people living with HIV in 216. Combined with dt reported by other countries, this mens tht the globl totl of people living with HIV who were strted on TB preventive tretment in 216 ws t lest 1.3 million. Finncing for TB prevention, dignosis nd tretment Funding for TB cre nd prevention reched US$ 6.9 billion in 217 in 118 low nd middle-income countries tht reported dt (nd ccounted for 97% of reported TB cses globlly). This ws n increse from US$ 6.3 billion in 216 nd more thn double the US$ 3.3 billion tht ws vilble in 26. Indi stood out s country in which the budget envelope for TB ws substntilly incresed in 217 (to US$ 525 million, lmost double the level of 216), following politicl commitment from the Prime Minister to the gol of ending TB by 225. The budget is fully funded, including US$ 387 million (74%) from domestic sources (triple the mount of US$ 124 million in 216) nd the reminder (26%) from interntionl donor sources. Overll, most funding during the period hs been provided from domestic sources, nd this remins the cse in 217 (84% of the globl totl of US$ 6.9 billion). However, ggregted figures concel substntil vrition mong countries. For exmple, domestic funding domintes (95% overll, rnge 74 1%) in Brzil, the Russin Federtion, Indi, Chin nd South Afric (BRICS), which collectively ccount for lmost hlf of the world s TB cses. In low-income countries, interntionl donor funding exceeds domestic funding nd in the 25 high TB burden countries outside BRICS levels of domestic nd interntionl donor funding re similr. Universl helth coverge, socil protection nd socil determinnts Projections of totl helth expenditures in low nd middleincome countries compred with estimtes of the funding required for progress towrds universl helth coverge nd chievement of other SDG-relted helth trgets hve been published in 217 WHO report, The SDG Helth Price Tg. Overll, they suggest tht most middleincome countries could mobilize the funding needed to chieve universl helth coverge nd other SDG-relted helth trgets during this period, but tht low-income countries re unlikely to hve the domestic resources to do so. Surveys of costs fced by TB ptients nd their households hve been completed in seven countries: Ghn, Keny, Mynmr, the Philippines, Republic of Moldov, Timor Leste nd Viet Nm. Finl results from Mynmr nd Viet Nm show high economic nd finncil burden due to TB disese. This is consistent with dt showing tht out-of-pocket expenditures on helth ccount for high proportion (>3%) of totl helth expenditures in most high TB burden countries. Of the 1.4 million incident cses of TB in 216, n estimted 1.9 million were ttributble to undernourishment, 1. million to HIV infection,.8 million to smoking nd.8 million to dibetes. Exmples of high TB burden countries doing reltively well in terms of t lest some of the indictors ssocited with TB incidence include Brzil, Indonesi, South Afric, Thilnd nd Viet Nm. TB reserch nd development Few dignostic technologies emerged in 217 nd the evlution of GeneXpert Omni, which is intended s close-to-cre pltform for rpid moleculr testing, hs been delyed. There re 17 drugs in Phse I, II or III trils, including eight new compounds, two drugs tht hve received ccelerted or conditionl regultory pprovl bsed on Phse IIb results, nd seven repurposed drugs. Vrious new combintion regimens re in Phse II or Phse III trils. There re 12 vccine cndidtes in clinicl trils: three in Phse I, nd nine in Phse II or Phse III. Country profiles Annex 2 contins country profiles for the 3 high TB burden countries. This yer, second pge hs been introduced to ech profile. This provides n overview of the ltest sttus of nd recent trends in the indictors included in the TB-SDG monitoring frmework developed by WHO in WHO hs published Globl Tuberculosis Report nnully since When n HIV-positive person dies from TB disese, the underlying cuse is clssified s HIV in the Interntionl clssifiction of diseses system (ICD-1). 3 Countries re listed in descending order of their number of incident cses. 4 MDR-TB is defined s resistnce to both isonizid nd rifmpicin, the two most effective first-line drugs. 5 The ten countries, in descending order of the size of their gp, were: Indi, Indonesi, Nigeri, the Philippines, South Afric, Pkistn, Bngldesh, the Democrtic Republic of the Congo, Chin nd the United Republic of Tnzni. 6 The ten countries, in descending order of the size of their gp, were: Indi, Chin, the Russin Federtion, Indonesi, the Philippines, Pkistn, Nigeri, Ukrine, Mynmr nd Uzbekistn. GLOBAL TUBERCULOSIS REPORT 217 3

15 n BOX 1.1 n Bsic fcts bout TB TB is n infectious disese cused by the bcillus Mycobcterium tuberculosis. It typiclly ffects the lungs (pulmonry TB) but cn lso ffect other sites (extrpulmonry TB). The disese is spred when people who re sick with pulmonry TB expel bcteri into the ir, for exmple by coughing. Overll, reltively smll proportion (5 15%) of the estimted 1.7 billion people infected with M. tuberculosis will develop TB disese during their lifetime. However, the probbility of developing TB disese is much higher mong people infected with HIV, nd lso higher mong people ffected by risk fctors such s under-nutrition, dibetes, smoking nd lcohol consumption. Dignostic tests for TB disese include the following: Rpid moleculr tests The only rpid test for dignosis of TB currently recommended by WHO is the Xpert MTB/RIF ssy (Cepheid, USA). It cn provide results within 2 hours, nd ws initilly recommended (in 21) for dignosis of pulmonry TB in dults. Since 213, it hs lso been recommended for use in children nd to dignose specific forms of extrpulmonry TB. The test hs much better ccurcy thn sputum smer microscopy; Sputum smer microscopy Developed more thn 1 yers go, this technique requires the exmintion of sputum smples using microscope to determine the presence of bcteri. In the current cse definitions recommended by WHO, one positive result is required for dignosis of smer-positive pulmonry TB; Culture-bsed methods The current reference stndrd, they require more developed lbortory cpcity nd cn tke up to 12 weeks to provide results. Globlly, use of rpid moleculr tests is incresing, nd mny countries re phsing out the use of smer microscopy for dignostic purposes (lthough microscopy nd culture remin necessry for tretment monitoring). Despite dvnces in dignostics, considerble proportion of the TB cses reported to WHO re still cliniclly dignosed rther thn bcteriologiclly confirmed. In 216, for exmple, only 57% of the pulmonry cses reported to WHO were bcteriologiclly confirmed. There re lso tests for TB tht is resistnt to first-line nd second-line nti-tb drugs. They include Xpert MTB/ RIF, which simultneously tests for TB nd resistnce to rifmpicin (the most effective first-line nti-tb drug); rpid line probe ssys (LPAs) tht test for resistnce to rifmpicin nd isonizid (referred to s first-line LPAs); rpid LPA tht tests for resistnce to fluoroquinolones nd injectble nti-tb drugs (referred to s second-line LPA); nd sequencing technologies. First-line LPAs were first recommended by WHO in 28; the second-line LPA ws first recommended in My 216. Culture-bsed methods currently remin the reference stndrd for drug susceptibility testing. Without tretment, the mortlity rte from TB is high. Studies of the nturl history of TB disese in the bsence of tretment with nti-tb drugs (conducted before drug tretments becme vilble) found tht bout 7% of individuls with sputum smer-positive pulmonry TB died within 1 yers of being dignosed, s did bout 2% of people with culture-positive (but smer-negtive) pulmonry TB. Effective drug tretments were first developed in the 194s. The currently recommended tretment for cses of drug-susceptible TB is 6-month regimen of four first-line drugs: isonizid, rifmpicin, ethmbutol nd pyrzinmide. The Globl TB Drug Fcility supplies complete 6-month course for bout US$ 4 per person. Tretment success rtes of t lest 85% for cses of drug-susceptible TB re regulrly reported to WHO by its 194 Member Sttes. Tretment for rifmpicin-resistnt TB (RR-TB) nd multidrug-resistnt TB (MDR-TB) b is longer, nd requires more expensive nd more toxic drugs. Until erly 216, the tretment regimens recommended by WHO typiclly lsted for 2 months, nd cost bout US$ 2 5 per person. As result of new evidence from severl countries, WHO issued updted guidnce in My 216. Shortened regimens of 9 12 months re now recommended for ptients (other thn pregnnt women) with pulmonry RR-TB or MDR-TB tht is not resistnt to second-line drugs. The cost of shortened drug regimen is bout US$ 1 per person. The ltest dt reported to WHO show tretment success rte for MDR-TB of 54%, globlly, reflecting high rtes of loss to follow-up, unevluted tretment outcomes nd tretment filure. There re 17 TB drugs in clinicl trils nd combintion regimens tht include new compounds s well s other drugs re lso being tested in clinicl trils. The bcille Clmette-Guérin (BCG) vccine, which ws developed lmost 1 yers go nd hs been shown to prevent severe forms of TB in children, is still widely used. However, there is currently no vccine tht is effective in preventing TB disese in dults, either before or fter exposure to TB infection. There re 12 TB vccines in Phse I, Phse II or Phse III trils. b Tiemersm EW, vn der Werf MJ, Borgdorff MW, Willims BG, Ngelkerke NJ. Nturl history of tuberculosis: durtion nd ftlity of untreted pulmonry tuberculosis in HIV negtive ptients: systemtic review. PLoS One. 211;6(4):e1761 ( ccessed 27 July 216). Defined s resistnce to isonizid nd rifmpicin, the two most powerful nti-tb drugs. 4 GLOBAL TUBERCULOSIS REPORT 217

16 CHAPTER 1. Introduction Tuberculosis (TB) hs existed for millenni nd remins mjor globl helth problem. It cuses ill-helth for pproximtely 1 million people ech yer nd is one of the top ten cuses of deth worldwide. For the pst 5 yers, it hs been the leding cuse of deth from single infectious gent, rnking bove HIV/AIDS. 1 This is despite the fct tht, with timely dignosis nd correct tretment, most people who develop TB disese cn be cured. Bsic fcts bout TB re summrized in Box 1.1. WHO hs published globl TB report every yer since The min im of the report is to provide comprehensive nd up-to-dte ssessment of the TB epidemic, nd of progress in prevention, dignosis nd tretment, t globl, regionl nd country levels. This is done in the context of recommended globl TB strtegies nd ssocited trgets, s well s broder development gols set by the United Ntions (UN). For the period , these re the End TB Strtegy nd Sustinble Development Gols (SDGs). The End TB Strtegy ws endorsed by WHO s 194 Member Sttes during the 214 World Helth Assembly, nd is for the period The SDGs were dopted by UN Member Sttes in September 215, nd re for the period The SDGs nd the End TB Strtegy shre common im: to end the globl TB epidemic. Trgets set in the End TB Strtegy include 9% reduction in TB deths nd n 8% reduction in TB incidence by 23, compred with 215. As usul, the 217 globl TB report is bsed primrily on dt gthered from countries nd territories. WHO hs implemented nnul rounds of globl TB dt collection since 1996, with n online system 2 used since 29. In 217, this system ws opened for reporting in April. Following the My dedline for reporting, nd subsequent review nd followup of submitted dt between June nd August, dt were vilble for 21 countries nd territories tht collectively ccount for more thn 99% of the world s popultion nd estimted TB cses. Dt reported in 217 were nlysed longside dt collected in previous rounds of globl TB dt collection. Other dt sources used in the report include the HIV deprtment in WHO nd the Joint United Ntions Progrmme on HIV/AIDS (UNAIDS), which collect informtion bout the provision of TB preventive tretment to people living with HIV, nd bout ntiretrovirl therpy for HIVpositive TB ptients; the creditor reporting system of the Orgnistion for Economic Co-opertion nd Development (OECD); the World Bnk, for development indictors; nd the WHO ntionl helth ccounts dtbse. All dt re stored in WHO s globl TB dtbse. 3 The yers 217 nd 218 re lndmrk ones for globl nd ntionl efforts to end TB. In November 217, WHO will host the first globl Ministeril Conference on TB in Moscow, Russin Federtion, with the theme of ending TB in the er of the SDGs. In the second hlf of 218, this will be followed by the first UN Generl Assembly high-level meeting on TB, t which multisectorl pproch to ending TB nd n ssocited multisectorl ccountbility frmework will be discussed by Heds of Stte. This globl TB report, published shortly in dvnce of the WHO Ministeril Conference, provides the ltest dt nd nlysis to inform discussions nd delibertions t both events. Chpter 2 provides n overview of the SDGs, the End TB Strtegy, nd new TB-SDG monitoring frmework developed by WHO in 217. This frmework goes beyond the TB-specific indictors of the End TB Strtegy nd the SDG trget tht is specific to TB, focusing ttention on 14 other indictors under seven SDGs tht will influence the future course of the TB epidemic. Chpter 3 provides estimtes of TB disese burden, nd Chpter 4 provides dt on dignosis nd tretment of TB, HIV-ssocited TB nd drug-resistnt TB, for the period The topics of Chpter 5 nd Chpter 6 re TB prevention services nd TB finncing, respectively. Chpter 7 ssesses progress towrds universl helth coverge nd nlyses the ltest sttus of, nd trends in, other indictors in the TB-SDG monitoring frmework. Chpter 8 discusses TB reserch nd development, which is criticl to chieving the technologicl brekthroughs required to end TB. The report lso hs four nnexes. Annex 1 describes the online WHO globl TB dtbse nd provides further detils bout the 217 round of globl TB dt collection. Annex 2 contins country profiles for the 3 high TB burden countries (profiles for other countries re vilble online 4 ) nd Annex 3 contins globl nd regionl profiles. Annex 4 provides dt tbles tht give detils of key indictors for the most recent yer for which dt or estimtes re vilble, for ll countries. 1 Further detils re provided in Chpter Further detils re provided in Annex GLOBAL TUBERCULOSIS REPORT 217 5

17 Children in Btd, Philippines IAN TROWER / ALAMY STOCK PHOTO

18 CHAPTER 2. The Sustinble Development Gols nd the End TB Strtegy From 2 to 215, globl nd ntionl efforts to reduce the burden of tuberculosis (TB) disese were focused on chieving trgets set within the context of the Millennium Development Gols (MDGs). The MDGs were estblished by the United Ntions (UN) in 2 nd trgets were set for 215. Trget 6c of MDG 6 ws to hlt nd reverse TB incidence. The Stop TB Prtnership, estblished in 21, dopted this trget nd set two dditionl trgets. These were to hlve TB prevlence nd TB mortlity rtes by 215 compred with their levels in 199. The globl TB strtegy developed by WHO for the decde , the Stop TB Strtegy, hd the overll gol of reching ll three trgets. In October 215, WHO published its ssessment of whether the 215 globl TB trgets for reductions in TB incidence, prevlence nd mortlity were chieved. 1 In 216, the MDGs were succeeded by new set of gols, known s the Sustinble Development Gols (SDGs). Adopted by the UN in September 215 following 3 yers of consulttions, the SDG frmework of gols, trgets nd indictors is for the period Similrly, WHO initited work on new globl TB strtegy in 212, which ws completed in 214. The End TB Strtegy ws unnimously endorsed by ll WHO Member Sttes t the 214 World Helth Assembly, nd is for the period This chpter provides n overview of both the SDGs (Section 2.1) nd the End TB Strtegy (Section 2.2). It then defines nd explins new TB-SDG monitoring frmework tht hs been developed by WHO in 217 (Section 2.3). This frmework is designed to focus ttention on, nd encourge nlysis of, SDG trgets nd indictors tht will influence the course of the TB epidemic. This is importnt, becuse chieving the mbitious trgets set in the SDGs nd End TB Strtegy requires tht these broder influences on the risks of developing TB nd the consequences of TB disese re ddressed. 4 1 World Helth Orgniztion. Globl tuberculosis report 215. Genev: WHO; 215 ( eng.pdf, ccessed 2 August 217). 2 United Ntions. Sustinble Development Gols ( sustinbledevelopment.un.org/topics/sustinbledevelopmentgols, ccessed 2 August 217). 3 Uplekr M, Weil D, Lonnroth K, Jrmillo E, Lienhrdt C, Dis HM, et l. WHO s new End TB Strtegy. Lncet. 215;385(9979): ( S ?vi%3Dihub, ccessed 2 August 217). 4 Anlysis of these indictors is fetured in Chpter 7. In Annex 2, the ltest dt nd recent trends for ech indictor re shown for high TB burden countries. In Annex 4, the ltest dt for ech indictor re shown for ll countries. For the first 5 yers of the SDGs nd End TB Strtegy (216 22), WHO hs defined three lists of high burden countries (HBCs): for TB, TB/HIV nd multidrug-resistnt TB (MDR-TB). Prticulr ttention is given to the countries in ech of these lists throughout this report, nd for this reson they re presented nd explined in Section The Sustinble Development Gols The 17 SDGs re shown in Box 2.1. Deprtures from the MDGs include broder gend (17 gols compred with the previous eight), one consolidted gol on helth compred with three helth-relted MDGs, nd desire for universl relevnce rther thn focus on issues mostly of concern to developing countries. The consolidted gol on helth is SDG 3. It is defined s Ensure helthy lives nd promote well-being for ll t ll ges, nd 13 trgets hve been set for this gol (Box 2.2). One of these trgets, Trget 3.3, explicitly mentions TB: By 23, end the epidemics of AIDS, tuberculosis, mlri nd neglected tropicl diseses nd combt heptitis, wterborne diseses nd other communicble diseses. The lnguge of ending epidemics is lso now prominent element of globl helth strtegies developed by WHO nd the Joint United Ntions Progrmme on HIV/AIDS (UNAIDS) for the post-215 er, 5 including the End TB Strtegy (Section 2.2). Such lnguge is much more mbitious thn the MDG lnguge of hlting nd reversing epidemics (or stopping them, s in the Stop TB Strtegy). The TB indictor for Trget 3.3 is TB incidence per 1 popultion per yer. SDG 3 lso includes trget (Trget 3.8) relted to universl helth coverge (UHC) in which TB is explicitly mentioned. The WHO/World Bnk definition of UHC is tht ll people receive the helth services they need, while t the sme time ensuring tht the use of these services does not expose the user to finncil hrdship. 6 Trget 3.8 includes n indictor on the coverge of essentil prevention, tretment nd cre interventions. This is composite indictor bsed 5 World Helth Orgniztion. Accelerting progress on HIV, tuberculosis, mlri, heptitis nd neglected tropicl diseses: A new gend for Genev: WHO; 215 ( orgnigrm/htm/progress-hiv-tb-mlri-ntd/en/, ccessed 2 August 217). 6 World Helth Orgniztion/World Bnk Group. Trcking universl helth coverge: first globl monitoring report. Genev: WHO; 215 ( who.int/iris/bitstrem/1665/174536/1/ _eng.pdf?u=1, ccessed 2 August 217). GLOBAL TUBERCULOSIS REPORT 217 7

19 n BOX 2.1 n The Sustinble Development Gols Gol 1. Gol 2. Gol 3. Gol 4. Gol 5. Gol 6. Gol 7. Gol 8. Gol 9. End poverty in ll its forms everywhere End hunger, chieve food security nd improved nutrition nd promote sustinble griculture Ensure helthy lives nd promote well-being for ll t ll ges Ensure inclusive nd equitble qulity eduction nd promote lifelong lerning opportunities for ll Achieve gender equlity nd empower ll women nd girls Ensure vilbility nd sustinble mngement of wter nd snittion for ll Ensure ccess to ffordble, relible, sustinble nd modern energy for ll Promote sustined, inclusive nd sustinble economic growth, full nd productive employment nd decent work for ll Build resilient infrstructure, promote inclusive nd sustinble industriliztion nd foster innovtion Gol 1. Reduce inequlity within nd mong countries Gol 11. Mke cities nd humn settlements inclusive, sfe, resilient nd sustinble Gol 12. Ensure sustinble consumption nd production ptterns Gol 13. Tke urgent ction to combt climte chnge nd its impcts Gol 14. Conserve nd sustinbly use the ocens, ses nd mrine resources for sustinble development Gol 15. Protect, restore nd promote sustinble use of terrestril ecosystems, sustinbly mnge forests, combt desertifiction, nd hlt nd reverse lnd degrdtion nd hlt biodiversity loss Gol 16. Promote peceful nd inclusive societies for sustinble development, provide ccess to justice for ll nd build effective, ccountble nd inclusive institutions t ll levels Gol 17. Strengthen the mens of implementtion nd revitlize the Globl Prtnership for Sustinble Development Acknowledging tht the United Ntions Frmework Convention on Climte Chnge is the primry interntionl, intergovernmentl forum for negotiting the globl response to climte chnge. 8 GLOBAL TUBERCULOSIS REPORT 217

20 n BOX 2.2 n Sustinble Development Gol 3 nd its 13 trgets SDG3: Ensure helthy lives nd promote well-being for ll t ll ges Trgets 3.1 By 23, reduce the globl mternl mortlity rtio to less thn 7 per 1 live births 3.2 By 23, end preventble deths of newborns nd children under 5 yers of ge, with ll countries iming to reduce neontl mortlity to t lest s low s 12 per 1 live births nd under-5 mortlity to t lest s low s 25 per 1 live births 3.3 By 23, end the epidemics of AIDS, tuberculosis, mlri nd neglected tropicl diseses nd combt heptitis, wter-borne diseses nd other communicble diseses 3.4 By 23, reduce by one third premture mortlity from non-communicble diseses through prevention nd tretment nd promote mentl helth nd well-being 3.5 Strengthen the prevention nd tretment of substnce buse, including nrcotic drug buse nd hrmful use of lcohol 3.6 By 22, hlve the number of globl deths nd injuries from rod trffic ccidents 3.7 By 23, ensure universl ccess to sexul nd reproductive helth-cre services, including for fmily plnning, informtion nd eduction, nd the integrtion of reproductive helth into ntionl strtegies nd progrmmes 3.8 Achieve universl helth coverge, including finncil risk protection, ccess to qulity essentil helth-cre services nd ccess to sfe, effective, qulity nd ffordble essentil medicines nd vccines for ll 3.9 By 23, substntilly reduce the number of deths nd illnesses from hzrdous chemicls nd ir, wter nd soil pollution nd contmintion 3. Strengthen the implementtion of the World Helth Orgniztion Frmework Convention on Tobcco Control in ll countries, s pproprite 3.b Support the reserch nd development of vccines nd medicines for the communicble nd noncommunicble diseses tht primrily ffect developing countries, provide ccess to ffordble essentil medicines nd vccines, in ccordnce with the Doh Declrtion on the TRIPS Agreement nd Public Helth, which ffirms the right of developing countries to use to the full the provisions in the Agreement on Trde-Relted Aspects of Intellectul Property Rights regrding flexibilities to protect public helth, nd, in prticulr, provide ccess to medicines for ll 3.c Substntilly increse helth finncing nd the recruitment, development, trining nd retention of the helth workforce in developing countries, especilly in lest developed countries nd smll islnd developing Sttes 3.d Strengthen the cpcity of ll countries, in prticulr developing countries, for erly wrning, risk reduction nd mngement of ntionl nd globl helth risks TRIPS, Trde-Relted Aspects of Intellectul Property Rights on the coverge of 16 so-clled trcer interventions, 1 one of which is TB tretment. In contrst with the MDGs, the SDGs include considerble emphsis on disggregted nlysis nd reporting of dt (s well s reporting for n entire country). Depending on the indictor, exmples include disggregtion by ge, sex, loction nd economic sttus (e.g. bottom 4%, or bottom versus top income quintiles). Some indictors lso give prticulr ttention to specific subpopultions, such s 1 There re mny different prevention nd tretment interventions. In this context, 16 interventions hve been selected s trcers for progress towrds UHC for ll interventions. pregnnt women, people with disbilities, victims of work injuries nd migrnts. In ddition to the specifiction of such disggregtion for mny SDG indictors under SDGs 1 16, SDG 17 includes two trgets nd ssocited indictors under the subheding of Dt, monitoring nd ccountbility, which specificlly refer to disggregted dt nd mechnisms needed to generte such dt (Tble 2.1). Emphsis is lso given to the importnce of deth registrtion within ntionl vitl registrtion systems for ccurte trcking of cuses of deth (this is Prt b of Indictor 17.19). Strengthening ntionl vitl registrtion systems s the bsis for direct mesurement of the number of TB deths is one of the five strtegic GLOBAL TUBERCULOSIS REPORT 217 9

21 TABLE 2.1 SDG 17, nd trgets nd indictors relted to dt, monitoring nd ccountbility SDG 17: Strengthen the mens of implementtion nd revitlize the globl prtnership for sustinble development TARGETS By 22, enhnce cpcity-building support to developing countries, including for lest developed countries nd smll islnd developing Sttes, to increse significntly the vilbility of high-qulity, timely nd relible dt disggregted by income, gender, ge, rce, ethnicity, migrtory sttus, disbility, geogrphic loction nd other chrcteristics relevnt in ntionl contexts By 23, build on existing inititives to develop mesurements of progress on sustinble development tht complement gross domestic product, nd support sttisticl cpcity-building in developing countries INDICATORS Proportion of sustinble development indictors produced t the ntionl level with full disggregtion when relevnt to the trget, in ccordnce with the Fundmentl Principles of Officil Sttistics Proportion of countries tht () hve conducted t lest one popultion nd housing census in the lst 1 yers; nd (b) hve chieved 1 per cent birth registrtion nd 8 per cent deth registrtion res of work of the WHO Globl Tsk Force on TB Impct Mesurement, s discussed further in Chpter 3. Disggregtion is intended to inform nlysis of within-country inequlities nd ssocited ssessments of equity, with findings used to identify prticulr res or subpopultions where progress is lgging nd greter ttention is needed. Such disggregtion is lso n importnt considertion for the TB community, given the influence of sex, ge, socio economic sttus nd differentil ccess to helth cre on the risks for nd consequences of TB infection nd disese. Chpter 3 nd Chpter 4 of this report include nlyses of TB dt disggregted by ge, sex nd loction. 2.2 The End TB Strtegy The End TB Strtegy t glnce is shown in Box 2.3. The overll gol is to End the globl TB epidemic, nd there re three high-level, overrching indictors nd relted trgets (for 23, linked to the SDGs, nd for 235) nd milestones (for 22 nd 225). The three indictors re: the number of TB deths per yer; the TB incidence rte per yer; nd the percentge of TB-ffected households tht experience ctstrophic costs s result of TB disese. The 235 trgets re 95% reduction in TB deths nd 9% reduction in the TB incidence rte, compred with levels in 215. The 23 trgets re 9% reduction in TB deths nd n 8% reduction in the TB incidence rte, compred with levels in 215. The most immedite milestones, set for 22, re 35% reduction in TB deths nd 2% reduction in the TB incidence rte, compred with levels in 215. The trjectories of TB incidence nd TB deths tht re required to rech these milestones nd trgets re shown in Fig For the third indictor (the percentge of TB-ffected households tht experience ctstrophic costs s result of TB disese), the milestone for 22 is zero, to be sustined therefter. The Stop TB Prtnership hs developed Globl Pln to End TB, , 1 which focuses on the ctions nd funding 1 The Globl Pln to End TB, Genev: Stop TB Prtnership; 215 ( ccessed 2 August 217). needed to rech the 22 milestones of the End TB Strtegy. More detils bout this pln re provided in Chpter 6. Progress towrds UHC nd ctions to ddress helth-relted risk fctors for TB s well s broder socil nd economic determinnts of TB will be fundmentl to chieving the trgets nd milestones for reductions in TB cses nd deths. There re two resons for this. First, reching the milestones for reductions in TB cses nd deths set for 22 nd 225 requires the nnul decline in the globl TB incidence rte to ccelerte from 1.5% per yer in 215 to 4 5% per yer by 22, nd then to 1% per yer by 225. A decline of 1% per yer is equivlent to the best-ever performnce to dte t ntionl level for exmple, in countries in western Europe during the 195s nd 196s. Declines of 1% per yer hve only been documented in the context of UHC combined with broder socil nd economic development. Second, the globl proportion of people with TB who die from the disese (the cse ftlity rtio, or CFR) needs to be reduced to 1% by 22 nd then to 6.5% by 225. A CFR of 6.5% is similr to the current level in mny high-income countries, but is only possible if ll those with TB disese cn ccess high-qulity tretment. Anlysis of CFRs t globl nd ntionl levels is included in Chpter 3. The percentge of TB ptients nd their households fcing ctstrophic costs is good trcer for progress towrds UHC s well s socil protection. If UHC nd socil protection re in plce, then people with TB should be ble to ccess high-qulity dignosis nd tretment without incurring ctstrophic costs. After 225, n unprecedented ccelertion in the rte t which TB incidence flls globlly is required if the 23 nd 235 trgets re to be reched. Such n ccelertion will depend on technologicl brekthrough tht cn substntilly reduce the risk of developing TB disese mong the pproximtely 1.7 billion people 2 who re lredy infected with Mycobcterium tuberculosis. Exmples include n effective post-exposure vccine or short, efficcious nd 2 Houben RM, Dodd PJ. The globl burden of ltent tuberculosis infection: re-estimtion using mthemticl modelling. PLoS Med. 216;13(1):e12152 ( ccessed 2 August 217). 1 GLOBAL TUBERCULOSIS REPORT 217

22 n BOX 2.3 n The End TB Strtegy t glnce VISION GOAL INDICATORS Percentge reduction in the bsolute number of TB deths (compred with 215 bseline) Percentge reduction in the TB incidence rte (compred with 215 bseline) Percentge of TB-ffected households experiencing ctstrophic costs due to TB (level in 215 unknown) A WORLD FREE OF TB zero deths, disese nd suffering due to TB END THE GLOBAL TB EPIDEMIC MILESTONES TARGETS SDG 23 END TB % 75% 9% 95% 2% 5% 8% 9% % % % % PRINCIPLES 1. Government stewrdship nd ccountbility, with monitoring nd evlution 2. Strong colition with civil society orgniztions nd communities 3. Protection nd promotion of humn rights, ethics nd equity 4. Adpttion of the strtegy nd trgets t country level, with globl collbortion PILLARS AND COMPONENTS 1. INTEGRATED, PATIENT-CENTRED CARE AND PREVENTION A. Erly dignosis of TB including universl drug-susceptibility testing, nd systemtic screening of contcts nd high-risk groups B. Tretment of ll people with TB including drug-resistnt TB, nd ptient support C. Collbortive TB/HIV ctivities, nd mngement of comorbidities D. Preventive tretment of persons t high risk, nd vccintion ginst TB 2. BOLD POLICIES AND SUPPORTIVE SYSTEMS A. Politicl commitment with dequte resources for TB cre nd prevention B. Enggement of communities, civil society orgniztions, nd public nd privte cre providers C. Universl helth coverge policy, nd regultory frmeworks for cse notifiction, vitl registrtion, qulity nd rtionl use of medicines, nd infection control D. Socil protection, poverty llevition nd ctions on other determinnts of TB 3. INTENSIFIED RESEARCH AND INNOVATION A. Discovery, development nd rpid uptke of new tools, interventions nd strtegies B. Reserch to optimize implementtion nd impct, nd promote innovtions Trgets linked to the Sustinble Development Gols (SDGs). sfe tretment for ltent TB infection (LTBI). The ltest sttus of the development pipelines for new TB dignostics, drugs nd vccines is presented in Chpter 8. To chieve the trgets nd milestones, the End TB Strtegy hs four underlying principles nd three pillrs. The principles re government stewrdship nd ccountbility, with monitoring nd evlution; strong colition with civil society orgniztions nd communities; protection nd promotion of humn rights, ethics nd equity; nd dpttion of the strtegy nd trgets t country level, with globl collbortion. The three pillrs re integrted, ptientcentred TB cre nd prevention; bold policies nd supportive systems (including UHC, socil protection nd ction on TB determinnts); nd intensified reserch nd innovtion. The 1 components of the three pillrs re shown in Box 2.3, nd the 1 priority indictors (defined in Mrch 215 in ssocition with the publiction of journl rticle bout the End TB Strtegy) 1 to monitor their implementtion re shown in Tble 2.2. The tble lso indictes the prticulr chpter of this report in which vilble dt for ech indictor cn be found. Dt for five of the 1 indictors cnnot be cptured routinely using the stndrd recording nd reporting forms for pper-bsed systems tht re included in the ltest revision of WHO s frmework for TB cse definitions nd reporting. 2 Collection of dt on the costs fced by TB ptients 1 Uplekr M, Weil D, Lonnroth K, Jrmillo E, Lienhrdt C, Dis HM, et l. WHO s new End TB Strtegy. Lncet. 215;385(9979): ( S ?vi%3Dihub, ccessed 2 August 217). The 1 indictors re defined nd explined in n ppendix. 2 World Helth Orgniztion. Definitions nd reporting frmework for tuberculosis 213 revision (updted December 214) (WHO/HTM/TB/213.2). Genev: WHO; 213 ( bitstrem/1665/79199/1/ _eng.pdf, ccessed 2 August 217). GLOBAL TUBERCULOSIS REPORT

23 FIG. 2.1 Projected incidence nd mortlity curves tht re required to rech End TB Strtegy trgets nd milestones, Incidence rte per 1 popultion per yer % reduction 5% reduction 8% reduction TARGET FOR 235 = 9% REDUCTION Deths (millions) % reduction 75% reduction 9% reduction TARGET FOR 235 = 95% REDUCTION nd their households, nd ssessment of whether these re ctstrophic (Indictor 3 in Tble 2.2) requires periodic surveys of representtive smple of TB ptients; further detils re provided in Chpter 7. For the other four indictors (Indictors 4, 5, 6 nd 8 in Tble 2.2), dt my lredy be cptured routinely in countries with electronic cse-bsed systems for recording nd reporting of dt, or these systems cn be dpted to do so. Alterntively, periodic surveys of the medicl records or ptient crds of rndom smple of TB ptients cn be done. Further guidnce is provided in WHO opertionl guidnce on the End TB Strtegy A TB-SDG monitoring frmework Monitoring of TB-specific indictors is well estblished t globl nd ntionl levels. For exmple, stndrdized monitoring of notifictions of TB cses nd their tretment outcomes t globl nd ntionl levels hs been in plce since 1995, nd estimtes of TB incidence nd mortlity hve been published nnully by WHO for more thn decde. In the er of the End TB Strtegy nd SDGs, such monitoring will continue, longside continued efforts to strengthen notifiction nd vitl registrtion systems so tht they cn be relibly used for direct mesurement of TB incidence nd TB deths (see lso Chpter 3), nd expnded monitoring to include new priority indictors (five of those listed in Tble 2.2 hve been introduced in the context of the End TB Strtegy). As explined in Section 2.2, chieving the End TB Strtegy trgets nd milestones requires progress in reducing helthrelted risk fctors for TB infection nd disese, s well s 1 World Helth Orgniztion. Implementing the End TB Strtegy: the essentils. Genev: WHO, 216 ( The_Essentils_to_End_TB/en/, ccessed 2 August 217). See in prticulr Prt II, Section 2.4. broder socil nd economic determinnts of TB infection nd disese. As explined in Section 2.1, the SDG frmework includes trgets nd indictors relted to these risk fctors nd determinnts. In this context, TB monitoring needs to be further expnded to include nlysis of selected SDG indictors tht will influence the course of the TB epidemic, to inform broder ctions in the helth sector nd beyond tht will be necessry to end the TB epidemic. Previously published work hs identified cler linkges between vrious SDG indictors nd TB incidence. 2,3,4,5 In 217, building on this previous work s well s further nlysis of the reltionship between SDG indictors nd TB incidence, 6 WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs (Tble 2.3). 2 Lönnroth K, Jrmillo E, Willims B, Dye C, Rviglione M. Tuberculosis: the role of risk fctors nd socil determinnts. In: Bls E & Kurup A (eds.), Equity, socil determinnts nd public helth progrmmes, WHO. 21 ( pdf, ccessed 2 August 217). 3 Lönnroth K, Cstro KG, Chky JM, Chuhn LS, Floyd K, Glziou P et l. Tuberculosis control nd elimintion 21 5: cure, cre, nd socil development. Lncet. 21;375(9728): ( S ?vi%3Dihub, ccessed 2 August 217). 4 Lienhrdt C, Glziou P, Uplekr M, Lönnroth K, Gethun H, Rviglione M. Globl tuberculosis control: lessons lernt nd future prospects. Nt Rev Microbiol. 212;1(6): ( v1/n6/full/nrmicro2797.html, ccessed 2 August 217). 5 Lönnroth K, Jrmillo E, Willims BG, Dye C, Rviglione M. Drivers of tuberculosis epidemics: the role of risk fctors nd socil determinnts. Soc Sci Med. 29;68(12): ( rticle/pii/s ?vi%3dihub, ccessed 2 August 217). 6 Monitoring nd evlution of TB in the context of the Sustinble Development Gols: Bckground Pper for WHO Ministeril Conference on TB in the context of the Sustinble Development Gols. Avilble on request. 12 GLOBAL TUBERCULOSIS REPORT 217

24 TABLE 2.2 Top 1 indictors (not rnked) for monitoring implementtion of the End TB Strtegy t globl nd ntionl levels, with recommended trget levels tht pply to ll countries. The trget level is for 225 t the ltest. INDICATOR RECOMMENDED TARGET LEVEL MAIN RATIONALE FOR INCLUSION IN TOP 1 MAIN METHOD OF MEASUREMENT, AND RELEVANT CHAPTER OF THIS REPORT 1 TB tretment coverge Number of new nd relpse cses tht were notified nd treted, divided by the estimted number of incident TB cses in the sme yer, expressed s percentge. 2 TB tretment success rte Percentge of notified TB ptients who were successfully treted. The trget is for drug-susceptible nd drug-resistnt TB combined, lthough outcomes should lso be reported seprtely. 9% 9% High-qulity TB cre is essentil to prevent suffering nd deth from TB nd to cut trnsmission. High coverge of pproprite tretment is fundmentl requirement for chieving the milestones nd trgets of the End TB Strtegy. In combintion, it is likely tht these two indictors will be used s trcer indictors for monitoring progress towrds UHC within the SDGs. Routinely collected notifiction dt used in combintion with estimte of TB incidence. Chpter 4 Routinely collected dt. Chpter 4 3 Percentge of TB-ffected households tht experience ctstrophic costs due to TB Number of people treted for TB (nd their households) who incur ctstrophic costs (direct nd indirect combined), divided by the totl number of people treted for TB. % One of the End TB Strtegy s three high-level indictors; key mrker of finncil risk protection (one of the two key elements of UHC) nd socil protection for TB-ffected households. Ntionl survey of notified TB ptients. Chpter 7 4 Percentge of new nd relpse TB ptients tested using WHO-recommended rpid dignostic (WRD) t the time of dignosis Number of new nd relpse TB ptients tested using WRD t the time of dignosis, divided by the totl number of new nd relpse TB ptients, expressed s percentge. 9% Accurte dignosis is fundmentl component of TB cre. Rpid moleculr dignostic tests help to ensure erly detection nd prompt tretment. Routinely collected dt (s prt of cse-bsed surveillnce), or ntionl survey of medicl records or ptient crds of TB ptients. Chpter 4 5 Ltent TB infection (LTBI) tretment coverge Number of people living with HIV newly enrolled in HIV cre nd the number of children ged <5 yers who re household contcts of cses strted on LTBI tretment, divided by the number eligible for tretment, expressed s percentge (seprtely for ech of the two groups). 9% Tretment of LTBI is the min tretment intervention vilble to prevent development of ctive TB disese in those lredy infected with Mycobcterium tuberculosis. Routinely collected dt (s prt of cse-bsed surveillnce), or ntionl survey of medicl records or ptient crds of people living with HIV nd TB ptients. Chpter 5 6 Contct investigtion coverge Number of contcts of people with bcteriologiclly confirmed TB who were evluted for TB, divided by the number eligible, expressed s percentge. 9% Contct trcing is key component of TB prevention, especilly in children. As bove for LTBI. 7 Drug-susceptibility testing (DST) coverge for TB ptients Number of ptients with bcteriologiclly confirmed pulmonry TB with DST result for t lest rifmpicin, divided by the totl number of notified cses of bcteriologiclly confirmed pulmonry TB in the sme yer, expressed s percentge. DST coverge includes results from moleculr (e.g. Xpert MTB/RIF) s well s conventionl phenotypic DST results. 1% Testing for drug susceptibility for WHO-recommended drugs is essentil to provide the right tretment for every person dignosed with TB. Routinely collected dt (s prt of cse-bsed surveillnce), or ntionl survey of medicl records or ptient crds of TB ptients. Chpter 4 8 Tretment coverge, new TB drugs Number of TB ptients treted with regimens tht include new (endorsed fter 21) TB drugs, divided by the number of notified ptients eligible for tretment with new TB drugs, expressed s percentge. 9% An indictor tht is relevnt to monitoring the doption of innovtions in ll countries. The definition of which ptients re eligible ptients for tretment with new drugs my differ mong countries. As bove for DST. 9 Documenttion of HIV sttus mong TB ptients Number of new nd relpse TB ptients with documented HIV sttus, divided by the number of new nd relpse TB ptients notified in the sme yer, expressed s percentge. 1% One of the core globl indictors used to monitor collbortive TB/HIV ctivities. Documenttion of HIV sttus is essentil to provide the best cre for HIV-positive TB ptients, including ntiretrovirl therpy. Routinely collected dt for ll TB ptients. Chpter 4 1 Cse ftlity rtio (CFR) Number of TB deths divided by estimted number of incident cses in the sme yers, expressed s percentge. 5% This is key indictor for monitoring progress towrds the 22 nd 225 milestones. A CFR of 6% is required to chieve the 225 globl milestone for reductions in TB deths nd cses. Mortlity divided by incidence. In countries with high-performnce surveillnce system, notifictions pproximte incidence. Chpter 3 CFR, cse ftlity rtio; DST, drug-susceptibility testing; HIV, humn immunodeficiency virus; LTBI, ltent TB infection; SDG, Sustinble Development Gol; TB, tuberculosis; UHC, universl helth coverge; WHO, World Helth Orgniztion; WRD, WHO-recommended rpid dignostic. Ctstrophic costs re provisionlly defined s totl costs tht exceed 2% of nnul household income. GLOBAL TUBERCULOSIS REPORT

25 TABLE 2.3A TB-SDG monitoring frmework: indictors to monitor within SDG 3 SDG 3: Ensure helthy lives nd promote well-being for ll t ll ges SDG TARGETS FOR 23 SDG INDICATORS ALTERNATIVE INDICATORS TO MONITOR RATIONALE DATA SOURCE COLLECT DATA FOR TB PATIENTS SPECIFICALLY? 3.3 End the epidemics of AIDS, TB, mlri nd neglected tropicl diseses nd combt heptitis, wter-borne diseses nd other communicble diseses Number of new HIV infections per 1 uninfected popultion TB incidence per 1 popultion HIV prevlence HIV is strong risk fctor for development of TB disese nd is ssocited with poorer tretment outcomes. HIV prevlence (rther thn incidence) will be monitored becuse it is directly mesured nd those newly infected with HIV re t lower risk of developing TB compred with those who hve been infected for more thn 1 yer. UNAIDS WHO Yes, lredy routinely collected. NA 3.4 Reduce premture mortlity by one third from non-communicble diseses nd promote mentl helth nd wellbeing Mortlity rte ttributed to crdiovsculr disese, cncer, dibetes or chronic respirtory disese Prevlence of dibetes Dibetes is strong risk fctor for development of TB disese, lthough link with TB incidence t the ntionl (s opposed to individul) level hs been difficult to estblish due to confounding. Dibetes prevlence is more relevnt thn mortlity for TB since it directly influences the risk of developing TB. WHO Could be considered t country level, to inform plnning of cre for comorbidities. 3.5 Strengthen prevention nd tretment of substnce buse, including nrcotic drug buse nd hrmful use of lcohol Alcohol consumption per cpit per yer (in litres of pure lcohol) mong those ged 15 yers (hrmful level defined ntionlly) Prevlence of lcohol use disorder Alcohol use is strong risk fctor for TB disese nd poorer tretment outcomes t the individul level, lthough link with TB incidence t the ntionl (s opposed to individul) level hs been hrd to estblish due to confounding. The prevlence of lcohol use disorder is the most relevnt indictor in the context of TB. WHO Could be considered t country level, to inform plnning of cre for comorbidities. 3.8 Achieve UHC, including finncil risk protection, ccess to qulity essentil helthcre services nd ccess to sfe, effective, qulity nd ffordble essentil medicines nd vccines for ll Coverge of essentil helth services (composite indictor, including TB tretment coverge s one of 16 trcer indictors) Proportion of popultion with lrge household expenditures on helth s shre of totl household expenditure or income NA Percentge of totl helth expenditures tht re out-ofpocket Helth expenditure per cpit Achieving UHC is required to chieve the three high-level trgets of the End TB Strtegy for reductions in the TB incidence rte, the number of TB deths nd eliminting ctstrophic costs for TB ptients nd their households. TB tretment coverge nd tretment success hve been monitored for yers nd the composite indictor of effective tretment coverge (the product of tretment coverge nd tretment success) is now one of 16 trcer indictors for UHC in the SDG frmework. Helth expenditure per cpit is correlted with TB incidence. WHO To ssess progress in elimintion of ctstrophic costs for TB ptients nd their households, periodic surveys of TB ptients re recommended. 3. Strengthen implementtion of the WHO Frmework Convention on Tobcco Control 3..1 Age-stndrdized prevlence of current tobcco use mong those ged 15 yers Prevlence of smoking mong those ged 15 yers (%) Smoking is strong risk fctor for TB disese t the individul level, lthough link with TB incidence t the ntionl (s opposed to individul) level hs been difficult to estblish due to confounding. WHO Could be considered (e.g. to inform ccess to smoking cesstion interventions). AIDS, cquired immune deficiency syndrome; HIV, humn immunodeficiency virus; NA, not pplicble; SDG, Sustinble Development Gol; TB, tuberculosis; UHC, universl helth coverge; UNAIDS, Joint United Ntions Progrmme on HIV/AIDS; WHO, World Helth Orgniztion. 14 GLOBAL TUBERCULOSIS REPORT 217

26 TABLE 2.3B TB-SDG monitoring frmework: indictors to monitor beyond SDG 3 SDG 1: End poverty in ll its forms everywhere SDG TARGETS FOR Erdicte extreme poverty for ll people everywhere 1.3 Ntionlly pproprite socil protection systems nd mesures for ll, including floors SDG INDICATORS Proportion of popultion living below the interntionl poverty line Proportion of popultion covered by socil protection floors/ systems ALTERNATIVE INDICATORS TO MONITOR NA NA RATIONALE Poverty is strong risk fctor for TB, operting through severl pthwys. Reducing poverty should lso fcilitte prompt helth-cre seeking. Countries with higher levels of socil protection hve lower TB burden. Progress on both indictors will help to chieve the End TB Strtegy trget to eliminte ctstrophic costs for TB ptients nd their households. DATA SOURCE UN SDG dtbse, World Bnk SDG 2: End hunger, chieve food security nd improved nutrition nd promote sustinble griculture 2.1 End hunger nd ensure ccess by ll people to sfe, nutritious nd sufficient food yerround Prevlence of undernourishment NA Under-nutrition wekens the body s defence ginst infections nd is strong risk fctor for TB t the ntionl nd individul level. SDG 7: Ensure ccess to ffordble, relible, sustinble, nd modern energy for ll 7.1 Ensure universl ccess to ffordble, relible nd modern energy services Proportion of popultion with primry relince on clen fuels nd technology NA Indoor ir pollution is risk fctor for TB disese t the individul level. There hs been limited study of mbient ir pollution but it is plusible tht it is linked to TB incidence. UN SDG dtbse SDG 8: Promote sustined, inclusive nd sustinble economic growth, full nd productive employment nd decent work for ll 8.1 Sustin per cpit growth with t lest 7% growth in GDP per yer in the lest developed countries Annul growth rte of rel GDP per cpit GDP per cpit SDG 1: Reduce inequlity within nd mong countries 1.1 Achieve nd sustin income growth of the bottom 4% of the popultion t rte higher thn the ntionl verge Growth rtes of household expenditure or income per cpit, overll nd for the bottom 4% of the popultion Gini index for income inequlity Historic trends in TB incidence re closely correlted with chnges in the bsolute level of GDP per cpit (but not with the growth rte). TB is disese of poverty, nd decesing income inequlities combined with economic growth should hve n effect on the TB epidemic. SDG 11: Mke cities nd humn settlements inclusive, sfe, resilient nd sustinble 11.1 Ensure ccess for ll to dequte, sfe nd ffordble housing nd bsic services nd upgrde slums Proportion of urbn popultion living in slums, informl settlements or indequte housing NA Living in slum is risk fctor for TB trnsmission due to its link with overcrowding. It is lso risk fctor for developing TB disese, due to links with ir pollution nd undernutrition. WHO World Bnk World Bnk OECD UN SDG dtbse COLLECT DATA FOR TB PATIENTS SPECIFICALLY? No Could be considered (e.g. to fcilitte ccess to socil protection). Could be considered (e.g. to pln food support). GDP, gross domestic product; NA, not pplicble; OECD, Orgnistion for Economic Co-opertion nd Development; SDG, Sustinble Development Gol; TB, tuberculosis; UN, United Ntions; WHO, World Helth Orgniztion. No No No No GLOBAL TUBERCULOSIS REPORT

27 For SDG 3, the seven indictors selected for monitoring re: coverge of essentil helth services; percentge of totl helth expenditures tht re out-ofpocket; helth expenditure per cpit; HIV prevlence; prevlence of smoking; prevlence of dibetes; nd prevlence of lcohol use disorder. For SDGs 1, 2, 7, 8, 1 nd 11, the seven indictors selected for monitoring re: proportion of the popultion living below the interntionl poverty line; proportion of the popultion covered by socil protection floors/systems; prevlence of undernourishment; proportion of the popultion with primry relince on clen fuels nd technology; gross domestic product (GDP) per cpit; Gini index for income inequlity; 1 nd proportion of the urbn popultion living in slums. The rtionle for the selection of these 14 indictors, dt sources nd comments on whether it is relevnt to collect dt for TB ptients specificlly re provided in Tble 2.3. The frmework includes only indictors for which reltionship with TB incidence could be estblished. It excludes: indictors tht re dditionl sub-indictors under indictors tht hve lredy been included (e.g. subindictors relted to UHC, under SDG 3); nd indictors tht re much more remotely ssocited with TB risks, nd tht operte minly through other SDGs (e.g. eduction under SDG 4, gender equlity under SDG 5 nd resilient infrstructure under SDG 9). Collection nd reporting of dt for the 14 indictors shown in Tble 2.3 does not require ny dditionl dt collection nd reporting efforts by ntionl TB progrmmes. Nor does it require dt collection nd reporting efforts tht go beyond those to which countries hve lredy committed in the context of the SDGs. At the globl level, the UN hs estblished monitoring system for SDG indictors, nd countries re expected to report dt on n nnul bsis vi the pproprite UN gencies (including WHO). Therefore, nlysis of the sttus of, nd trends in, the 14 indictors relted to TB will be bsed primrily on ccessing the dt held in the UN s SDG dtbse, s shown in Tble 2.3. In those cses where the SDG indictor is not considered the best metric, nd better (but closely relted) lterntive hs been identified nd justified (five indictors under SDG 3, one under SDG 8 nd one under SDG 1), dt sources re 1 The index cn tke vlues between nd 1, with representing perfect equlity nd 1 representing perfect inequlity. either WHO, the Orgnistion for Economic Co-opertion nd Development (OECD), UNAIDS or the World Bnk (lso shown in Tble 2.3). The dt for the indictors shown in Tble 2.3 tht will be vilble in the WHO, OECD, UN nd World Bnk dtbses will be for ntionl popultions. They will not be vilble for TB ptients specificlly, with the exception of HIV prevlence (HIV sttus mong TB ptients hs been routinely monitored s prt of ntionl TB surveillnce for more thn decde). This is not problem for monitoring of TB risk fctors nd determinnts, since it is the popultion-level prevlence tht influences popultion-level TB risks. Collection of dt for few of the indictors included in Tble 2.3 could be considered for TB ptients specificlly. However, there is cler risk of mking routine TB surveillnce fr too complex, nd this risk needs to be voided. If the indictor is considered importnt enough to monitor mong TB ptients t country level, periodic surveys should be considered s n lterntive to routine surveillnce (in which dt would be collected for ll TB ptients). Anlysis of the indictors in the TB-SDG monitoring frmework for high TB burden countries is included in Chpter 7. The ltest sttus nd recent trends in ech indictor re lso shown for these countries on the second pge of the country profiles in Annex 2 (this informtion is shown for other countries in profiles tht re vilble online 2 ). 2.4 Lists of high-burden countries being used by WHO during the period During the period 1998 to 215, the concept of n HBC becme fmilir nd widely used in the context of TB. In 215, three HBC lists for TB, TB/HIV nd MDR-TB were in use. The HBC list for TB (22 countries) hd remined unchnged since 22, nd the HBC lists for TB/HIV (41 countries) nd MDR-TB (27 countries) hd not been updted since 29 nd 28, respectively. With 215 mrking the end of the MDGs nd new er of SDGs, nd the lst yer of the Stop TB Strtegy before its replcement with the End TB Strtegy, it ws n idel time to revisit these three HBC lists. Following wide consulttion process, 3 WHO defined three new HBC lists for the period : one for TB, one for MDR-TB nd one for TB/HIV (Fig. 2.2, Tble 2.4). 4 Ech list contins 3 countries (Tble 2.4). These re defined s the top 2 in terms of the bsolute number of estimted incident cses, plus the dditionl 1 countries with the most severe burden in terms of incidence rtes per cpit tht do 2 (Accessed 2 August 217) 3 World Helth Orgniztion Strtegic nd Technicl Advisory Group for TB. Use of high burden country lists for TB by WHO in the post-215 er (discussion pper). Genev: WHO; 215 ( publictions/globl_report/high_tb_burdencountrylists pdf?u=1, ccessed 28 July 217). 4 As explined in the lst row of Tble 2.4, the three lists hve lifetime of 5 yers, nd the countries included in ech list nd the criteri used to define ech list will be reviewed in June GLOBAL TUBERCULOSIS REPORT 217

28 FIG. 2.2 Countries in the three high-burden country lists for TB, TB/HIV nd MDR-TB being used by WHO during the period , nd their res of overlp Azerbijn Belrus Kzkhstn Kyrgyzstn Peru Republic of Moldov Somli Tjikistn Ukrine Uzbekistn Bngldesh DPR Kore Pkistn Philippines Russin Federtion Viet Nm MDR-TB TB Cmbodi Sierr Leone Angol Chin DR Congo Ethiopi Indi Indonesi Keny Mozmbique Mynmr Nigeri Ppu New Guine South Afric Thilnd Zimbbwe Brzil Centrl Africn Republic Congo Lesotho Liberi Nmibi UR Tnzni Zmbi TB/HIV Botswn Cmeroon Chd Ghn Guine-Bissu Mlwi Swzilnd Ugnd DPR Kore, Democrtic People s Republic of Kore; DR Congo, Democrtic Republic of the Congo; HIV, humn immunodeficiency virus; MDR, multidrug-resistnt; TB, tuberculosis; UR Tnzni, United Republic of Tnzni; WHO, World Helth Orgniztion. Indictes countries tht re included in the list of 3 high TB burden countries on the bsis of the severity of their TB burden (i.e. TB incidence per 1 popultion), s opposed to the top 2, which re included on the bsis of their bsolute number of incident cses per yer. not lredy pper in the top 2 nd tht meet minimum threshold in terms of their bsolute numbers of incident cses (1 per yer for TB, nd 1 per yer for TB/HIV nd MDR-TB). The lists were defined using the ltest estimtes of TB disese burden vilble in October 215. Ech list ccounts for bout 9% of the globl burden, with most of this ccounted for by the top 2 countries in ech list. There is overlp mong the three lists, but 48 countries pper in t lest one list. The 14 countries tht re in ll three lists (shown in the centrl dimond in Fig. 2.2) re Angol, Chin, the Democrtic Republic of the Congo, Ethiopi, Indi, Indonesi, Keny, Mozmbique, Mynmr, Nigeri, Ppu New Guine, South Afric, Thilnd nd Zimbbwe. The 3 high TB burden countries re given prticulr ttention in the min body of this report. Where estimtes of disese burden nd ssessment of progress in the response re for TB/HIV nd MDR-TB specificlly, the countries in the TB/HIV nd MDR-TB lists, respectively, re given prticulr ttention. Annex 2 contins two-pge profile for ech of the 3 high TB burden countries, with cler demrction between the 2 countries included on the bsis of bsolute numbers of incident cses nd the 1 dditionl countries included on the bsis of the incidence rte per cpit. Dt for ll countries re included in Annex 4 nd in WHO s online globl TB dtbse. Country profiles for ll countries (with the sme content s those presented in Annex 2) re lso vilble online GLOBAL TUBERCULOSIS REPORT

29 TABLE 2.4 The three high-burden country lists for TB, TB/HIV nd MDR-TB being used by WHO during the period LIST THE 3 HIGH TB BURDEN COUNTRIES THE 3 HIGH TB/HIV BURDEN COUNTRIES THE 3 HIGH MDR-TB BURDEN COUNTRIES Purpose nd trget udience To provide focus for globl ction on TB in the countries where progress is most needed to chieve End TB Strtegy nd SDG trgets nd milestones, to help build nd sustin ntionl politicl commitment nd funding in the countries with the highest burden in terms of bsolute numbers or severity, nd to promote globl monitoring of progress in well-defined set of countries. To provide focus for globl ction on HIV-ssocited TB in the countries where progress is most needed to chieve End TB Strtegy, UNAIDS nd SDG trgets nd milestones, to help build nd sustin ntionl politicl commitment nd funding in the countries with the highest burden in terms of bsolute numbers or severity, nd to promote globl monitoring of progress in well-defined set of countries. To provide focus for globl ction on the MDR-TB crisis in the countries where progress is most needed to chieve End TB Strtegy trgets nd milestones, to help build nd sustin ntionl politicl commitment nd funding in the countries with the highest burden in terms of bsolute numbers or severity, nd to promote globl monitoring of progress in well-defined set of countries. Definition The 2 countries with the highest estimted numbers of incident TB cses, plus the top 1 countries with the highest estimted TB incidence rte tht re not in the top 2 by bsolute number (threshold, >1 estimted incident TB cses per yer). The 2 countries with the highest estimted numbers of incident TB cses mong people living with HIV, plus the top 1 countries with the highest estimted TB/HIV incidence rte tht re not in the top 2 by bsolute number (threshold, >1 estimted incident TB/HIV cses per yer). The 2 countries with the highest estimted numbers of incident MDR-TB cses, plus the top 1 countries with the highest estimted MDR-TB incidence rte tht re not in the top 2 by bsolute number (threshold, >1 estimted incident MDR-TB cses per yer). Countries in the list The top 2 by estimted bsolute number (in lphbeticl order): Angol Bngldesh Brzil Chin DPR Kore DR Congo Ethiopi Indi Indonesi Keny Mozmbique Mynmr Nigeri Pkistn Philippines Russin Federtion South Afric Thilnd UR Tnzni Viet Nm The dditionl 1 by estimted incidence rte per 1 popultion nd with minimum number of 1 cses per yer (in lphbeticl order): Cmbodi Centrl Africn Republic Congo Lesotho Liberi Nmibi Ppu New Guine Sierr Leone Zmbi Zimbbwe The top 2 by estimted bsolute number (in lphbeticl order): Angol Brzil Cmeroon Chin DR Congo Ethiopi Indi Indonesi Keny Lesotho Mlwi Mozmbique Mynmr Nigeri South Afric Thilnd Ugnd UR Tnzni Zmbi Zimbbwe The dditionl 1 by estimted incidence rte per 1 popultion nd with minimum number of 1 cses per yer (in lphbeticl order): Botswn Centrl Africn Republic Chd Congo Ghn Guine-Bissu Liberi Nmibi Ppu New Guine Swzilnd The top 2 by estimted bsolute number (in lphbeticl order): Bngldesh Chin DPR Kore DR Congo Ethiopi Indi Indonesi Kzkhstn Keny Mozmbique Mynmr Nigeri Pkistn Philippines Russin Federtion South Afric Thilnd Ukrine Uzbekistn Viet Nm The dditionl 1 by estimted rte per 1 popultion nd with minimum number of 1 cses per yer (in lphbeticl order): Angol Azerbijn Belrus Kyrgyzstn Ppu New Guine Peru Republic of Moldov Somli Tjikistn Zimbbwe Shre of globl incidence in 216 (%) 84% 2.8% 85% 4.4% 84% 5.7% Lifetime of list 5 yers (review criteri nd included countries in June 22). 5 yers (review criteri nd included countries in June 22). 5 yers (review criteri nd included countries in June 22). DPR Kore, Democrtic People s Republic of Kore; DR Congo, Democrtic Republic of the Congo; HIV, humn immunodeficiency virus; MDR, multidrug resistnt; SDG, Sustinble Development Gol; TB, tuberculosis; UNAIDS, Joint United Ntions Progrmme on HIV/AIDS; UR Tnzni, United Republic of Tnzni; WHO, World Helth Orgniztion. 18 GLOBAL TUBERCULOSIS REPORT 217

30

31 A cured TB ptient hs follow-up chest X-ry in Howrh, Indi IMAGEBROKER / ALAMY STOCK PHOTO

32 CHAPTER 3. TB disese burden n KEY FACTS AND MESSAGES n TB is the ninth leding cuse of deth worldwide nd the leding cuse from single infectious gent, rnking bove HIV/AIDS. In 216, there were n estimted 1.3 million TB deths mong HIVnegtive people (down from 1.7 million in 2) nd n dditionl 374 deths mong HIV-positive people. An estimted 1.4 million people (9% dults; 65% mle; 1% people living with HIV) fell ill with TB in 216 (i.e. were incident cses). Most of the estimted number of incident cses in 216 occurred in the WHO South-Est Asi Region (45%), the WHO Africn Region (25%) nd the WHO Western Pcific Region (17%); smller proportions of cses occurred in the WHO Estern Mediterrnen Region (7%), the WHO Europen Region (3%) nd the WHO Region of the Americs (3%). The top five countries, with 56% of estimted cses, were (in descending order) Indi, Indonesi, Chin, the Philippines nd Pkistn. Globlly, the TB mortlity rte is flling t bout 3% per yer. TB incidence is flling t bout 2% per yer; this needs to improve to 4 5% per yer by 22 to rech the first milestones of the End TB Strtegy. Regionlly, the fstest decline in TB incidence is in the WHO Europen Region (4.6% from 215 to 216). The decline since 21 hs exceeded 4% per yer in severl high TB burden countries, including Ethiopi, Keny, Lesotho, Nmibi, the Russin Federtion, the United Republic of Tnzni, Zmbi nd Zimbbwe. Regionlly, the fstest declines in the TB mortlity rte re in the WHO Europen Region nd the WHO Western Pcific Region (6.% nd 4.6% per yer, respectively, since 21). High TB burden countries with rtes of decline exceeding 6% per yer since 21 include Ethiopi, the Russin Federtion, the United Republic of Tnzni, Viet Nm nd Zimbbwe. Globlly, the proportion of people who develop TB nd die from the disese (the cse ftlity rtio, or CFR) ws 16% in 216. This needs to fll to 1% by 22 to rech the first milestones of the End TB Strtegy. There is considerble country vrition in the CFR, from under 5% in few countries to more thn 2% in most countries in the WHO Africn Region. This shows considerble inequlities mong countries in ccess to TB dignosis nd tretment tht need to be ddressed. Between 2 nd 216, TB tretment verted n estimted 44 million deths mong HIV-negtive people. Among HIV-positive people, TB tretment supported by ART verted n dditionl 9 million deths. Drug-resistnt TB is persistent thret, with 49 million cses of multidrug-resistnt TB (MDR-TB) emerging in 216 nd n dditionl 11 cses tht were susceptible to isonizid but resistnt to rifmpicin (RR-TB), the most effective first-line nti-tb drug. The countries with the lrgest numbers of MDR/RR-TB cses (47% of the globl totl) were Chin, Indi nd the Russin Federtion. Ntionl notifiction nd vitl registrtions systems need to be strengthened towrds the gol of direct mesurement of TB incidence nd mortlity in ll countries. Ntionl TB prevlence surveys provide n interim pproch to directly mesuring the burden of TB disese in n importnt subset of high TB burden countries. Between 27 nd the end of 216, totl of 25 surveys tht used the screening nd dignostic methods recommended by WHO were implemented. When n HIV-positive person dies from TB disese, the underlying cuse is clssified s HIV in the interntionl clssifiction of diseses system (ICD-1). GLOBAL TUBERCULOSIS REPORT

33 The burden of tuberculosis (TB) disese cn be mesured in terms of: incidence the number of new nd relpse cses of TB rising in given time period, usully 1 yer; prevlence the number of cses of TB t given point in time; nd mortlity the number of deths cused by TB in given time period, usully 1 yer. Globl trgets nd milestones for reductions in the burden of TB disese hve been set s prt of the Sustinble Development Gols (SDGs) nd WHO s End TB Strtegy (Chpter 2). 1 SDG 3 includes trget to end the globl TB epidemic by 23, with TB incidence (per 1 popultion per yer) defined s the indictor for mesurement of progress. The 23 trgets set in the End TB Strtegy re 9% reduction in TB deths nd n 8% reduction in TB incidence, compred with levels in 215. Trgets for 235 nd milestones for 22 nd 225 hve lso been defined (Tble 3.1). TABLE 3.1 Trgets for percentge reductions in TB disese burden set in WHO s End TB Strtegy INDICATORS Percentge reduction in the bsolute number of TB deths (compred with 215 bseline) Percentge reduction in the TB incidence rte (compred with 215 bseline) MILESTONES TARGETS This chpter hs five mjor sections. Section 3.1 nd Section 3.2 present the ltest WHO estimtes of TB incidence nd mortlity between 2 nd 216, nd highlight sources of dt nd ctions needed to improve mesurement of TB incidence nd mortlity. Section 3.3 focuses on the burden of drug-resistnt TB, including progress in globl surveillnce of resistnce to nti-tb drugs, nd estimtes of the incidence of multidrug-resistnt TB (MDR-TB) nd rifmpicin-resistnt TB (RR-TB). Section 3.4 discusses ntionl TB prevlence surveys. TB prevlence is not n indictor for which globl trget hs been set during the period Nevertheless, in mny countries, ntionl TB prevlence surveys still provide the best method for estimting the burden of TB disese (including by ge nd sex) nd for plnning ctions needed to reduce tht burden. In ddition, results from ntionl TB prevlence surveys cn inform estimtes of TB incidence nd mortlity, nd thus contribute to monitoring of progress towrds SDG nd End TB Strtegy trgets. Finlly, Section World Helth Orgniztion. WHO End TB Strtegy: globl strtegy nd trgets for tuberculosis prevention, cre nd control fter 215. Genev: WHO; 215 ( ccessed 8 August 216). 2 This is in contrst to the period covered by the Stop TB Strtegy (26 215), when trget of hlving prevlence by 215 compred with bseline of 199 ws set. covers estimtes of TB incidence nd mortlity disggregted by ge nd sex. This is in line with the incresing emphsis on the importnce of within-country disggregtion of key indictors in the SDGs nd the End TB Strtegy (Chpter 2). WHO updtes its estimtes of the burden of TB disese nnully, using the ltest vilble dt nd nlyticl methods. 3,4 Since 26, concerted efforts hve been mde to improve the vilble dt nd methods used, under the umbrell of the WHO Globl Tsk Force on TB Impct Mesurement (Box 3.1). A summry of the min updtes to vilble dt nd methods since the 216 globl TB report is provided in Box TB incidence Methods to estimte TB incidence TB incidence hs never been mesured t ntionl level becuse this would require long-term studies mong lrge cohorts (hundreds of thousnds) of people, which would involve high costs nd chllenging logistics. However, notifictions of TB cses provide good proxy indiction of TB incidence in countries tht hve high-performnce surveillnce systems (e.g. with little underreporting of dignosed cses), nd in which the qulity of nd ccess to helth cre mens tht few cses re not dignosed. In the lrge number of countries tht hve not yet met these criteri, better estimtes of TB incidence cn be obtined from n inventory study (i.e. survey to quntify the level of underreporting of detected TB cses); lso, if certin conditions re met, results from n inventory study cn be combined with cpture recpture methods to estimte TB incidence. 5 To dte, such studies hve been undertken in only few countries, but interest nd implementtion is growing (Box 3.3). The ultimte gol is to directly mesure TB incidence from TB notifictions in ll countries. This requires combintion of strengthened surveillnce, better quntifiction of underreporting (i.e. the number of cses tht re missed by surveillnce systems) nd universl helth coverge. A TB surveillnce checklist developed by the WHO Globl Tsk Force on TB Impct Mesurement (Box 3.1) defines the stndrds tht need to be met for notifiction dt to provide direct mesure of TB incidence. 6 By August 217, totl of 3 The online technicl ppendix is vilble t 4 The updtes cn ffect the entire time-series bck to 2. Therefore, estimtes presented in this chpter for supersede those of previous reports, nd direct comprisons (e.g. between the 215 estimtes in this report nd the 215 estimtes in the previous report) re not pproprite. 5 Inventory studies cn be used to mesure the number of cses tht re dignosed but not reported. For guide to inventory studies, see World Helth Orgniztion. Assessing tuberculosis underreporting through inventory studies. Genev: WHO; 212 ( publictions/inventory_studies/en/, ccessed 15 August 216). 6 World Helth Orgniztion. Stndrds nd benchmrks for tuberculosis surveillnce nd vitl registrtion systems: checklist nd user guide. Genev: WHO; 214 ( stndrdsndbenchmrks/en/, ccessed 24 August 216). One of the stndrds is tht levels of underreporting of detected TB cses should be miniml. 22 GLOBAL TUBERCULOSIS REPORT 217

34 n BOX 3.1 n The WHO Globl Tsk Force on TB Impct Mesurement Estblishment nd progress mde, The WHO Globl Tsk Force on TB Impct Mesurement (herefter referred to s the Tsk Force) ws estblished in 26 nd is convened by the TB Monitoring nd Evlution unit of WHO s Globl TB Progrmme. Its originl im ws to ensure tht WHO s ssessment of whether 215 trgets set in the context of the MDGs were chieved t globl, regionl nd country levels ws s rigorous, robust nd consensus-bsed s possible. Three strtegic res of work were pursued: strengthening routine surveillnce of TB cses (vi ntionl notifiction systems) nd deths (vi ntionl VR systems) in ll countries; undertking ntionl TB prevlence surveys in 22 globl focus countries; nd periodiclly reviewing methods used to produce TB disese burden estimtes. Work on strengthened surveillnce included the following: Development of TB surveillnce checklist of stndrds nd benchmrks (with 1 core nd three supplementry stndrds). This checklist cn be used to systemticlly ssess the extent to which surveillnce system meets the stndrds required for notifiction nd VR dt, to provide direct mesurement of TB incidence nd mortlity, respectively. By the end of 215, 38 countries including 16 high burden countries hd used the checklist. Electronic recording nd reporting. Cse-bsed electronic dtbses re the reference stndrd for recording nd reporting TB surveillnce dt. A guide ws produced in 212, b nd efforts to introduce such systems were supported. Development of guide on inventory studies to mesure underreporting of detected TB cses, c nd support such studies in priority countries. An inventory study cn be used to quntify the number of cses tht re detected but not reported to ntionl surveillnce systems, nd cn serve s bsis for improving estimtes of TB incidence nd ddressing gps in reporting. Expnded use of dt from VR systems nd mortlity surveys to produce estimtes of the number of TB deths, nd contributions to wider efforts to promote VR systems. By 215, VR dt were used to produce estimtes of TB mortlity in 127 countries, up from three in 28. There ws substntil success in the implementtion of ntionl TB prevlence surveys , which hs continued. Between 27 nd the end of 215, totl of 23 countries completed survey nd further two hd done so by the end of 216; this included 18 of the 22 globl focus countries. A Tsk Force subgroup undertook mjor review nd updte of methods between June 28 nd October 29. A second thorough nd comprehensive review ws undertken in 215, with consensus reched on methods to be used for the 215 trgets ssessment published in WHO s 215 globl TB report. d Updted strtegic res of work, In the context of new er of SDGs nd WHO s End TB Strtegy, the Tsk Force met in April 216 to review nd reshpe its mndte nd strtegic res of work for the post-215 er. An updted mndte nd five strtegic res of work for the period were greed. e The mndte ws defined s follows: To ensure tht ssessments of progress towrds End TB Strtegy nd SDG trgets nd milestones t globl, regionl nd country levels re s rigorous, robust nd consensus-bsed s possible. To guide, promote nd support the nlysis nd use of TB dt for policy, plnning nd progrmmtic ction. The five strtegic res of work re s follows: 1. Strengthening ntionl notifiction systems for direct mesurement of TB cses, including drug-resistnt TB nd HIV-ssocited TB specificlly. 2. Strengthening ntionl VR systems for direct mesurement of TB deths. 3. Priority studies to periodiclly mesure TB disese burden, including:. ntionl TB prevlence surveys b. drug resistnce surveys c. mortlity surveys d. surveys of costs fced by TB ptients nd their households. 4. Periodic review of methods used by WHO to estimte the burden of TB disese nd ltent TB infection. 5. Anlysis nd use of TB dt t country level, including:. disggregted nlyses (e.g. by ge, sex, loction) to ssess inequlities nd equity; b. projections of disese burden; nd c. guidnce, tools nd cpcity building. The SDG nd End TB Strtegy trgets nd milestones referred to in the mndte re the trgets (23, 235) nd milestones (22, 225) set for the three high-level indictors; tht is, TB incidence, the number of TB deths nd the percentge of TB-ffected households tht fce ctstrophic costs s result of TB disese (Chpter 2). Strtegic res of work 1 3 re focused on direct mesurement of TB disese burden (epidemiologicl nd, in the cse of cost surveys, economic). The underlying principle for the Tsk Force s work since 26 hs been tht estimtes of the level of nd trends in disese burden should be bsed on direct mesurements from routine surveillnce nd surveys s much s possible (s opposed to indirect estimtes bsed on modelling nd expert opinion). However, strtegic re of work 4 remins necessry becuse indirect estimtes will be required until ll countries hve the surveillnce systems or the periodic studies required to provide direct mesurements. Strtegic re of work 5 recognizes the importnce of nlysing nd using TB dt t country level (s well s generting dt, s in strtegic res of work 1 3), including the disggregted nlyses tht re now given much greter ttention in the SDGs nd End TB Strtegy. GLOBAL TUBERCULOSIS REPORT

35 In the yers up to 22, the top priorities for the Tsk Force re strengthening of ntionl notifiction nd VR systems s the bsis for direct mesurement of TB incidence nd TB mortlity. Further detils bout the work of the Tsk Force re vilble online; f n up-to-dte summry is provided in the ltest brochure bout its work. g b World Helth Orgniztion. Stndrds nd benchmrks for tuberculosis surveillnce nd vitl registrtion systems: checklist nd user guide. Genev: WHO; 214 ( stndrdsndbenchmrks/en/, ccessed 24 August 217). World Helth Orgniztion. Electronic recording nd reporting for tuberculosis cre nd control. Genev: WHO; 212 ( int/tb/publictions/electronic_recording_reporting/en/, ccessed 11 September 217). c d e f g World Helth Orgniztion. Assessing tuberculosis underreporting through inventory studies. Genev: WHO; 212 ( tb/publictions/inventory_studies/en/, ccessed 15 August 217). World Helth Orgniztion Globl Tsk Force on TB Impct Mesurement. Third meeting of the TB estimtes subgroup: methods to use for WHO s definitive ssessment of whether 215 globl TB trgets re met. Genev: WHO; 215 ( tb/dvisory_bodies/impct_mesurement_tskforce/meetings/ consulttion_pril_215_tb_estimtes_subgroup/en/, ccessed 11 September 217). World Helth Orgniztion Globl Tsk Force on TB Impct Mesurement. Report of the sixth meeting of the full Tsk Force; April 216, Glion-sur-Montreux, Switzerlnd. Genev: WHO; 215 ( tskforce/meetings/tf6_report.pdf?u=1, ccessed 11 September 217). Avilble t: Avilble t: impctmesurement.pdf?u=1 n BOX 3.2 n Updtes to estimtes of TB disese burden in this report nd nticipted updtes Updtes in this report 1. New dt from ntionl TB prevlence surveys Between October 216 nd August 217, finl results from ntionl TB prevlence surveys in Bngldesh, the Democrtic People s Republic of Kore, Keny nd the Philippines becme vilble. The post-survey estimte of TB prevlence in the Philippines ws significntly higher thn nticipted from the results of previous ntionl prevlence surveys, which hd found decline between 1997 (the second ntionl survey) nd 27 (the third ntionl survey). Between 27 nd 216, there ws no decline. Bsed on survey results, there were n estimted 1 million prevlent cses in 216 (1 in 15 of the prevlent cses globlly) nd 57 incident cses. Broder socil nd economic influences on the TB epidemic re plusible resons for the burden of TB disese being higher thn expected. These influences include undernourishment, with prevlence of 14% in 215 nd no improvement since 28; lrge proportion of the popultion living below the ntionl poverty line (25% in 212); nd low coverge of helth insurnce nd socil protection (4% in the poorest quintile in 213), resulting in finncil brriers to ccessing helth services nd high levels of out-of-pocket expenditures on helth cre (34% in 214). The prevlence of HIV in the generl popultion remins below.1% nd hs limited impct on the size of the TB epidemic. Further detils re provided in Box 3.6. The best estimte of TB incidence in Keny bsed on the prevlence survey ws higher thn the pre-survey estimte, but with overlpping uncertinty intervls. The post-survey estimte of TB incidence for Bngldesh ws slightly lower, nd for the Democrtic Republic of Kore it ws similr to the pre-survey estimte. The survey in the Democrtic Republic of Kore confirmed tht the country hs one of the highest burdens of TB disese mong countries where the prevlence of HIV in the generl popultion is under 1%. One fctor contributing to the severity of the TB epidemic is high levels of undernourishment, which increses the risk of brekdown to TB disese mong infected people (see lso Chpter 2 nd Chpter 7). The prevlence of undernourishment ws 42% in 215 (38% in 2), nd the percentge of TB cses ttributble to undernourishment (popultion ttributble frction) ws estimted t 48%. This demonstrted the need for stronger intersectorl response to TB, ddressing undernourishment nd other socil nd economic determinnts of the TB epidemic. Dt on the prevlence of HIV mong prevlent TB cses identified during ntionl prevlence surveys re now vilble from seven countries. These dt were used to re-estimte TB incidence in Nigeri, ccounting for the lower prevlence of HIV mong survey cses compred with notified cses (Fig. B3.2.1). As result of this djustment, the updted incidence estimte ws reduced by 32%. This cn be explined by the fct tht lower HIV prevlence mong prevlent TB cses increses the estimted verge durtion of disese. With incidence FIG B3.2.1 HIV prevlence rtio (survey/notified TB cses) Keny, Mlwi, 213 Rwnd, 212 UR Tnzni, 212 Ugnd, 215 Zmbi, 214 Zimbbwe, 214 RE Model.53 [.4,.7].51 [.35,.74].7 [.1,.45].2 [.11,.38].7 [.32, 1.1].44 [.33,.59].73 [.58,.91].47 [.34,.65] HIV prevlence rtio (prevlent/notified TB) 24 GLOBAL TUBERCULOSIS REPORT 217

36 estimted s prevlence divided by disese durtion, this increse in estimted disese durtion results in reduction in estimted incidence. 2. Newly reported dt nd estimtes from other gencies New VR dt were reported to WHO between mid-216 nd mid-217. This included dt from the Islmic Republic of Irn for nd updtes by other countries to historicl dt. Updted estimtes of the burden of disese cused by HIV were obtined from UNAIDS in mid-july 217. In most instnces, ny resulting chnges to TB burden estimtes were well within the uncertinty intervls of previously published estimtes, nd trends were generlly consistent. For 18 countries (Fig. 3.1), estimtes of TB mortlity mong HIV-negtive people were bsed on estimtes from the Institute of Helth Metrics nd Evlution (IHME). These re bsed on combining dt from ntionl VR systems, dt from smple VR systems nd dt from verbl utopsy surveys in Byesin frmework tht includes predictors of mortlity. For the 18 countries, the quntity of mortlity dt vilble to IHME is lrger thn the mount vilble to WHO. Estimtes in South Afric re djusted by IHME for miscoding of deths cused by HIV nd TB. b,c IHME estimtes used in this report were djusted to fit WHO estimtes of the totl number of deths (referred to s the mortlity envelope). The medin country-yer envelope rtio (WHO/IHME) ws 1.3 (interqurtile rnge, ). 3. Ntionl TB epidemiologicl reviews In-depth epidemiologicl reviews with n ssessment of the performnce of TB surveillnce (Fig. 3.1) inform estimtes of TB disese burden. The min updte from such review in this report is for the Russin Federtion. During review in Februry 217, best estimtes of TB incidence were revised downwrds by 15%, with notifictions ssumed to be good proxy for TB incidence (previously, stndrd djustment hd been pplied to notifiction dt to llow for underreporting or underdignosis). This updte ws justified for four mjor resons. First, there is n extensive nd regulr screening progrmme, with ll dults screened every 1 2 yers, ll children nd dolescents screened every yer, nd contct trcing undertken for ll TB cses. This mkes underdignosis unlikely. Second, notifiction of cses is mndtory nd the reporting system hs complete ntionl coverge, leving little room for underreporting of detected TB cses. Third, culture or moleculr testing (or both) re routinely used for dignosis. Fourth, there hve been no mjor chnges in screening, dignostic nd reporting prctices in recent yers. In ddition, there my be some over-dignosis of people screening positive for TB but with no bcteriologicl confirmtion using the most sensitive TB dignostics, which would compenste for ny underdignosis or underreporting. Further detils re provided in Box Country-level estimtes of TB incidence nd mortlity disggregted by ge nd sex Previous reports hve included globl, regionl nd country-specific estimtes of TB incidence nd TB mortlity by ge (dults nd children) nd sex. This report includes estimtes for more ge ctegories ( 4, 5 14, 15 24, 25 34, 35 44, 45 54, nd 65 yers). Updtes nticipted in the ner future Updtes to estimtes of TB disese burden re expected in 218 for Mynmr, Mozmbique, Nmibi, South Afric nd Viet Nm, following the completion of ntionl TB prevlence surveys. The surveys in Mynmr nd Viet Nm re repet surveys. A ntionl TB prevlence survey in Indi is plnned for 218. b c Downloded from July 217 Murry CJ, Ortbld KF, Guinovrt C, Lim SS, Wolock TM, Roberts DA et l. Globl, regionl, nd ntionl incidence nd mortlity for HIV, tuberculosis, nd mlri during : systemtic nlysis for the Globl Burden of Disese Study 213. Lncet. 214;384(9947):15 17 ( rticle/pii/s ?vi%3dihub, ccessed 24 August 216). Groenewld P, Nnnn N, Bourne D, Lubscher R, Brdshw D. Identifying deths from AIDS in South Afric. AIDS. 25;19(2): ( ccessed 24 August 216). 61 countries, including 23 of the 3 high TB burden countries (listed in Tble 3.1) hd completed the checklist, often in ssocition with TB epidemiologicl review or regionl workshop focused on nlysis of TB dt (Fig. 3.1). Methods currently used by WHO to estimte TB incidence cn be grouped into four mjor ctegories, s follows (Fig. 3.2): Results from TB prevlence surveys. Incidence is estimted using prevlence survey results nd estimtes of the durtion of disese, with the ltter derived from model tht ccounts for the impct of HIV coinfection on the distribution of disese durtion. This method is used for 24 countries, of which 23 hve ntionl survey dt nd one Indi hd survey in one stte. The 24 countries ccounted for 68% of the estimted globl number of incident cses in 216. Notifictions in high-income countries djusted by stndrd fctor to ccount for underreporting nd under dignosis. This method is used for 134 countries tht comprise ll high-income countries except the Netherlnds nd the United Kingdom, plus selected uppermiddle-income countries with low levels of underreporting, including Brzil, Chin nd the Russin Federtion. For three countries (Frnce, Republic of Kore nd Turkey) the djustment ws country specific, bsed on results from studies of underreporting. These 134 countries ccounted for 15% of the estimted globl number of incident cses in 216. GLOBAL TUBERCULOSIS REPORT

37 n BOX 3.3 n Inventory studies to mesure the underreporting of detected TB cses: progress to dte In countries with stte-of-the-rt ntionl surveillnce systems, where most, if not ll, new TB cses re dignosed nd registered, the number of notified TB cses provides good proxy for TB incidence. In mny countries, however, underreporting of detected cses s well s underdignosis men tht there re gps between the number of notified TB cses nd TB incidence. Ntionl TB inventory studies cn be used to quntify one of these gps the level of underreporting nd in turn cn inform better estimtes of TB incidence s well s the ctions needed to minimize levels of underreporting. If certin ssumptions re met, results cn lso be used to estimte TB incidence using cpture recpture methods. in children in Pkistn, nd completion of fieldwork for the first-ever such studies (covering dults nd children) in Indonesi nd Viet Nm. Finl results from these three studies re expected by erly 218. Ntionl studies in Denmrk, the Netherlnds nd Portugl re lso under wy s prt of project funded by the Europen Centre for Disese Prevention nd Control, nd study protocol is being developed for study in South Afric. As countries begin working towrds the TB incidence trgets set within the SDGs nd the End TB Strtegy, there is need for incresed commitment, from ntionl TB progrmmes (NTPs) nd funding gencies, to conduct nd fund TB inventory studies. Countries in which ntionl inventory study hs been implemented since 2 re shown in Fig. B Progress in includes the completion of study focused on the underreporting of TB cses World Helth Orgniztion. Assessing tuberculosis underreporting through inventory studies. Genev: WHO; 212 ( int/tb/publictions/inventory_studies/en/, ccessed 15 August 217). FIG. B3.3.1 Countries in which ntionl inventory studies of the underreporting of detected TB cses hve been implemented since 2 (sttus in August 217) Ntionl inventory study completed Ntionl inventory study ongoing Ntionl inventory study plnned No dt Not pplicble Pkistn hs completed second inventory study focusing on children with TB. Nigeri is plnning to undertke subntionl level study (in metropolitn Lgos). The Netherlnds is crrying out repet of the inventory study conducted in GLOBAL TUBERCULOSIS REPORT 217

38 FIG. 3.1 Strengthening ntionl TB surveillnce (sttus in August 217) Countries in which ntionl TB epidemiologicl review hs been undertken since July Not pplicble Countries in which checklist of stndrds nd benchmrks hs been completed since Jnury 213 Number of stndrds met (out of 13) Not pplicble Countries covered by regionl or countryspecific workshop focused on TB dt nlysis nd use for ction since October 215 Completed Not pplicble GLOBAL TUBERCULOSIS REPORT

39 FIG. 3.2 Min methods used to estimte TB incidence Min method Cpture recpture Cse notifictions, expert opinion Cse notifictions, stndrd djustment Prevlence survey No dt Not pplicble Results from inventory studies nd cpture recpture nlysis. This method is used for five countries: Egypt, Irq, the Netherlnds, the United Kingdom nd Yemen. These countries ccounted for.5% of the estimted globl number of incident cses in 216. Cse notifiction dt combined with expert opinion bout cse-detection gps. Expert opinion, elicited through regionl workshops or country missions, is used to estimte levels of underreporting nd underdignosis. Trends re estimted through mortlity dt, surveys of the nnul risk of infection or exponentil interpoltion using estimtes of cse-detection gps for 3 yers. In this report, this method is used for 54 countries tht ccounted for 17% of the estimted globl number of incident cses in 216. Of the four methods, the lst one is the lest preferred nd it is relied upon only if one of the other three methods cnnot be used. As explined in Box 3.1, the underlying principle for the WHO Globl Tsk Force on TB Impct Mesurement since its estblishment in 26 hs been tht estimtes of the level of nd trends in TB disese burden should be bsed on direct mesurements from routine surveillnce nd surveys s much s possible, s opposed to indirect estimtes tht rely on modelling nd expert opinion. Further detils bout these methods re provided in the online technicl ppendix. 1 1 The online technicl ppendix is vilble t Estimtes of TB incidence in 216 Globlly in 216 there were n estimted 1.4 million incident cses of TB (rnge, 8.8 million to 12.2 million), 2 equivlent to 14 cses per 1 popultion (estimtes of bsolute numbers re shown in Tble 3.2 nd estimtes of rtes per cpit re shown in Tble 3.3). Most of the estimted number of cses in 216 occurred in the WHO South-Est Asi Region (45%), the WHO Africn Region (25%) nd the WHO Western Pcific Region (17%); smller proportions of cses occurred in the WHO Estern Mediterrnen Region (7%), the WHO Europen Region (3%) nd the WHO Region of the Americs (3%). The 3 high TB burden countries 3 ccounted for 87% of ll estimted incident cses worldwide. The five countries tht stood out s hving the lrgest number of incident cses in 216 were (in descending order) Indi, Indonesi, Chin, the Philippines nd Pkistn (Fig. 3.3), which together ccounted for 56% of the globl totl. Of these, Chin, Indi nd Indonesi lone ccounted for 45% of globl cses in 216. Nigeri nd South Afric ech ccounted for 4% of the globl totl. The nnul number of incident TB cses reltive to popultion size (the incidence rte) vried widely mong countries in 216, from under 1 per 1 popultion in most high-income countries to 15 3 in most of the 3 high TB burden countries (Fig. 3.4), nd bove 5 in 2 Here nd elsewhere in the report, rnge refers to the 95% uncertinty intervl. 3 These countries re listed in Tble 3.2 nd Tble 3.3. For n explntion of how the list of 3 high TB burden countries ws defined, see Chpter GLOBAL TUBERCULOSIS REPORT 217

40 TABLE 3.2 Estimted epidemiologicl burden of TB in 216 for 3 high TB burden countries, WHO regions nd globlly. Numbers in thousnds. b c POPULATION HIV-NEGATIVE TB MORTALITY HIV-POSITIVE TB MORTALITY b INCIDENCE HIV-POSITIVE TB INCIDENCE BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL Angol Bngldesh Brzil Cmbodi Centrl Africn Republic Chin Congo DPR Kore DR Congo Ethiopi Indi c Indonesi Keny Lesotho Liberi Mozmbique Mynmr Nmibi Nigeri Pkistn Ppu New Guine Philippines < Russin Federtion Sierr Leone South Afric Thilnd UR Tnzni Viet Nm Zmbi Zimbbwe High TB burden countries Afric The Americs Estern Mediterrnen Europe South-Est Asi Western Pcific GLOBAL Numbers shown to two significnt figures if under 1 nd to three significnt figures otherwise. Deths mong HIV-positive TB cses re clssified s HIV deths ccording to ICD-1. Estimtes of TB incidence nd mortlity for Indi re interim in nture, pending results from the ntionl TB prevlence survey plnned for 218/219. GLOBAL TUBERCULOSIS REPORT

41 TABLE 3.3 Estimted epidemiologicl burden of TB in 216 for 3 high TB burden countries, WHO regions nd globlly. Rtes per 1 popultion except where indicted. b HIV-NEGATIVE TB MORTALITY HIV-POSITIVE TB MORTALITY TOTAL TB INCIDENCE HIV PREVALENCE IN INCIDENT TB (%) BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL Angol Bngldesh Brzil Cmbodi Centrl Africn Republic Chin Congo DPR Kore DR Congo Ethiopi Indi b Indonesi Keny Lesotho Liberi Mozmbique Mynmr Nmibi Nigeri Pkistn Ppu New Guine Philippines < Russin Federtion Sierr Leone South Afric Thilnd UR Tnzni Viet Nm Zmbi Zimbbwe High TB burden countries Afric The Americs Estern Mediterrnen Europe South-Est Asi Western Pcific GLOBAL Deths mong HIV-positive TB cses re clssified s HIV deths ccording to ICD 1. Estimtes of TB incidence nd mortlity for Indi re interim in nture, pending results from the ntionl TB prevlence survey plnned for 218/ GLOBAL TUBERCULOSIS REPORT 217

42 FIG. 3.3 Estimted TB incidence in 216, for countries with t lest 1 incident cses Chin Philippines Pkistn Number of incident cses 1 Nigeri Indi 5 Indonesi South Afric FIG. 3.4 Estimted TB incidence rtes, 216 Incidence per 1 popultion per yer No dt Not pplicble GLOBAL TUBERCULOSIS REPORT

43 FIG. 3.5 Estimted HIV prevlence in new nd relpse TB cses, 216 HIV prevlence, ll ges (%) No dt Not pplicble few countries including the Democrtic People s Republic of Kore, Lesotho, Mozmbique, the Philippines nd South Afric (Tble 3.3). An estimted 1% (rnge, 8 12%) of the incident TB cses in 216 were mong people living with HIV (Tble 3.2, Tble 3.3). The proportion of TB cses coinfected with HIV ws highest in countries in the WHO Africn Region, exceeding 5% in prts of southern Afric (Fig. 3.5). The risk of developing TB in the 37 million people living with HIV ws 21 times higher thn the risk in the rest of the world popultion (rnge, 16 27). The reltive risk increses s the prevlence of HIV in the generl popultion decreses. Estimtes of the incidence of zoonotic TB re shown in Box Estimted trends in TB incidence, Consistent with previous globl TB reports, the number of incident cses is flling slowly, in both bsolute terms nd per cpit (Fig. 3.6, Fig. 3.7). Globlly, the verge rte of decline in the TB incidence rte ws 1.4% per yer in 2 216, nd 1.9% between 215 nd 216. This needs to ccelerte to 4 5% per yer by 22 to chieve the milestones for reductions in cses nd deths set in the End TB Strtegy (Chpter 2). Trends re shown for the six WHO regions in Fig. 3.8 nd for the 3 high TB burden countries in Fig The fstest declines re in the WHO Europen Region (4.6% from 215 to 216). The estimted decline in the incidence rte since 21 hs exceeded 4% per yer in severl high TB burden countries, including Zimbbwe (11%), Lesotho (7%), Keny (6.9%), Ethiopi (6.9%), the United Republic of Tnzni (6.7%), Nmibi (6.%), Zmbi (4.8%) nd the Russin Federtion (4.5%). 3.2 TB mortlity Deths from TB mong HIV-negtive people re clssified s TB deths in the most recent version of the Interntionl clssifiction of diseses (ICD-1). 1 When n HIV-positive person dies from TB, the underlying cuse is clssified s HIV. For consistency with these interntionl clssifictions, this section mkes cler distinction between TB deths in HIVnegtive people nd TB deths in HIV-positive people Methods to estimte TB mortlity TB mortlity mong HIV-negtive people cn be mesured directly using dt from ntionl vitl registrtion (VR) systems, provided tht these systems hve high coverge nd tht cuses of deth re ccurtely determined nd coded ccording to ICD-1. Smple VR systems covering representtive res of the country (the pproch used, for exmple, in Chin) provide n interim solution. Mortlity surveys cn lso be used to estimte deths cused by TB. In 216, most countries with high burden of TB lcked ntionl 1 World Helth Orgniztion. Interntionl sttisticl clssifiction of diseses nd helth relted problems (The) ICD-1. Genev: WHO; 216.( who.int/clssifictions/icd1/browse/216/en). 32 GLOBAL TUBERCULOSIS REPORT 217

44 n BOX 3.4 n Zoonotic TB Zoonotic TB is predominntly cused by M. bovis, which belongs to the M. tuberculosis complex. In humns, there were n estimted 147 new cses of zoonotic TB nd 12 5 deths due to the disese in 216 (Tble B3.4.1). This burden of disese cnnot be reduced without improving stndrds of food sfety nd controlling bovine TB in the niml reservoir. The orgnism is host-dpted to cttle, where it is referred to s bovine TB; it lso cuses TB in other niml species, including wildlife. Bovine TB hs n importnt economic impct nd thretens livelihoods. In , rodmp for zoonotic TB ws developed by the triprtite of WHO, the World Orgnistion for Animl Helth (OIE) nd the Food nd Agriculturl Orgniztion of the United Ntions (FAO), together with the Interntionl Union Aginst Tuberculosis nd Lung Disese. The rodmp clls for multidisciplinry One Helth pproch tht includes more comprehensive nlysis of risks, better coverge of interventions, more efficient use of resources, reduced costs nd, ultimtely, improved helth of humn nd niml popultions. The rodmp is centred on 1 priorities grouped under three core themes: Improve the scientific evidence bse Collect nd report more complete nd ccurte dt Improve dignosis in people Address reserch gps Reduce trnsmission t the niml humn interfce Ensure sfer food Improve niml helth Reduce the risk to people Strengthen intersectorl nd collbortive pproches Increse wreness, enggement nd collbortion Develop policies nd guidelines Implement joint interventions Advocte for investment TABLE B3.4.1 Estimted incidence nd mortlity due to M. bovis TB. Best estimtes (bsolute numbers) re followed by the lower nd upper bounds of the 95% uncertinty intervl. INCIDENT CASES DEATHS REGION BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL Afric The Americs Estern Mediterrnen Europe South-Est Asi Western Pcific GLOBAL GLOBAL TUBERCULOSIS REPORT

45 FIG. 3.6 Globl trends in the estimted number of incident TB cses nd the number of TB deths (in millions), Shded res represent uncertinty intervls. TB incidence TB deths Millions per yer 1 5 All TB cses HIV-positive TB cses Notifictions of new nd relpse cses Millions per yer TB deths mong HIV-negtive people TB deths mong HIV-positive people FIG. 3.7 Globl trends in estimted TB incidence nd mortlity rtes, Shded res represent uncertinty intervls. TB incidence TB mortlity (HIV-negtive) Rte per 1 popultion per yer All TB cses HIV-positive TB cses Notifictions of new nd relpse cses Rte per 1 popultion per yer or smple VR systems, nd few hd conducted mortlity surveys. In the bsence of VR systems or mortlity surveys, TB mortlity cn be estimted s the product of TB incidence nd the cse ftlity rtio (CFR), or through ecologicl modelling using mortlity dt from countries with VR systems. TB mortlity mong HIV-positive people is hrd to mesure even when VR systems re in plce, becuse deths mong HIV-positive people re coded s HIV deths, nd contributory cuses (e.g. TB) re often not relibly ssessed nd recorded. TB deths mong HIV-positive people were estimted s the product of TB incidence nd the CFR, with the ltter ccounting for the protective effect of ntiretrovirl therpy (ART). Until 28, WHO estimtes of TB mortlity used VR dt for only three countries. This ws substntilly improved to 89 countries in 29, lthough most of the dt were from countries in the WHO Europen Region nd the WHO Region of the Americs, which ccounted for less thn 1% of the world s TB cses. For the current report, VR dt were used for 129 countries (Fig. 3.1), which collectively ccounted for 57% of the estimted number of TB deths (mong HIVnegtive people) globlly in 216. For 18 countries, nlyses of VR dt nd resulting estimtes of TB deths published by the Institute of Helth Metrics nd Evlution (IHME) t the University of Wshington, United Sttes of Americ (USA) were used. 1 The WHO Africn Region is the prt of the world tht hs the gretest need to introduce or strengthen VR systems in which cuses of deth re clssified ccording to ICD-1. Detils bout the methods used to produce estimtes of TB mortlity re provided in the online technicl ppendix Estimtes of TB mortlity in 216 Estimtes of the number of deths cused by TB re shown globlly, for the six WHO regions nd for the 3 high TB 1 Downloded from July The online technicl ppendix is vilble t 34 GLOBAL TUBERCULOSIS REPORT 217

46 FIG. 3.8 Regionl trends in estimted TB incidence rtes by WHO region, Totl TB incidence rtes re shown in green nd incidence rtes of HIV-positive TB re shown in red. Shded res represent uncertinty intervls. The blck lines show notifictions of new nd relpse cses for comprison with estimtes of the totl incidence rte. 4 Afric 4 The Americs 15 Estern Mediterrnen Rte per 1 popultion per yer Europe South Est Asi Western Pcific burden countries, in Tble 3.2. There were n estimted 1.3 million (rnge, 1.2 million to 1.4 million) deths from TB mong HIV-negtive people in 216 nd n dditionl 374 (rnge, ) deths from TB mong HIV-positive people. TB is the ninth leding cuse of deth worldwide, nd for the pst five yers ( ) hs been the leding cuse of deth from single infectious gent, rnking bove HIV/AIDS (Fig. 3.11, Fig. 3.12, Fig. 3.13). 1 Most of these deths could be prevented with erly dignosis nd pproprite tretment (Chpter 1). For exmple, mong people whose TB ws detected, reported nd treted in 215, the tretment success rte ws 83% globlly (Chpter 4); nd in high-income countries with universl helth coverge the proportion of people who die from TB cn be under 5% (section 3.2.4). About 82% of TB deths mong HIV-negtive people occurred in the WHO Africn Region nd the WHO South-Est Asi Region in 216; these regions ccounted for 85% of the combined totl of TB deths in HIV-negtive nd HIV-positive people. Indi ccounted for 33% of globl TB deths mong HIV-negtive people, nd for 26% of the combined totl TB deths in HIV-negtive nd HIV-positive people. Estimtes of TB mortlity rtes (per 1 popultion) 1 WHO Globl Helth Observtory dt repository, vilble t who.int/gho/dt/node.min.ghecod?lng=en (ccessed 23 August 217). re shown globlly, for the six WHO regions nd for the 3 high TB burden countries, in Tble 3.3. Globlly, the number of TB deths mong HIV-negtive people per 1 popultion ws 17 in 216, nd 22 when TB deths mong HIV-positive people were included. There ws considerble vrition mong countries (Fig. 3.14), rnging from less thn one TB deth per 1 popultion in mny high-income countries to 4 or more deths per 1 popultion in much of the WHO Africn Region nd in five high TB burden countries in Asi (Bngldesh, the Democrtic People s Republic of Kore, Indonesi, Mynmr nd Ppu New Guine). Estimtes of the number of deths cused by zoonotic TB re shown in Box Estimted trends in TB mortlity, Globlly, the bsolute number of TB deths mong HIVnegtive people hs been flling since 2, from 1.7 million in 2 to 1.3 million in 216 (Fig. 3.6). The TB mortlity rte (per 1 popultion) fell by 37% between 2 nd 216 (Fig. 3.7), nd by 3.4% between 215 nd 216. Rtes hve lso been flling in ll six of the WHO regions (Fig. 3.15). Since 21, the fstest verge rtes of decline in the mortlity rte hve been in the WHO Europen Region nd the WHO Western Pcific Region (6.% nd 4.6% per yer, respectively), nd slowest in the WHO Estern Mediterrnen GLOBAL TUBERCULOSIS REPORT

47 FIG. 3.9 Trends in estimted TB incidence in the 3 high TB burden countries, TB incidence rtes re shown in green nd incidence rtes of HIV-positive TB re shown in red. Shded res represent uncertinty intervls. The blck lines show notifictions of new nd relpse cses for comprison with estimtes of the totl incidence rte. Angol Bngldesh Brzil Cmbodi Centrl Africn Republic Chin Congo DPR Kore DR Congo Ethiopi Rte per 1 popultion per yer Indi Indonesi Keny Lesotho Liberi Mozmbique Mynmr Nmibi Nigeri Pkistn Ppu New Guine Philippines Russin Federtion b Sierr Leone South Afric Thilnd UR Tnzni Viet Nm Zmbi Zimbbwe b Estimtes of TB incidence for Indi re interim in nture, pending results from the ntionl TB prevlence survey plnned for 218/219. For n explntion of why notifictions re ssumed to be equivlent to TB incidence in the Russin Federtion, see Box GLOBAL TUBERCULOSIS REPORT 217

48 FIG. 3.1 Min methods used to estimte TB mortlity in HIV-negtive people Min method Indirect estimte VR (IHME) VR (WHO) No dt Not pplicble Mortlity is estimted s the product of TB incidence nd the TB cse ftlity rtio. Further detils re provided in the online technicl ppendix. FIG Top cuses of deth worldwide in 215.,b,c Deths from TB mong HIV-positive people re shown in grey. Ischemic hert disese Stroke Lower respirtory infections Chronic obstructive pulmonry disese Trche, bronchus, lung cncers Dibetes mellitus Alzheimer disese nd other dementis Dirrhoel diseses FIG Estimted number of deths from HIV/AIDS nd TB in 216. Deths from TB mong HIV-positive people re shown in grey.,b b TB HIV/AIDS Millions (216) For HIV/AIDS, the ltest estimtes of the number of deths in 216 tht hve been published by UNAIDS re vilble t documents/217/hiv_estimtes_with_uncertinty_bounds_ For TB, the estimtes for 216 re those published in this report. Deths from TB mong HIV-positive people re officilly clssified s deths cused by HIV/AIDS in the Interntionl clssifiction of diseses. Tuberculosis Rod injury b c Millions (215) This is the ltest yer for which estimtes for ll cuses re currently vilble. See WHO Globl Helth Observtory dt repository, vilble t gho/dt/node.min.ghecod (ccessed 28 August 217). For HIV/AIDS, the ltest estimtes of the number of deths in 216 tht hve been published by UNAIDS re vilble t documents/217/hiv_estimtes_with_uncertinty_bounds_ For TB, the estimtes for 216 re those published in this report. Deths from TB mong HIV-positive people re officilly clssified s deths cused by HIV/AIDS in the Interntionl clssifiction of diseses. GLOBAL TUBERCULOSIS REPORT

49 FIG Globl trends in the estimted number of deths cused by TB nd HIV (in millions), ,b Shded res represent uncertinty intervls. Millions of deths per yer b 2. HIV deths TB deths in HIV-negtive people TB deths in HIV-positive people For HIV/AIDS, the ltest estimtes of the number of deths in 216 tht hve been published by UNAIDS re vilble t documents/217/hiv_estimtes_with_uncertinty_bounds_ For TB, the estimtes for 216 re those published in this report. Deths from TB mong HIV-positive people re officilly clssified s deths cused by HIV/AIDS in the Interntionl clssifiction of diseses. Deths from TB mong HIV-positive people ccounted for 37% of deths clssified s cused by HIV/AIDS in 216. Region (2.2% per yer). Trends in mortlity rtes in the 3 high TB burden countries vry mrkedly (Fig. 3.16), rnging from substntil reductions since 2 (e.g. in Cmbodi, Chin, Ethiopi, Mynmr, the Russin Federtion nd Viet Nm) to limited chnges (e.g. in Angol, Congo nd South Afric). High TB burden countries with rtes of decline exceeding 6% per yer since 21 included Ethiopi, the Russin Federtion, the United Republic of Tnzni, Viet Nm nd Zimbbwe. Further detils bout trends in TB disese burden in the Russin Federtion, bsed on n epidemiologicl review conducted in Februry 217, re provided in Box The CFR nd cross-country equity The CFR is the proportion of people with TB who die from the disese; it cn be pproximted s the number of TB deths divided by TB incidence in the sme yer. The CFR llows ssessment of vrition in equity in terms of ccess to TB dignosis nd tretment mong countries (becuse if everyone with TB hd ccess to timely dignosis nd highqulity tretment, the CFR would be low in ll countries). To chieve the milestones for reductions in TB deths set for 22 nd 225 in the End TB Strtegy, the globl CFR needs to fll to 1% by 22 nd to 6% by 225 (Chpter 2). In 216, the globl CFR (clculted s the combined number of TB deths in HIV-negtive people nd HIV-positive people, divided by the totl number of incident cses in both FIG Estimted TB mortlity rtes excluding TB deths mong HIV-positive people, 216 Mortlity per 1 popultion per yer No dt Not pplicble 38 GLOBAL TUBERCULOSIS REPORT 217

50 FIG Regionl trends in estimted TB mortlity rtes by WHO region, Estimted TB mortlity rtes in HIV-negtive people re shown in blue, nd estimted mortlity rtes of HIV-positive TB re shown in red. Shded res represent uncertinty intervls. Afric The Americs Estern Mediterrnen Rte per 1 popultion per yer Europe South-Est Asi Western Pcific HIV-negtive nd HIV-positive people) 1 ws 16%. It vried widely mong countries (Fig. 3.17), from under 5% in few countries to more thn 2% in most countries in the WHO Africn Region. Intensified efforts re required to reduce the CFR to 1% globlly by Estimted number of deths verted by TB tretment, The ctul numbers of TB deths (presented bove) cn be compred with the number of TB deths tht would hve occurred in the bsence of TB tretment, to estimte the number of deths verted by TB interventions. The number of deths tht would hve occurred ech yer in the bsence of TB tretment (nd without ART provided longside TB tretment for HIV-positive cses) cn be conservtively estimted s the number of estimted incident cses (Section 3.1) multiplied by the relevnt estimted CFR for untreted TB. 2 Estimtes re 1 The CFR ws clculted bsed on the combined totl of deths in HIV-negtive nd HIV-positive people for the purpose of cross-country comprisons, in prticulr to illustrte the high CFRs in Africn countries, which could be reduced by effective detection nd cre progrmmes. CFRs restricted to HIV-negtive TB deths nd cses cn lso be clculted but re not shown here. At the subntionl level, CFRs cn lso be restricted to HIV-negtive TB deths, depending on the country nd its HIV burden. 2 Further detils bout methods used to estimte lives sved, including CFRs for different ctegories of TB cse, re provided in the online technicl ppendix, vilble t conservtive becuse they do not ccount for the impct of TB services or the vilbility of ART on the level of TB incidence, or for the indirect, downstrem impct of these interventions on future levels of infections, cses nd deths. Between 2 nd 216, TB tretment lone verted n estimted 44 million deths mong HIV-negtive people (Tble 3.4). Among HIV-positive people, TB tretment supported by ART verted n dditionl 8.5 million deths. 3.3 Drug-resistnt TB Drug-resistnt TB thretens globl TB cre nd prevention, nd remins mjor public helth concern in mny countries. Three mjor ctegories re used for globl surveillnce nd tretment. MDR-TB is TB tht is resistnt to both rifmpicin nd isonizid, the two most powerful nti-tb drugs; it requires tretment with second-line regimen. RR-TB lso requires tretment with second-line drugs. 3 With incresing use of Xpert MTB/RIF for simultneous detection of TB nd resistnce to rifmpicin, growing number of RR-TB cses (without further testing for isonizid resistnce) re being detected nd notified (Chpter 4). Extensively drugresistnt TB (XDR-TB) is defined s MDR-TB plus resistnce to 3 World Helth Orgniztion. WHO tretment guidelines for drug-resistnt tuberculosis (216 updte) (WHO/HTM/TB/216.4). Genev: WHO; 216 ( resources/en/, ccessed 16 August 217). GLOBAL TUBERCULOSIS REPORT

51 FIG Trends in estimted TB mortlity rtes in the 3 high TB burden countries, TB mortlity rtes in HIV-negtive people re shown in blue nd mortlity rtes of HIV-positive TB re shown in red. The blck lines show observtions from vitl registrtion systems. Shded res represent uncertinty intervls Angol Bngldesh Brzil Cmbodi Centrl Africn Republic Chin Congo DPR Kore DR Congo Ethiopi Indi Indonesi Keny Lesotho Liberi Rte per 1 popultion per yer Mozmbique Mynmr Nmibi Nigeri Pkistn Ppu New Guine Philippines Russin Federtion Sierr Leone South Afric Thilnd UR Tnzni Viet Nm Zmbi Zimbbwe Estimtes of TB mortlity for Indi re interim in nture, pending results from the ntionl TB prevlence survey plnned for 218/ GLOBAL TUBERCULOSIS REPORT 217

52 n BOX 3.5 n The burden of TB disese is flling in the Russin Federtion, but the incidence of MDR-TB is incresing A ntionl TB epidemiologicl review ws undertken in the Russin Federtion in Februry 217. It included thorough review of the ltest epidemiologicl dt, including TB cse notifictions, deth registrtion dt from the ntionl VR system nd results from DST for nti-tb drug resistnce. The min conclusions from this review were tht the burden of TB disese (incidence nd mortlity) is flling but the incidence of MDR-TB is incresing. Dt from the VR system show tht the TB mortlity rte (excluding TB deths in HIV-positive people) hs been flling rpidly since 29, t n verge rte of 11% per yer. This trend is consistent in ll of the eight federl regions (okrugs), lthough the decline hs been especilly impressive (t 17% per yer) in the North Cucsus region (Fig. B3.5.1). The cse notifiction rte of new nd relpse TB cses hs fllen t n verge rte of 4.8% per yer since 29 (Fig. B3.5.2). This is considered to be good proxy for the trend in TB incidence, for four min resons: There is extensive nd regulr screening for TB. It is mndtory for every citizen ged 17 nd bove to be screened every 1 2 yers (with the frequency depending on residence); this screening is typiclly done using fluorogrphy, nd otherwise using sputum microscopy. Children nd dolescents re screened nnully using tuberculin skin tests. Contcts of TB cses re lso screened (in 215, 47 contcts were screened). The high coverge of ctive cse finding mens tht there is low probbility of missed dignoses. Insted, it is more likely tht there is some overreporting of cses due to the lower predictive vlue of lbortory tests mong the generl popultion. FIG B3.5.2 Notifictions of new nd relpse cses in the Russin Federtion, The dshed line shows the notifiction rte of new cses tht were bcteriologiclly confirmed. Rte per 1 popultion per yer Furthermore, there seems to be n over-relince on clinicl dignostic criteri, since lrge proportion of the notified cses found through screening do not hve bcteriologicl confirmtion of pulmonry TB, despite the systemtic use of sensitive nd modern dignostic tests. Notifiction of detected TB cses is mndtory, nd the TB notifiction system hs complete coverge. Underreporting of detected cses is unlikely. Culture or moleculr tests re routinely used for dignosis. There hve been no mjor chnges to TB screening, dignostic nd reporting prctices since 29. FIG. B3.5.1 Annul TB mortlity rtes per 1 popultion for eight federl regions (okrugs), Rtes were djusted for ill-defined cuses of deth. Rte per 1 popultion per yer Centrl North-West Volg Url Siberi Fr-Est North Cucsus South GLOBAL TUBERCULOSIS REPORT

53 Trends in ll of the eight federl regions (okrugs) re brodly consistent with the ntionl trend. The fr-estern region reports the highest notifiction rtes (123/1 in 215); the lowest rtes re found in the centrl region (43/1 in 215) nd the North Cucsus region (41/1 in 215). Despite the stedy decline in the overll TB notifiction rte, concerning ntionl trend is tht the cse notifiction rte for MDR- TB hs been incresing, from 8 per 1 popultion in 21 (6 cses) to 11 per 1 popultion in 215 (8 cses). The proportion of TB cses with DST result who hd MDR-TB hs risen from 17% in 21 to 27% in 215 (Fig. B3.5.3). Resons for this increse, which is in contrst to the overll decline in TB burden, re not cler. Coverge of DST mong lbortory-confirmed cses hs been consistently high over the period (Fig. B3.5.4). It will be importnt to closely monitor trends nd to continuously ssess the performnce of the ntionl response to MDR-TB. FIG. B3.5.3 MDR-TB detection mong new cses of pulmonry TB, MDR-TB mong tested (%) 2 1 Number of MDR-TB cses FIG. B3.5.4 Culture confirmtion nd DST coverge mong new cses of pulmonry TB, Lbortory confirmed (%) DST coverge in confirmed (%) TABLE 3.4 Cumultive number of deths verted by TB nd TB/HIV interventions (in millions), globlly nd by WHO region WHO REGION BEST ESTIMATE HIV-NEGATIVE PEOPLE HIV-POSITIVE PEOPLE TOTAL UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL Afric The Americs Estern Mediterrnen Europe South-Est Asi Western Pcific GLOBAL GLOBAL TUBERCULOSIS REPORT 217

54 FIG Estimtes of the cse ftlity rtio (CFR), (including HIV-negtive nd HIV-positive people), 216 CFR (%) No dt Not pplicble t lest one drug in both of the two most importnt clsses of medicines in n MDR-TB regimen: fluoroquinolones nd second-line injectble gents (mikcin, cpreomycin or knmycin). Estimtes of the disese burden cused by drug-resistnt TB presented in this chpter focus on MDR/RR-TB Globl surveillnce of nti-tb drug resistnce Since the lunch of the Globl Project on Anti-tuberculosis Drug Resistnce Surveillnce in 1994, dt on drug resistnce hve been systemticlly collected nd nlysed from 16 countries worldwide (82% of the 194 WHO Member Sttes), which collectively hve more thn 97% of the world s popultion nd TB cses. This includes 9 countries tht hve continuous surveillnce systems bsed on routine dignostic drug susceptibility testing (DST) of ll TB ptients, nd 7 countries tht rely on epidemiologicl surveys of representtive smples of ptients (Fig. 3.18). Surveys conducted bout every 5 yers represent the most common pproch to investigting the burden of drug resistnce in resource-limited settings where routine DST is not ccessible to ll TB ptients, owing to lck of lbortory cpcity or resources. Progress towrds chieving globl coverge of drug resistnce surveillnce dt is shown in Fig Among the 3 high TB burden countries nd the 3 high MDR-TB burden countries (which comprise totl of 4 countries, becuse of overlp between the two groups 1 ), 37 hve dt on levels of drug resistnce. The three countries tht tht hve never conducted drug resistnce survey re Angol, Congo nd Liberi. Among the other 37 high TB burden or high MDR-TB burden countries, the dt for Sierr Leone re from before the yer 2, nd four countries (Brzil, Centrl Africn Republic, Democrtic People s Republic of Kore nd Ppu New Guine) rely on drug resistnce surveillnce dt gthered from subntionl res only. In , the first-ever ntionl drug resistnce surveys were completed in Burkin Fso, Democrtic Republic of the Congo, Ghn, Indi nd Sudn, nd repet surveys were completed in Côte d Ivoire, Mongoli nd Zimbbwe. In , drug resistnce surveys were ongoing in 11 countries, with the first ntionwide surveys in four countries (Burundi, Eritre, Indonesi, Lo People s Democrtic Republic, Mli nd Togo) nd repet surveys in seven countries (Bngldesh, Cmbodi, Ethiopi, Mlwi, Sri Lnk, Swzilnd, Thilnd nd the United Republic of Tnzni) Estimtes of the disese burden cused by MDR/RR-TB Globlly in 216, n estimted 4.1% (95% confidence intervl [CI]: %) of new cses nd 19% (95% CI: %) of previously treted cses hd MDR/RR-TB (Tble 3.5). The proportions of new nd previously treted TB cses with 1 For full list of the high TB burden nd high MDR-TB burden countries, see Chpter 2. GLOBAL TUBERCULOSIS REPORT

55 FIG Dt sources vilble to estimte levels of TB drug resistnce Source of dt Surveillnce Survey No dt Not pplicble Dt shown refer to new TB cses only. FIG Globl coverge of surveillnce dt on drug resistnce, Yer of most recent dt Ongoing in 217 No dt Subntionl dt Not pplicble 44 GLOBAL TUBERCULOSIS REPORT 217

56 TABLE 3.5 Estimted incidence of MDR/RR-TB in 216 for 3 high MDR-TB burden countries, WHO regions nd globlly ESTIMATED % OF NEW CASES WITH MDR/RR-TB ESTIMATED % OF PREVIOUSLY TREATED CASES WITH MDR/ RR-TB INCIDENCE OF MDR/RR TB b BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL NUMBER (IN 1S) UNCERTAINTY INTERVAL RATE b UNCERTAINTY INTERVAL Angol Azerbijn Bngldesh Belrus Chin DPR Kore DR Congo Ethiopi Indi Indonesi Kzkhstn Keny Kyrgyzstn Mozmbique Mynmr Nigeri Pkistn Ppu New Guine Peru Philippines Republic of Moldov Russin Federtion Somli South Afric Tjikistn Thilnd Ukrine Uzbekistn Viet Nm Zimbbwe MDR/RR HBCs Afric The Americs Estern Mediterrnen Europe South-Est Asi Western Pcific GLOBAL Best estimtes re for the ltest vilble yer. Rtes re per 1 popultion. % OF MDR AMONG MDR/RR-TB GLOBAL TUBERCULOSIS REPORT

57 FIG. 3.2 Percentge of new TB cses with MDR/RR-TB Percentge of cses No dt Not pplicble Figures re bsed on the most recent yer for which dt hve been reported, which vries mong countries. Dt reported before 22 re not shown. FIG Percentge of previously treted TB cses with MDR/RR-TB Percentge of cses No dt Not pplicble Figures re bsed on the most recent yer for which dt hve been reported, which vries mong countries. Dt reported before 22 re not shown. The high percentges of previously treted TB cses with MDR-TB in Bhms, Belize, French Polynesi, Puerto Rico nd So Tomé nd Principe refer to only smll number of notified cses (rnge: 1 8 notified previously treted TB cses). 46 GLOBAL TUBERCULOSIS REPORT 217

58 FIG Estimted incidence of MDR/RR-TB in 216, for countries with t lest 1 incident cses Russin Federtion Chin Number of incident cses 1 1 Indi 1 15 MDR/RR-TB t the country level re shown in Fig. 3.2 nd Fig There were n estimted 6 (rnge, ) incident cses of MDR/RR-TB in 216, with cses of MDR-TB ccounting for 82% (49 ) of the totl (Tble 3.5). The countries with the lrgest numbers of MDR/RR-TB cses (47% of the globl totl) were Chin, Indi nd the Russin Federtion (Fig. 3.22). There were bout 24 (rnge, ) deths from MDR/RR-TB in 216, similr to the best estimte for 215 tht ws published in the 216 edition of the WHO globl TB report. Dt compiled from surveys nd continuous surveillnce of drug resistnce mong TB ptients lso llow estimtion of the number of MDR/RR-TB cses mong notified TB ptients with pulmonry TB. These re the MDR/RR-TB cses tht could be detected if ll notified ptients were tested for drug resistnce to rifmpicin nd isonizid using WHOrecommended dignostic tests. Globlly in 216, there were n estimted 35 (rnge, ) MDR/RR-TB cses mong notified TB ptients Trends in drug resistnce Of the 4 countries with high TB or MDR-TB burden (or both), only 22 hve repeted survey t lest once to evlute trends in drug resistnce. Among these countries, nine hve t lest 3 yers of dt: Belrus, Kzkhstn, Mynmr, Peru, Republic of Moldov, Russin Federtion, Thilnd, Ukrine nd Viet Nm. For these settings, Fig shows trends in the number of new TB cses notified, the proportion of new TB cses with MDR, nd per cpit TB nd MDR-TB rtes. Bsed on these dt, there is slight trend for cses of MDR-TB to increse s proportion of ll TB cses in these countries, with the burden of MDR-TB either incresing fster or decresing more slowly thn the overll TB burden in ech country Resistnce to isonizid nd to second-line nti-tb drugs Levels of resistnce to isonizid without concurrent rifmpicin resistnce re vilble for 158 countries over the period The proportions of TB ptients resistnt to isonizid but susceptible to rifmpicin in ech country were weighted ccording to the number of new TB cses tht were notified in the country to generte globl verge. Among ll TB cses, the globl verge of isonizid resistnce without concurrent rifmpicin resistnce ws 8.5% (95% CI: ). In new nd previously treted TB cses, the globl verges were 7.3% (95% CI: ) nd 14% (95% CI: 12 17), respectively. By the end of 216, XDR-TB hd been reported by 123 WHO Member Sttes. Of these, 91 countries nd five territories reported representtive dt from continuous surveillnce or surveys regrding the proportion of MDR-TB cses tht hd XDR-TB. Combining their dt, the verge proportion of MDR-TB cses with XDR-TB ws 6.2% (95% CI: %), with the best estimte lower thn those bsed on dt vilble in previous yers (9.5% in 215, 9.7% in 214 GLOBAL TUBERCULOSIS REPORT

59 FIG Trends in levels of drug resistnce in selected high MDR-TB burden countries with t lest three yers of dt. The blue line shows the number of new notified MDR-TB cses per 1 popultion. The red line shows the number of MDR-TB cses mong new TB ptients per 1 popultion. 1 1 Belrus Kzkhstn Mynmr 1 1-6% per yer -8% per yer 1 1 5% per yer 1-6% per yer 1-2% per yer 1 8% per yer TB nd MDR-TB cses per 1 popultion (log scle) Peru Republic of Moldov Russin Federtion 1 1-3% per yer -5% per yer 1 1-6% per yer 1-1% per yer 1 2% per yer 1% per yer Thilnd Ukrine Viet Nm 1 1 3% per yer -11% per yer % per yer % per yer 1 1-1% per yer 1 1 4% per yer nd 9.% in 213). This decrese is explined by the use of lrger quntity of routine surveillnce dt nd more precise country-specific mesures of the prevlence of second-line drug resistnce mong MDR/RR-TB cses. Among the 4 countries with high TB or MDR-TB burden, 22 hve surveillnce dt on resistnce to second-line nti-tb drugs. The proportion of MDR-TB/RR-TB cses with resistnce to ny fluoroquinolone for which testing ws done including ofloxcin, levofloxcin nd moxifloxcin ws 2% (95% CI: 14 26%). 3.4 Ntionl TB prevlence surveys The prevlence of TB disese is not n indictor in the SDGs or high-level indictor of the End TB Strtegy, nd no globl trget hs been set for the period Furthermore, indirect estimtes of prevlence suffer from considerble uncertinty, becuse they re derived from incidence nd ssumptions bout disese durtion. For these two resons, indirect estimtes of TB prevlence (i.e. estimtes tht re not from ntionl TB prevlence survey) re not presented in this chpter. 2 In n importnt subset of countries with lrge proportion of the world s TB burden, however, ntionl TB prevlence 1 This is in contrst to the er of the Millennium Development Gols (MDGs) nd Stop TB Strtegy, when one of the globl trgets for reductions in TB disese burden ws to hlve prevlence between 199 nd WHO will continue to produce indirect estimtes of TB prevlence. These cn be provided upon request to tbdt@who.int. 48 GLOBAL TUBERCULOSIS REPORT 217

60 surveys continue to provide the best method for mesuring the burden of TB disese (both in bsolute terms nd to ssess trends when repet surveys re done, nd by ge nd sex). Findings cn inform ssessment of ctions needed to reduce this burden s well s estimtes of TB incidence (Fig. 3.2), thus contributing to monitoring of progress towrds SDG nd End TB Strtegy trgets. The WHO Globl Tsk Force on TB Impct Mesurement hs retined ntionl TB prevlence surveys within its strtegic res of work (Box 3.1), nd defined the group of countries where they continue to be relevnt s those with reltively high burden of TB (bout 15 incident cses per 1 popultion) tht do not yet hve helth, ntionl notifiction nd VR systems of the qulity nd coverge required to provide relible nd routine direct mesurements of the number of TB cses nd deths. 1 An excellent recent exmple of prevlence survey tht hs informed understnding of trends in TB disese burden, estimtes of TB incidence nd identifiction of ctions required to reduce the burden of TB disese is the 216 survey in the Philippines (Box 3.6). Countries in which ntionl prevlence surveys were implemented in or re plnned for re shown in Fig nd Fig An unprecedented number of surveys were implemented in , period in which the WHO Globl Tsk Force on TB Impct Mesurement defined ntionl TB prevlence surveys in 22 globl focus countries s one of its three strtegic res of work (Box 3.1). Between 27 nd the end of 216, totl of 25 surveys tht used the screening nd dignostic methods recommended in the second edition of the WHO hndbook on prevlence surveys 2 were completed. This included 13 surveys in Asin countries (of which two were in the Philippines) nd 12 in Africn countries. In 216, surveys were completed in Bngldesh, the Democrtic People s Republic of Kore, Keny nd the Philippines. A further 1 surveys will be implemented in 217 or 218, including in Indi, Mozmbique, Mynmr, South Afric nd Viet Nm. The surveys in Mynmr nd Viet Nm re repet surveys. A comprison of estimtes of TB prevlence before nd fter the implementtion of ntionl survey is shown for the 25 surveys in Fig Post-survey prevlence estimtes were lmost lwys more precise (i.e. hd nrrower uncertinty intervls). For 18 countries, estimtes were within the 1 In the Tsk Force s April 216 meeting, epidemiologicl criteri for conducting survey were defined for two groups of countries: those tht implemented survey in nd in which repet survey could be considered; nd those tht hve never conducted survey. There were 24 countries in the first group nd 33 in the second group. For ny of these 57 countries, it ws emphsized tht fesibility criteri must lso be considered. In prticulr, the prerequisites for conducting survey defined in the WHO hndbook on ntionl TB prevlence surveys (see next footnote) should be met. For further detils, see World Helth Orgniztion Globl Tsk Force on TB Impct Mesurement. Report of the sixth meeting of the full Tsk Force; April 216, Glion-sur-Montreux, Switzerlnd. Genev: WHO; 215 ( meetings/tf6_report.pdf?u=1, ccessed 11 September 217). 2 World Helth Orgniztion. Tuberculosis prevlence surveys: hndbook (WHO/HTM/TB/21.17). Genev: WHO; 211 ( dvisory_bodies/impct_mesurement_tskforce/resources_documents/ thelimebook/, ccessed 24 August 217). FIG Globl progress in implementing ntionl surveys of the prevlence of TB disese, ctul (2 217) nd expected (218) b 2 Chin Cmbodi 23 Mlysi 24 Indonesi 25 Eritre 26 Thilnd 27 Philippines Viet Nm 28 Bngldesh 29 Mynmr 21 Chin 211 Cmbodi Ethiopi Lo PDR Pkistn 212 Gmbi Nigeri Rwnd UR Tnzni Thilnd 213 Mlwi Ghn Sudn 214 Indonesi Zmbi Zimbbwe 215 Bngldesh Keny Mongoli Ugnd 216 DPR Kore Philippines 217 Mozmbique b South Afric b Mynmr b Nmibi b Viet Nm b 218 Botswn Indi Lesotho Nepl Swzilnd The surveys in Bngldesh (28) nd Eritre (25) collected sputum smples from ll individuls (ged 15 yers), nd did not use chest X-ry nd/or symptom questionnire to screen individuls for sputum submission. These surveys hve strted or field opertions re scheduled to strt in 217. pre-survey uncertinty intervl, wheres for the other seven countries the survey found burden tht ws either significntly bove (six countries) or below (one country) the burden tht hd been estimted in the bsence of survey dt. The distribution of TB disese by ge (in dults) nd sex bsed on prevlence survey dt is shown in Fig nd Fig In Asi nd some Africn countries (e.g. Ghn, Mlwi, Rwnd, the United Republic of Tnzni nd Zimbbwe), prevlence increses with ge. However, in severl Africn countries (e.g. Ethiopi, Gmbi, Nigeri, Sudn, Ugnd nd Zmbi), prevlence per 1 popultion peks mong those ged yers. The mle to femle (M:F) rtio of cses for the sme set of surveys shows systemticlly higher burden of TB disese mong men, with rtios rnging from 1.2 (in Ethiopi) to 4.5 (in Viet Nm) for bcteriologiclly confirmed TB. In most countries, the rtio ws in the rnge 2 4. The rtio of prevlence to notifictions (P:N) cn be used to compre detection nd reporting gps (Fig. 3.29) nd vrition in these gps by sex (Fig. 3.29b). The P:N rtios from surveys implemented in suggest tht women re ccessing vilble dignostic nd tretment services more effectively thn men. The higher disese burden in men, combined with lrger gps in detection nd reporting, lso suggests tht strtegies to improve ccess to nd use of helth services mong men re required. GLOBAL TUBERCULOSIS REPORT

61 n BOX 3.6 n The 216 ntionl TB prevlence survey in the Philippines: results nd lessons lerned The fourth ntionl survey of the prevlence of TB disese in the Philippines ws conducted from Mrch to December 216, following surveys in , 1997 nd 27. It ws implemented by the Foundtion for the Advncement of Clinicl Epidemiology, under the Ntionl TB Control Progrmme, Deprtment of Helth nd the Philippine Council for Helth Reserch nd Development. The min survey objective ws to estimte the prevlence of pulmonry TB (bcteriologiclly confirmed; i.e. culturepositive TB or Xpert MTB/RIF, or both) mong the generl popultion ged 15 yers or more. Methods Survey design nd overll methods followed the interntionl recommendtions of the WHO Globl Tsk Force on TB Impct Mesurement (Box 3.1). All survey prticipnts were screened for symptoms by interview nd by digitl chest X-ry exmintion. Prticipnts with ny of the following cough of t lest 2 weeks nd/or hemoptysis (screening symptoms) or rdiologicl lesion(s) in the lung consistent with TB were sked to submit two sputum specimens (one spot nd one erly morning). These were exmined by direct light-emitting diode (LED-FM) microscopy, culture (Ogw solid medi) nd Xpert MTB/RIF in one of six lbortories. A totl of people of ll ges were enumerted during the survey, which covered 16 rndomly selected clusters cross four strt. b Of these, (69%) were eligible nd invited to prticipte in the survey bsed on ge ( 15 yers) nd residency sttus. Residents were defined s hving spent t lest the pst 2 weeks in the cluster or hving slept in the household more thn 5% of the time in the pst month. Of those who were eligible, people (76%) prticipted in the survey s cluster opertions. Prticiption ws higher for femles (82%) thn mles (7%) (Fig. B3.6.1). The verge number of prticipnts per cluster ws 44 (rnge ). Of ll prticipnts, (29%) screened positive for TB by both screening methods. A further 58 prticipnts who were symptomtic but did not hve chest X-ry were lso FIG. B3.6.1 Survey prticiption rte by ge group nd sex Prticiption rte (%) Femle Mle Age group (yers) sked to submit sputum smples (Fig. B3.6.2). Among the prticipnts eligible for sputum collection, (87%) submitted t lest one sputum specimen. Best-prctice nlyticl methods were used to estimte TB prevlence, tking into ccount clustered smpling, s well s non-prticiption nd other missing dt. c Min results A totl of 466 bcteriologiclly confirmed pulmonry TB cses were found in the survey, of whom 173 hd smerpositive TB nd 293 hd smer-negtive TB. Of the 466 cses, 238 (51%) were dignosed by Xpert MTB/RIF only, 159 (34%) were dignosed by Xpert MTB/RIF nd culture, nd 69 (15%) were dignosed by culture only. Of the 466 bcteriologiclly confirmed cses, 15 (32%) reported screening symptoms, nd 43 (92%) screened positive on chest X-ry. Of the 173 smer-positive TB cses, 88 (51%) reported screening symptoms nd 159 (92%) screened positive on chest X-ry. TB prevlence per 1 popultion ged 15 yers or more ws estimted s 434 (95% CI: ) for smer-positive TB, nd 1159 (95% CI: ) for bcteriologiclly confirmed TB. Prevlence ws much higher mong men thn women: 673 (95% CI: ) per 1 popultion compred with 25 (95% CI: ) per 1 popultion for smer-positive TB, nd 1713 (95% CI: ) compred with 627 (95% CI: ) per 1 popultion for bcteriologiclly confirmed TB. Prevlence ws highest in the yer ge group (Fig. B3.6.3). There ws no sttisticlly significnt vrition between the four geogrphicl strt. Compring the prevlence of smer-positive TB mong prticipnts ged 15 yers or more to the cse notifiction rte for smer-positive TB cses in 216 (142 per 1 popultion) in the sme ge group gve P:N rtio of 3.1 (Fig. B3.6.4). The P:N rtio ws higher in men thn women, nd ws prticulrly high in the yer ge group. A totl of 17 survey prticipnts (.4%) reported being on TB tretment t the time of the survey (111 men nd 59 women). Most of these people reported tking or obtining tretment in locl helth centres or in TB clinics (77%), followed by privte phrmcies (12%), privte clinics or hospitls (7.6%), nd provincil hospitls or public medicl centres (1.8%). There were 2615 (5.6%) survey prticipnts who reported pst history of TB tretment (1595 men nd 12 women). A totl of 2815 (6%) survey prticipnts reported the presence of screening symptoms t the time of interview. Of the 2815 prticipnts, only 534 (19%) consulted helth-cre worker, with more femles (23%) seeking consulttion compred with mles (16%); 1143 (41%) took no ction (younger more so thn older prticipnts, nd men more thn women) nd 113 (4%) self-medicted (predominntly women). Of the 466 bcteriologiclly confirmed TB cses identified in the survey, 15 (32.3%) hd screening symptoms of t lest 2 weeks cough or hemoptysis, or both. However, 5 GLOBAL TUBERCULOSIS REPORT 217

62 FIG. B3.6.2 Consort digrm of the 216 ntionl TB prevlence survey in the Philippines Individuls enumerted in census Eligible study popultion (69%) Ineligible individul (31%) Children <15 yers (99%) Ineligible of residentil criteri 247 (.9%) Missing dt 65 (.2%) Totl prticipnts (76%) Symptom screening Cough 2 weeks only 2 25 (8%) Hemoptysis only 357 (13%) Cough 2 weeks & hemoptysis 28 (7.4%) Totl Chest X-ry screening Suspicious for TB (29%) Not suspicious for TB (71%) Totl chest X-ry tken Eligible for sputum exmintion (4%) Submitted specimens At lest one specimen (87%) Both specimens (84%) Only one specimen 695 (3.7%) Symptom positive, chest X-ry positive (7.3%) Symptom positive, chest X-ry negtive or N/A (7.8%) Symptom negtive, chest X-ry positive 1 72 (56%) Others 5 8 (27%) Lbortory results Totl vilble (99.9%) Any Xpert MTB/RIF positive 397 (83%) Any culture MTB positive 232 (48%) Centrl pnel review for finl confirmtion nd clssifiction of survey cses Totl bcteriologiclly confirmed TB cses 466 Smer-positive TB cses 173 (37%) Smer-negtive TB cses 289 (63%) Smer not done TB cses 4 (.9%) Symptom positive, chest X-ry positive 132 (28%) Symptom positive, chest X-ry negtive or N/A 18 (3.8%) Symptom negtive, chest X-ry positive 298 (64%) Others 18 (3.9%) Xpert MTB/RIF only 238 (51%) Culture MTB only 69 (15%) Xpert MTB/RIF nd culture 159 (34%) Symptom screening negtive but chest X-ry exempted. GLOBAL TUBERCULOSIS REPORT

63 FIG. B3.6.3 Prevlence of smer nd bcteriologiclly confirmed pulmonry TB Prevlence per 1 popultion Bcteriologiclly confirmed Smer-positive Age group (yers) FIG. B3.6.4 Rtio of prevlence to notifiction P:N rtio (yers) Femle Mle Totl Prevlence is for bcteriologiclly confirmed smer-positive TB cses, 15 yers. Notifictions re for ll pulmonry smer-positive TB in 216, 15 yers. only 44 (29%) of these people consulted helth-cre worker, with 33 (75%) consulting public provider nd 1 (23%) going to privte provider. There were 56 (37%) people who self-medicted nd 51 (34%) who did not tke ny ction t the time they experienced the symptoms. The smple size in 216 ws not designed to detect specified effect size in comprison with the 27 survey, but rther to obtin n estimte of prevlence in 216 with specified precision. The 216 survey ws therefore not powered to detect smll differences with the 27 survey. Nonetheless, this limittion did not prevent n ssessment of the trend in TB disese burden since 27. Adjustments were mde to ensure tht the two dt sets nd methods were s comprble s possible, resulting in n upwrd djustment of the 27 survey results to ccount for the more sensitive screening nd dignostic methods used in the 216 survey. Bsed on these djustments, the prevlence of culturepositive TB ws 463 per 1 popultion (95% CI: ) in 27 nd 512 per 1 popultion (95% CI: 42 63) in 216. The probbility tht prevlence did not decline over the period ws estimted t 75%. Updted estimtes of TB disese burden Results from the 216 prevlence survey were used to updte estimtes of TB incidence nd mortlity, d with both revised upwrds (see lso Box 3.2). The estimte of TB incidence fter the survey ws 554 ( ) per 1 popultion, compred with the pre-survey WHO estimte (which hd ssumed decline in incidence since 27) of 322 per 1 (95% CI ). The estimted mortlity rte bsed on the survey ws 21 (21 22) per 1 popultion in 216, compred to pre-survey estimte of 13 (8.7 19). Progrmmtic implictions Notwithstnding the limittion of 76% prticiption rte, survey results re of high qulity nd hve provided robust nd up-todte mesurement of the burden of TB disese in the Philippines. Of the 23 surveys implemented since 29, when the WHO Globl Tsk Force on TB Impct Mesurement greed on stndrd recommendtion for dignostic nd screening prctices in surveys, the survey in the Philippines found the highest prevlence of bcteriologiclly-confirmed TB. Although it is not surprising tht use of Xpert MTB/RIF incresed the dignostic yield, the prevlence of culture-confirmed TB lone ws high (587 per 1 ; 95% CI: ). The Philippines is thus fcing one of the highest burdens of TB in the world. When prevlence is extrpolted to ll ges nd ll forms of TB, it is estimted tht there re bout 1 million people in the Philippines with TB disese, which is equivlent to 1 in 15 of ll prevlent cses globlly. The lck of decline in TB prevlence since 27 cn be explined by combintion of cse-detection gps, possibly significnt delys in dignosis, helth system weknesses, nd broder socil nd economic influences on the TB epidemic. These broder influences include the level of undernourishment, with prevlence of 14% in 215 nd no improvement since 28; the level of poverty, with 25% of people living below the ntionl poverty line in 212; nd low coverge of helth insurnce nd socil protection, with coverge of only 4% in the poorest quintile in 213, leding to finncil brriers to ccessing helth services nd high levels of out-of-pocket expenditures on helth cre (34% in 214). The prevlence of HIV in the generl popultion remins below.1% nd hs limited impct on the size of the TB epidemic. In response to the high estimte of TB prevlence, the NTP nd prtners hve defined eight strtegic ctions t the locl level under the generl pproch of REACH, CURE nd PROTECT. These re: 1. Replce smer microscopy with rpid point-of-cre dignostic test, such s Xpert MTB/RIF, in ll DOTS fcilities nd enhnce sputum delivery mechnism t ll levels. 2. Increse enggement of privte providers by expnding the TB service delivery network nd humn resources nd by enforcing the policy of mndtory TB cse notifiction. e 3. Improve the vilbility of ptient-centred helth fcilities providing qulity services through revised certifiction progrmme, n improved Phil Helth TB pckge nd socil protection. 4. Use integrted communiction strtegies to influence community helth-cre seeking behviour. 5. Implement chest X-ry screening mong high-risk groups, including 4Ps members (these re beneficiries of conditionl csh trnsfer progrmme for mternl child helth, the elderly, contcts, inmtes, indigenous popultions, people with dibetes nd smokers). 6. Undertke intensive supervision nd monitoring bsed on electronic cse-bsed mngement systems. 52 GLOBAL TUBERCULOSIS REPORT 217

64 7. Network with other government gencies nd other key stkeholders to ddress socil determinnts. 8. Ensure the governnce nd sustinble funding of locl governnce units to support implementtion of the End TB Strtegy. The min priorities re protecting those who re finncilly vulnerble to TB through expnded socil insurnce nd helth insurnce coverge, preventing TB mong those who do not yet hve it, nd reducing the percentge of TB ptients nd their households fcing ctstrophic costs s result of TB to zero. f It is nticipted tht the eight strtegic ctions cn be implemented with the full support of the Deprtment of Helth, full mobiliztion of the helth sector with deployment of sufficient humn resources t ntionl nd subntionl levels, incresed domestic funding, presidentil executive order for drug regultion, estblishment of high-level steering group, nd ensuring finncil protection for more thn 9% of the poor through incresed coverge of Phil Helth nd expnded socil protection progrmmes. At the most fundmentl level, ending TB will require not only greter investment to find nd cure TB cses but lso comprehensive nd sustined poverty llevition efforts, linked to the SDGs nd multisectorl prtnerships t the ntionl nd locl levels. b c d e f Ntionl TB Reference Lbortory; Medicl Reserch Lbortory, Philippine Generl Hospitl; Cebu TB Reference Lbortory; Region 2 TB Reference Lbortory; Dvo TB Reference Lbortory; nd Northern Mindno TB Reference Lbortory. Strtum 1: the Ntionl Cpitl Region, Region 3 nd 4A; Strtum 2: the rest of Luzon; Strtum 3: Visys; nd Strtum 4: Mindno. Floyd S, Sismnidis C, Ymd N, Dniel R, Lghid J, Mectti F et l. Anlysis of tuberculosis prevlence surveys: new guidnce on best-prctice methods. Emerg Themes Epidemiol. 213;1(1):1 ( pubmed/ , ccessed 11 September 217). Incidence is indirectly estimted from prevlence using plusible distributions of disese durtion, nd mortlity is indirectly estimted from prevlence using CFRs estimted from VR dt. Other detils re provided in the online technicl ppendix, which is vilble t Mndtory notifiction of TB cses (Republic Act No. 1767), encted in April 216, still needs to be effectively implemented. The NTP implemented survey of costs fced by TB ptients nd their households from December 216 to July 217. Preliminry results indicte tht 35% of TBffected households spent t lest 2% of their household income on costs relted to TB, rising to 67% for those with drug-resistnt TB. FIG Countries in which ntionl popultion-bsed surveys of the prevlence of TB disese hve been implemented using currently recommended screening nd dignostic methods since 2 or re plnned in the future (sttus in August 217) No survey plnned Survey plnned Repet survey plnned b Survey ongoing c One survey completed d 1 repet survey completed e Not pplicble b c d e Screening methods include field chest X-ry; t lest culture ws used to confirm dignosis. Recent surveys completed in Bngldesh, Keny nd the Philippines used both culture nd Xpert MTB/RIF to confirm dignosis. A country hs submitted t lest drft survey protocol nd budget pln to the WHO Globl Tsk Force on TB Impct Mesurement. Countries were implementing field opertions in August 217 or were undertking dt clening nd nlysis. A survey ws conducted in ccordnce with WHO recommendtions s outlined in Tuberculosis prevlence surveys: hndbook (211) nd t lest preliminry report hs been published. A repet ntionl survey is one in which prticipnts were screened with chest X-ry, nd (t lest) culture ws used to dignose TB cses. GLOBAL TUBERCULOSIS REPORT

65 FIG Estimtes of TB prevlence (ll ges, ll forms of TB) for 25 countries, before (in blue) nd fter (in red) results from ntionl TB prevlence surveys becme vilble since 27. Pnels re ordered ccording to the before-fter difference. UR Tnzni Mlwi Ghn Keny Nigeri Zmbi Ugnd Rwnd Sudn Zimbbwe Ethiopi Gmbi Afric Philippines Lo PDR Indonesi Mongoli Cmbodi Philippines b Thilnd Chin Pkistn Mynmr DPR Kore Viet Nm Bngldesh c Asi Prevlence per 1 popultion (log scle) These dt relte to the repet prevlence survey conducted in 216. b These dt relte to the prevlence survey conducted in 27. c These dt relte to the prevlence survey conducted in FIG Age-specific prevlence rte rtio of bcteriologiclly confirmed TB in surveys implemented Afric Mlwi 25 1 Asi Cmbodi Lo PDR Mynmr Viet Nm Bngldesh Chin Prevlence rtio 5 Sudn Ghn Zimbbwe Zmbi Ugnd Nigeri Keny 5 Pkistn Indonesi Philippines b DPR Kore Thilnd Philippines c 1 Ethiopi 1 Mongoli Age group (yers) Age group (yers) Age-specific prevlence rtios were clculted using the prevlence of the yer ge group s the bseline. Dt in the presented ge groups were not vilble for Gmbi nd Rwnd. Dt re not shown for UR Tnzni becuse lbortory chllenges during the survey ment tht it ws only possible to directly estimte the prevlence of smer-positive (s opposed to bcteriologiclly confirmed) TB. b These dt relte to the prevlence survey conducted in 27. c These dt relte to the repet prevlence survey conducted in GLOBAL TUBERCULOSIS REPORT 217

66 FIG The mle to femle rtio of bcteriologiclly confirmed dult TB cses detected in prevlence surveys implemented b c d Viet Nm Ugnd Rwnd Bngldesh b Gmbi Chin Mongoli Philippines c Thilnd Philippines d Mynmr Keny DPR Kore Lo PDR Indonesi Nigeri Cmbodi Sudn Zmbi Mlwi Pkistn Ghn Zimbbwe Ethiopi Sex rtio (mle:femle) A vlue is not shown for UR Tnzni becuse lbortory chllenges during the survey ment tht it ws only possible to directly estimte the prevlence of smer positive (s opposed to bcteriologiclly confirmed) TB. These dt relte to the prevlence survey conducted in These dt relte to the repet prevlence survey conducted in 216. These dt relte to the prevlence survey conducted in Estimtes of TB incidence nd mortlity disggregted by ge nd sex This section presents estimtes of TB incidence nd TB mortlity disggregted by ge nd sex Methods to disggregte estimtes by ge nd sex Estimtes of TB incidence in children (ged under 15 yers) were bsed on cse notifictions djusted for underdignosis nd underreporting 1 combined with estimtes derived from dynmic modelling. 2 Results for the 14 ge group ( 4 nd 5 14 yers) in ech country were then further disggregted using outputs from n estblished deterministic model, 2 followed by disggregtion by sex using results from metnlysis of the M:F notifiction rtio. Estimtes of TB incidence in dults were derived by first subtrcting incidence in children from incidence in ll ges. The estimte for dults ws then disggregted into six ge groups (15 24, 25 34, 35 44, 45 54, nd 65 yers) using dt from ntionl TB prevlence surveys implemented in (Section 3.4). Country-specific distributions were used for countries tht hd implemented survey, wheres for other countries the ge distribution ws predicted using prevlence survey dt. Disggregtion by sex ws bsed on ctul M:F rtios for countries tht hd implemented surveys. For other countries, this disggregtion ws bsed on regionl M:F rtios from systemtic review nd met-nlysis. 3 TB mortlity in children ws estimted for the two ge groups using previously published pproch derived from dynmic modelling, 4 nd then by sex, on the ssumption tht the pttern ws the sme s tht for incidence. If vilble, dt on TB deths mong dults were disggregted for six ge groups (15 24, 25 34, 35 44, 45 54, nd 65 yers) using VR dt. For countries whose mortlity estimtes were not bsed on VR dt, CFR ws pplied to the dult ge- nd sex-disggregted incidence. This CFR ccounted for differences between HIV-positive nd HIV-negtive TB cses, nd vrition in HIV prevlence by ge nd sex. Detils of the methods used re provided in the online technicl ppendix. 5 1 Jenkins HE, Tolmn AW, Yuen CM, Prr JB, Keshvjee S, Pérez-Vélez CM et l. Incidence of multidrug-resistnt tuberculosis disese in children: systemtic review nd globl estimtes. The Lncet. 214;383(9928): ( S ?vi%3Dihub, ccessed 24 August 217). 2 Dodd PJ, Grdiner E, Coghln R, Seddon JA. Burden of childhood tuberculosis in 22 high-burden countries: mthemticl modelling study. Lncet Glob Helth. 214;2(8):e ( pii/s221419x ?vi%3dihub, ccessed 24 August 217). 3 World Helth Orgniztion Globl Tsk Force on TB Impct Mesurement. Report of the sixth meeting of the full tsk force; April 216, Glion-sur-Montreux, Switzerlnd. Genev: WHO; 215 ( tb/dvisory_bodies/impct_mesurement_tskforce/meetings/tf6_report. pdf?u=1, ccessed 11 September 217). 4 Dodd PJ, Yuen CM, Sismnidis C, Seddon JA, Jenkins HE. The globl burden of tuberculosis mortlity in children: mthemticl modelling study. Lncet Glob Helth. 217;5(9):e898-e96 ( rticle/pii/s221419x ?vi%3dihub, ccessed 11 September 217). 5 The online technicl ppendix is vilble t GLOBAL TUBERCULOSIS REPORT

67 FIG. 3.29A The prevlence to notifiction (P:N) rtio of dult TB cses in prevlence surveys implemented FIG. 3.29B The prevlence to notifiction (P:N) rtio by sex for dult TB cses in prevlence surveys implemented Nigeri Sudn Lo PDR Keny Philippines b UR Tnzni Pkistn Ugnd Bngldesh c Zimbbwe Mongoli Mlwi Ghn Viet Nm Indonesi Mynmr Zmbi DPR Kore Philippines d Thilnd Chin Cmbodi Rwnd Ethiopi Gmbi Nigeri Sudn Lo PDR Keny Philippines b UR Tnzni Pkistn Ugnd Bngldesh c Zimbbwe Mongoli Mlwi Ghn Viet Nm Indonesi Mynmr Zmbi DPR Kore Philippines d Thilnd Chin Cmbodi Rwnd Ethiopi Gmbi femle mle P:N rtio (yers) P:N rtio (yers) b c d The P:N rtio is for smer positive TB, except for Ugnd nd Zimbbwe where it is bsed on bcteriologiclly confirmed TB. Prevlence estimtes re from cross-sectionl survey, nd therefore only represent one point in time. Notifiction dt re from the min yer of the survey (shown in Fig. 3.24). These dt relte to the repet prevlence survey conducted in 216. These dt relte to the prevlence survey conducted in These dt relte to the prevlence survey conducted in GLOBAL TUBERCULOSIS REPORT 217

68 3.5.2 TB incidence disggregted by ge nd sex Estimtes of TB incidence disggregted by ge nd sex re shown in Fig. 3.3 (globl), Fig (WHO regions) nd Fig (3 high TB burden countries). Globlly in 216, there were n estimted 6.7 million (rnge, 4. million to 9.4 million) incident cses of TB mong mles, of which 6.2 million (rnge, 3.7 million to 8.6 million) were dults nd 55 (rnge, ) were children. There were 3.7 million (rnge, 2.2 million to 5.2 million) incident cses of TB in femles, of which 3.2 million (rnge, 1.9 million to 4.5 million) were dults nd 49 (rnge, 3 68 ) were children. These numbers correspond to 65% of cses being mles nd 35% femles, nd 9% of cses being dults nd 1% children. 1 The M:F rtio of incident TB cses for ll ges rnged from 1.3 in the WHO Estern Mediterrnen Region to 2.1 in the WHO Western Pcific Region. Similr M:F rtios were estimted for dults, wheres for children the M:F rtio ws close to 1.1 in ll WHO regions. Most of the estimted cses mong mles in 216 were in Asi (64%) nd the WHO Africn Region (24%), wheres for femles the percentges were 59% FIG. 3.3 Globl estimtes of TB incidence (blck line) nd cse notifictions disggregted by ge nd sex (femle in red; mle in green), 216 Age group (yers) Number of TB cses FIG Regionl estimtes of TB incidence (blck line) nd cse notifictions disggregted by ge nd sex (femle in red; mle in green), 216 Age group (yers) Afric The Americs Estern Mediterrnen Europe South-Est Asi Western Pcific Age group (yers) Number of TB cses Number of TB cses Number of TB cses 1 Further brekdowns by HIV sttus re not possible, becuse dt on the HIV sttus of TB cses by ge nd sex re not vilble. GLOBAL TUBERCULOSIS REPORT

69 FIG Estimtes of TB incidence (blck line) nd cse notifictions disggregted by ge nd sex (femle in red; mle in green), 216, in the 3 high TB burden countries Angol Bngldesh Brzil Cmbodi Centrl Africn Republic Chin Congo DPR Kore DR Congo Ethiopi Indi Indonesi Keny Lesotho Liberi Age group (yers) Mozmbique Mynmr Nmibi Nigeri Pkistn Ppu New Guine Philippines Russin Federtion b Sierr Leone South Afric Thilnd UR Tnzni Viet Nm Zmbi Zimbbwe Number of TB cses b No ge nd sex disggregted cse notifictions were vilble for Mozmbique. For n explntion of why notifictions re ssumed to be equivlent to TB incidence in the Russin Federtion, see Box GLOBAL TUBERCULOSIS REPORT 217

70 FIG Globl distribution of TB mortlity in HIV-negtive people by ge group nd sex (femle in red; mle in green), 216 Age group (yers) Globl The totl re represents globl TB mortlity nd ll rectngles re proportionl to their shre of totl TB mortlity. for Asi nd 27% for the WHO Africn Region. For children, the top three regions were the WHO South-Est Asi Region with 35% of incident TB cses in 215, followed by the WHO Africn Region with 3% nd the WHO Western Pcific Region with 2% TB mortlity disggregted by ge nd sex Estimtes of TB mortlity disggregted by ge nd sex re shown in Fig (globl), Fig (WHO regions) nd Fig (3 high TB burden countries), nd in Tble 3.6. Estimtes re shown for HIV-positive nd HIV-negtive people seprtely, given tht the cuse of TB deths mong HIV-positive people is clssified s HIV in ICD-1 (see lso Section 3.2). TB mortlity mong HIV-negtive people Globlly in 216, there were n estimted 718 (rnge, ) deths from TB mong HIV-negtive men nd 11 (rnge, ) mong boys. There were n dditionl 378 (rnge, ) deths from TB mong HIV-negtive women nd 91 (rnge, ) mong girls. These numbers correspond to 55% of FIG Regionl distribution of TB mortlity in HIV-negtive people by ge group nd sex (femle in red; mle in green), 216 Afric The Americs Estern Mediterrnen Age group (yers) Europe South-Est Asi Western Pcific Age group (yers) The totl re represents TB mortlity nd ll rectngles re proportionl to their shre of totl TB mortlity by region. GLOBAL TUBERCULOSIS REPORT

71 FIG Distribution of TB mortlity in HIV-negtive people in the 3 high TB burden countries by ge group nd sex (femle in red; mle in green), 216 Angol Bngldesh Brzil Cmbodi Centrl Africn Republic Chin Congo DPR Kore DR Congo Ethiopi Age group (yers) Indi Indonesi Keny Lesotho Liberi Mozmbique Mynmr Nmibi Nigeri Pkistn Ppu New Guine Philippines Russin Federtion Sierr Leone South Afric Thilnd UR Tnzni Viet Nm Zmbi Zimbbwe The totl re represents TB mortlity nd ll rectngles re proportionl to their shre of totl TB mortlity by country. 6 GLOBAL TUBERCULOSIS REPORT 217

72 TABLE 3.6 Estimted number of TB deths (in thousnds) by HIV sttus in children nd dults, globlly nd for WHO regions, 216 HIV-NEGATIVE WHO REGION BEST ESTIMATE TOTAL MALE 14 YEARS FEMALE 14 YEARS MALE 15 YEARS FEMALE 15 YEARS UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL Afric The Americs Estern Mediterrnen Europe South-Est Asi Western Pcific GLOBAL HIV-POSITIVE WHO REGION BEST ESTIMATE TOTAL MALE 14 YEARS FEMALE 14 YEARS MALE 15 YEARS FEMALE 15 YEARS UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL Afric The Americs Estern Mediterrnen Europe South-Est Asi Western Pcific GLOBAL Numbers shown to two significnt figures if under 1 nd to three significnt figures otherwise. deths occurring in men, 29% in women, nd 16% in children. Higher numbers of TB deths mong men re consistent with the estimte tht 65% of incident cses were mong men in 216. They re lso consistent with evidence from prevlence surveys, which show tht TB disese ffects men more thn women (Fig. 3.28), nd tht gps in cse detection nd reporting re higher mong men (Fig. 3.29b). TB mortlity mong HIV-positive people There were n estimted 27 (rnge, ) TB deths mong HIV-positive men, 115 (rnge, ) mong HIV-positive women nd 52 (rnge, ) mong HIV-positive children in 216 (Tble 3.6). The WHO Africn Region ccounted for 86% of these deths, with the M:F rtio being 1.8. The M:F rtio in other regions vried from 1.3 in the WHO Estern Mediterrnen Region to 2.4 in the WHO Europen Region. GLOBAL TUBERCULOSIS REPORT

73 A TB ptient psses helth promotion poster bout TB in Lim, Peru CRIS BOURONCLE / GETTY IMAGES

74 CHAPTER 4. Dignosis nd tretment: TB, HIV-ssocited TB nd drug-resistnt TB n KEY FACTS AND MESSAGES n Globlly in 216, 6.6 million people with tuberculosis (TB) were notified to ntionl TB progrmmes (NTPs) nd reported to WHO. Of these, just over 6.3 million hd n incident episode (new or relpse) of TB. The globl number of new nd relpse TB cses notified nd the notifiction rte per 1 popultion hve both been incresing since 213, mostly explined by 37% increse in notifictions in Indi. In 216, 41% of the 3.4 million new bcteriologiclly confirmed nd previously treted TB cses notified globlly were reported to hve been tested for resistnce to rifmpicin, up from 31% in 215. Coverge ws 33% for new TB ptients nd 6% for previously treted TB ptients. Globlly, cses of multidrug-resistnt TB nd rifmpicinresistnt TB (MDR/RR-TB) were notified in 216, nd were enrolled in tretment. Globlly in 216, 57% of notified TB ptients hd documented HIV test result, up from 55% in 215 nd 19-fold increse since 24. In the WHO Africn Region, where the burden of HIV-ssocited TB is highest, 82% of TB ptients hd documented HIV test result. A totl of TB cses mong HIV-positive people were reported nd of these, 85% were on ntiretrovirl therpy (ART). Despite increses in notifictions of TB, MDR/RR-TB nd HIV-ssocited TB, progress in closing detection nd tretment gps is slow nd big gps remin. In 216, there ws gp of 4.1 million (39%) between notifictions of new nd relpse cses nd the best estimte of the number of incident cses, reflecting mixture of underreporting of detected TB cses (especilly in countries with lrge privte sectors) nd underdignosis (especilly in countries where there re mjor geogrphicl or finncil brriers to ccessing cre). The number of MDR/RR-TB cses strted on tretment in 216 ws only 22% of the estimted incidence of MDR/RR-TB. The number of notified HIV-positive TB cses ws only 46% of the estimted incidence of TB mong people living with HIV. From globl perspective, closing detection nd tretment gps requires progress in prticulr subset of countries. Ten countries ccount for 76% of the totl estimted gp between TB incidence nd notifictions, with Indi, Indonesi nd Nigeri ccounting for lmost hlf of the totl. Ten countries ccounted for 75% of the gp between enrolments in MDR-TB tretment in 216 nd the estimted number of incident MDR/RR-TB cses in 216; Chin nd Indi ccounted for 39% of the totl gp. Most of the gps in detection of HIV-positive TB cses nd provision of ART in 216 were ccounted for by the Africn Region. The globl mle:femle (M:F) rtio for notifictions ws 1.7. Results from ntionl TB prevlence surveys of dults show higher M:F rtios, indicting tht notifiction dt understte the shre of the TB burden ccounted for by men in some countries. Globlly, children (ged <15 yers) ccounted for 6.9% of the new nd relpse cses tht were notified in 216. The WHO-recommended rpid dignostic test for detection of TB nd rifmpicin resistnce currently vilble is the Xpert MTB/RIF ssy. The number of crtridges procured by countries eligible for concessionl prices ws 6.9 million in 216. Of the 48 countries in t lest one of the lists of high burden countries, 28 hd dopted ntionl lgorithms positioning Xpert MTB/RIF s the initil dignostic test for ll people suspected of hving pulmonry TB by the end of 216. The ltest tretment outcome dt show tretment success rtes of 83% for TB (215 cohort), 78% for HIV-ssocited TB (215 cohort), 54% for MDR/RR-TB (214 cohort) nd 3% for extensively drug-resistnt TB (XDR-TB) (214 cohort). At lest 35 countries in Afric nd Asi hve introduced shorter regimens for tretment of MDR/RR-TB, with high tretment success rtes (87 9%). As prt of efforts to improve outcomes for MDR/XDR-TB, 89 countries nd territories hd strted using bedquiline nd 54 hd used delmnid by June 217. GLOBAL TUBERCULOSIS REPORT

75 Prompt nd ccurte dignosis of tuberculosis (TB), HIVssocited TB nd drug-resistnt TB, followed by provision of tretment in line with interntionl stndrds, prevents deths nd limits ill-helth mong people who develop the disese. It lso prevents further trnsmission of infection to others. The 22 nd 225 milestones for reductions in TB incidence nd TB deths set in the End TB Strtegy (Chpter 2) require the cse ftlity rtio (the proportion of people with TB who die from the disese) to fll to 1% by 22 nd to 6.5% by 225. The ltter is only fesible if ll people with TB re promptly dignosed nd effectively treted. Ptient-centred cre nd prevention bcked by bold policies nd supportive systems such s universl helth coverge (UHC) nd socil protection re Pillrs 1 nd 2 of the End TB Strtegy (Box 4.1). They re mong the mjor themes tht will be discussed t the WHO Globl Ministeril Conference on ending TB in the er of the Sustinble Development Gols (SDGs), which is to be held in November This chpter provides the ltest ntionl dt reported to WHO on the dignosis nd tretment of TB, HIV-ssocited TB nd drug-resistnt TB, nd highlights progress in the compiltion, sfegurding nd use of subntionl dt. Section 4.1 presents nd discusses dt for 216 on notifictions of TB cses nd ssocited coverge of dignostic testing, s well s trends since 2. It includes dt on the contribution of community enggement nd public public nd public privte mix (PPM) inititives to cse-finding efforts. Section 4.2 focuses on tretment coverge (nd detection nd tretment gps) for ptients with TB, HIV-ssocited TB nd drug-resistnt TB, compring numbers detected nd treted with underlying estimtes of disese burden. Section 4.3 provides the most recent dt on tretment outcomes, for new nd relpse TB ptients, TB ptients living with HIV nd ptients with multidrug-resistnt TB nd rifmpicin-resistnt TB (MDR/RR-TB), s well s globl trends for these three groups between 212 nd 215. Section 4.4 describes globl inititive to help countries mke better use of subntionl dt, summrizes the number of countries for which regionl- or district-level dt hve now been stored for time period of t lest 5 yers, nd illustrtes how such dt cn be used through country cse study. Throughout the chpter, dt re presented t globl, regionl nd country levels, giving prticulr ttention to high burden countries (HBCs). 2 Further country-specific detils for ll of the indictors covered in this chpter re provided in Annex 2 nd Annex 4. New guidnce relted to the topics covered in this chpter tht ws issued by WHO in 217 is fetured in Box Cse notifictions nd testing coverge TB cse notifictions nd bcteriologicl confirmtion In 216, 6.6 million people with TB were notified to ntionl TB progrmmes (NTPs) nd reported to WHO (Tble 4.1). Of these, close to 6.3 million hd new or relpse (incident) episode of TB (shown s the totl of new nd relpse cses), nd n dditionl 3 hd been previously dignosed with TB but their tretment ws chnged to retretment regimen. n BOX 4.1 n Pillrs 1 nd 2 of the End TB Strtegy Pillr 1 of the End TB Strtegy is Integrted, ptient-centred cre nd prevention. It hs four components: erly dignosis of TB including universl drug-susceptibility testing (DST), nd systemtic screening of contcts nd high-risk groups; tretment of ll people with TB, including drug-resistnt TB, nd ptient support; collbortive TB/HIV ctivities, nd mngement of comorbidities; nd preventive tretment of persons t high risk, nd vccintion ginst TB. The fourth component of Pillr 1 is the topic of Chpter 5. Pillr 2 of the End TB Strtegy is Bold policies nd supportive systems. This pillr lso hs four components: politicl commitment with dequte resources for TB cre nd prevention; enggement of communities, civil society orgniztions, nd providers of public nd privte cre; UHC policy nd regultory frmeworks for cse notifiction, vitl registrtion, qulity nd rtionl use of medicines, nd infection control; nd socil protection, poverty llevition nd ctions on other determinnts of TB. The components of Pillr 2 re primrily discussed in Chpter 7. For n overview of ll spects of the End TB Strtegy, see Chpter 2. 1 WHO Globl Ministeril Conference. Ending tuberculosis in the SDG er: multisectorl response November 217. World Helth Orgniztion ( ccessed 21 August 217). 2 The three lists of HBCs (for TB, HIV-ssocited TB nd MDR-TB) re explined in Chpter GLOBAL TUBERCULOSIS REPORT 217

76 n BOX 4.2 n ETHICS GUIDANCE FOR THE IMPLEMENTATION OF THE END TB STRATEGY TREATMENT OF TUBERCULOSIS Guidelines for tretment of drug-susceptible tuberculosis nd ptient cre 217 UPDATE New guidelines on ethics in TB nd tretment of drug-susceptible TB issued by WHO in 217 Guidelines on ethics in TB: Protecting humn rights, ethics nd equity is one of the four key principles of the End TB Strtegy. In ll countries, TB remins closely ssocited with the most vulnerble nd mrginlized popultions, nd there re brriers to the equitble nd ethicl delivery of cre. New guidnce on ethics for TB cre nd prevention tht ddresses these chllenges ws relesed on World TB Dy 217. The guidnce ws produced by ffected individuls nd brod constituency of other experts from NTPs, civil society nd the fields of public helth, ethics, helth lw nd humn rights. Guidelines on the tretment of drugsusceptible TB: An updted edition of guidelines on the tretment of drugsusceptible TB ws published in April 217. b The revised guidelines include strong recommendtion to tret new pulmonry TB ptients with drug-susceptible TB with 6-month regimen of 2HRZE/4HR (i.e. 2 months of isonizid, rifmpicin, pyrzinmide nd ethmbutol, followed by 4 months of isonizid nd rifmpicin). If the 8-month regimen of 2HRZE/6HE (i.e. 2 months of isonizid, rifmpicin, pyrzinmide nd ethmbutol, followed by 6 months of isonizid nd ethmbutol) for such ptients is still in use, it is recommended tht it be phsed out. The recommendtions lso stte tht dily therpy is preferred to thrice weekly dosing, nd tht fixed-dose combintion tblets re preferred to single drug formultions. Wider use of DST is supported so tht people with drug-resistnt TB re treted with regimens pproprite for their pttern of drug resistnce. WHO is updting the 216 tretment guidelines for drug-resistnt TB to include evidence-bsed recommendtions for the tretment of rifmpicinsusceptible but isonizid-resistnt TB. This updte follows Guideline Development Group meeting held in April 217. A compendium tht summrizes ll WHO policies on TB dignosis nd tretment in one document is scheduled for publiction in lte 217. b World Helth Orgniztion. Ethics guidnce for the implementtion of the End TB Strtegy. Genev: WHO; 217 ( m/1665/25482/1/ eng.pdf, ccessed 11 July 217). World Helth Orgniztion. Tretment of tuberculosis: guidelines for tretment of drug-susceptible tuberculosis nd ptient cre (217 updte) (WHO/HTM/TB/217.5). Genev: WHO; 217 ( m/1665/25552/1/ eng.pdf, ccessed 11 July 217). The number of new nd relpse TB cses notified nd the notifiction rte per 1 popultion incresed between 2 nd 29, then fell slowly until 213, nd hs subsequently incresed (Fig. 4.1). The increse since 213 is mostly explined by continuous increse in notifictions in Indi (+37% between 213 nd 216), following the introduction of ntionl policy of mndtory notifiction in 212 nd the rollout (lso since 212) of ntionwide webbsed nd cse-bsed reporting system (clled Nikshy ) tht fcilittes reporting of detected cses by cre providers in the public nd privte sectors. The distribution of notified cses in 216 by ge nd sex is shown globlly nd for WHO regions in Fig The globl mle:femle (M:F) rtio for notifictions ws 1.7. In contrst, the M:F rtio of cses identified in 25 ntionl TB disese prevlence surveys of dults in Africn nd Asin countries implemented in pproximted 2.4 overll, nd reched 4.5 in Viet Nm. This indictes tht notifiction dt understte the shre of the TB burden ccounted for by men in some countries (see Chpter 3 for further detils). Children (ged <15 yers) ccounted for 6.9% of the new nd relpse cses tht were notified globlly. In the WHO Estern Mediterrnen, South-Est Asi nd Western Pcific regions, the TB epidemic is mrkedly geing one, with progressive increse in the notifiction rte with ge, nd pek mong those ged 65 yers or over. Elsewhere, nd most noticebly in the WHO Africn Region, notifiction rtes were highest mong younger dults. In severl centrl nd estern Europen countries, s well s three high TB burden countries in Asi Chin, Thilnd nd Viet Nm less thn 2% of notified cses were children (Fig. 4.3). Vrition mong countries in the child:dult nd M:F rtios of cses my reflect rel differences in epidemiology, differentil ccess to or use of helth-cre services, or differentil reporting prctices. Of the nerly 5.4 million new nd relpse pulmonry TB ptients notified globlly in 216, 57% were bcteriologiclly confirmed. 1 The remining ptients were dignosed cliniclly; tht is, bsed on symptoms, bnormlities on chest rdiogrphy or suggestive histology. The percentge of cses with bcteriologicl confirmtion worldwide hs declined slightly since 213 (Fig. 4.4), minly reflecting trends in the WHO South-Est Asi (67% to 61%) nd Western Pcific regions (43% to 38%). There ws n improvement in the WHO Africn (57% to 67%) nd Europen regions (59% to 66%). 1 A bcteriologiclly confirmed cse is one from whom biologicl specimen is positive by smer microscopy, culture or WHO-recommended rpid dignostic, such s Xpert MTB/RIF. GLOBAL TUBERCULOSIS REPORT

77 TABLE 4.1 Notifictions of TB, HIV-positive TB nd MDR/RR-TB cses, globlly nd for WHO regions, 216 TOTAL NOTIFIED NEW AND RELAPSE PULMONARY NEW AND RELAPSE NUMBER OF WHICH BACTERIOLOGICALLY CONFIRMED (%) EXTRAPULMONARY NEW AND RELAPSE (%) HIV-POSITIVE NEW AND RELAPSE MDR/RR-TB XDR-TB Afric % 16% The Americs % 15% Estern Mediterrnen % 24% Europe % 15% South-Est Asi % 15% Western Pcific % 8% GLOBAL % 15% New nd relpse includes cses for which the tretment history is unknown. It excludes cses tht hve been re-registered s tretment fter filure, s tretment fter lost to follow up or s other previously treted (whose outcome fter the most recent course of tretment is unknown or undocumented). FIG. 4.1 Cse notifiction rtes (new nd relpse cses, ll forms) (blck) compred with estimted TB incidence rtes (green), globlly nd for WHO regions, Shded res represent uncertinty bnds Afric The Americs Estern Mediterrnen Europe Rte per 1 popultion per yer South-Est Asi Western Pcific Globl GLOBAL TUBERCULOSIS REPORT 217

78 FIG. 4.2 New nd relpse TB cse notifiction rtes by ge nd sex in 216, globlly nd for WHO regions Afric The Americs Estern Mediterrnen Europe Age group (yers) South-Est Asi Western Pcific Globl Femle Mle TB cse notifiction rte per 1 popultion per yer Countries not reporting cses in these ctegories re excluded. Cses included ccount for 89% of reported cses. FIG. 4.3 Percentge of new nd relpse TB cses tht were children (ged <15), 216 Percentge No dt Not pplicble 215 dt were used for 15 countries. GLOBAL TUBERCULOSIS REPORT

79 FIG. 4.4 Percentge of new nd relpse pulmonry TB cses with bcteriologicl confirmtion, globlly nd for WHO regions, Afric The Americs Estern Mediterrnen Europe Percentge bcteriologiclly confirmed South-Est Asi Western Pcific Globl The clcultion is for new pulmonry cses in yers prior to 213 bsed on smer results, except for the Europen Region where dt on confirmtion by culture were lso vilble for the period FIG. 4.5 Percentge of new nd relpse pulmonry TB cses with bcteriologicl confirmtion, 216 Percentge No dt Not pplicble 215 dt were used for 17 countries. 68 GLOBAL TUBERCULOSIS REPORT 217

80 FIG. 4.6 Percentge of extrpulmonry cses mong new nd relpse TB cses, 216 Percentge No dt Not pplicble 215 dt were used for 17 countries. Considerble vrition in the percentge of new nd relpse pulmonry TB ptients tht re bcteriologiclly confirmed is evident even mong countries with similr epidemiologicl profile (Fig. 4.5). Resons for low proportion of cses being bcteriologiclly confirmed should be ssessed t country level, s should reductions over time. The microbiologicl detection of TB llows ptients to be correctly dignosed nd strted on the most effective tretment regimen s erly s possible, nd is criticl for infection control. Most clinicl fetures of TB nd bnormlities on chest rdiogrphy or histology results generlly ssocited with TB hve low specificity, which my led to flse dignoses of TB, nd hence to people being enrolled in TB tretment unnecessrily. Extrpulmonry TB represented 15% of the 6.3 million incident cses tht were notified in 216, rnging from 8% in the WHO Western Pcific Region to 24% in the WHO Estern Mediterrnen Region (Fig. 4.6 nd Tble 4.1). Enggement of ll cre providers in the public nd privte sectors should be integrl components of ntionl TB strtegies, nd PPM inititives hve prticulr relevnce to HBCs in Asi nd Afric. The contribution of PPM to totl notifictions in countries tht hve reported PPM dt for severl yers re shown in Box 4.3. In res where monitoring ws in plce, the contribution of PPM to totl notifictions incresed by more thn 1% between 212 nd 216 in Bngldesh, Indi nd the Philippines. Elsewhere, trends hve remined sttic or declined HIV testing for TB ptients, detection of HIVssocited TB nd screening for TB mong people living with HIV In 216, 167 countries reported 3.6 million notified new nd relpse TB ptients with documented HIV test result, equivlent to 57% of notified TB cses (up from 55% in 215). This represented 19-fold increse in testing coverge since 24, when WHO first sked countries to report dt (Fig. 4.7). In 116 countries nd territories, t lest 75% of TB cses knew their HIV sttus (Fig. 4.8). Documenttion of HIV sttus verged 66% of TB ptients in the 3 high TB/ HIV burden countries, but vried considerbly, from 14% in Indonesi to bove 8% in 18 high TB/HIV burden countries in the WHO Africn Region. 1 In the Russin Federtion, reported testing coverge incresed from 66% in 215 to 87% in 216, following inclusion of dt from prisons. In the WHO Africn Region, which ccounted for 74% of the globl burden of HIVssocited TB in 216 (Chpter 3), 82% of TB ptients hd their HIV sttus documented. Globlly, cses of TB mong people living with HIV were notified in 216 (Tble 4.1), equivlent to 13% of TB ptients with n HIV test result. The number notified ws only 46% of the estimted number of incident cses mong people living with HIV (Fig. 4.9), 2 similr to the gp in Although the ntionl figure for Chin ws 43%, in the counties defined s hving high burden of HIV-ssocited TB the figure ws 87%. 2 See lso Tble 3.2 in Chpter 3 for the globl estimte of TB incidence mong people living with HIV. GLOBAL TUBERCULOSIS REPORT

81 n BOX 4.3 n Trends in the contribution of PPM to TB cse notifictions Public public mix is defined s enggement by the NTP of public sector providers of TB cre tht re not under the direct purview of the NTP, including public hospitls, public medicl colleges, prisons or detention centres, militry fcilities, rilwys nd public helth insurnce orgniztions. Public privte mix is defined s enggement by the NTP of privte sector providers of TB cre; these include privte individul nd institutionl providers, the corporte or business sector, mission hospitls, nongovernmentl orgniztions nd fith-bsed orgniztions. In ll countries, especilly those with mny public providers of TB cre operting outside the remit of the ministry of helth or lrge privte helth sector, PPM is needed to ensure prompt referrl by non-treting providers, reporting of ll detected cses, nd use of interntionl stndrds of cre for dignosis nd tretment. Exmples of pproches used to engge public nd privte cre providers include strengthening coordintion within hospitls, estblishing linkges between hospitls nd peripherl helth centres, public sector support to privte providers (with or without finncil incentives, including linking TB insurnce pyments to notifiction), nd regultory pproches such s enforcing mndtory TB cse notifiction nd the rtionl use of TB medicines. FIG. B4.3.1 Contribution of public public mix to TB cse notifictions in eight countries, Contribution of public public mix to totl notifictions (%) Afghnistn Bngldesh Chin Indi Indonesi Philippines Thilnd Viet Nm As in previous yers, the region with the highest proportion of HIV-positive cses mong those tested for HIV ws the WHO Africn Region (34%). Overll, the percentge of TB ptients testing HIV-positive hs been flling globlly since 28. This decline is evident in ll WHO regions with the exception of the WHO Europen Region, where the proportion of TB ptients testing HIV-positive hs incresed from 3% in 28 to 15% in 216. Systemtic symptom screening for TB mong people living with HIV is recommended by WHO s n essentil component of the HIV cre pckge. In 216, 9 countries reported dt on the number of TB cses notified mong those newly enrolled in HIV cre (up from 76 countries in 215). In totl, 88 2 (7%) of the 1.3 million people who were newly enrolled in HIV cre in 216 were dignosed with TB during the sme yer; dt for the 14 high TB/HIV burden countries tht reported dt re shown in Tble 4.2. Improvements in the coverge nd qulity of dt for this indictor re necessry to trck the impct of HIV cre in prticulr, ntiretrovirl therpy (ART) nd TB preventive tretment on the burden of TB mong people living with HIV Rpid testing for TB Incresing ptient ccess to erly nd ccurte dignosis using WHO-recommended rpid dignostic (WRD 1 ) is one of the three min objectives of TB lbortory strengthening efforts under the End TB Strtegy. As first step towrds reching this objective nd s the first indictor of the Frmework of indictors nd trgets for lbortory strengthening under the End TB Strtegy, 2 which ws lunched in 216, countries should dopt policies tht include dignostic lgorithms in 1 WRDs use moleculr techniques to detect TB mong people with signs or symptoms of TB. They include the XpertMTB/RIF ssy (Cepheid, United Sttes) nd the Loopmp TM MTBC Detection Kit (Eiken Chemicl Compny Ltd, Jpn). 2 World Helth Orgniztion. Frmework of indictors nd trgets for lbortory strengthening under the End TB Strtegy (WHO/HTM/ TB/216.18). Genev: WHO; 216 ( lbindictors/en/, ccessed 21 August 217). 7 GLOBAL TUBERCULOSIS REPORT 217

82 The contribution of PPM to cse notifictions quntifies the enggement of different providers in the delivery of TB cre, nd the lignment of their TB mngement prctices with ntionl nd interntionl stndrds. Trends in the contribution of PPM to notifictions in selected countries where PPM hs been recognized s priority nd from which dt hve been reported to WHO for ech yer re shown in Fig. B4.3.1 nd Fig. B Inventory studies tht quntify the underreporting of detected TB cses in both public nd privte sectors cn help to identify where further PPM efforts re needed. They cn lso indicte the shre of notifictions tht would be ccounted for by PPM in the bsence of underreporting, nd thus inform the setting of trgets for the shre of notifictions tht should come from PPM. Of the countries shown in Fig. B4.3.1 nd Fig. B4.3.2, inventory studies hve been implemented in Indi nd Pkistn, nd re underwy in Chin, Indonesi nd Viet Nm; further detils re provided in Chpter 3. In Pkistn, the level of underreporting of dult cses ws 24% in 214, while PPM ccounted for 18% of notifictions; to chieve zero underreporting, the trgeted level for the contribution of PPM would thus be 43%. By 216, following further efforts bsed on the results of the inventory study, the contribution of PPM hd risen to 28%. i.e. t = c(1-u) + U, where t is the trget level, c is the overll PPM contribution to totl notifictions nd U is the level of underreporting mesured in n inventory study. FIG. B4.3.2 Contribution of public privte mix to TB cse notifictions in eight countries, Contribution of public privte mix to totl notifictions (%) Bngldesh Ethiopi Indi Indonesi Keny Mynmr Pkistn Philippines which WRD is the initil dignostic test for ll people with signs or symptoms of TB. This is n especilly high priority for the 48 countries included in one or more of the lists of high TB, TB/HIV nd MDR-TB burden countries, nd 28 HBCs reported tht such n lgorithm ws in plce by the end of 216 (Tble 4.3). The second indictor of the frmework is the percentge of new nd relpse TB cses tested with WRD s the initil dignostic test. Of 19 reporting countries nd territories, 18 indicted tht their routine surveillnce system cptures the dt required to monitor this indictor. Among the 48 HBCs, only Belrus, Kzkhstn, the Republic of Moldov, South Afric nd Swzilnd reported tht more thn hlf of their notified TB cses hd received WRD s the initil dignostic test. The Xpert MTB/RIF ssy (Cepheid, United Sttes) is currently the WRD used most frequently by countries worldwide; it simultneously detects both TB nd resistnce to rifmpicin. The ssy is performed using the GeneXpert pltform, modulr testing device tht cn detect multiple diseses. 1 Between 21 nd 216, cumultive totl of 6659 GeneXpert instruments, comprising modules, were procured by the public sector in 13 of 145 countries eligible for concessionl pricing. In 216, 6.9 million test crtridges were procured by eligible countries. Of these, 35% (2.4 million) went to South Afric; this percentge hs fllen from high of 63% in 213, s other prts of the world hve dopted the technology. Despite the mjor scle-up in procurement of crtridges globlly, instlled instruments re still underused in mny countries due to chllenges such s network infrstructure, trnsport of specimens nd vrition in clinicl demnd. Outside South Afric (where mchine throughput is reltively high), the number of procured crtridges in 216 compred with the totl number of instrument modules s of 1 World Helth Orgniztion (217). Considertions for doption nd use of multidisese testing devices in integrted lbortory networks (WHO/HTM/ TB/217.5). Genev: WHO ( considertions_multidisese_testing_devices_217/en/, ccessed 21 August 217). GLOBAL TUBERCULOSIS REPORT

83 FIG. 4.7 Percentge of new nd relpse TB cses with documented HIV sttus, , globlly nd for WHO regions 1 Afric The Americs Estern Mediterrnen Europe Percentge with documented sttus South-Est Asi Western Pcific Globl The clcultion is for ll cses in yers prior to 215. FIG. 4.8 Percentge of new nd relpse TB cses with documented HIV sttus, 216 Percentge No dt Not pplicble 215 dt were used for 9 countries. 72 GLOBAL TUBERCULOSIS REPORT 217

84 FIG. 4.9 Globl numbers of notified new nd relpse cses known to be HIV-positive (blck), number strted on ntiretrovirl therpy (blue) nd estimted number of incident HIV-positive TB cses (red), Shded res represent uncertinty bnds. New nd relpse cses per yer (millions) The clcultion is for ll cses in yers prior to 215. TABLE 4.2 Number of people newly enrolled in HIV cre in 216 who were lso notified s TB cse in high TB/HIV burden countries tht reported dt. NUMBER OF PEOPLE NEWLY ENROLLED IN HIV CARE NUMBER NOTIFIED AS A TB CASE NOTIFIED TB CASES AS A PERCENTAGE OF THOSE NEWLY ENROLLED IN HIV CARE Angol Chin Ethiopi Indi Indonesi Liberi Mlwi Mynmr Nigeri Ppu New Guine Swzilnd Thilnd Ugnd Zimbbwe TOTAL reflects n verge rte of only 1. test per module per working dy globlly DST nd detection of drug-resistnt TB Drug-resistnt TB thretens globl TB cre nd prevention, nd it remins mjor public helth concern in mny countries. Three ctegories re used for globl surveillnce nd tretment: RR-TB, MDR-TB nd XDR-TB. MDR-TB is TB tht is resistnt to both rifmpicin nd isonizid, the two most powerful nti-tb drugs; it requires tretment with second-line regimen. RR-TB lso requires tretment with second-line drugs. 1 With incresing use of Xpert MTB/RIF for simultneous detection of TB nd resistnce to rifmpicin, growing number of RR-TB cses (without further testing for isonizid resistnce) re being detected nd notified. 2 Extensively drug-resistnt TB (XDR-TB) is defined s MDR-TB plus resistnce to t lest one fluoroquinolone nd secondline injectble gent (mikcin, cpreomycin or knmycin), the two most importnt clsses of medicines in n MDR-TB regimen. The End TB Strtegy clls for universl ccess to drugsusceptibility testing (DST); tht is, DST for t lest rifmpicin for ll TB cses, plus DST for t lest fluoroquinolones nd 1 World Helth Orgniztion. WHO tretment guidelines for drug-resistnt tuberculosis, 216 updte (October 216 revision). (WHO/HTM/TB/216.4). Genev: WHO; 216 ( ccessed 15 August 217). 2 Surveillnce nd survey dt show tht bout 83% of RR-TB cses hve MDR-TB. Further detils re provided in Chpter 3. second-line injectble gents mong ll TB cses with rifmpicin resistnce. DST methods include both phenotypic (conventionl) nd genotypic (moleculr) testing methods. The most widespred technology currently vilble to test for drug resistnce is Xpert MTB/RIF. DST for first-line drugs nd detection of MDR/RR-TB Fig. 4.1 shows progress in DST coverge since 29, when WHO intensified efforts to trck progress in the progrmmtic response to drug-resistnt TB. 3 In 216, 1.4 million (41%) of the 3.4 million new bcteriologiclly confirmed nd previously treted TB cses notified globlly were tested for rifmpicin resistnce (up from 31% in 215), with coverge of 33% for new TB ptients nd 6% for previously treted TB ptients. These figures represent n improvement since 215, when 25% of new nd 53% of previously treted TB cses hd test result for rifmpicin resistnce; they lso represent mjor progress since 29, when the figures were 2.9% nd 5.9%, respectively. DST coverge incresed in five of the six WHO regions between 215 nd 216, with high of 84% in the WHO Europen Region in 216. There ws reduction in coverge in the WHO Africn Region, but this reflected 3 This hppened following ministeril conference for high MDR-TB burden countries, held in Beijing, Chin, in April 29 preceding World Helth Assembly resolution the following month: WHA62.15: Prevention nd control of multidrug-resistnt tuberculosis nd extensively drug-resistnt tuberculosis. Sixty-second World Helth Assembly, Genev, My 29, Resolutions nd decisions; nnexes; 29 ( ebwh/pdf_files/wha62-rec1/wha62_rec1-en.pdf, ccessed 11 July 217). GLOBAL TUBERCULOSIS REPORT

85 TABLE 4.3 Ntionl policies nd their implementtion to increse ccess to rpid TB testing nd universl DST, 216 Yes No HIGH TB BURDEN HIGH TB/HIV BURDEN HIGH MDR-TB BURDEN NATIONAL POLICY AND ALGORITHM INDICATE A WRD AS THE INITIAL DIAGNOSTIC TEST FOR ALL PEOPLE PRESUMED TO HAVE TB PERCENTAGE OF NOTIFIED NEW AND RELAPSE TB CASES TESTED WITH A WRD AS THE INITIAL DIAGNOSTIC TEST NATIONAL POLICY AND ALGORITHM INDICATE UNIVERSAL ACCESS TO DST PERCENTAGE OF NOTIFIED BACTERIOLOGICALLY CONFIRMED TB CASES WITH DST RESULTS FOR RIFAMPICIN PERCENTAGE OF NOTIFIED RIFAMPICIN-RESISTANT TB CASES WITH DST RESULTS FOR FLUOROQUINOLONES AND SECOND-LINE INJECTABLE AGENTS Angol Azerbijn Bngldesh 3 14 Belrus Botswn 4.7 Brzil Cmbodi 12 Cmeroon Centrl Africn Republic 3.8 Chd Chin 47 Congo DPR Kore 2.6 DR Congo Ethiopi >1 b 4. Ghn 64 Guine-Bissu Indi Indonesi < Kzkhstn 85 >1 b Keny Kyrgyzstn Lesotho Liberi 6 Mlwi Mozmbique >1 b 95 Mynmr 48 Nmibi Nigeri 57 Pkistn Ppu New Guine 61 Peru >1 b 76 Philippines Republic of Moldov Russin Federtion 7 74 Sierr Leone.5 1 Somli South Afric Swzilnd 82 >1 b 1 Tjikistn Thilnd Ugnd Ukrine 87 1 UR Tnzni Uzbekistn Viet Nm Zmbi 2.5 Zimbbwe 53 Dt were not vilble. The 48 countries shown in the tble re the countries tht re in one of more of the three lists of high TB, TB/HIV nd MDR-TB burden countries (see lso Chpter 2, Figure 2.2 nd Tble 2.4). b Testing in cses with unknown previous tretment history is not included. The percentge exceeded 1% for severl resons, e.g. smples rther thn cses re counted in the numertor; lbortory specimen results re not linked to the denomintor dt source when enumerted; or there is incomplete reporting of bcteriologiclly confirmed cses in the denomintor. Bcteriologiclly confirmed extrpulmonry cses re not included in the denomintor becuse they cnnot be differentited from cliniclly dignosed ones in the wy dt re reported to WHO. 74 GLOBAL TUBERCULOSIS REPORT 217

86 FIG. 4.1 Percentge of bcteriologiclly confirmed TB cses tested for RR-TB, globlly nd for WHO regions, Afric b The Americs Estern Mediterrnen Europe Percentge of cses 1 8 South-Est Asi Western Pcific Globl b Among new lbortory confirmed nd retretment cses; test results in cses with unknown previous history re not included. The increse in the Africn Region from 214 to 215 ws to due big increse in reporting of lbortory results for cses in South Afric in 215. chnge in reporting in South Afric. 1 DST coverge vried substntilly between countries, even within the sme region, nd mong the 3 high MDR-TB burden countries (Fig. 4.11). Globlly, cses of MDR/RR-TB were detected nd notified in 216 (Tble 4.1). This ws smll increse from 215 (Fig. 4.12), lthough ggregte globl trends concel considerble progress in some countries (Fig. 4.13). Between 215 nd 216, the number of reported MDR/RR-TB cses incresed by more thn 3% in nine of the 3 high MDR-TB burden countries (Democrtic People s Republic of Kore, Democrtic Republic of Congo, Mozmbique, Nigeri, Ppu New Guine, the Philippines, the Russin Federtion, Somli nd Thilnd). The globl number of MDR/RR-TB cses notified in 216 ws 26% of the estimted 6 incident cses in 216 (Fig. 4.12; incidence estimtes re discussed in more detil in Chpter 3) nd 44% of the estimted 35 cses of MDR/RR-TB mong notified TB cses. Closing these lrge detection gps will require improvements in both overll TB detection (Section 4.2) nd coverge of dignostic DST. The ltter requires further strengthening of lbortory cpcity nd wider uptke of new rpid dignostics. 1 DST results were reported seprtely for new nd previously treted cses in 215, but this ws not done in 216. Drug-susceptibility testing for second-line drugs nd detection of XDR-TB Among MDR/RR-TB ptients notified in 216, 39% were tested for resistnce to both fluoroquinolones nd secondline injectble gents, slight increse from 36% in 215. Coverge vried widely mong countries (Fig. 4.14). A totl of 814 cses of XDR-TB were reported by 72 countries, with 75% of cses from the WHO Europen nd South-Est Asi regions (Tble 4.1). The five countries tht reported the lrgest numbers of cses were Chin (525), Belrus (572), South Afric (967), Ukrine (1195) nd Indi (2464). 4.2 Tretment coverge The SDGs include trget to Achieve universl helth coverge, including finncil risk protection, ccess to qulity essentil helth-cre services nd ccess to sfe, effective, qulity nd ffordble essentil medicines nd vccines for ll (Chpter 2). One of the indictors for Trget 3.8 of SDG 3 is the coverge of essentil helth services; this is composite indictor bsed on 16 trcer indictors, one of which is TB tretment coverge. Achieving UHC is fundmentl requirement for chieving the milestones nd trgets of the End TB Strtegy; hence, both TB tretment coverge nd the percentge of TB ptients nd their households tht fce ctstrophic costs s result of TB disese re priority GLOBAL TUBERCULOSIS REPORT

87 FIG Percentge of bcteriologiclly confirmed TB cses tested for RR-TB, 216 Percentge No dt Not pplicble Among new lbortory confirmed nd previously treted cses; cses with unknown previous tretment history re not included. 215 dt were used for 19 countries. FIG Globl number of MDR/RR-TB cses detected (purple) nd number enrolled on MDR-TB tretment (green), , compred with estimte for 216 of the number of incident cses of MDR/RR-TB (uncertinty intervl shown in blue) nd the number of MDR/RR-TB cses mong notified pulmonry cses (uncertinty intervl shown in blck) Number of cses (thousnds) indictors for monitoring progress in implementing the End TB Strtegy (Chpter 2). TB tretment coverge is defined s the number of new nd relpse cses detected nd treted in given yer, divided by the estimted number of incident TB cses in the sme yer, expressed s percentge. In this section, numbers of notified new nd relpse cses in 216 re used s the numertor for the indictor, becuse these re the dt tht re vilble. However, s discussed further below, there re people with TB who re treted but not notified to ntionl uthorities (nd in turn re not notified to WHO), nd people who re notified but who my not hve strted tretment. ART is recommended for ll HIV-positive TB ptients, nd second-line MDR-TB tretment regimen is recommended for people with MDR/RR-TB. This section includes estimtes of tretment coverge for these two interventions s well TB tretment coverge Trends in notifictions of new nd relpse cses nd estimted incidence re shown for the 3 high TB burden countries in Fig Estimtes of TB tretment coverge in 216 (clculted s notifictions of new nd relpse cses divided by estimted TB incidence) re shown globlly, for WHO regions nd the 3 high TB burden countries, in Fig Globlly, TB tretment coverge ws 61% (rnge, 52 72%) in 216, up from 53% (rnge, 46 64%) in 21 nd 35% (rnge, 3 43%) in 2. Three WHO regions chieved levels bove 75%: the WHO Region of the Americs, the WHO 76 GLOBAL TUBERCULOSIS REPORT 217

88 FIG Number of MDR/RR-TB cses detected (purple) nd enrolled on MDR-TB tretment (green), , 3 high MDR-TB burden countries Angol Azerbijn Bngldesh Belrus Chin DPR Kore DR Congo Ethiopi Indi Indonesi Number of cses Kzkhstn Keny Kyrgyzstn Mozmbique Mynmr Nigeri Pkistn Ppu New Guine Peru Philippines Republic of Moldov Russin Federtion Somli South Afric Tjikistn Thilnd Ukrine Uzbekistn Viet Nm Zimbbwe Enrolment my exceed detection of MDR/RR-TB cses for number of resons, including the empiricl tretment of TB ptients considered t risk of hving MDR-TB but for whom lbortory-confirmed dignosis is missing, incomplete reporting of cses with lbortory dignosis of MDR/RR-TB, or enrolment of bcklogs of MDR-TB ptients who were detected before 216. GLOBAL TUBERCULOSIS REPORT

89 FIG Percentge of MDR/RR-TB cses tested for susceptibility to second-line drugs, 216 Percentge No dt Not pplicble 215 dt were used for 2 countries. Europen Region nd the WHO Western Pcific Region. High TB burden countries with high levels of tretment coverge in 216 (>8%) included Brzil, Chin, the Russin Federtion, Viet Nm nd Zimbbwe. The lowest levels, with best estimtes of 5% or less, were in Indonesi, Keny, Lesotho, Liberi, Mozmbique, Nigeri nd the United Republic of Tnzni. Globlly in 216, there ws gp of bout 4.1 million (39%) between the 6.3 million new nd relpse cses tht were notified, nd the estimted 1.4 million incident TB cses in the sme yer (Chpter 3). The globl gp hs been nrrowing, especilly in the WHO Estern Mediterrnen nd Western Pcific regions, nd to lesser extent in the WHO South-Est Asi Region. 1 Ten countries ccount for 76% of the totl estimted gp between incidence nd notifictions (Fig. 4.17), with Indi, Indonesi nd Nigeri ccounting for lmost hlf of the totl. There re three min resons for gp between notifictions nd estimted incidence: Underreporting of detected TB cses. In mny countries, levels of underreporting my be high; this is especilly the cse for those countries tht lck policies on mndtory notifiction nd other mesures to ensure reporting of detected cses by ll cre providers nd lrge privte helth sectors. 1 Time trends in countries nd regions re shown in Annex 2 nd Annex 3, respectively. Underdignosis of people with TB. Underdignosis cn occur for resons such s poor geogrphicl nd finncil ccess to helth cre; lck of or limited symptoms tht dely seeking of helth cre; filure to test for TB when people do present to helth fcilities; nd dignostic tests tht re not sensitive or specific enough to ensure ccurte identifiction of ll cses. Uncertinty bout the level of TB incidence. In this report, estimtes of TB incidence for 54 countries with 17% of the world s estimted cses re bsed on expert opinion bout levels of underreporting nd underdignosis, s opposed to direct mesurements from surveillnce or survey dt (Chpter 3). Uncertinty intervls round the best estimtes of TB incidence cn be wide, nd gps my be lower or higher thn the best estimtes quoted in this section. In some of the countries with the lrgest estimted gps between notifictions nd TB incidence, there is lredy good evidence bout the resons for such gps, nd ctions to ddress them re being tken or re plnned. In Indi, multiple sources of evidence from surveys nd surveillnce show lrge underreporting of detected TB cses, especilly in the privte sector. 2 Three exmples of ctions tht hve been tken to close reporting gps re mndtory notifiction, simplified 2 For further detils, see Box 3.3 in World Helth Orgniztion. Globl tuberculosis report 216 (WHO/HTM/TB/216.13). Genev: WHO; 216 ( pdf, ccessed 21 August 217). 78 GLOBAL TUBERCULOSIS REPORT 217

90 FIG Cse notifiction rtes (new nd relpse cses, ll forms) (blck) compred with estimted TB incidence rtes (green), 2 216, 3 high TB burden countries. Shded res represent uncertinty bnds. 6 Angol Bngldesh Brzil Cmbodi Centrl Africn Republic Chin Congo DPR Kore DR Congo Ethiopi Rte per 1 popultion per yer Indi Indonesi Keny Lesotho Liberi Mozmbique Mynmr Nmibi Nigeri Pkistn Ppu New Guine Philippines Russin Federtion b Sierr Leone South Afric Thilnd UR Tnzni Viet Nm Zmbi Zimbbwe b Estimtes of TB incidence for Indi re interim in nture, pending results from the ntionl TB prevlence survey plnned for 218/219. For n explntion of why notifictions re ssumed to be equivlent to TB incidence in the Russin Federtion, see Box 3.5 in Chpter 3. GLOBAL TUBERCULOSIS REPORT

91 FIG Estimted TB tretment coverge (new nd relpse ptients s percentge of estimted TB incidence) in 216, 3 high TB burden countries, WHO regions nd globlly Russin Federtion DPR Kore Brzil Chin Zimbbwe Viet Nm Nmibi Ppu New Guine Mynmr Ethiopi Pkistn Indi Sierr Leone Bngldesh Cmbodi Zmbi Philippines Thilnd Angol South Afric Congo Centrl Africn Republic DR Congo Liberi Lesotho Keny Mozmbique UR Tnzni Indonesi Nigeri The Americs Western Pcific Europe Estern Mediterrnen South-Est Asi Afric Globl Tretment coverge (%) Estimtes of TB incidence for Indi re interim in nture, pending results from the ntionl TB prevlence survey plnned for 218/219. ntionl electronic reporting system tht fcilittes reporting of cses, nd further efforts to engge ll cre providers through PPM schemes. In Indonesi, the ntionl TB prevlence survey showed high levels of underreporting of detected TB cses, leding to recommendtions such s mndtory policy on notifiction (encted in Jnury 217), nd intensified enggement with public nd privte hospitls where mny people with TB were being treted. 1 Similr findings re emerging from the 216 ntionl TB prevlence survey in the Philippines (Chpter 3). In Nigeri, the 212 prevlence survey found tht 75% of the smer-positive cses detected hd symptoms tht met ntionl screening criteri but hd not been previously dignosed, suggesting high levels of underdignosis nd need to strengthen ccess to dignostic nd tretment services. 2 1 For further detils, see Box 2.4 in World Helth Orgniztion. Globl tuberculosis report 215 (WHO/HTM/TB/215.22). Genev: WHO; 215 ( pdf, ccessed 27 July 217). 2 For further detils, see Box 2.2 in World Helth Orgniztion. Globl tuberculosis report 214 (WHO/HTM/TB/214.8). Genev: WHO; 214 ( pdf, ccessed 15 August 217). In countries where underreporting is thought to exist, inventory studies in which electronic lists of notified cses re compred with electronic lists of TB cses detected by ll cre providers, idelly employing unique identifiers, cn be used to quntify levels of underreporting. 3 Such studies hve lredy been used to inform estimtes of TB incidence in severl countries (Chpter 3), nd re plnned or underwy in six high TB burden countries: Chin, Indonesi, Nigeri (metropolitn Lgos), the Philippines, South Afric nd Viet Nm. When these studies re done prospectively (s opposed to retrospectively, using electronic dtbses tht re lredy vilble), the mpping of providers tht is required t the beginning cn subsequently help with efforts to engge ll cre providers, including in reporting (Box 4.3). Exmples of mechnisms to ensure reporting of ll detected cses include linking reimbursement from helth insurnce schemes to notifiction of cses (s in the Republic of Kore) 3 For guide to inventory studies, see World Helth Orgniztion. Assessing tuberculosis under-reporting through inventory studies. Genev: WHO; 212 ( ccessed 15 August 217). 8 GLOBAL TUBERCULOSIS REPORT 217

92 FIG The ten countries with the lrgest gps between notifictions of new nd relpse (incident) TB cses nd the best estimtes of TB incidence, 216 Chin Pkistn Bngldesh Philippines 1 5 Nigeri DR Congo Indi UR Tnzni Indonesi 1 South Afric The ten countries rnked in order of the size of the gp between notified cses nd the best estimtes of TB incidence in 216, re Indi, Indonesi, Nigeri, the Philippines, South Afric, Pkistn, Bngldesh, DR Congo, Chin nd UR Tnzni. Estimtes of TB incidence for Indi re interim in nture, pending results from the ntionl TB prevlence survey plnned for 218/219. nd linking the supply of first-line drugs to notifiction of cses (s in Brzil). Recent ntionl TB prevlence surveys 1 hve lso shown tht, in both Afric nd Asi, detection nd reporting gps re systemticlly higher for men thn for women (Chpter 3). This suggests tht specific efforts re needed to improve ccess to TB dignosis nd tretment for men. Systemtic screening for ctive TB mong specific popultions cn lso help to ensure erly dignosis nd reduce levels of underdignosis. WHO recommends such screening for contcts of bcteriologiclly confirmed cses, people living with HIV nd people exposed to silic dust. 2,3 Other individuls t risk should be considered for systemtic screening bsed on n ssessment of TB epidemiology in ech setting. To dte, there hve been few ssessments of the implementtion nd outcomes of systemtic screening in countries tht re currently introducing or scling it up. However, systemtic screening is expected to become 1 See tskforce/meetings/tf6_p6_prevlence_surveys_29_215.pdf 2 World Helth Orgniztion. Systemtic screening for ctive tuberculosis: principles nd recommendtions (WHO/HTM/TB.213.4). Genev: WHO; 213 ( ccessed 15 August 217). The dt requested in the globl monitoring done by WHO focus on screening mong people living with HIV nd close contcts. 3 For this reson, the dt requested in WHO s nnul round of globl TB dt collection focus on screening mong people living with HIV nd close contcts. These dt re presented in Chpter 5. more prominent prt of ntionl progrmme monitoring nd evlution efforts in future. Engging communities cn lso dd vlue to efforts to improve cse detection nd ptient support (Box 4.4) Tretment coverge of ART for HIV-positive TB cses WHO recommends ART for ll HIV-positive TB ptients within the first 8 weeks of strting TB tretment. The number of notified HIV-positive TB ptients on ART hs grown in recent yers (Fig. 4.18); it reched in 216, equivlent to 85% of the notified TB ptients known to be HIV-positive (Tble 4.1). 4 In the 3 high TB/HIV burden countries, overll, 86% of the TB ptients known to be HIV-positive were on ART; six of these countries (Indi, Keny, Mlwi, Mozmbique, Nmibi nd Swzilnd) mintined coverge of t lest 9% in both 215 nd In contrst, there were six high TB/ HIV burden countries (Brzil, Congo, Ghn, Guine-Bissu, Indonesi nd Liberi) in which less thn 5% of HIV-positive TB ptients were strted on ART in 216. Angol nd Chd did not report dt on ART for TB ptients. ART tretment coverge for people with TB cn lso 4 There my be discrepncies in dt on provision of ART to HIV-positive TB ptients tht re reported by NTPs nd ntionl HIV progrmmes. These discrepncies hve reduced in recent yers nd re mostly resolved through follow-up nd vlidtion efforts. 5 Further detils re provided in Annex 4. GLOBAL TUBERCULOSIS REPORT

93 n BOX 4.4 n Community contributions to TB notifictions nd tretment support Enggement of communities, NGOs nd other civil society orgniztions (CSOs) is one of the four underlying principles s well s one of the core components of the End TB Strtegy. Community-bsed TB ctivities include wide rnge of ctivities tht contribute to the detection, referrl nd tretment of people with drug-susceptible, drug-resistnt nd HIV-ssocited TB tht re crried out by community helth workers (CHWs) nd community volunteers. Such ctivities cn be prt of public helth services or ctivities implemented by NGOs or CSOs. In some countries, CHWs re n integrl prt of the helth system, nd enjoy the rights nd privileges of forml employment. An exmple is Ethiopi, where the use of CHWs hs helped to trnsform primry helth cre. In WHO s 217 round of globl TB dt collection, 53 countries reported dt bout the contribution of communities through CHWs to TB notifictions or tretment support. This represents more thn threefold increse in reporting since 213, when dt were first collected on the two core indictors (referrls nd tretment support) used to monitor community enggement. In these 53 countries, 57% (3/53) reported ntionwide coverge by ll bsic mngement units of community enggement in referrls of cses (thus contributing to cse notifictions) or community-bsed tretment support in 216 (Fig B4.4.1). In res where community-bsed referrl ctivities were in plce, the percentge of notified TB ptients ttributed to community referrls verged 16%. Globlly, over 1.5 million TB ptients received some form of tretment dherence support from CHWs nd volunteers in 216. The proportion of TB ptients receiving such community-bsed tretment support rnged considerbly mong countries. Almost two thirds of the countries (34/53) reported informtion bout the tretment success rte mong TB ptients who received tretment support in the community. Tretment success rtes rnged from 57% in Colombi to 1% in Afghnistn, Hondurs, Jordn nd Mozmbique. In 31 other countries, community-bsed TB ctivities were crried out nd supported TB services, but dt collection systems do not llow the contribution of ll such ctivities to be reported t ntionl level. Thirteen of these 31 countries (42%) reported countrywide coverge of community-bsed ctivities in ll bsic mngement units. Further effort is needed to updte the dt recording systems in these countries to reflect community contributions. Community helth workers nd community volunteers re defined here: World Helth Orgniztion. ENGAGE-TB Approch: Opertionl guidnce: integrting community-bsed tuberculosis ctivities into the work of nongovernmentl nd other civil society orgniztions (WHO/HTM/TB/212.8). Genev: WHO; 212 ( publictions/212/engge_tb_policy/en/, ccessed 15 August 217). FIG. B4.4.1 Percentge of bsic mngement units in which there is community contribution to new cse finding nd/or to tretment dherence support, 216 Percentge No dt Not pplicble Dt only requested from 114 countries. 82 GLOBAL TUBERCULOSIS REPORT 217

94 FIG Number of new nd relpse cses known to be HIV-positive (blck) nd number strted on ART (blue) compred with estimted number of incident HIV-positive TB cses (red), , 3 high TB/HIV burden countries 3 Angol Botswn Brzil Cmeroon Centrl Africn Republic Chd Chin Congo DR Congo Ethiopi New nd relpse cses per yer (thousnds) Ghn Guine-Bissu Indi Indonesi Keny Lesotho Liberi Mlwi Mozmbique Mynmr Nmibi Nigeri Ppu New Guine South Afric Swzilnd Thilnd Ugnd UR Tnzni Zmbi Zimbbwe The clcultion is for ll cses in yers prior to 215. GLOBAL TUBERCULOSIS REPORT

95 FIG Estimted ART tretment coverge for HIV-positive TB cses (HIV-positive TB ptients on ART s percentge of the estimted incidence of HIV-positive TB) in 216, 3 high TB/HIV burden countries, WHO regions nd globlly Nmibi Zimbbwe Swzilnd Mlwi Ethiopi Zmbi Botswn Cmeroon Ugnd South Afric Indi Keny Chin Mozmbique Lesotho UR Tnzni Mynmr Brzil Thilnd DR Congo Centrl Africn Republic Nigeri Liberi Ppu New Guine Ghn Guine-Bissu Congo Indonesi Chd Angol Europe The Americs Afric Western Pcific South-Est Asi Estern Mediterrnen Globl Tretment coverge (%) No dt. be ssessed by compring the number of HIV-positive TB ptients on ART with the estimted number of HIV-positive incident TB cses (Fig. 4.19). This comprison revels lrger gps. Globlly in 216, the number of HIV-positive TB ptients on ART ws 39% of the estimted globl number of incident HIV-positive TB cses. There ws considerble vrition mong the high TB/HIV burden countries nd, ccording to best estimtes, only five countries chieved ART coverge of more thn 5% (Ethiopi, Mlwi, Nmibi, Swzilnd nd Zimbbwe). Improvements re still needed in the detection of ctive TB disese mong HIV-positive people, the coverge of HIV testing mong TB ptients, nd the enrolment of HIV-positive TB ptients on ART. An overview of progress nd gps in TB preventive tretment mong people living with HIV is provided in Chpter Tretment coverge for MDR/RR-TB Trends in the number of ptients enrolled in MDR-TB tretment globlly nd in the 3 high MDR-TB countries since 29 re shown in Fig nd Fig. 4.13, respectively. The number of people enrolled in tretment globlly ws in 216, representing more thn fourfold increse since 29 (when WHO first requested countries to report dt), but limited progress since 215 (when people were enrolled in tretment). There ws notble increse in enrolments in Indi between 215 nd 216 (from to ), nd modest increses in severl other high MDR-TB burden countries. However, the number of enrolments fell in 1 high MDR-TB burden countries, nd fell by more thn 1 ptients in the Russin Federtion, South Afric nd Ukrine. Globlly, the ptients strting second-line MDR-TB tretment in 216 represented 22% of the 6 estimted MDR/RR-TB incident cses in 216 (Fig. 4.2). Ten countries ccounted for round 75% of the gp between enrolments 84 GLOBAL TUBERCULOSIS REPORT 217

96 FIG. 4.2 Estimted tretment coverge for MDR/RR-TB (ptients strted on tretment for MDR-TB s percentge of the estimted incidence of MDR/RR-TB) in 216, 3 high MDR-TB burden countries, WHO regions nd globlly Kzkhstn South Afric Peru Republic of Moldov Ukrine Russin Federtion Belrus Azerbijn Viet Nm Tjikistn Kyrgyzstn Indi Zimbbwe Thilnd Mynmr Philippines DPR Kore Ppue New Guine Ethiopi Mozmbique Keny Pkistn Bngldesh DR Congo Angol Chin Nigeri Somli Indonesi Uzbekistn Europe The Americs South-Est Asi Afric Western Pcific Estern Mediterrnen Globl Tretment coverge (%) No dt. in MDR-TB tretment in 216 nd the estimted number of incident MDR/RR-TB cses in 216; Chin nd Indi ccounted for 39% of the totl gp (Fig. 4.21). The number of cses strting MDR-TB tretment in 216 ws equivlent to 85% of the MDR/RR-TB ptients notified in 216 (Fig. 4.12). The figure exceeded 9% in 14 high MDR-TB burden countries (Fig. 4.13) nd the WHO Europen Region nd the Region of the Americs; however, it ws much lower in the WHO Africn nd Western Pcific regions. 1 Enrolments represented less thn 6% of the number of notified MDR/RR-TB cses in two high MDR- TB burden countries in 216: Chin (5%) nd South Afric (59%). These low percentges show tht progress in detection is outstripping cpcity to provide tretment; they my lso reflect weknesses in dt collection systems. In these settings the risk of trnsmission of DR-TB is high nd efforts re needed to rpidly close enrolment/notifiction gps. In mny countries, one of the brriers to dequte ccess to tretment of drug-resistnt TB is tht the network for the progrmmtic mngement of drug-resistnt TB (PMDT) is too centrlized nd relint on hospitl-bsed models of cre. Greter decentrliztion nd more use of outptient models of cre re needed. Globlly, 8511 ptients with XDR-TB were enrolled in tretment in 68 countries nd territories, 17% increse compred with 215. In 29 of these countries, the number of XDR-TB cses enrolled in tretment ws less thn the number notified. Tretment coverge will not improve globlly unless there is n intensifiction of efforts in the countries with the lrgest burden, prticulrly Chin, Indi nd Indonesi. 1 For dt for WHO regions, see Annex 3. GLOBAL TUBERCULOSIS REPORT

97 FIG The ten countries with the lrgest gps between the number of ptients strted on tretment for MDR-TB nd the best estimtes of MDR/RR-TB incidence, 216 Ukrine Russin Federtion Chin Pkistn Bngldesh Mynmr Philippines Nigeri Indi 1 Indonesi 5 1 The ten countries rnked in order of the size of the gp between the gp of ptients strted on MDR-TB tretment nd the best estimte of MDR/RR-TB incidence in 216 re Indi, Chin, Indonesi, the Philippines, Pkistn, Russin Federtion, Nigeri, Ukrine, Mynmr nd Bngldesh. 4.3 Tretment outcomes This section summrizes the ltest results of tretment for new nd relpse cses of TB who strted tretment on firstline regimen in 215 (including people with HIV-ssocited TB), nd people detected with RR-TB, MDR-TB or XDR-TB who strted second-line MDR-TB regimen in The incresing role of digitl technologies in tretment support, s bsis for improving tretment outcomes, is discussed in Box 4.5. Most new nd relpse cses do not hve MDR/RR-TB, but in some prts of the world, especilly countries of the former Soviet Union, more thn 2% of new nd relpse cses do (Chpter 3). Universl ccess to DST is required to ensure tht ll people with TB receive pproprite tretment, s discussed in Section Tretment outcomes for new nd relpse TB ptients Dt on tretment outcomes for new nd relpse cses of TB in 215 re shown for the world, the six WHO regions nd the 3 high TB burden countries in Fig The globl trend 1 For definitions of tretment outcomes, see World Helth Orgniztion. Definitions nd reporting frmework for tuberculosis 213 revision (updted December 214) (WHO/HTM/TB/213.2). Genev: WHO; 213 ( ccessed 1 July 217) is shown in Fig Globlly, the tretment success rte for the 5.9 million new nd relpse cses who were treted in the 215 cohort ws 83%, s in 214. The bsolute number of TB ptients reported to hve been successfully treted hs risen substntilly over the pst 15 yers, both globlly nd in ll WHO regions (Fig. 4.24), Among the six WHO regions, the highest tretment success rtes in 215 were in the WHO Western Pcific Region (92%) nd the WHO Estern Mediterrnen Region (91%). The lowest rtes (t 76%) were in the WHO Region of the Americs (due to high levels of loss to follow-up nd missing dt) nd the WHO Europen Region (due to high rtes of tretment filure nd deth, influenced by the high frequency of MDR/RR-TB). Only seven of the 3 high TB burden countries reched or exceeded 9% tretment success rte, lthough the vlidity of tretment outcome dt ws not lwys scertined. However, in severl high TB burden countries, the completeness of outcome reporting ws low. In four countries (Centrl Africn Republic, Congo, Liberi nd Ppu New Guine), loss to follow-up exceeded 1%, nd in four countries (Brzil, Congo, Ethiopi nd Indi), more thn 1% of cses were not evluted. In Brzil (71% success), 21% of cses were either lost to follow-up or their tretment outcome ws missing. 86 GLOBAL TUBERCULOSIS REPORT 217

98 n BOX 4.5 n Digitl technologies in support of TB mediction dherence nd delivery The updted TB tretment guidelines for drug-susceptible TB published by WHO in April 217 (Box 4.2) include, for the first time, evidence-bsed recommendtions relted to the use of digitl technologies. These include short messge service (SMS, mobile phone texting), video-supported TB tretment nd electronic mediction monitors. Although dt on the impct of these interventions on improving tretment outcomes of TB ptients nd reducing costs to helth services remin limited, severl studies tht re expected to improve the qulity of the evidence nd provide more informtion on their performnce in different settings re now underwy. Digitl technologies re being used in vriety of wys in TB cre (Fig. B4.5.1). Some interventions re pilot projects wheres others re implemented t much lrger scle. Among high TB burden countries, doption in the public sector hs been reported by Cmbodi, Chin, Ppu New Guine, the Russin Federtion nd Viet Nm; use in the privte sector hs been reported by the Democrtic Republic of the Congo, Indi, Keny nd Lesotho. Mny countries in the WHO Africn Region report no use wheres severl countries especilly high-income ones re not currently ble to report informtion bout the use of digitl technologies. As ccess to the Internet nd to high-performnce mobile devices (especilly smrtphones) grows globlly, digitl tools re likely to be used (or considered for use) much more widely to help with dherence nd other spects of progrmmtic work (e.g. surveillnce, logistics mngement nd e-lerning). Continuous development nd diversifiction of technologies will crete new opportunities to mke interventions more effective or efficient, while lso mking it more chllenging to generte n evidence bse bout their effectiveness. With incresing demnd for technicl ssistnce on how to implement digitl helth interventions t lrge scle, the WHO Globl Tsk Force on digitl helth for TB is developing prcticl hndbook to ddress this need. b b World Helth Orgniztion. Tretment of tuberculosis: guidelines for tretment of drug-susceptible tuberculosis nd ptient cre (217 updte) (WHO/HTM/TB/217.5). Genev: WHO; 217 ( who.int/iris/bitstrem/1665/25552/1/ eng.pdf, ccessed 11 July 217). See (ccessed 1 August 217). digitl-helth/en/ FIG. B4.5.1 Use of short messge service, video-supported tretment or electronic mediction monitors to improve TB tretment dherence nd delivery, 216 Public only Privte only Public nd privte Not used No dt Not pplicble GLOBAL TUBERCULOSIS REPORT

99 FIG Tretment outcomes for new nd relpse TB cses in 215, 3 high TB burden countries, WHO regions nd globlly FIG Tretment outcomes for new nd relpse TB cses, new nd relpse HIV-positive TB cses, nd MDR/RR-TB cses, globlly New nd relpse TB cses Cmbodi Chin Pkistn Bngldesh Viet Nm Philippines DPR Kore UR Tnzni DR Congo Sierr Leone Mozmbique Mynmr Keny Indonesi Zmbi Ethiopi Nigeri Nmibi Thilnd South Afric Zimbbwe Centrl Africn Republic Liberi Lesotho Ppu New Guine Indi Russin Federtion Brzil Congo Angol Yer strted on tretment Yer strted on tretment HIV-positive new nd relpse TB cses Western Pcific Estern Mediterrnen Afric South-Est Asi Europe The Americs Globl Percentge of cohort (%) Yer strted on tretment MDR/RR-TB cses Percentge of cohort (%) Tretment success Filure Died Lost to follow-up Not evluted No dt reported Tretment outcomes re for new cses only. MDR/RR-TB nnul tretment cohorts re reported one yer lter thn other TB cohorts. 88 GLOBAL TUBERCULOSIS REPORT 217

100 FIG Tretment outcomes for new nd relpse TB cses (bsolute numbers), 2 215, globlly nd for WHO regions Number of cses (millions) Number of cses (millions) Number of cses (millions) Number of cses (millions) Globl Afric Estern Mediterrnen South-Est Asi Tretment success Not evluted Cohorts before 212 included new cses only The Americs Europe Western Pcific Filure/Died/Lost to follow-up Tretment outcomes for new nd relpse TB ptients coinfected with HIV A totl of 11 countries reported tretment outcomes for the 215 ptient cohort disggregted by HIV sttus; collectively, these countries ccounted for 93% of the HIV-positive TB ptients reported by NTPs in 215. These 11 countries included 24 of the 3 high TB/HIV burden countries; no dt were reported by Angol, Chd, the Democrtic Republic of the Congo, Ethiopi, Liberi nd Ppu New Guine (Fig. 4.25). Overll, the tretment success rte ws 78%, up from 68% in 212 (Fig. 4.23), lthough still worse thn the level of 83% for ll new nd relpse TB ptients. Globlly, the proportion of HIV-positive TB ptients reported hving died during tretment ws 11%, similr to previous yers nd bout three times the level mong ll new nd relpse cses (4%). The reltive difference ws smllest in the WHO Africn Region (9% versus 7%) nd highest in the WHO Western Pcific Region (13% versus 2%). Resons for comprtively poor outcomes for HIV-positive TB ptients include lte detection of HIV-ssocited TB, nd delys in strting ART or TB tretment. To reduce excessive TB mortlity in HIV-positive people, WHO recommends routine HIV testing mong presumptive nd dignosed TB cses; TB screening mong people living with HIV; erly ART; improved infection control; nd provision of TB preventive tretment. Strtegic plcement of WHO-recommended rpid moleculr TB dignostics such s Xpert MTB/RIF within HIV cre settings nd uptke of the lterl flow urine liporbinmnnn ssy (LF-LAM) for seriously ill people living with HIV could help to ensure erlier dignosis Tretment outcomes for TB ptients with MDR/RR-TB nd XDR-TB A totl of 138 countries nd territories reported tretment outcomes for people strted on MDR-TB tretment in 214. The number of cses reported in nnul cohorts hs stedily incresed over time, reching cses globlly in the 214 cohort. Overll, the proportion of MDR/RR-TB ptients in the 214 cohort who successfully completed tretment (i.e. cured or tretment completed) ws 54%: in 8% the tretment filed, 16% died, 15% were lost to follow-up nd 7% hd no outcome informtion (Fig. 4.26). Globlly, tretment success hs incresed slightly in recent yers, s hs the completeness of outcome reporting (Fig. 4.23). In the 214 cohort, the tretment success rte ws highest in the WHO Estern Mediterrnen Region (65%) nd lowest in the WHO Region of the Americs (46%). In contrst, tretment filure ws highest in the WHO Europen Region (13%), nd the deth rte ws highest in the WHO Africn nd South-Est Asi regions (2%). Loss to follow-up ws highest in the WHO Region of the Americs (21%), which lso hd the highest percentge of cses without outcome dt (2%). Among the 3 high MDR-TB burden countries, 14 hd MDR/ RR-TB cohorts in 214 with more thn 1 cses; mong these, only Kzkhstn, Mynmr nd Viet Nm reported GLOBAL TUBERCULOSIS REPORT

101 FIG Tretment outcomes for new nd relpse HIVpositive TB cses in 215, 3 high TB/HIV burden countries, WHO regions nd globlly FIG Tretment outcomes for rifmpicin-resistnt TB cses strted on tretment in 214, 3 high MDR- TB burden countries, WHO regions nd globlly Chin Zmbi Mozmbique UR Tnzni Keny Cmeroon Mlwi South Afric Nmibi Zimbbwe Swzilnd Botswn Indi Lesotho Nigeri Ghn Centrl Africn Republic Ugnd Mynmr Thilnd Guine-Bissu Indonesi Brzil Congo Angol Chd DR Congo Ethiopi Liberi Ppu New Guine DPR Kore Mynmr Somli Kzkhstn Viet Nm DR Congo Nigeri Bngldesh Keny Ethiopi Pkistn Belrus Azerbijn Thilnd Kyrgyzstn South Afric Ppu New Guine Zimbbwe Russin Federtion Indonesi Republic of Moldov Mozmbique Tjikistn Ukrine Indi Philippines Angol Chin Peru Uzbekistn Afric Western Pcific South-Est Asi Europe Estern Mediterrnen The Americs Estern Mediterrnen Afric Europe Western Pcific South-Est Asi The Americs Globl 78 Globl Percentge of cohort (%) Percentge of cohort (%) Tretment success Filure Died Lost to follow-up Not evluted No dt reported tretment success of more thn 75%. Tretment success ws less thn 5% in Chin, Indi, Peru, the Philippines nd Ukrine, due to high deth rtes in Indi (21%) nd Ukrine (17%), high rtes of tretment filure in Ukrine (18%) nd loss to follow-up or missing dt in ll five countries (19 6%) (no tretment outcome dt were reported by Uzbekistn for the 214 cohort). Among 694 ptients strted on tretment for XDR-TB in 214, in 52 countries nd territories for which outcomes were reported, 3% completed tretment successfully, 28% died, tretment filed for 21%, nd 2% were lost to followup or their tretment outcome ws not evluted. Indi, the Russin Federtion nd Ukrine ccounted for 68% of the 214 XDR-TB cohort. Among seven countries with XDR-TB cohorts of more thn 1 individuls, mortlity ws highest (42%) in Indi nd South Afric. Although improving globlly nd in some countries, tretment success rtes for drug-resistnt TB remin uncceptbly low. The wider use of shorter MDR-TB tretment regimens of 9 12 months nd of new TB drugs for ptients with MDR/ XDR-TB could help to improve this sitution. 1 1 World Helth Orgniztion. WHO tretment guidelines for drug-resistnt tuberculosis (216 updte) (WHO/HTM/TB/216.4). Genev: WHO; 216 ( resources/en/, ccessed 15 August 217). 9 GLOBAL TUBERCULOSIS REPORT 217

102 FIG Countries tht hd used shorter MDR-TB tretment regimens by the end of 216 Country response Shorter MDR-TB tretment regimens used Not used No dt Not pplicble By 216, 35 countries, mostly in Afric nd Asi, reported hving used shorter MDR-TB regimens (Fig. 4.27). These regimens hve been reported to chieve high tretment success rtes (87 9%) in selected MDR/RR-TB ptients nd stndrdized shorter MDR-TB regimen is recommended by WHO subject to eligibility criteri. By June 217, 89 countries were known to hve imported or strted using bedquiline nd 54 countries hd used delmnid (Fig nd Fig. 4.29). Most (75%) of the ptients treted with bedquiline were reported by two countries: the Russin Federtion nd South Afric. With the introduction of new drugs nd regimens, there is need for ctive TB drug-sfety monitoring nd mngement (DSM), defined s the ctive nd systemtic clinicl nd lbortory ssessment of ptients on tretment with new TB drugs, novel MDR-TB regimens or XDR-TB regimens to detect, mnge nd report suspected or confirmed drug toxicities. 1 In 216, 13 of the 3 high MDR-TB burden countries reported dt on dverse events collected from their TB informtion systems. 4.4 Subntionl TB dt: vilbility nd use Notifiction nd tretment outcome dt for subntionl res re not routinely requested by WHO in nnul rounds of globl TB dt collection. However, these dt re usully vilble t country level nd re key source of informtion, including for TB epidemiologicl reviews nd ssessment of the performnce of TB surveillnce. 2 The nlysis nd use of routinely collected dt t both ntionl nd subntionl levels re essentil to understnd the TB epidemic, inform ntionl nd locl response efforts, nd trck progress. In countries tht still rely on pper-bsed recording nd reporting systems, or hve done so until very recently, mjor chllenge in using nd nlysing subntionl TB dt is tht the dt re not vilble in electronic formt or, if they re in n electronic formt, the formt is not conducive to nlysis (e.g. multiple Microsoft Excel spredsheets). In 216, WHO strted n inititive to ddress this problem, linked to preprtions for three regionl workshops on the nlysis nd use of TB dt: two in Afric nd one in Asi. 3,4,5 1 World Helth Orgniztion. Active tuberculosis drug-sfety monitoring nd mngement (DSM): frmework for implementtion (WHO/HTM/ TB/215.28). Genev: WHO; 215 ( bitstrem/1665/24465/1/who_htm_tb_215.28_eng.pdf, ccessed 15 August 217). 2 These re discussed in more detil in Chpter 3. 3 The first workshop included countries in the West Africn Regionl Network for TB (WARN-TB) tht hs been estblished by TDR: Benin, Burkin Fso, Cpe Verde, Côte d Ivoire, Gmbi, Ghn, Guine (Conkry), Guine-Bissu, Liberi, Mli, Muritni, Niger, Nigeri, Senegl, Sierr Leone nd Togo. 4 The second workshop included Cmeroon, Centrl Africn Republic, Chd, the Democrtic Republic of the Congo, Ethiopi, Keny, Lesotho, Mlwi, Mozmbique, Nmibi, Sudn, Swzilnd, Ugnd, the United Republic of Tnzni, Zmbi nd Zimbbwe. 5 The third workshop included Bngldesh, Cmbodi, Indi, Indonesi, Mynmr, Nepl, Pkistn, the Philippines, Thilnd nd Viet Nm. GLOBAL TUBERCULOSIS REPORT

103 FIG Countries tht hd used bedquiline for the tretment of M/XDR-TB s prt of expnded ccess, compssionte use or under norml progrmmtic conditions by the end of June 217 Bedquiline used Bedquiline not used No dt Not pplicble Dt shown reflects country reporting supplemented with dditionl informtion from phrmceuticl mnucturers. FIG Countries tht hd used delmnid for the tretment of M/XDR-TB s prt of expnded ccess, compssionte use or under norml progrmmtic conditions by the end of June 217 Delmnid used Delmnid not used No dt Not pplicble Dt shown reflects country reporting supplemented with dditionl informtion from phrmceuticl mnucturers. 92 GLOBAL TUBERCULOSIS REPORT 217

104 FIG. 4.3 Subntionl dt stored in the DHIS2 pltform developed by WHO, August 217 District/fcility-level (t lest 5 yers) Regionl-level (t lest 5 yers) Limited dt Not pplicble Informtion shown only for countries where ntionl TB progrmme stff prticipted in DHIS2 workshops in The first workshop, for countries in west Afric, ws orgnized in collbortion with the Specil Progrmme for Reserch nd Trining in Tropicl Diseses (TDR), hosted by WHO nd the Globl Fund to Fight AIDS, Tuberculosis nd Mlri (Globl Fund); the second ws for countries in est, centrl nd southern Afric with the Globl Fund; nd the third ws for countries in Asi with the Globl Fund nd the Stop TB Prtnership. Before the workshops, pltform using open-source DHIS2 softwre 1 ws developed to llow the electronic compiltion nd storge of historicl TB surveillnce dt from qurterly reporting forms (both the 26 nd 213 versions) in dedicted module. Subntionl popultion estimtes, disggregted by ge nd sex wherever possible, were lso entered, nd geogrphicl informtion system shpe-files were included to llow the genertion of mps for ech indictor. Stndrd dshbords for visulizing the results from the nlyses recommended in the WHO hndbook for understnding nd using TB dt were lso developed. 2 During the workshops, prticipnts focused on exmining dt qulity nd epidemiologicl indictors displyed s stndrd grphs nd tbles, using the dt visuliztion dsh bord to help in the discussion nd inter prettion of trends, in the context of recent interventions nd TB determinnts. The workshops lso provided n opportunity for discussions between stff responsible for ntionl helth informtion systems nd stff from NTPs bout the possibility of integrting the TB module into existing DHIS2 systems, for prospective (s opposed to historic) collection of ggregtelevel dt. Prticipnts used the results to develop monitoring nd evlution investment plns, to identify key ctivities for strengthening TB surveillnce. The sttus of the vilbility of subntionl dt for the countries tht prticipted in the workshops is shown in Fig Of the 4 countries, 21 now hve their district- or fcility-level dt vilble in the DHIS2 pltform for t lest the pst 5 yers, 18 hve regionl-level dt for t lest the pst 5 yers, nd one hd uploded limited dt to the pltform. A country exmple of the subntionl nlyses conducted in the workshops is provided in Box 4.6. Efforts re now underwy to obtin the clernces necessry from other countries to feture subntionl dt in future editions of the globl TB report. Other future work includes the development of module in DHIS2 for entry of ptient-level dt. 1 See 2 World Helth Orgniztion. Understnding nd using tuberculosis dt. Genev: WHO Globl Tsk Force on TB Impct Mesurement; 214 ( ccessed 24 August 217). GLOBAL TUBERCULOSIS REPORT

105 n BOX 4.6 n Using subntionl-level TB surveillnce dt to guide locl ction in Cmbodi Cmbodi ws one of the 1 Asin countries tht prticipted in regionl workshop on the nlysis nd use of TB dt in April 217. This workshop included nlysis of subntionl dt for cse notifiction rtes, the proportion of new nd relpse cses by site of disese nd ge group, nd the coverge of HIV testing. Provincil dt for these indictors re shown in Fig. B In 216, the ntionl TB cse notifiction rte in Cmbodi ws 222 per 1 popultion; 34% of ll new nd relpse TB cses were extrpulmonry; 16% of notified cses were children ged under 15 yers; nd 86% of ll TB cses knew their HIV sttus. However, these ntionl figures conceled wide geogrphicl vrition. The highest TB cse notifiction rtes (>3 per 1 popultion) were in the northwest nd southest of the country, nd the lowest (75 per 1 popultion) were in the northest long the border with Lo People s Democrtic Republic nd Viet Nm. Extrpulmonry TB ccounted for more thn 45% of new nd relpse TB cses in five provinces, nd less thn 15% in Preh Viher province, wheres childhood TB ppered to be either underdignosed or underreported (<5% of new nd relpse cses) in six provinces, nd possibly overdignosed in 12 provinces (>15% of new nd relpse cses). In four of the 25 provinces, less thn 8% of TB ptients knew their HIV sttus, with the lowest coverge being in Mondulkiri province (51%). This subntionl vrition my indicte differences in the performnce for recording nd reporting, possible issues with ccess to helth cre, some provinces hving lrge referrl centres for dignosis or tretment, hot spots for ongoing trnsmission, nd migrtion or vrition in dignostic prctices for extrpulmonry or childhood TB. Anlysis of the dt t this level llowed the NTP to generte hypotheses for further investigtion, either through opertionl reserch or routine monitoring nd evlution mechnisms, nd to immeditely identify key provinces where locl ction to improve HIV testing coverge or investigte the possible over or underdignosis of childhood TB is required. Future monitoring of indictors t provincil level will llow the impct of corrective ctions to be ssessed. FIG. B4.6.1 Subntionl heterogeneity in TB indictors in Cmbodi: difficult interprettion TB cse notifiction rte per 1 popultion Proportion of extrpulmonry TB mong new nd relpse TB cses (%) All new nd relpse cses under 15 yers old (%) TB ptients with known HIV sttus (%) Source: Dt provided by the NTP Cmbodi for TB dt nlysis workshop in Bngkok, Thilnd (April 217). 94 GLOBAL TUBERCULOSIS REPORT 217

106

107 A ptient ttending helth fcility is given informtion bout TB in Dhk, Bngldesh GARY HAMPTON / WHO 96 GLOBAL TUBERCULOSIS REPORT 217

108 CHAPTER 5. TB prevention services n KEY FACTS AND MESSAGES n Prevention of new infections of Mycobcterium tuberculosis nd their progression to tuberculosis (TB) disese is criticl to reduce the burden of disese nd deth cused by TB, nd to chieve the End TB Strtegy trgets set for 23 nd 235. Current helth interventions for TB prevention re tretment of ltent TB infection (LTBI), with prticulr ttention to children ged under 5 yers who re household contcts of bcteriologiclly confirmed pulmonry TB cses, nd to people living with HIV; prevention of trnsmission of M. tuberculosis through infection control; nd vccintion of children with the bcille Clmette-Guérin (BCG) vccine. Globlly, in 216, there were n estimted 1.3 million children ged under 5 yers who were household contcts of bcteriologiclly confirmed pulmonry TB cses nd who were eligible for TB preventive tretment ccording to current policy recommendtions. The number of children in this ge group reported to hve been strted on TB preventive tretment incresed by 85% between 215 nd 216 (from to ), but ws still only 13% of those estimted to be eligible. Bsed on dt from 6 countries, totl of people who were newly enrolled in HIV cre were strted on TB preventive tretment in 216. As in previous yers, South Afric ccounted for the lrgest shre of the totl (41%), followed by Mozmbique, Zimbbwe nd Mlwi. In Keny, dt on the number of people newly enrolled in HIV cre who were strted on TB preventive tretment in 216 were not vilble. However, TB preventive tretment ws provided to totl of people living with HIV in 216. Combined with dt reported by other countries, this mens tht the globl totl of people living with HIV who were strted on TB preventive tretment in 216 ws t lest 1.3 million. Of the 3 high TB/HIV burden countries, 18 did not report ny provision of preventive tretment in 216. In the 12 high TB/HIV burden countries tht did report dt, coverge mong people newly enrolled in HIV cre rnged from 2.4% in Indonesi to 73% in Zimbbwe. In countries with low burden of TB, there is need to improve initition, completion nd reporting of TB preventive tretment for other t-risk popultions, including clinicl risk groups such s ptients with silicosis, ptients strting nti-tumour necrosis fctor (TNF) therpy nd ptients prepring for orgn trnsplnttion. The rtio of the TB notifiction rte mong helthcre workers to the TB notifiction rte in the generl dult popultion is good indictor of the impct of TB infection control in helth fcilities. In 216, totl of 8144 helth-cre workers were reported with TB from 6 countries; Chin ccounted for 39% of these cses. In seven countries (Burkin Fso, Colombi, Dominicn Republic, Georgi, Lithuni, Mexico nd Venezuel), the number of TB cses per 1 helth-cre workers ws more thn double the notifiction rte in the generl dult popultion. BCG vccintion should be provided s prt of ntionl childhood immuniztion progrmmes ccording to country s TB epidemiology. In 216, 154 countries reported providing BCG vccintion s stndrd prt of these progrmmes, of which 111 reported coverge bove 9%. Monitoring nd evlution of TB prevention services is chllenging given the lck of stndrd systems for recording nd reporting dt, nd the involvement of multiple service providers. WHO hs developed mobile phone ppliction (pp) to fcilitte monitoring nd evlution of the progrmmtic mngement of LTBI. Development nd expnded use of shorter regimens for TB preventive tretment, which require smller number of doses nd re ssocited with fewer dverse events, will fcilitte lrge-scle implementtion. Additionlly, innovtive dignostic tests with improved performnce nd predictive vlue re needed to trget individuls who will benefit most from TB preventive tretment. World Helth Orgniztion. WHO End TB Strtegy: globl strtegy nd trgets for tuberculosis prevention, cre nd control fter 215. Genev: WHO; 215 ( tb/post215_strtegy/en/, ccessed 8 August 216). GLOBAL TUBERCULOSIS REPORT

109 Prevention of new infections of Mycobcterium tuberculosis nd their progression to tuberculosis (TB) disese is criticl to reduce the burden of disese nd deth cused by TB, nd to chieve the End TB Strtegy trgets set for 23 nd The trgets of n 8% reduction in TB incidence from the 215 level by 23, nd 9% reduction by 235, will require historiclly unprecedented ccelertion in the rte t which TB incidence flls fter 225 (Chpter 2). This ccelerted rte is possible only if the probbility of progression from ltent TB infection (LTBI) to ctive TB disese mong the 1.7 billion people lredy infected worldwide 2 is drsticlly reduced below the current lifetime risk of 5 15%. 3 In some low-burden countries, rectivtion ccounts for bout 8% of new cses of disese. 4,5 Interventions tht could result in much greter reduction include more effective tretments for LTBI nd development of vccine to prevent rectivtion of LTBI in dults. Currently, three mjor ctegories of helth interventions re vilble for TB prevention: tretment of LTBI through ny of the following: isonizid dily for 6 or 9 months, isonizid plus rifmpicin dily for 3 4 months, rifmpicin dily for 3 4 months, or isonizid plus rifpentine weekly for 3 months; prevention of trnsmission of M. tuberculosis through infection control; nd vccintion of children with the bcille Clmette-Guérin (BCG) vccine. The three min sections of this chpter present nd discuss progress in provision of these services. Prticulr ttention is given to the 3 high TB burden countries nd the 3 high TB/ HIV burden countries (Chpter 2). 5.1 Tretment of ltent TB infection LTBI is defined s stte of persistent immune response to M. tuberculosis without cliniclly mnifested evidence of ctive TB disese. WHO recommends specific efforts to dignose nd tret LTBI in two prticulr t-risk groups: children ged under 5 yers who re household contcts of bcteriologicllyconfirmed pulmonry TB cses, nd people living with HIV. 6 1 World Helth Orgniztion. WHO End TB Strtegy: globl strtegy nd trgets for tuberculosis prevention, cre nd control fter 215. Genev: WHO; 215 ( ccessed 8 August 216). 2 Houben RM, Dodd PJ. The globl burden of ltent tuberculosis infection: re-estimtion using mthemticl modelling. PLoS Med. 216;13(1):e12152 ( ccessed 2 August 217). 3 Vynnycky E, Fine PE. Lifetime risks, incubtion period, nd seril intervl of tuberculosis. Am J Epidemiol. 2;152(3): Heldl E, Docker H, Cugnt DA, Tverdl A. Pulmonry tuberculosis in Norwegin ptients. The role of rectivtion, re-infection nd primry infection ssessed by previous mss screening dt nd restriction frgment length polymorphism nlysis. Int J Tuberc Lung Dis. 2;4(4): She KM, Kmmerer JS, Winston CA, Nvin TR, Horsburgh CR. Estimted rte of rectivtion of ltent tuberculosis infection in the United Sttes, overll nd by popultion subgroup. Am J Epidemiol. 214;179(2): World Helth Orgniztion. Guidelines on the mngement of ltent tuberculosis infection. Genev: WHO; 215 ( publictions/ltbi_document_pge/en/, ccessed 3 August 216). Coverge of contct investigtion nd tretment of LTBI mong child contcts nd people living with HIV re mong the 1 indictors listed s highest priority for monitoring implementtion of the End TB Strtegy, with trget of over 9% coverge by 225 t the ltest (Chpter 2, Tble 2.2). Dt on provision of TB preventive tretment for people living with HIV hve been collected by WHO for more thn 1 yers. However, until 216 there ws no stndrdized globl guidnce on how to monitor the coverge of preventive tretment mong child contcts or other high-risk groups. Such guidnce ws developed by WHO globl LTBI tsk force in 216, 7 nd the recommended indictors re shown in Tble 5.1. The rest of this section presents nd discusses dt bout TB preventive tretment for these three risk groups. The dt were gthered from countries nd territories in WHO s 217 round of globl TB dt collection Child contcts ged under 5 yers who re household contcts of TB cses There were 191 countries tht reported t lest one notified bcteriologiclly confirmed pulmonry TB cse in 216. Of these countries, 118 (63%) reported dt bout the number of household contcts ged under 5 yers who were strted on TB preventive tretment (Fig. 5.1), including 16 of the 3 high TB burden countries (compred with nine countries tht reported dt for 215). Among the 118 countries, 11 reported t lest one child strted on preventive tretment (compred with 89 countries in 215). A totl of child household contcts were reported to hve been initited on TB preventive tretment (Tble 5.2) in 216, n 85% increse from in 215. The lrgest numbers were reported by the WHO Africn Region (46% of the globl totl) nd the South-Est Asi Region (19% of the globl totl). At country level, Mozmbique reported the lrgest number (19 634), followed by Afghnistn (15 417). Comprisons of the number of children strted on TB preventive tretment in 216 with ntionl estimtes of the number of children ged under 5 yers who were contcts of bcteriologiclly confirmed pulmonry TB cses nd thus eligible for such tretment re shown in Tble Globlly, the children strted on TB preventive tretment in 216 represented 13% of the 1.3 million children estimted to be eligible for tretment. Higher levels of coverge were chieved in the WHO Region of the Americs (best estimte 68%; rnge, 64 72%), followed by the Europen Region (best estimte 55%; rnge, 52 58%) People living with HIV Provision of TB preventive tretment to those newly enrolled in HIV cre hs grown substntilly since 29, lbeit from low levels, nd reched people in 216 (Fig. 5.2). Most of the increse occurred from 29 to 214, nd hs The online technicl ppendix is vilble t 98 GLOBAL TUBERCULOSIS REPORT 217

110 TABLE 5.1 Summry of monitoring nd evlution indictors recommended by WHO for the progrmmtic mngement of LTBI CORE GLOBAL AND NATIONAL INDICATORS CORE NATIONAL INDICATORS OPTIONAL INDICATORS 1) Proportion of children less thn 5 yers old who re household TB contcts (ccording to ntionl guidelines) who hve completed TB investigtions. 2) Proportion of children under 5 yers old who re household TB contcts (ccording to ntionl guidelines) who re eligible for strting on TB preventive therpy tht hve strted tretment. 3) Proportion of eligible people living with HIV newly enrolled in HIV cre, strted on TB preventive therpy. 4) Proportion of eligible individuls from t risk popultions (ccording to ntionl guidelines) tested for ltent TB infection. 5) Proportion of individuls from t risk popultions (ccording to ntionl guidelines) with positive ltent TB test who re eligible for strting TB preventive therpy tht hve strted tretment. 6) Proportion of individuls from t risk popultions (ccording to ntionl guidelines) with positive ltent TB test who hve strted on TB preventive therpy tht hve completed the course. 7) Proportion of eligible people living with HIV who completed course of TB preventive therpy. 8) Proportion of children less thn 5 yers old who re household TB contcts (ccording to ntionl guidelines) who hve completed course of TB preventive therpy. 9) TB incidence rte mong risk popultions (s defined by ntionl guidelines). FIG. 5.1 Avilbility of dt on the number of children ged <5 yers who were household contcts of bcteriologiclly confirmed pulmonry TB cses nd were strted on TB preventive tretment, 216 Country response Number vilble from routine surveillnce Number estimted from survey Number not vilble No dt Not pplicble GLOBAL TUBERCULOSIS REPORT

111 TABLE 5.2 TB preventive tretment in 216 for people living with HIV nd children under 5 yers of ge who were household contcts of bcteriologiclly confirmed pulmonry TB cse, 23 high TB or TB/HIV burden countries tht reported dt, WHO regions nd globlly NUMBER OF PEOPLE LIVING WITH HIV NEWLY ENROLLED IN CARE IN 216 (A) PEOPLE NEWLY ENROLLED IN HIV CARE WHO WERE STARTED ON TB PREVENTIVE TREATMENT IN 216 NUMBER (B) COVERAGE, % (B*1 A) ESTIMATED NUMBER OF CHILD HOUSEHOLD CONTACTS UNDER 5 YEARS OF AGE ELIGIBLE FOR TB PREVENTIVE TREATMENT, IN 216 (C) b CHILDREN UNDER 5 YEARS OF AGE WHO WERE STARTED ON TB PREVENTIVE TREATMENT IN 216 NUMBER (D) COVERAGE, % (D*1 C) Bngldesh 49 (45 53 ) (16 19) Cmbodi ( ) (33 39) DPR Kore 11 ( ) c DR Congo 75 (68 82 ) ( ) Ethiopi (26 31 ) Guine-Bissu 21 ( ) ( ) Indi (33 39 ) (1.7 2) Indonesi (6 71 ) ( ) Liberi ( ) (4. 4.8) Mlwi ( ) (46 55) Mozmbique (18 21 ) (91 1) Mynmr (15 18 ) ( ) Nmibi 3 1 ( ) (24 28) Nigeri (43 51 ) (17 2) Philippines (51 6 ) ( ) Russin Federtion ( ) 9 85 d Sierr Leone ( ) South Afric (42 5 ) Swzilnd ( ) Ugnd 21 (19 23 ) ( ) UR Tnzni (19 22 ) (28 34) Viet Nm (14 17 ) (18 21) Zimbbwe ( ) (58 69) Afric (45 47 ) (16 17) The Americs (22 25 ) (64 72) Estern Mediterrnen (14 16 ) (15 17) Europe (13 14 ) (52 58) South-Est Asi (48 55 ) ( ) Western Pcific (89 1 ) (9.5 11) GLOBAL ( ) (12 13) Blnk cells indicte dt not reported. There were 15 other countries in the list of high TB or TB/HIV burden countries tht did not report dt for either risk group. These were Angol, Botswn, Brzil, Centrl Africn Republic, Chd, Chin, Congo, Ghn, Guine-Bissu, Keny, Lesotho, Pkistn, Ppu New Guine, Thilnd, nd Zmbi. b This is the estimted number of children under 5 yers of ge who were household contcts of notified bcteriologiclly confirmed pulmonry TB cse, nd eligible for TB preventive tretment, 216. Estimtes re shown to two significnt figures for numbers below 1 million, nd to three significnt figures for numbers bove 1 million. c d This number includes contcts ged 5 7 yers. Therefore, the estimted coverge ws not clculted. This number includes contcts other thn household contcts. Therefore, estimted coverge ws not clculted. The number ws lso not included in the regionl nd globl figures. 1 GLOBAL TUBERCULOSIS REPORT 217

112 FIG. 5.2 Provision of TB preventive tretment to people living with HIV, Number of people living with HIV (thousnds) Rest of world Globl Rest of Afric South Afric subsequently levelled off. In 216, totl of 6 countries (representing 7% of the estimted globl burden of HIVssocited TB) reported providing preventive TB tretment to people newly enrolled in HIV cre, compred with 57 countries in 215. As in previous yers, South Afric ccounted for the lrgest proportion (41%) of the globl totl in 216 (Fig. 5.2), followed by Mozmbique, Zimbbwe nd Mlwi (Tble 5.2). Lrge bsolute increses compred with 215 numbers were reported in Zimbbwe ( ), Mozmbique ( ) nd Nigeri ( ). Two of the 3 high TB/HIV burden countries, Indi nd Liberi, reported dt for the first time. In Keny, dt on the number of people newly enrolled in HIV cre who were strted on TB preventive tretment in 216 were not vilble. However, TB preventive tretment ws provided to totl of people living with HIV in 216. Combined with dt reported by other countries, this mens tht the globl totl of people living with HIV who were strted on TB preventive tretment in 216 ws t lest 1.3 million. Despite progress in some countries, much remins to be done. For exmple, of the 3 high TB/HIV burden countries, 18 did not report ny provision of TB preventive tretment in 216; nd in the 12 countries tht provided dt, coverge mong people newly enrolled in HIV cre vried considerbly, from 2.4% in Indonesi to 73% in Zimbbwe (Tble 5.2). Fig. 5.3 shows gps in the provision of TB preventive tretment to people living with HIV for selected high TB burden countries or high TB/HIV burden countries. Accelerting progress in the globl nd ntionl response to HIV-ssocited TB is one of the eight themtic trcks t the WHO Ministeril Conference on Ending TB in the SDG Er, to be held in November 217. This theme will include specific focus on ending TB deths mong people living with HIV, including through wider use of TB preventive tretment. It is hoped tht the conference will glvnize greter politicl commitment, nd in turn expedite the scle-up of key interventions for HIV-ssocited TB, including TB preventive tretment. FIG. 5.3 Gps in TB preventive tretment for people who were newly enrolled in HIV cre in 216, selected countries 1 8 Percentge Indonesi Mynmr Indi Liberi Swzilnd Sierr Leone Nigeri Philippines Mlwi Ethiopi Zimbbwe Strted on preventive tretment Detected nd notified with ctive TB disese Gp in TB detection nd TB prevention b b The selected countries re high TB or TB/HIV burden countries tht reported on ll three of the following: the number of people newly enrolled in HIV cre; the number of TB cses detected mong people newly enrolled on HIV cre; nd the number of people newly enrolled on HIV cre who were strted on TB preventive tretment. In high TB burden countries, testing for LTBI is not requirement for initition of TB preventive tretment, such tht ll those without ctive TB disese re eligible for TB preventive tretment. The gp represents people living with HIV who should hve undergone complete evlution for TB disese or TB preventive tretment. GLOBAL TUBERCULOSIS REPORT

113 TABLE 5.3 Provision of TB preventive tretment to other t-risk popultions in 216, for selected low TB burden countries for which dt could be reported NUMBER OF INDIVIDUALS AMONG AT RISK POPULATIONS ELIGIBLE AND STARTED ON TB PREVENTIVE TREATMENT AT-RISK POPULATIONS FOR WHICH THERE IS A STRONG RECOMMENDATION TO PROVIDE PREVENTIVE THERAPY AT-RISK POPULATIONS FOR WHICH THERE IS A CONDITIONAL RECOMMENDATION TO PROVIDE PREVENTIVE THERAPY CHILDREN AGED 5 YEARS OR OLDER AND ADULT CONTACTS OF TB CASES PATIENTS INITIATING ANTI-TNF TREATMENT PATIENTS RECEIVING DIALYSIS PATIENTS PREPARING FOR ORGAN OR HAEMATOLOGICAL TRANSPLANTATION PATIENTS WITH SILICOSIS IMMIGRANTS FROM HIGH TB BURDEN COUNTRIES HEALTH WORKERS PRISONERS HOMELESS PEOPLE ILLICIT DRUG USERS Frnce 275/55 186/397 b 18/18 b 177/3 b Jpn Netherlnds 686/867 6/66 17/19 4/4 / 88/17 31/42 Portugl c 87 Republic of Kore 2133/ / /23 Slovki 35/55 158/352 28/64 1/2 2/2 15/12 15/15 6/36 /2 Blnk cells indicte dt not reported. The denomintor is n estimte bsed on extrpoltion from dt reported in 215. b Dt re limited to individuls identified through contct trcing. c This number includes 64 people in community housing Other t-risk popultions Dt on provision of TB preventive tretment to other t-risk popultions were reported by six countries: Frnce, Jpn, the Netherlnds, Portugl, Republic of Kore nd Slovki (Tble 5.3). These countries reported providing preventive tretment to children ged 5 yers or more nd to dult contcts. Coverge ws more thn 5% in the four countries tht reported denomintors (i.e. dt on the number of people eligible). Dt for clinicl risk groups such s ptients strting nti-tumour necrosis fctor (TNF) therpy nd those prepring for orgn trnsplnttion were reported by the Netherlnds, Portugl nd Slovki Fcilitting collection nd nlysis of dt on TB preventive tretment Routine collection of dt bout TB preventive tretment remins chllenging, prticulrly dt for clinicl risk groups. Resons include the fct tht notifiction of LTBI is not mndtory in most countries; the existence of multiple pper-bsed registers; frgmenttion of monitoring nd evlution systems mong multiple service providers; nd lrge, unregulted privte helth sector in some countries. To fcilitte fster nd more complete dt collection, WHO hs developed mobile phone ppliction (pp) to record nd report cse-bsed dt on TB preventive tretment (Box 5.1). 5.2 TB infection control TB infection control is one of the components of Pillr 2 of the End TB Strtegy (Chpter 2); it is lso one of the collbortive TB/HIV ctivities tht flls under Pillr 1. The risk of TB trnsmission is high in helth-cre nd other congregte settings. This puts helth-cre workers t greter risk of TB infection nd disese, nd nosocomil outbreks of multidrug-resistnt TB (MDR-TB) nd extensively drug-resistnt TB (XDR-TB) mong people living with HIV hve been documented in the literture. 1,2 TB infection control should be prt of ntionl infection prevention nd control policy. Thus, TB nd HIV progrmmes t ntionl nd subntionl level should provide mngeril direction to implement TB infection control mesures. In helthcre fcilities nd congregte settings, comprehensive set of infection control mesures comprising dministrtive, environmentl nd personl protection mesures should be implemented. 3 Periodic ssessment of TB infection control in helth-cre fcilities is essentil to ensure tht pproprite mesures re in plce. 4 In the ltest revision of WHO guidnce on monitoring nd evlution of collbortive TB/HIV ctivities, 5 the risk of TB mong helth-cre workers reltive to the risk in the generl dult popultion is one of the globl indictors recommended to mesure the impct of TB infection control ctivities in helthcre fcilities. If effective TB infection control mesures re in plce, the reltive risk of TB in helth-cre workers compred with the generl dult popultion should be close to 1. 1 Gndhi NR, Weissmn D, Moodley P, Rmthl M, Elson I, Kreiswirth BN et l. Nosocomil trnsmission of extensively drug-resistnt tuberculosis in rurl hospitl in South Afric. J Infec Dis. 213;27(1): Moro ML, Gori A, Errnte I, Infuso A, Frnzetti F, Sodno L et l. An outbrek of multidrug-resistnt tuberculosis involving HIV-infected ptients of two hospitls in Miln, Itly. AIDS. 1998;12(9): World Helth Orgniztion. WHO policy on TB infection control in helth-cre fcilities. Genev: WHO; 29 ( bitstrem/1665/44148/1/ _eng.pdf, ccessed 31 August 216). 4 World Helth Orgniztion. Checklist for periodic evlution of TB infection control in helth-cre fcilities. Genev: WHO; 215 ( tb/res-of-work/preventive-cre/checklist_for_periodic_evlution_of_ tb_infection_control_in_helth_fcilities.pdf, ccessed 13 July 217). 5 World Helth Orgniztion. A guide to monitoring nd evlution for collbortive TB/HIV ctivities: 215 revision. Genev: WHO; 215 ( ccessed 31 August GLOBAL TUBERCULOSIS REPORT 217

114 n BOX 5.1 n A mobile ppliction for cse-bsed recording nd reporting for LTBI Coverge of contct investigtion nd tretment of LTBI mong child contcts nd people living with HIV re both in the 1 indictors listed s highest priority for monitoring implementtion of the End TB Strtegy. However, systemtic monitoring nd evlution of the progrmmtic mngement of LTBI remins wek in mny countries. The estblishment of monitoring systems is prticulrly chllenging when multiple helth-cre service providers re involved. A globl consulttion on LTBI convened by WHO in 216 recognized the potentil role of digitl helth in fcilitting implementtion of the progrmmtic mngement of LTBI, nd the ssocited monitoring nd evlution. After the consulttion, mobile phone ppliction to fcilitte monitoring nd evlution of progrmmtic mngement of LTBI ccording to interntionl stndrds ws developed by WHO, with support from the Europen Respirtory Society. The ppliction uses DHIS2 softwre nd cn be integrted into existing ntionl electronic surveillnce systems. It is designed to help helth-cre workers to collect client vribles (e.g. demogrphic, clinicl nd tretment outcome vribles) required to monitor indictors for TB preventive tretment. The ppliction genertes unique identifiers (bsed on the demogrphic dt) tht llow cse-bsed recording nd reporting. If required, dt cn be entered offline nd synchronized to the centrl dtbse lter. Using n online dshbord, users cn trck indictors in rel time. Indictors re disggregted by risk groups t ntionl, subntionl nd fcility levels. The dshbord lso provides geosptil dt nd llows users to visulize the loction of clients on mp. This fcilittes the provision of preventive tretment nd follow-up visits, prticulrly for household contcts. The ppliction is freely downlodble from the WHO website nd cn be dpted to meet country-specific contexts, such s the vilbility of ntionl unique identifiers, the existence of DHIS2 system, nd the presence of different risk groups. WHO is plnning to strt field-testing of the ppliction to investigte ccess nd cceptbility in severl settings lter in en/ (ccessed 9 October 217) In 216, 8144 TB cses mong helth-cre workers were reported from 6 countries; Chin ccounted for 39% of these cses nd Brzil for 13%. The notifiction rte mong helthcre workers could be clculted for 54 of the 6 countries; it rnged from zero to 71 cses per 1 popultion, with the highest rte observed in Mozmbique. The notifiction rte mong the generl dult popultion in ech country ws clculted bsed on the number of notified TB cses in dults nd the estimted size of the dult popultions from the United Ntions popultion division (217 revision). The rtios of the TB notifiction rte mong helthcre workers to the rte in the generl dult popultion re shown in Fig The rtio ws bove two in seven countries (Burkin Fso, Colombi, Dominicn Republic, Georgi, Lithuni, Mexico nd the Bolivrin Republic of Venezuel). In five high TB/HIV burden countries for which the rtio could be clculted, the rtio ws between 1 nd 2 in two countries (Botswn nd Mozmbique) nd below 1 in three countries (Angol, Chin nd Nmibi). 5.3 TB vccintion There is cler need for vccine tht is more effective thn the BCG vccine, in prticulr to reduce the risk of infection with M. tuberculosis nd the risk of progression from infection to ctive TB disese in dults. Although there re 12 cndidtes in the TB vccine pipeline, new TB vccine is not expected in the ner future (Chpter 8). BCG vccintion hs been shown to prevent disseminted disese; this ctegory includes TB meningitis nd miliry TB, which re ssocited with high mortlity in infnts nd young children. Currently, WHO recommends tht, in countries with high TB burden, single dose of the BCG vccine should be provided to ll infnts s soon s possible fter birth s prt of childhood immuniztion progrmmes. In countries with low TB incidence rtes, provision of the BCG vccine my be limited to neontes nd infnts in recognized high-risk groups, or to older children who re skin-test negtive for TB infection. Fig. 5.5 summrizes ntionl policies on BCG vccintion. 1 Among 178 countries for which dt were collected, 153 recommended universl BCG vccintion; the remining countries hd policies of selective vccintion for t-risk individuls in high-risk groups. The ltest dt on BCG coverge 2 (for 216) re shown in 1 The BCG world tls 2nd Edition. ccessed 25 July tscovergebcg.html, ccessed 25 July 217. GLOBAL TUBERCULOSIS REPORT

115 FIG. 5.4 Notifiction rte rtio of TB mong helthcre workers compred with the generl dult popultion, 216 Notifiction rte rtio No dt Not pplicble FIG. 5.5 BCG vccintion policy by country BCG recommendtion type A B C No dt Not pplicble A. The country currently hs universl BCG vccintion progrmme. B. The country used to recommend BCG vccintion for everyone, but currently does not. C. The country recommends BCG vccintion only for specific groups. Source: The BCG World Atls 2nd Edition. ccessed 25 July GLOBAL TUBERCULOSIS REPORT 217

116 FIG. 5.6 Coverge of BCG vccintion, 216 Percentge No dt Not pplicble The trget popultion of BCG coverge vries depending on ntionl policy, but is typiclly for the number of live births in the yer of reporting. Source: ccessed 25 July 217. Fig In the 154 countries tht reported dt, 111 reported coverge of more thn 9%. Among the 3 high TB burden countries, coverge rnged from 58% in Angol nd Nigeri to 99% in Cmbodi, Chin, Mozmbique, the United Republic of Tnzni nd Zmbi, nd 12 reported coverge of t lest 9%. In ddition to Angol nd Nigeri, coverge ws below 8% in two other high TB burden countries: Lesotho nd Ppu New Guine. GLOBAL TUBERCULOSIS REPORT

117 Ptients queue t hospitl phrmcy in Zomb, Mlwi SIMON RAWLES / ALAMY STOCK PHOTO

118 CHAPTER 6. Finncing for TB prevention, dignosis nd tretment n KEY FACTS AND MESSAGES n The Stop TB Prtnership s Globl Pln to End TB, (the Globl Pln) estimtes tht, in low- nd middle-income countries, US$ 52 billion is required over 5 yers to implement interventions tht re currently vilble. The mount required for 217 is US$ 9.2 billion, which increses to US$ 12.3 billion in 22. Most of this funding is for dignosis nd tretment of drug-susceptible tuberculosis (TB) (e.g. US$ 7. billion in 217), but the mount for dignosis nd tretment of multidrug-resistnt TB (MDR-TB) increses from US$ 2. billion in 217 to US$ 3.6 billion by 22; the reminder is for TB/HIV interventions. From 216 to 22, further US$ 6.3 billion is needed for high-income countries, nd n dditionl US$ 9. billion is needed for TB reserch nd development. Bsed on dt reported to WHO by 118 low- nd middle-income countries with 97% of the world s notified TB cses, US$ 6.9 billion is vilble for TB prevention, dignosis nd tretment in 217. Although n increse from previous yers, this figure still represents shortfll of US$ 2.3 billion compred with the estimted requirement for this group of countries in the Globl Pln. Incresed domestic nd interntionl donor commitments re needed to close the funding gps. Of the totl US$ 6.9 billion vilble in 118 low- nd middle-income countries in 217, US$ 5.8 billion (84%) is from domestic sources. However, this ggregte figure is strongly influenced by the BRICS group of countries (Brzil, the Russin Federtion, Indi, Chin nd South Afric). BRICS ccounted for 46% of the vilble funding for TB in 217 (nd 48% of the world s notified TB cses), with 95% (rnge 89% 1%) of their funding coming from domestic sources. In other countries with high TB burden, interntionl donor funding remins crucil, ccounting for 48% of the funding vilble in the 25 high TB burden countries outside BRICS (which hve 38% of the world s notified TB cses) nd for 56% of funding in low-income countries. In Indi, the country with the lrgest burden of TB disese, mrked increse occurred in the TBspecific budget nd the domestic funding for this budget in 217. This followed high-level (Prime Ministeril) politicl commitment to n mbitious gol of ending TB by 225 nd the development of new ntionl strtegic pln for TB The budget in 217 is US$ 525 million (lmost double the 216 budget of US$ 28 million), nd is fully funded, including US$ 387 million (74%) from domestic sources (triple the 216 mount of US$ 124 million). Interntionl donor funding reported by ntionl TB progrmmes mounts to US$ 1.1 billion in 217. The single lrgest source (8% of the totl) is the Globl Fund to Fight AIDS, Tuberculosis nd Mlri. The lrgest bilterl donor is the United Sttes government, which lso provides bout one-third of the contributions received by the Globl Fund. Interntionl donor funding for TB flls fr short of the US$ 2.6 billion nnul requirement included in the Globl Pln, nd remins much less thn donor contributions for HIV nd mlri. The ltest dt from the Orgnistion for Economic Co-opertion nd Development (OECD) creditor reporting system, which re for 215, show disbursement totls of US$ 6.2 billion for HIV, US$ 1.8 billion for mlri nd US$.8 billion for TB. To provide some context for these mounts, the ltest estimtes (for 215) of the burden of disese in terms of disbility-djusted life yers (DALYs) lost due to illness nd deth re 67 million for HIV/AIDS, 56 million for mlri nd 4 million for TB. The medin cost per ptient treted in 216 ws US$ 1253 for drug-susceptible TB nd US$ 9529 for MDR-TB. Helth finncing dt from ntionl helth ccounts provide importnt insights into the current sttus of progress towrds universl helth coverge, s discussed in Chpter 7. The Globl Pln to End TB, Genev: Stop TB Prtnership; 215 ( ccessed 14 July 217). GLOBAL TUBERCULOSIS REPORT

119 Progress in tuberculosis (TB) prevention, dignosis nd tretment requires dequte funding sustined over mny yers. WHO begn nnul monitoring of funding for TB in 22, with findings published in globl TB reports nd peerreviewed publictions. 1 This chpter hs four min sections. It strts with summry of the most up-to-dte estimtes of the finncil resources required to chieve the 22 milestones of the End TB Strtegy (Section 6.1). It then presents nd discusses trends in funding for TB prevention, dignosis nd tretment by ctegory of expenditure nd source of funding for the period , both globlly nd for mjor country groupings (Section 6.2). More detiled country-specific dt for 217 re lso presented for the 3 high TB burden countries. The third section nlyses funding gps reported by ntionl TB progrmmes (NTPs) to WHO, with brekdowns by ctegory of expenditure nd country group (Section 6.3). The finl section provides the ltest estimtes (for 216) of the unit costs of tretment for drug-susceptible TB nd multidrugresistnt TB (MDR-TB) (Section 6.4). As highlighted in the previous two editions of the Globl tuberculosis report, 2,3 nlysis of helth finncing dt cn provide importnt insights into progress towrds universl helth coverge (UHC), which is necessry to chieve the End TB Strtegy milestones set for 22 nd 225 (Chpter 2). Mesurement of costs fced by TB ptients nd their households is lso required to ssess progress towrds one of the three high-level indictors of the End TB Strtegy; tht is, the percentge of TB ptients nd their households who fce ctstrophic costs s result of TB disese. The 22 milestone of zero set for this indictor requires progress in terms of both UHC nd socil protection (included under Pillr 2 of the End TB Strtegy). These two topics nlysis of helth finncing dt, nd mesurement of costs fced by TB ptients nd their households re discussed in Chpter 7. Further country-specific dt on TB finncing cn be found in finnce profiles tht re vilble online Estimtes of funding required to chieve the 22 milestones of the End TB Strtegy The 22 milestones of the End TB Strtegy re 35% reduction in TB deths compred with deths in 215, 2% reduction in the TB incidence rte compred with 215, nd tht no TB ptients nd their households fce ctstrophic 1 The most recent publiction is: Floyd K, Fitzptrick C, Pntoj A, Rviglione M. Domestic nd donor finncing for tuberculosis cre nd control in low-income nd middle-income countries: n nlysis of trends, 22 11, nd requirements to meet 215 trgets. Lncet Glob Helth. 213;1(2):e ( ccessed 14 July 217). 2 World Helth Orgniztion. Globl tuberculosis report 215. Genev: WHO; 215 ( eng.pdf, ccessed 14 July 217). 3 World Helth Orgniztion. Globl tuberculosis report 216. Genev: WHO; 216 ( eng.pdf, ccessed 14 July 217). 4 costs s consequence of TB disese (Chpter 2). Estimtes of the funding required to chieve these milestones hve been set out in the Stop TB Prtnership s Globl Pln to End TB, (the Globl Pln). 5 Worldwide, the totl mount required for implementtion of TB prevention, dignostic nd tretment interventions is US$ 58 billion for the period , rising from US$ 9.5 billion in 216 to US$ 14 billion in An dditionl US$ 9. billion is needed for globl TB reserch nd development in the sme period. 6 Of the US$ 58 billion required over 5 yers (excluding reserch nd development), n estimted US$ 52 billion is required in low- nd middle-income countries, growing from US$ 8.3 billion in 216 to US$ 12 billion in 22 (Fig. 6.1). In 217, n estimted totl of US$ 9.2 billion is required: US$ 7. billion (75%) for dignosis nd tretment of drug-susceptible TB, US$ 2. billion for drug-resistnt TB 7 nd the reminder for TB/HIV interventions. The mount for TB/HIV interventions is comprtively smll becuse it does not include the funding needed for ntiretrovirl therpy for HIV-positive TB ptients; this figure is insted included in estimtes of funding required for HIV, published by UNAIDS. 8 In the Globl Pln, estimtes of the funding tht could be mobilized from domestic nd interntionl donor sources FIG. 6.1 Estimtes of funding required for TB prevention, dignosis nd tretment in low- nd middleincome countries in the Globl Pln to End TB US$ billions Drug-susceptible TB MDR-TB TB/HIV collbortive ctivities Funding estimtes for TB/HIV exclude the cost of ntiretrovirl therpy (ART) for TB ptients living with HIV. Such costs re included in globl estimtes of the funding required for HIV, published by UNAIDS. Source: Dt from Stop TB Prtnership Globl Pln to End TB The Globl Pln to End TB, Genev: Stop TB Prtnership; 215 ( ccessed 14 July 217). 6 Funding for TB reserch nd development, which is monitored by the Tretment Action Group, is discussed further in Chpter 8. 7 The burden of drug-resistnt TB (in terms of cses per yer) is not projected to increse between 216 nd 22. Incresed funding is required to close detection nd tretment gps (see lso Chpter 4). 8 World Helth Orgniztion. Globl tuberculosis report 216. Genev: WHO; 216 ( ccessed 2 July 217). 18 GLOBAL TUBERCULOSIS REPORT 217

120 FIG 6.2 The 118 low- nd middle-income countries included in nlyses of TB finncing, Countries were included in trend nlyses if t lest three yers of high-qulity finnce dt were vilble in the period were restricted to countries eligible to pply to the Globl Fund to Fight AIDS, Tuberculosis nd Mlri (the Globl Fund). 1 For eligible countries, the funding required over 5 yers mounted to US$ 29 billion. Of this totl, it ws estimted tht bout US$ 16 billion could be mobilized from domestic sources, nd tht the reminder (n verge of US$ 2.6 billion per yer) would need to be provided by interntionl donors. The Globl Pln did not ttempt to ssess the broder investments required to increse the overll coverge nd qulity of helth-cre services or to remove finncil brriers to ccessing cre. Such investments re needed for mny essentil preventive, tretment nd cre interventions, not only for TB. Progress on these fronts is criticl, s explined in Chpter 2 nd s reflected in Pillr 2 of the End TB Strtegy. The costings in the Globl Pln cn thus be seen s the finncil resources required for Pillrs 1 nd 3 of the End TB Strtegy. Recent estimtes of the funding required in low- nd middleincome countries to chieve UHC by 23 re presented nd discussed in Chpter TB funding, overll nd by ctegory of expenditure nd source of funding, Dt reported by NTPs to WHO since 26 were used to nlyse funding trends for in 118 low- nd middle- 1 Countries not eligible to pply to the Globl Fund include Brzil, Chin, the Russin Federtion nd bout hlf of the other 52 countries clssified s upper middle income. income countries (Fig. 6.2). These countries ccounted for 97% of the globl number of TB cses notified in 216. The methods used to collect, review nd nlyse finncil dt re summrized in Box 6.1. In these 118 low- nd middle-income countries, funding for TB prevention, dignosis nd tretment reched US$ 6.9 billion in 217, up from US$ 6.3 billion in 216 nd more thn double the US$ 3.3 billion tht ws vilble in 26 (Fig. 6.3; ll figures re in constnt 217 dollrs). Despite this growth in funding, mounts fll short of wht is needed. The shortfll FIG. 6.3 Funding for TB prevention, dignosis nd tretment in totl nd by ctegory of expenditure, , 118 countries with 97% of reported cses US$ billions (constnt vlues for 217) Other TB/HIV Totl Drug-susceptible TB MDR-TB GLOBAL TUBERCULOSIS REPORT

121 n BOX 6.1 n Methods used to compile, vlidte nd nlyse finncil dt reported to WHO WHO begn monitoring government nd interntionl donor finncing for TB in 22. All dt re stored in the WHO globl TB dtbse. The stndrd methods used to compile, review, vlidte nd nlyse these dt hve been described in detil elsewhere;,b this box provides summry. Ech yer, WHO sks ll NTPs in low- nd middle-income countries to report: the funding they estimte will be needed for TB prevention, dignosis nd tretment in their current fiscl yer, by ctegory of expenditure nd source of funding; nd expenditures for the most recently completed fiscl yer, lso by ctegory of expenditure nd source of funding. In the 217 round of globl TB dt collection, the fiscl yers were 216 nd 217. Consistency in ctegories of expenditure used to report TB budget nd expenditure dt hs been mintined s fr s possible to enble monitoring of trends. For low- nd middle-income countries, the ctegories of expenditure for drugsusceptible TB used in the 217 round of globl TB dt collection were: lbortory infrstructure, equipment nd supplies; NTP stff t centrl nd subntionl levels (e.g. NTP mngers nd provincil or district TB coordintors); first-line drugs; progrmme costs (e.g. mngement nd supervision ctivities, trining, policy development, meetings, purchse of office equipment nd vehicles, recording nd reporting of notifictions nd tretment outcomes, dvoccy nd communiction, public privte mix ctivities nd community enggement); nd opertionl reserch, including surveys. For MDR-TB, two expenditure ctegories were used: second-line drugs nd progrmme costs specificlly relted to MDR-TB. Strting in 215, seprte ctegory for ptient support ws included, linked to the emphsis on finncil nd socil protection in the End TB Strtegy. There is lso seprte ctegory for collbortive TB/ HIV ctivities (this excludes ny budget items finnced by HIV progrmmes, such s ntiretrovirl therpy for TB ptients living with HIV, nd TB preventive tretment for people newly enrolled in HIV cre). A brekdown of the totl mount of vilble funding is requested in four ctegories: domestic funding excluding lons; externl lons, lso considered domestic funding; the Globl Fund; nd grnt finncing from sources other thn the Globl Fund. As in previous yers, in 217 ll high-income countries were sked to report funding requirements nd expenditures in totl, without ny brekdown by ctegory of expenditure or source of funding. However, only few countries reported finncing dt nd therefore dt for high-income countries re not fetured in Chpter 6. As in previous yers, in 217 ll countries (irrespective of income level) were sked to report on the use of inptient nd outptient cre for tretment of people with drug-susceptible TB nd MDR-TB on per-ptient bsis (i.e. the verge number of dys spent in hospitl, nd the verge number of outptient visits to helth fcility). These dt cn be bsed on ctul use of services (preferble where vilble), or on the expected use of services bsed on the typicl pproch used to deliver tretment (which my be defined in ntionl policy documents). They re combined with other dt to estimte the finncil resources used for TB tretment tht re not reflected in NTP-reported budgets nd expenditures (further detils re provided below). The core methods used to review nd vlidte dt hve remined consistent since 22. They include: routine checks for plusibility nd consistency, including vlidtion checks tht re built into the online reporting system exmples of vlidtion checks re checks for implusibly lrge yer-to-yer chnges (e.g. in totl reported funding by source nd by ctegory of expenditure), or implusibly high or low vlues of funding for drugs reltive to the number of TB ptients (tht differ substntilly from prices quoted by the Globl TB Drug Fcility); discussions with country respondents to resolve queries; nd tringultion with other dt sources such sources include estimtes of unit costs from independent economic evlutions c,d nd funding pplictions submitted to the Globl Fund; e comprehensive budgets for ntionl strtegic plns for TB re n essentil requirement for funding pplictions to the Globl Fund. Further detils bout the comprisons with other dt sources re vilble from WHO upon request. In review nd vlidtion of dt, prticulr ttention hs lwys been given to the high TB burden countries. Since 214, n extr question bout the verge cost of drugs per ptient treted hs been sked, to llow reviewers to better ssess the vlidity of budgets reported for first-line nd second-line drugs, nd to identify whether reported budgets include funding for buffer stocks. In 217, specific efforts to improve the qulity of finncil dt reported to WHO included discussions with NTP stff t the June 217 meeting of WHO s Strtegic nd Technicl Advisory Group for TB nd n ssocited summit in which NTP mngers from the 3 high TB burden countries prticipted; discussions with NTP stff during workshops on TB modelling; nd individul nd customized follow-up with in-country stff involved in the development of ntionl strtegic plns. Usully, TB funding reported by NTPs does not include the finncil costs ssocited with the inptient nd outptient cre required during TB tretment. Since mny detiled costing studies in wide rnge of countries show tht these costs cn ccount for lrge shre of the cost of treting someone with TB, WHO nlyses of TB finncing hve lwys included estimtes of the 11 GLOBAL TUBERCULOSIS REPORT 217

122 funding required for both inptient nd outptient cre. These costs hve been estimted from provider perspective only, nd do not include the costs fced by TB ptients nd their households. Incresing ttention is now being given to costs fced by TB ptients nd their households, s discussed in Chpter 7. WHO estimtes the funding used to provide inptient nd outptient cre for TB ptients by multiplying the number of outptient visits nd dys of inptient cre per ptient (reported by NTPs ech yer) by the cost per bed dy nd per clinic visit vilble from the WHO CHOosing Interventions tht re Cost- Effective (WHO-CHOICE) dtbse, f nd then by the reported number of TB ptients notified or projected to be notified. These estimtes re done seprtely for drug-susceptible TB nd MDR- TB. In 217, costs per bed dy nd per clinic visit were estimted using the CHOICE regression model nd the ltest dt vilble from the World Bnk. For four countries (Indi, South Afric, Thilnd nd Viet Nm), WHO-CHOICE estimtes were replced with estimtes of unit costs obtined directly from ntionl helth ccount dt, or from recent studies nd discussions with experts supporting the costing of ntionl strtegic plns. Where possible, estimtes re compred with hospitl nd clinic expenditure dt for drug-susceptible nd MDR-TB tht re being trcked through the System of Helth Accounts (SHA). g In 217, SHA dt were vilble for 27 countries for one or two yers, including six high burden countries (Cmbodi, Democrtic Republic of the Congo, Nmibi, the Philippines, Sierr Leone nd United Republic of Tnzni). h After review, the SHA dt were used in preference to estimtes bsed on reported use nd unit costs estimtes from WHO-CHOICE. The WHO Helth Governnce nd Finncing Deprtment hs initited process to ssess the vlidity of the ltest results from the new SHA, including disese-specific results. Expnded implementtion of SHA nd vlidtion ginst existing disese-specific trcking systems my fcilitte more comprehensive reporting of domestic funding for TB, especilly reporting of the contributions from subntionl dministrtive levels tht re not lwys known or compiled t the ntionl level. Although much of this contribution is probbly for delivery of inptient nd outptient cre (which is included in current WHO estimtes of domestic funding for TB, s explined bove), reporting of funding from these levels (including TB-specific budgets) is prticulr chllenge in lrge countries with decentrlized systems for TB tretment (e.g. Indonesi, Nigeri nd South Afric). b c d e f g h Floyd K, Pntoj A, Dye C. Finncing tuberculosis control: the role of globl finncil monitoring system. Bull World Helth Orgn. 27;85(5): ( ccessed 29 July 216). Floyd K, Fitzptrick C, Pntoj A, Rviglione M. Domestic nd donor finncing for tuberculosis cre nd control in low-income nd middle-income countries: n nlysis of trends, 22 11, nd requirements to meet 215 trgets. Lncet Glob Helth. 213;1(2):e ( ccessed 28 July 216). Globl Helth Cost Consortium unit cost study dt repository, ccessed 13 July 217 ( Lurence YV, Griffiths UK, Vssll A. Costs to helth services nd the ptient of treting tuberculosis: systemtic literture review. Phrmcoeconomics. 215;33(9): ( ccessed 29 July 216). Globl Fund Dt nd the Open Dt Protocol odt/, ccessed My 217 nd country finncil gp nlysis mterils pproved for funding in the first rounds of New Funding Model. Cost effectiveness nd strtegic plnning (WHO-CHOICE): helth service delivery costs. Genev: World Helth Orgniztion; 28 ( cost-effectiveness/inputs/helth_service/en/, ccessed 13 July 217). OECD/Eurostt/WHO. A system of helth ccounts. OECD Publishing; 211 ( ccessed 29 July 216). Helth ccounts. Genev: World Helth Orgniztion; dt shred by WHO Helth Governnce nd Finncing Deprtment on 11 July 217. compred with the Globl Pln estimte (Section 6.1) is US$ 2.3 billion in 217 (US$ 6.9 billion vilble compred with n estimted requirement of US$ 9.2 billion). Of the totl US$ 6.9 billion vilble in 217, US$ 4.8 billion (73%) is for the dignosis nd tretment of drug-susceptible TB. This is US$ 2.1 billion less thn the requirement estimted in the Globl Pln. Funding for MDR-TB reched US$ 1.7 billion in 217; the nnul mount incresed stedily from 26 to 214, declined from 214 to 216, nd then slightly incresed from 216 to 217 (Fig. 6.3). This ggregte trend reflects the pttern in the BRICS group of countries (Brzil, Russin Federtion, Indi, Chin nd South Afric) (Fig. 6.4), where downturn fter 214 is explined by decresing funding in the Russin Federtion ( ) nd South Afric ( ). Funding in other countries hs been incresing (Fig. 6.4). The shortfll between the funding vilble in 217 nd the requirement of US$ 2. billion in 217 estimted in the Globl Pln is comprtively smll (US$.3 billion). However, funding for dignosis nd tretment of MDR-TB needs to increse substntilly. This is evident from lrge nd persistent gps in detection nd tretment of MDR-TB, both globlly nd in most countries with high burden of MDR-TB (for detils, see Chpter 4). It is lso evident from the Globl Pln, in which the nnul funding required for MDR-TB reches US$ 3.6 billion in 22, more thn double the mount of US$ 1.7 billion vilble in 217. Overll, most funding during the period hs been provided from domestic sources, nd this remins the cse in 217 (Fig. 6.5). 1 Thus, in 217, US$ 5.8 billion (84%) of the totl funding of US$ 6.9 billion for TB is from domestic sources. However, ggregted figures for the 118 low- nd 1 Domestic funding includes both funding for TB-specific budgets nd funding for inptient nd outptient cre (usully funded through more generl budget lines), s lso explined in Box 6.1. In Fig. 6.5 nd Fig. 6.6, it is ssumed tht funding for inptient nd outptient cre is funded domesticlly nd not by interntionl donors. This is justified on the bsis tht most (93%) of the funding estimted to be used for inptient nd outptient cre for TB ptients is ccounted for by middle-income countries, where interntionl donor funding for such components of cre is unlikely (such support is more likely to occur in low-income countries, vi generl budget support to the helth sector). GLOBAL TUBERCULOSIS REPORT

123 FIG. 6.4 Funding for drug-susceptible TB nd MDR-TB, , by country group BRICS (n=5) 25 TB HBCs outside BRICS Other countries (n=88) US$ millions (constnt vlues for 217) Drug-susceptible TB MDR-TB BRICS ccounted for 48% of the world s notified TB cses (216). The 25 high TB burden countries outside BRICS ccounted for 38% of the world s notified TB cses (216), nd the reminder (11%) were in other countries. FIG. 6.5 Funding for TB prevention, dignosis nd tretment by funding source, , 118 countries with 97% of reported TB cses US$ billions (constnt vlues for 217) Totl Domestic funding Interntionl donor funding Domestic funding includes TB-specific budgets nd the estimted resources used for inptient nd outptient cre (see Box 6.1). 93% of the funding of US$ 3 billion for inptient nd outptient cre in 217 is ccounted for by middleincome countries; such countries do not typiclly receive interntionl donor funding for inptient nd outptient cre services. middle-income countries concel substntil vrition mong countries in the shre of funding from domestic nd inter ntionl sources (Fig. 6.6). While domestic funding domintes in eight of the nine (not mutully exclusive) country groups shown in Fig. 6.6, including BRICS where domestic funding ccounts for 95% of totl funding in 217 (rnge 89%-1% mong the five countries), interntionl donor funding exceeds funding from domestic sources in lowincome countries (56% of the totl in 217) nd is similr to levels of domestic funding in the 25 high TB burden countries outside BRICS (48% of the totl in 217). 1 1 The list of 3 high TB burden countries being used by WHO during the period is explined in Chpter 2. The countries re those listed in Fig. 6.7, Tble 6.1 nd Tble 6.2. Interntionl donor funding reported by NTPs to WHO mounts to US$ 1.1 billion in 217. Of this, most (8%) ws provided by the Globl Fund. However, becuse funding reported by NTPs to WHO does not cpture ll interntionl donor funding for TB, 2 complementry nlysis bsed on donor reports to the Orgnistion for Economic Coopertion nd Development (OECD) is provided in Box The importnce of interntionl donor funding in high TB burden countries is prticulrly evident when considering only the TB-specific budgets included in ntionl strtegic plns for TB (Fig. 6.7, Tble 6.1, Tble 6.2). In 23 of the 3 high TB burden countries, more thn 8% of funding for the TBspecific budgets included in ntionl strtegic plns for TB is from interntionl donors in 217. Both Fig. 6.7 nd recent developments in Indi illustrte the potentil to increse domestic funding in some high TB burden countries. In the group of nine low-income high TB burden countries, the proportion of the reported TB budget funded from domestic sources in 217 rnges from.3% in Zimbbwe to 24% in Liberi. In the group of 15 lower-middleincome high TB burden countries the proportion rnges from 6.8% in Bngldesh to 88% in Congo. In the group of six upper-middle-income countries, the proportion rnges from 3% in Nmibi to 1% in the Russin Federtion. In Indi, the country with the lrgest burden of TB disese (Chpter 3), there ws mrked increse in both the TBspecific budget nd the domestic funding for this budget in 217. This increse followed high-level (Prime Ministeril) politicl commitment to n mbitious gol of ending TB by 225, nd the development of new ntionl strtegic pln for TB tht ims to ccelerte progress towrds 2 Donor funding is lso provided to entities other thn NTPs, including interntionl nd ntionl governmentl nd nongovernmentl orgniztions. 3 Out-of-pocket expenditures re lso not included in the finncing dt reported by NTPs. These re discussed in more detil in Chpter GLOBAL TUBERCULOSIS REPORT 217

124 FIG. 6.6 Funding for TB prevention, dignosis nd tretment from domestic sources nd interntionl donors, , 9 country groups. BRICS b. 25 HBCs outside BRICS c. Rest of world US$ billions (constnt vlues for 217) d. Low-income countries e. Lower-middle-income countries f. Upper-middle-income countries US$ billions (constnt vlues for 217) US$ billions (constnt vlues for 217) g. Afric h. Asi b i. Other regions c Domestic funding Interntionl donor funding b c Rest of the world includes 88 countries tht re not in the list of 3 high TB burden countries. Asi includes the WHO regions of South-Est Asi nd the Western Pcific. Other regions consist of three WHO regions: the Estern Mediterrnen Region, the Europen Region, nd the Region of the Americs. GLOBAL TUBERCULOSIS REPORT

125 n BOX 6.2 n Interntionl donor funding for TB prevention, dignosis nd tretment, bsed on donor reports to the OECD Not ll interntionl donor funding tht is provided for TB prevention, dignosis nd tretment is chnnelled through NTPs. The creditor reporting system (CRS) of the OECD is the most comprehensive source of informtion bout interntionl donor funding. Funding dt (both commitments nd disbursements) re provided by 31 multilterl donor orgniztions, the 26 countries tht re members of the OECD s Development Assistnce Committee, nd further two non-committee members (Kuwit nd the United Arb Emirtes). Disbursement dt include both direct trnsfers to countries nd the provision of goods nd services, such s in-kind trnsfers or technicl ssistnce. Dt on gross disbursements for TB (code 12263: Tuberculosis control) received by non- OECD countries during were nlysed. Funding for TB tht flows from one OECD member to n institution or government within the OECD, such s grnts from the United Sttes (US) Ntionl Institutes for Helth flowing to the United Kingdom, is not cptured in the CRS. Also, government contributions to multilterl orgniztions re not ttributed to the government of origin, only to the multilterl orgniztion. b FIG. B6.2.1 Interntionl donor funding for TB prevention, dignosis nd tretment by source, US$ millions (constnt vlues for 215) World Bnk Globl Fund United Sttes United Kingdom Other Fig. B6.2.1 shows trends in interntionl donor funding between 26 nd 215, from five mjor sources. The totl from ll sources in 215 ws US$ 754 million, incresed from US$ 22 million in 26. In 215, 64% of interntionl TB donor funding ws provided by the Globl Fund (US$ 484 million); the second lrgest contributor ws the US government c (26%, US$ 199 million). Given tht bout one third of the contributions to the Globl Fund re from the US government, bout 47% of interntionl donor funding for TB globlly originted from the US government in 215. The remining funding cme from the United Kingdom (3%), the World Bnk (1%), nd other sources (6%), within which the lrgest contributing country ws Belgium From 26 to 215, the Globl Fund ws consistently the lrgest provider of interntionl donor funding, but mrked drop occurred from pek of US$ 712 million in 213 to US$ 399 million in 214, followed by recovery to US$ 484 million in 215. This pttern my reflect the trnsition to new funding model tht strted in 213, nd some ssocited delys in pproving nd disbursing funds. Disbursements from the US government stedily incresed from 24 to 214, peking t US$ 249 million in 214 nd then declining in 215 to US$ 199 million. c Fig. B6.2.2 shows the flow of TB funding in 215. Almost hlf of ll funding from the US ws given bilterlly, primrily to non-oecd countries in Asi nd Afric. Frnce, Germny, Jpn nd the United Kingdom lso provided funding strems directly to countries in ddition to their disbursements to the Globl Fund. In 215, Asi received the lrgest shre of TB FIG. B6.2.2 Interntionl donor funding flows for TB prevention, dignosis nd tretment to non-oecd countries, 215 USA Asi United Kingdom Frnce Germny Other countries Afric Europe Americs Multilterls Globl Fund Jpn Oceni 114 GLOBAL TUBERCULOSIS REPORT 217

126 FIG. B6.2.3 Interntionl donor funding for TB, HIV nd mlri, US$ billions (constnt vlues for 215) HIV Mlri TB funding (5%), followed by Afric (36%). Fig. B6.2.3 shows tht interntionl funding for TB is less thn hlf tht for mlri nd pproximtely one eighth tht for HIV. The disbility-djusted life yers (DALYs) lost due to illness nd deth for these three diseses re 67 million for HIV/AIDS, 56 million for mlri nd 4 million for TB. d b c d As opposed to commitments, which my not mterilize. An importnt exmple is funding from the Globl Fund to non-oecd countries, which is ttributed to the Globl Fund nd not to the governments or other entities tht contribute to the Globl Fund. Disbursements from the US government cptured in the OECD dtbse re lower thn officil lloctions. In 215, the officil lloction for TB ws US$ 242 million nd there ws dditionl funding of US$ 132 million for TB/HIV vi the President s Emergency Pln for AIDS Relief (PEPFAR). Source: ccessed on 13 July 17. this gol. Fig. 6.8 shows tht the budget in 217 is US$ 525 million (lmost double the budget of US$ 28 million in 216). The budget is fully funded, including US$ 387 million (74%) from domestic sources (triple the mount of US$ 124 million in 216). 6.3 Funding gps reported by ntionl TB progrmmes, Despite growth in funding from domestic nd interntionl donor sources, mny NTPs continue to be unble to mobilize ll the funding required for full implementtion of their ntionl strtegic plns (Fig. 6.7, Fig. 6.9, Tble 6.1). Funding gps (i.e. the difference between ssessments by NTPs of funding needs for TB prevention, dignosis nd tretment, nd the ctul mount of funds mobilized) hve persisted, nd in 217 they mounted to reported totl of US$.9 billion. This is less thn hlf of the gp of US$ 2.3 billion tht exists between the US$ 9.2 billion estimted to be needed in low- nd middle-income countries in 217 ccording to the Globl Pln (Section 6.1) nd the US$ 6.9 billion vilble in 217 (Section 6.2). The difference cn be explined by the fct tht, in mny countries, ntionl strtegic plns for TB re less mbitious thn the trgets set in the Globl Pln (Section 6.1). Of the US$.9 billion funding gp reported by NTPs in 217, US$.75 billion (81%) is for drug-susceptible TB nd US$.18 billion (19%) is for MDR-TB. Reltive to totl funding needs, the funding gp is lrger for drug-susceptible TB thn for MDR-TB (not shown). Lower-middle-income countries ccount for the lrgest reported funding gp (US$ 626 million) in 217 (Fig. 6.9). In 217, the lrgest funding gps mong low-income countries were for high TB burden countries: the United Republic of Tnzni (US$ 4 million), Ethiopi (US$ 36 million), the Democrtic Republic of the Congo (US$ 28 million) nd the Democrtic People s Republic of Kore (US$ 13 million) (Tble 6.1). Funding gps were reltively smll in uppermiddle-income countries in 217 (US$ 97 million), nd hve fllen in recent yers. This trend is mostly explined by lrge reductions in the funding gps reported by Chin, Kzkhstn nd the Russin Federtion, which reported funding gps in but negligible or zero gps therefter. Geogrphiclly, hlf of the totl reported funding gp in 217 is ccounted for by countries in the WHO Africn Region (US$ 52 million), with Nigeri reporting the lrgest gp (US$ 215 million). Most of the remining gp ws reported in the South-Est Asi Region, primrily by Indonesi (US$ 98 million) nd Bngldesh (US$ 36 million) (Fig. 6.9). 6.4 Unit costs of tretment for drugsusceptible TB nd multidrug-resistnt TB, 216 The cost per ptient treted in 216 for drug-susceptible TB nd MDR-TB ws estimted for 111 nd 8 countries, respectively. 1 All countries in the lists of high TB burden countries nd high MDR-TB burden countries were included in the nlyses. 2 Unit cost estimtes re shown in Fig. 6.1 nd Fig. 6.11, nd nlyticl methods re summrized in Box Drug-susceptible TB The medin cost per ptient treted for drug-susceptible TB in 216 ws US$ 1253 (Fig. 6.1). 3 In generl, bout 6% of this 1 Anlysis for drug-susceptible TB ws limited to countries tht notified t lest 1 TB cses in 216. For MDR-TB, estimtes were restricted to countries tht reported t lest 1 ptients on second-line tretment for MDR-TB. 2 For further detils bout both lists, see Chpter 2. 3 Medin vlues re cited rther thn mens becuse of extreme vlues for few countries. GLOBAL TUBERCULOSIS REPORT

127 FIG. 6.7 Sources of funding nd funding gps for the TB-specific budgets included in ntionl strtegic plns for TB in 217, 3 high TB burden countries Low-income Liberi DPR Kore Centrl Africn Republic Ethiopi Mozmbique Sierr Leone UR Tnzni DR Congo Zimbbwe Lower-middle-income Congo Indi Angol Ppu New Guine Indonesi Philippines Keny Lesotho Mynmr Cmbodi Nigeri Zmbi Viet Nm Pkistn Bngldesh Upper-middle-income Russin Federtion Chin South Afric Brzil Thilnd Nmibi Percentge Domestic funding Globl Fund Interntionl donor funding (excluding Globl Fund contributions) Budget gp 116 GLOBAL TUBERCULOSIS REPORT 217

128 TABLE 6.1 Reported budget, vilble funding for this budget from domestic nd interntionl donor sources, funding gp nd shre of budget in ntionl strtegic pln for TB provided by domestic nd interntionl donor funding, 3 high TB burden countries, 217 (current US$ millions) BUDGET IN NATIONAL STRATEGIC PLAN FOR TB DOMESTIC FUNDING (A) INTERNATIONAL DONOR FUNDING (B) SHARE OF AVAILABLE FUNDING (A+B) PROVIDED FROM DOMESTIC SOURCES (%) SHARE OF AVAILABLE FUNDING (A+B) PROVIDED BY INTERNATIONAL DONORS (%) Angol % 4% 7.2 Bngldesh % 88% 36 Brzil <.1 1% % 12 Cmbodi % 8% 19 Centrl Africn Republic % 79%.3 Chin % 3% 4. Congo % 12% DPR Kore % 6% 13 DR Congo % 95% 28 Ethiopi % 8% 37 Indi % 26% Indonesi % 39% 98 Keny % 7% 26 Lesotho % 8%.8 Liberi % 76% Mozmbique % 96% Mynmr % 84%.1 Nmibi % 38% 29 Nigeri % 74% 215 Pkistn % 9% 3 Ppu New Guine % 73% Philippines % 73% 29 Russin Federtion % % Sierr Leone % 97% South Afric % 1% Thilnd b % 19% 1.1 UR Tnzni % 94% 41 Viet Nm % 77% 44 Zmbi % 86% 5.4 Zimbbwe 18 <.1 18 % 1% 3 high TB burden countries % 24% 677 Blnk cells indicte dt not reported. indictes vlues tht cnnot be clculted. In 217, the budget reported by Bngldesh is for the clendr yer (s opposed to the fiscl yer). b In 217, the budget reported by Thilnd ws for the centrl level only. c The funding gp reflects the nticipted gp for the yer t the time country reported dt to WHO in the 217 round of globl TB dt collection. Totls re computed prior to rounding. FUNDING GAP c GLOBAL TUBERCULOSIS REPORT

129 TABLE 6.2 Reported budget in Ntionl Strtegic Pln for TB, by intervention re nd estimted cost of inptient nd outptient cre for drug-susceptible (DS-TB) nd MDR-TB, 3 high TB burden countries, 217 (current US$ millions) BUDGET IN NATIONAL STRATEGIC PLAN FOR TB ADDITIONAL RESOURCES REQUIRED FOR INPATIENT AND OUTPATIENT CARE TOTAL DS-TB MDR-TB TB/HIV DS-TB MDR-TB TOTAL RESOURCES REQUIRED FOR TB CARE Angol Bngldesh Brzil Cmbodi Centrl Africn Republic < < Chin b Congo <.1 < < DPR Kore DR Congo Ethiopi Indi Indonesi Keny Lesotho Liberi Mozmbique Mynmr Nmibi Nigeri Pkistn Ppu New Guine Philippines Russin Federtion b,c Sierr Leone South Afric Thilnd d < UR Tnzni Viet Nm Zmbi Zimbbwe high TB burden countries indictes vlues tht cnnot be clculted. Totls re computed prior to rounding. In 217, the budget reported by Bngldesh is for the clendr yer (s opposed to the fiscl yer). b No mounts for the dditionl resources required for inptient nd outptient cre re shown for Chin nd the Russin Federtion becuse the NTP budgets reported by those countries include ll budgets for inptient nd outptient cre. c The totl budgets reported for stff nd infrstructure costs were llocted to DS-TB (52%) nd MDR-TB (48%) by WHO, bsed on the reported proportion of beddys used by ptients with DS-TB nd MDR-TB, respectively. d In 217, the budget reported by Thilnd ws for the centrl level only. 118 GLOBAL TUBERCULOSIS REPORT 217

130 FIG. 6.8 Ntionl budget for TB nd sources of funding in Indi, US$ millions (constnt vlues for 217) Domestic funding Interntionl donor funding Funding gp FIG. 6.9 Reported funding gps for TB by income group nd by WHO region, US$ millions (constnt vlues for 217) Low-income countries Lower-middle-income countries Upper-middle-income countries Totl gp in 217 = US$ 929 million cost ws ccounted for by reported NTP expenditures, with the reminder being inptient nd outptient cre. There ws positive reltionship between the cost per ptient treted nd gross domestic product (GDP) per cpit, nd negtive reltionship with the size of the ptient cse-lod (indicting economies of scle, e.g. in Chin nd Indi). In 29 of the 3 high TB burden countries included in the nlysis, the cost per ptient treted for drug-susceptible TB ws less thn GDP per cpit; the exception ws Sierr Leone. The cost per ptient treted ws typiclly higher in countries in the WHO Europen Region. Estern Europe nd Centrl Asi (EECA) countries hve reltively high costs owing to extensive use of hospitliztion for ptients in the intensive phse of tretment, with hospitl dmissions verging 62 dys per person. High progrmme costs reltive to smller pool of ptients lso help to explin comprtively high perptient costs in some countries (e.g. Bosni nd Herzegovin). However, some EECA countries hve mrkedly reduced their relince on hospitliztion nd hve chnged the model of cre for ptients with drug-susceptible TB. From 214 to 216, five of the 12 EECA countries reduced the number of bed dys per ptient treted for drug-susceptible TB: Armeni (1%), Azerbijn (47%), Georgi (38%), Kyrgyzstn (33%) nd the Russin Federtion (66%) Multidrug-resistnt TB For MDR-TB, the medin cost per ptient treted ws US$ 9529 in 216 (Fig. 6.11). As with drug-susceptible TB, the cost per ptient treted ws positively correlted with GDP per cpit. New shortened regimens of 9 12 months cost bout US$ 1 per person. These regimens hve been recommended since 216 by WHO for ptients (other thn pregnnt women) with rifmpicin-resistnt or MDR pulmonry TB who do not hve resistnce to second-line drugs. 1 The uptke of such regimens should contribute to decrese in the unit cost of tretment for MDR-TB in future. US$ millions (constnt vlues for 217) Totl gp in 217 = US$ 929 million Afric The Americs Estern Mediterrnen Europen South-Est Asi Western Pcific 1 For further detils bout this recommendtion, see Chpter 1. GLOBAL TUBERCULOSIS REPORT

131 FIG. 6.1 Estimted cost per ptient treted for drug-susceptible TB in 111 countries, 216 Cost per ptient treted (217 US$, log scle) TB cselod (notified TB cses) Russin Federtion Nmibi Sierr Leone Zmbi DPR Kore Zimbbwe Angol Nigeri South DR Congo Afric Thilnd Brzil Keny Philippines Chin Indonesi Ethiopi Congo Liberi Lesotho Ppu New Guine WHO region Mozmbique UR Tnzni Mynmr Viet Nm Centrl Africn Republic Bngldesh Pkistn Indi Afric The Americs Estern Mediterrnen Europe South-Est Asi Western Pcific GDP per cpit (217 US$, log scle) Limited to countries with t lest 1 ptients on first-line tretment in 216. FIG Estimted cost per ptient treted for MDR-TB in 8 countries, 216 Cost per ptient treted (217 US$, log scle) MDR-TB cselod (notified cses) 3 Somli 1 1 Ukrine Moldov Ppu New Guine Bngldesh Kyrgyzstn Nigeri Ethiopi DPR Kore Keny DR Congo MDA Peru South Indonesi Angol Afric Thilnd Tjikistn Pkistn Uzbekistn Chin Viet Nm Indi WHO region Mozmbique Zimbbwe Mynmr Philippines Belrus Afric The Americs Estern Mediterrnen Kzkhstn Russin Federtion Europe South-Est Asi Western Pcific GDP per cpit (217 US$, log scle) Limited to countries with t lest 2 ptients on second-line tretment in GLOBAL TUBERCULOSIS REPORT 217

132 n BOX 6.3 n Methods used to estimte the cost per ptient treted for drug-susceptible TB nd MDR-TB Two min dt sources were used to estimte the cost per ptient treted for drug-susceptible TB nd MDR-TB. The first ws the vlidted expenditure dt reported by NTPs tht re stored in the WHO globl TB dtbse. The second ws country-specific estimtes of the unit costs of bed dys nd outptient visits, vilble from the WHO-CHOICE model nd ssocited dtbse (mnged by the WHO Helth Governnce nd Finncing Deprtment). In the few instnces in which no expenditure dt were reported, informtion bout the totl funding vilble or reported drug expenditure per ptient treted ws used s proxy for expenditures. Costs were clculted seprtely for drug-susceptible TB nd MDR-TB. In ech cse, the numertor ws the totl estimted cost of tretment, which hs two min prts: the ntionl expenditures reported by the NTP, nd the costs ssocited with the use of helth services for TB ptients. As explined in Box 6.1, the NTP expenditures of countries re reported nnully to WHO using the online WHO globl TB dt collection system, nd re then reviewed nd vlidted. Ctegories of expenditure considered s costs for MDR-TB were second-line drugs nd ll other inputs or ctivities implemented for the progrmmtic mngement of MDR-TB. All other ctegories (except collbortive TB/ HIV ctivities) were ssumed to be for drug-susceptible TB. An exception ws mde for the Russin Federtion: expenditures for stff nd infrstructure were llocted by WHO to drug-susceptible TB (52%) nd MDR-TB (48%), bsed on the proportion of bed dys used for these two ctegories of ptients. For most countries, the totl costs ssocited with use of inptient nd outptient cre were clculted using informtion bout the typicl number of dys of inptient cre nd outptient visits required on per-ptient bsis during tretment (reported seprtely for drug-susceptible TB nd MDR-TB by NTPs) combined with WHO-CHOICE unit cost estimtes, multiplied by the number of ptients treted in given yer (bsed on notifiction dt; see Chpter 4). For 27 countries (including six high burden countries, see Box 6.1), TB inptient nd outptient expenditures vilble from ntionl helth ccounts b were used insted of the estimted cost from this ingredientsbsed pproch. Unit costs were then clculted s the sum of 216 NTP expenditures nd totl costs for use of inptient nd outptient cre, divided by the reported number of ptients treted. Agin, this clcultion ws crried out seprtely for drug-susceptible TB nd MDR-TB. b Cost effectiveness nd strtegic plnning (WHO-CHOICE): helth service delivery costs. Genev: World Helth Orgniztion; 28 ( who.int/choice/cost-effectiveness/inputs/helth_service/en/, ccessed 13 July 217). Helth ccounts. Genev: World Helth Orgniztion; dt shred by WHO Helth Governnce nd Finncing Deprtment on 11 July 217. GLOBAL TUBERCULOSIS REPORT

133 Urbniztion in Rio de Jneiro, Brzil MIHAI ANDRITOIU / ALAMY STOCK PHOTO

134 CHAPTER 7. Universl helth coverge, socil protection nd socil determinnts n KEY FACTS AND MESSAGES n Achieving the tuberculosis (TB) trgets nd milestones of the Sustinble Development Gols (SDGs) nd End TB Strtegy requires provision of TB cre nd prevention within the broder context of universl helth coverge (UHC) nd multisectorl ction to ddress the socil nd economic determinnts nd consequences of TB. In 217, WHO published estimtes of the funding required for progress towrds UHC in low- nd middle-income countries during the period nd compred these with projections of totl helth expenditures. Overll, these estimtes nd projections suggest tht most middle-income countries cn mobilize the resources required to mke progress towrds UHC nd rech other SDGrelted helth trgets by 23, but tht low-income countries re unlikely to hve the resources to do so. Improved revenue genertion nd mngement of public expenditures s well s incresed public helth budgets re needed. In most high TB burden countries, out-of-pocket expenditures ccount for high proportion (>3%) of totl helth expenditures. Incresing the shre of finncing tht is derived from compulsory prepid sources nd pooled to spred risk cross the popultion is criticl to reduce the finncil hrdships rising from out-of-pocket expenditures nd enble ccess to cre. In ddition, funds must then be directed to priority services nd popultions through the mechnisms used to py providers. Results from surveys of costs fced by TB ptients nd their households revel high economic nd finncil burden due to TB disese. Some of the min cost drivers could be reduced or eliminted through improved models of cre, while others require use of new tools nd socil support. Most high TB burden countries hve ntionl policies tht provide the foundtion for expnding socil protection, including csh trnsfer progrmmes for some poor nd vulnerble popultions; finding wys to link TB ptients into these schemes is importnt. WHO hs developed TB-SDG monitoring frmework of 14 indictors tht re ssocited with TB incidence, under seven SDGs. Exmples include levels of poverty, income inequlity, housing qulity, undernourishment, coverge of socil protection progrmmes, coverge of essentil helth services, HIV prevlence, smoking nd dibetes. Monitoring of these indictors cn be used to identify key influences on the TB epidemic t ntionl level nd inform the multisectorl ctions required to end the TB epidemic. Anlysis of these indictors for the 3 high TB burden countries shows tht most hve mjor chllenges hed to rech SDG trgets. Of the 1.4 million incident cses of TB globlly in 216, n estimted 1.9 million were ttributble to undernourishment, 1. million to HIV infection,.8 million to smoking nd.8 million to dibetes. GLOBAL TUBERCULOSIS REPORT

135 The End TB Strtegy nd the Sustinble Development Gols (SDGs) include common im: to end the globl TB epidemic. Specific trgets set in the End TB Strtegy include 9% reduction in TB deths nd n 8% reduction in TB incidence (new cses per yer) by 23, compred with 215; more immedite milestones for 22 re reductions of 35% nd 2%, respectively. As highlighted elsewhere in this report, in prticulr in Chpter 2, chieving these trgets requires provision of TB cre nd prevention within the broder context of universl helth coverge (UHC), multisectorl ction to ddress the socil nd economic determinnts nd consequences of TB, nd technologicl brekthrough by 225 so tht incidence cn fll fster thn rtes chieved historiclly. This chpter hs three mjor sections. The first provides n overview of estimtes of the resources required for progress towrds UHC nd chievement of other SDG-relted helth trgets during the period , published by WHO in 217. The second section summrises recent dt for indictors relted to UHC, including levels of out-of-pocket (OOP) expenditures on helth nd costs borne by TB ptients nd their households s result of TB disese. Implictions for improving finncing, TB cre delivery, nd socil protection mesures tht could help to llevite these burdens, nd exmples of efforts to better pln for the finncing nd policy chnges needed t country level to rech UHC, re discussed. The third section includes estimtes of the shre of the globl TB burden in 216 tht cn be ttributed to five mjor determinnts of the TB epidemic (undernutrition, HIV infection, lcohol misuse, smoking nd dibetes), nd n ssessment of the ltest sttus of these nd other indictors ssocited with TB incidence in the 3 high TB burden countries bsed on the TB-SDG monitoring frmework defined in Chpter UHC finncing prospects, SDG Trget 3.8 is to Achieve UHC, including finncil risk protection, ccess to qulity essentil helthcre services nd ccess to sfe, effective, qulity nd ffordble essentil medicines nd vccines (Chpter 2). 1 UHC mens tht ll people nd communities cn use the promotive, preventive, curtive, rehbilittive nd pllitive helth services they need, of sufficient qulity to be effective, while lso ensuring tht the use of these services does not expose the user to finncil hrdship. In 217, WHO published estimtes of the resources needed during the period to mke progress towrds UHC nd rech other SDG-relted helth trgets, 2 nd compred 1 Two indictors hve been defined for Trget 3.8. The first is the coverge of essentil helth services; this is composite indictor tht includes TB tretment coverge s one of 16 trcer indictors. The second is the proportion of the popultion with lrge household expenditures on helth s shre of totl household expenditure or income. Methods to clculte the first indictor re under development. WHO will publish dt relted to these UHC indictors on UHC dy 217 (in December); these dt will be vilble t 2 One of these is the trget of ending the TB epidemic, which is included s prt of SDG Trget 3.3. these with projected totl helth expenditures in the sme time period. Referred to in shorthnd s the WHO SDG Helth Price Tg, 3 the estimtes re for 67 low- nd middle-income countries tht ccount for 75% of the world s popultion nd focus on the dditionl (or incrementl) resources needed compred with levels in 214. Two scenrios were considered for resource needs (termed progress nd mbitious ) nd two scenrios (referred to s moderte nd optimistic ) were lso considered for totl helth expenditures. Key findings include: In the mbitious scenrio for resource needs (bsed on chievement of 23 SDG trgets), the dditionl investment (compred with 214) required per yer grows from US$ 134 billion in 216 to US$ 371 billion (equivlent to n extr US$ 58 per person) in 23. Most of the incresed investment required (75% of the totl) is for expnding nd strengthening the helth workforce nd helth services infrstructure (including buildings nd medicl equipment) to rech recommended benchmrks. The reminder is for specific priorities, including TB. The lrgest shre of investments needed for specific diseses or progrmmes is ccounted for by noncommunicble diseses (NCDs). Overll, helth expenditure is projected to be sufficient to cover mbitious scenrio investment needs in middleincome countries. However, there is uneven cpcity to mobilize dditionl resources nd some countries re expected to fce gps, especilly in the first few yers. In the period , n verge of five out of the 39 middle-income countries included in the nlysis re predicted to fce funding gps. Overll, projected helth expenditure is not sufficient to cover investment needs in low-income countries. Improved revenue genertion nd mngement of public expenditures s well s incresed public helth budgets re needed, in both low nd middle-income countries. Further nlyses bsed on the WHO SDG Helth Price Tg, focusing on comprisons of totl (s opposed to incrementl) investment needs with projections of totl helth expenditures, re shown in Fig. 7.1, Fig. 7.2 nd Fig These illustrte the sme key messges in terms of the extent to which the resources needed to chieve UHC nd other SDGrelted helth trgets cn be mobilized in low nd middleincome countries. In ddition, they indicte tht totl funding needs s percentge of gross domestic product (GDP) would rise from 5.6% in 214 to 7.5% by 23 cross ll 67 countries (Fig 7.2), with much greter increse needed in low-income countries (from n verge of 6% in 214 to round 12% by 224). By 23, totl verge helth spending would need 3 Stenberg K, Hnssen O, Tn-Torres Edejer T et l. Finncing trnsformtive helth systems towrds chievement of the helth Sustinble Development Gols: model for projected resource needs in 67 low-income nd middle-income countries. (published online July 17) Lncet Glob Helth.217; GLOBAL TUBERCULOSIS REPORT 217

136 FIG. 7.1 Funding needs to progressively expnd services towrds UHC nd rech other SDG helth trgets in 67 low-nd middle-income countries compred with projected totl helth expenditures, Low-nd middle-income countries (n=67) FIG. 7.2 Funding needs (s percentge of projected GDP) to progressively expnd services towrds UHC nd rech other SDG helth trgets in 67 low-nd middle-income countries, Funding needs s % of GDP Low-income countries All (n=67) Lower-middle-income countries Upper-middle-income countries Low-income countries (n=28) Source: Dt from Stenberg K, Hnssen O, Tn-Torres Edejer T et l. Finncing trnsformtive helth systems towrds chievement of the helth Sustinble Development Gols: model for projected resource needs in 67 low-income nd middle-income countries. Lncet Globl Helth 217; 5: e US$ bilions (constnt vlues for 214) Lower-middle-income countries (n=22) Upper-middle-income countries (n=17) FIG. 7.3 Funding needs (per cpit) to progressively expnd services towrds UHC nd rech other SDG helth trgets by 23, by country income group US$ (constnt vlues for 214) per cpit Low-income countries (n=28) Lower-middle income countries (n=22) Upper-middle income countries (n=17) Additionl helth sector resource needs by 23 Current helth expenditure per cpit (214) Income groups re defined s of July 216. Per person helth costs re reported s popultion-weighted men vlues per income group per yer. Source: Dt from Stenberg K, Hnssen O, Tn-Torres Edejer T et l. Finncing trnsformtive helth systems towrds chievement of the helth Sustinble Development Gols: model for projected resource needs in 67 low-income nd middle-income countries. Lncet Globl Helth 217; 5: e Totl helth expenditure (moderte scenrio) Totl helth expenditure (optimistic scenrio) Helth sector resource needs (mbitious scenrio) Source: Dt from Stenberg K, Hnssen O, Tn-Torres Edejer T et l. Finncing trnsformtive helth systems towrds chievement of the helth Sustinble Development Gols: model for projected resource needs in 67 low-income nd middle-income countries. Lncet Globl Helth 217; 5: e GLOBAL TUBERCULOSIS REPORT

137 FIG. 7.4 Out-of-pocket expenditure s percentge of totl helth expenditure, 214 Percentge No dt Not pplicble Dt for 215 will be vilble in December 217. Source: Dt extrcted from WHO s Globl Helth Expenditure Dtbse ( to increse to US$ 112 per cpit in low-income countries, US$ 146 per cpit in lower-middle-income countries nd US$ 536 per cpit in upper-middle income countries (Fig. 7.3). 7.2 Reducing finncil hrdship nd incresing socil protection Out-of-pocket expenditures nd finncil hrdship UHC requires tht people cn ccess needed services without suffering finncil hrdship. The percentge of totl helth expenditure ccounted for by OOP expenditure provides proxy mesure of the extent to which finncil protection is in plce. In 214, 1 OOP expenditures were less thn 15% of totl helth spending in 44 of the 19 countries for which dt were vilble, including high TB burden countries such s Nmibi, South Afric nd Thilnd (Fig. 7.4). However, there were 46 countries in which OOP expenditures ccounted for t lest 45% of totl helth expenditures. This included 11 high TB burden countries: Bngldesh, Cmbodi, Centrl Africn Republic, Indi, Indonesi, Mynmr, Nigeri, Pkistn, the Philippines, the Russin Federtion nd Sierr Leone. 1 The ltest yer for which dt re vilble; WHO will report on updted dt in December Ntionl surveys of costs fced by TB ptients nd their households As introduced in the Globl TB report 216, WHO ims to nnully report on results from ntionl surveys of costs fced by TB ptients nd their households. These surveys hve two primry objectives: to document the mgnitude nd min drivers of different types of costs incurred by TB ptients (nd their households), in order to guide policies to reduce finncil brriers to ccessing cre nd minimize the dverse socioeconomic impct of TB; nd to determine the bseline nd periodiclly mesure the percentge of TB ptients (nd their households) treted in the ntionl TB progrmme (NTP) network who incur ctstrophic totl costs due to TB. This informtion is needed to monitor progress towrds one of the three highlevel indictors of the End TB Strtegy for which trgets nd milestones hve been set (Chpter 2). The distinction between the indictor of ctstrophic totl costs due to TB disese nd the broder indictor of ctstrophic expenditures on helth is explined in Box 7.1. WHO recommends conducting bseline survey by 22 t the ltest. Findings re needed to inform the improved design or implementtion of cre nd to ssess whether the 126 GLOBAL TUBERCULOSIS REPORT 217

138 FIG. 7.5 Ntionl surveys of costs fced by TB ptients nd their households: progress nd plns s of August 217 Completed Ongoing b Plnned 217/218 Not pplicble b At lest field work hs been completed. Subntionl surveys re ongoing in Bolivi (Cochbmb) nd Brzil (So Polo). n BOX 7.1 n The difference between ctstrophic totl costs for TB ptients nd their households, nd ctstrophic expenditures on helth It is importnt to distinguish the indictor of ctstrophic totl costs due to TB from the indictor of ctstrophic expenditures on helth being used within the SDG monitoring frmework nd in regionl frmeworks for UHC. The ltter is popultion-bsed indictor tht mesures the shre of the popultion incurring ctstrophic expenditures on helth, with threshold defined bsed on household bility to py. Expenditures re defined s direct expenditures on medicl cre. The TB-specific indictor incorportes not only direct medicl pyments for dignosis nd tretment but lso direct non-medicl pyments (such s for trnsporttion nd lodging) nd indirect costs (such s lost income). The TB-specific indictor is lso restricted to prticulr popultion: dignosed TB ptients treted by providers tht re prt of NTP networks. 22 milestone of the End TB Strtegy (tht no TB ptients nd their households should fce ctstrophic totl costs due to TB) is chieved. 1 Socil protection progrmmes re one mechnism tht cn help to mitigte costs. WHO developed drft protocol nd survey instrument for the conduct of these ntionlly-representtive nd 1 This trget is in line with policy efforts to move helth systems closer to UHC, becuse ccess to TB prevention nd cre requires tht generl brriers to ccessing helth cre re ddressed. helth-fcility-bsed surveys in By erly 218, WHO hndbook for conducting these surveys will be vilble, nd will include n updted protocol. This hndbook builds on lessons lerned from surveys implemented nd 2 World Helth Orgniztion. Protocol for survey to determine direct nd indirect costs due to TB nd to estimte proportion of TB-ffected households experiencing ctstrophic costs due to TB: field testing version. Genev: WHO; 215 ( mesurement_tskforce/meetings/tf6_bckground_5_ptient_cost_ surveys_protocol.pdf, ccessed 2 August 217). GLOBAL TUBERCULOSIS REPORT

139 n BOX 7.2 n Mesuring costs fced by TB ptients nd their households in Viet Nm From July to October 216, the NTP in Viet Nm worked with the Viet Nm Integrted Center for TB nd Respirology Reserch (VICTORY), Vietnmese reserch network, to conduct the first ntionl survey of costs fced by TB ptients nd their households. Viet Nm is lower-middle-income country nd is one of the 3 high TB burden countries. This ws the second ntionl survey in which the WHO-recommended protocol ws pplied, following survey in Mynmr in VIET NAM FIRST NATIONAL SURVEY OF COSTS FACED BY TB PATIENTS AND THEIR HOUSEHOLDS CLUSTERS SURVEY COVERAGE sssssssss sssssssss sssssssss sssssssss ssssssss ssssssss sssssssssssssssx1 ssssss x1 677 TB PATIENTS 58 DRUG-RESISTANT TB (MDR-TB) PATIENTS KEY RESULTS Proportion of households tht experienced 1 ctstrophic costs of households ffected by TB or MDR-TB 63% experienced costs tht were bove 2% of their nnul household income ÇÇÇÇÇÇÇ ÇÇÇ 98% 2 of households ffected by MDR-TB experienced ctstrophic costs The poorest households were the most ffected, with costs representing on verge 347% of nnul household income Costs experienced by households ffected by TB or MDR-TB, on verge Ptients fced direct nd indirect costs mounting on verge to: US$168 FOR AN EPISODE OF TB of which US$ 519 (49%) ws reported household income loss US$4289 FOR AN EPISODE OF MDR-TB of which US$ 2142 (5%) ws for trvel, ccommodtion, nutritionl supplements nd specil foods Trvel, ccommodtion, food, nutritionl supplements (post-dignosis) Reported household income loss Medicl expenditures (post-dignosis) Trvel, ccommodtion, food, nutritionl supplements (pre-dignosis) Medicl expenditures (pre-dignosis) Coping strtegies nd perceived impct Households ffected by TB 38% 22% 27% of households employed one of these strtegies: tking lon, use of svings, borrowing or sle of ssets of households experienced food insecurity of households perceived the finncil burden s serious or very serious Households ffected by MDR-TB 52% 32% 47% MDR-TB TB US$ of households employed one of these strtegies: tking lon, use of svings, borrowing or sle of ssets of households experienced food insecurity of households perceived the finncil burden s serious or very serious Source: Mesuring ctstrophic costs due to tuberculosis in Vietnm Ho B. Nguyen et l. 217 (in press) The cross-sectionl public-fcility-bsed survey involved 735 ptients with either drug-susceptible or MDR-TB who were receiving tretment in helth fcilities cross 2 clusters. The instrument included questions on costs, time losses, coping mesures nd sset ownership. Totl costs were expressed s percentge of nnul household income, nd if they exceeded 2% of household income the household ws clssified s experiencing ctstrophic totl costs. Survey results (see infogrphic) suggested tht, in Viet Nm, n estimted 63% of TB-ffected households nd 98% of the households of ptients with MDR-TB experienced totl costs tht were ctstrophic. On verge, the cost ws US$ 168 for n episode of drug-susceptible TB nd US$ 4289 per episode of MDR-TB. The most importnt cost drivers were reported income losses nd non-medicl costs fter dignosis. Significnt predictors for experiencing ctstrophic costs were being in the poorest or less poor household welth quintiles. Using the results of this bseline survey, Viet Nm s NTP hs defined rodmp (217 22) involving non-helth ctors to ddress ccess brriers nd n opertionl reserch pln. A commitment to periodiclly monitor TB ptient costs hs lso been mde. Subsequently, stkeholders meeting to review survey results nd refine the elements of the rodmp nd the monitoring nd evlution frmework ws held. Prticipnts included representtives from the socil protection deprtment of the Ministry of Lbour-Invlids nd Socil Affirs (MOLISA); the Ministry of Helth (MoH) deprtments of plnning nd finnce, medicl services dministrtion, interntionl coopertion nd helth strtegy; the Frmer s Union; the Women s Union; WHO; VICTORY; former TB ptients; nd locl nd interntionl reserch institutions. The rodmp ims to enble policy guidnce nd interventions to reduce nd compenste for costs fced by TB ptients nd their households. It includes the development nd costing of pckge of mbultory TB services to be explored for inclusion in the new Ntionl helth insurnce (NHI) scheme, nd dvocting for donor support for TBspecific ptient socil support. Other elements re the lunch of chrity fund for TB ptients tht cn be used for purchsing of helth insurnce crds for the poor; providing trvel vouchers, food pckges or csh; nd developing rodmp for how the MoH cn collborte with MOLISA to: scle up nd dpt for TB ptients the existing mechnism to purchse helth insurnce crds for the poor; enble ccess to other socil protection schemes nd dpt them to the needs of TB ptients; ssess dditionl finncil nd humn resource needs; trin helth service stff in socil protection prctices, nd socil service stff in TB issues; nd monitor nd evlute inititives. A MOLISA pilot on socil protection for MDR-TB ptients will be ssessed. MOLISA will lso be engged to ssess nd strengthen current regultions for workers protection, nd to use existing nd new reserch pltforms to test new pproches to reduce ptient costs. 128 GLOBAL TUBERCULOSIS REPORT 217

140 dvice provided by WHO TB Ptient Cost Tsk Force. The Globl TB report 216 included results from the first ntionl survey using the WHO protocol, which ws conducted in Mynmr ( ). The sttus of survey plnning nd implementtion s of August 217 is shown in Fig Seven surveys hd been completed, in Ghn, Keny, Mynmr, the Philippines, Republic of Moldov, Timor Leste nd Viet Nm, with results in the process of being nlysed, reviewed by ntionl stke holders nd prepred for publiction. Six surveys were ongoing nd ten re scheduled to strt lter in 217 or in 218. It is nticipted tht severl dditionl countries will strt plnning surveys in 218. A profile of the survey conducted in Viet Nm in 216 is provided in Box 7.2. The findings re similr to those in Mynmr, demonstrting tht high proportion of TB ptients re experiencing ctstrophic totl costs s result of TB (using threshold of costs representing more thn 2% of household income 1 ). The findings lso suggest tht people with multidrug-resistnt TB (MDR-TB) fce prticulrly serious burden, nd tht some of these costs could be reduced through improved (more ptient-centred) models of cre nd doption of new tools, while others indicte need for socil ssistnce nd other forms of socil protection Estblishing or strengthening ntionl socil protection schemes TB ptient cost surveys nd relted studies show tht TB ptients nd their households cn fce debilitting nd often ctstrophic totl costs due to TB disese, relted to indirect costs such s income loss, direct medicl costs, trnsport or food costs. The second pillr of the End TB Strtegy (bold policies nd systems) includes the pursuit of socil protection for TB ptients nd their households. In ddition, WHO guidnce on the tretment of drug-susceptible nd drugresistnt TB highlights evidence tht economic nd socil support is ssocited with improved tretment results. The Globl TB report 216 nd the WHO guide to implementing the End TB Strtegy 2 included exmples (e.g. in Brzil, Indi nd the Philippines) of generl socil protection systems, including csh trnsfer progrmmes for poor nd vulnerble popultions. In these countries nd mny others, TB-specific socil support projects re in plce to ssist ptients, for exmple by providing food, csh, vouchers, or other economic or psycho-socil support. Both publictions lso signled the need to explore more efficient, systemtic nd possibly more sustinble pproches through estblishment of linkges with existing socil ssistnce efforts. In prt stimulted by the doption of the Interntionl Lbour Orgniztion (ILO) recommendtion on socil protec- 1 Further explntion nd justifiction of this threshold is provided in the forthcoming WHO hndbook on surveys of costs fced by TB ptients nd their households. 2 World Helth Orgniztion. Implementing the End TB Strtegy: the essentils (WHO/HTM/TB/215.31). Genev: WHO; 215 ( publictions/215/end_tb_essentil.pdf?u=1). tion floors in 212, 3 nd collbortion with other institutions including the World Bnk, WHO nd the United Ntions Children s Fund (UNICEF), mny low nd middle-income countries hve strted to expnd their socil protection systems, with focus on bsic services, socil ssistnce or socil insurnce, nd lbour progrmmes, nd with prticulr ttention to the needs of low-income popultions. Bsed on vilble documenttion compiled by the WHO Globl TB Progrmme for policy briefs on socil protection systems in high TB burden countries, 4 Tble 7.1 shows the bsic components of socil protection policy nd csh trnsfer schemes tht exist in the 3 high TB burden countries. The focus is on three mjor elements of socil protection schemes tht my be of substntil relevnce to efforts to improve socil protection for TB ptients nd households specificlly: the existence of overll policy, strtegy or legisltive frmeworks; register of trget popultions or beneficiries; nd some level of coverge of csh trnsfers for specific poor or vulnerble popultions or disbled persons. Of the 3 high TB burden countries, 26 hve policy document, strtegy or relevnt legisltion for socil protection, nd most hve some form of csh trnsfer system. Dt on coverge levels re not esy to obtin, but coverge in mny countries remins low nd frgmented. 5 Nevertheless, these inititives re incresingly bcked by domestic policies, they re mnged by dministrtive uthorities or gencies, they hve some opertionl experience nd finncing, nd they re likely more systemtic thn most TB-specific socil support projects. They lso indicte collbortion between ministries of helth nd socil protection gencies. Stkeholder workshops to discuss the results from surveys of costs fced by TB ptients nd their households offer n opportunity to engge cross ministries nd with nongovernmentl prtners on wys to provide socil protection for TB ptients, s well s to define reserch tht my be required to inform these efforts Improving ptient ccess through tilored provider pyment mechnisms Incresing the shre of finncing tht is derived from compulsory prepid sources nd pooled to spred risk cross the popultion is criticl to reduce the finncil hrdships rising from out-of-pocket expenditures nd enble ccess to cre. However, incresing such pooled funding lone is not sufficient; the funds must then be directed to priority services nd popultions through the mechnisms used to py providers. The Globl TB report 216 provided exmples of compulsory prepyment nd pooling to spred risk within the 3 Interntionl Lbour Orgniztion. R22 Socil Protection Floors Recommendtion, 212 (no. 22), Adoption: Genev, 11st ILC session (14 June 212). 4 WHO. Globl TB Progrmme Country Socil Protection Briefs ( tb/resofwork/socilprotection/en). 5 See World Helth Orgniztion. Report from the first consulttion of the Helth nd Socil Protection Action Reserch & Knowledge Shring (SPARKS) Network (WHO/HTM/TB/ 217.1). 217 ( publictions/sprksreport/en/). GLOBAL TUBERCULOSIS REPORT

141 n BOX 7.3 n Provider pyment for TB cre under PhilHelth, the Philippines NHI progrmme,b,c PhilHelth, the Philippines NHI progrmme, hs mde importnt contributions to helth service delivery, including for TB. The benefit pckge for TB cre (referred to within PhilHelth s the DOTS pckge) includes reimbursement for elements of TB cre delivery (such s follow-up testing once TB ptients re dignosed, consulttion services nd helth eduction nd counselling during tretment) delivered by ccredited providers nd TB drugs re provided by the NTP. PhilHelth reimburses helth fcilities nd providers for providing TB services with cse-bsed pyment mechnism, comprising flt-rte pyment for new nd retretment cses of drug-susceptible pulmonry nd extr-pulmonry TB in children nd dults. Reimbursement is provided in two pyments n initil pyment fter the ccredited fcility hs finished provision of the intensive phse of TB tretment (2 months); nd second pyment t the end of the continution phse (4 months). To be eligible for TB benefits, PhilHelth member must hve TB disese bsed on the dignostic criteri defined by the NTP nd the cre must be mnged by n ccredited TB cre fcility. The ptient must be n ctive PhilHelth member, mening tht the person is registered, with qulifying contributions. Mnging the benefit pckge through PhilHelth hs required strengthening processes in res such s ccredittion, dministrtion of TB cre benefits, regultion nd coordintion, ptient informtion nd privte sector enggement. Despite substntil chievements, mesures still need to be tken, in prticulr, to stremline the cre nd ccredittion process nd, s consequence, increse the number of ccredited TB cre centres ccessible to ptients nd the number of ptients using the PhilHElth TB benefits. Sometimes, there re lso difficulties in enbling reimbursement of providers, becuse pyments mde to locl government units re not lwys then pssed long to the fcilities or providers tht hd provided the services. Furthermore, MDR-TB tretment is not yet included in the benefits pckge, which is significnt limittion, given tht the Philippines is high MDR-TB burden country. Work is underwy to resolve ech of these chllenges. b c USAID TB CARE II Project Synthesis report: inclusion of TB in ntionl insurnce progrms. United Sttes Agency for Interntionl Development (USAID); 213 ( files/synthesis%2report%2on%2country%2%2assessments%2 on%2tb%2insurnce%2study%2tb%2care%2ii%2finl.pdf, ccessed 2 August 217). Piczo OF, Gilbert V, Ulep T, et l. A criticl nlysis of PhilHelth. Discussion pper series Philippine Institute for Development Studies; 215. Revised guidelines for the PhilHelth outptient ntituberculosis directly-observed tretment short-course (DOTS) benefit pckge. PhilHelth Circulr, 214. Kiser K, Bredenkmp C, Iglesis R. Sin tx reform in the Philippines: trnsforming public finnce, helth, nd governnce for more inclusive development. World Bnk Publictions helth finncing systems of severl countries tht re considered pthfinders in Asi, including those in Indonesi, the Philippines nd Thilnd. It lso commented on relted opportunities nd chllenges for TB cre nd prevention. One concern in these countries is how public nd especilly privte providers receive pyments for services. The privte sector domintes helth-cre provision even in mny low-income communities; there cn be considerble spending on services tht re lrgely free in the public sector, but re more esily ccessible or of perceived higher qulity. In such contexts, provider pyment systems tht include privte providers my enble greter ccess without finncil burdens for the users. However, the wy providers re enrolled or ccredited nd then pid cn ffect the coverge nd qulity of cre, s well s how much users, including TB ptients, benefit from lowcost or free cre. Therefore, the design nd mngement of provider pyment rrngements, s well s benefit pckges for TB ptients, cn ffect cre nd costs. Typiclly, finncing systems tht include these mechnisms involve distinct gency responsible for implementing provider pyments, such s Ntionl Helth Insurnce (NHI) Fund. In such contexts, ensuring tht services for TB ptients re pid nd cre coordinted effectively depends on collbortion mong the insurnce gency, generl helth services, public nd privte providers, nd TB progrmmes within the Ministry of Helth. The PhilHelth NHI Fund in the Philippines ws one of the exmples profiled in lst yer s report. An up-to-dte summry of TB cre provider pyment rrngements in plce under PhilHelth is provided in Box Addressing broder determinnts of the TB epidemic The influence of vrious socil nd economic determinnts on the TB epidemic hs been long recognized. For exmple, TB incidence nd mortlity strted to decline in western Europe well before effective drug tretments becme vilble, nd the fstest historic rtes of decline in TB incidence t ntionl level occurred in the sme prt of the world during the 195s nd 196s, when the vilbility of effective tretments coincided with rpid socil nd economic development. The links between TB nd poverty, socil protection, the prevlence of undernutrition, dibetes, HIV, lcohol use, smoking, indoor ir pollution nd income per cpit hve been nlysed, 13 GLOBAL TUBERCULOSIS REPORT 217

142 TABLE 7.1 Socil protection policy nd csh trnsfer schemes in 3 high TB burden countries Yes Not identified STRATEGY/POLICY REGISTRY b POOR AND VULNERABLE TARGETING c Angol Bngldesh Brzil Cmbodi Centrl Africn Republic Chin DR Congo Congo DPR Kore Ethiopi Indi Indonesi Keny Lesotho Liberi Mozmbique Mynmr Nmibi Nigeri Pkistn Ppu New Guine Philippines Russin Federtion Sierr Leone South Afric Thilnd UR Tnzni Viet Nm Zmbi Zimbbwe Strtegy/policy indictes whether ntionl strtegy, nd/or policy/legisltive frmework for socil protection ws identified. b Registry indictes whether socil nd/or beneficiry registry system for socil ssistnce progrmmes is in plce. c Trgeting indictes whether there re ny identified non-contributory csh trnsfer schemes specificlly for poor nd vulnerble groups nd the disbled. Poor nd vulnerble groups include trnsfers to individuls nd households bsed on socio-economic criteri nd my include children, the elderly, poor people with disbilities, nd those fcing food insecurity; disbled refers to persons hving disbility regrdless of socio-economic sttus. Sources: WHO Globl TB Progrmme Country Socil Protection Briefs ( dditionl informtion on registries: The stte of socil sfety nets 215 ( Socil registries for socil ssistnce nd beyond: guidnce note & ssessment tool ( DISABLED GLOBAL TUBERCULOSIS REPORT

143 TABLE 7.2 TB cses ttributble to selected risk fctors RISK FACTOR RELATIVE RISK EXPOSED (MILLIONS IN 215) GLOBAL POPULATION ATTRIBUTABLE FRACTION (%) ATTRIBUTABLE TB CASES (MILLIONS IN 215) Undernourishment HIV infection Smoking Dibetes Hrmful use of lcohol Source: Lönnroth K, Cstro KG, Chky JM et l. Tuberculosis control nd elimintion 21 5: cure, cre, nd socil development. Lncet. 21 My 22;375(9728): The reltive risk for HIV infection is bsed on dt from UNAIDS nd estimtes from this Globl TB report. reviewed or summrized in recent publictions (further detils re provided in Chpter 2). 1,2,3,4 Tble 7.2 shows new WHO estimtes of the number of incident TB cses tht were ttributble to selected risk fctors. Undernutrition is responsible for nerly twice s mny TB cses s HIV, due to the lrge size of the popultion ffected. A reduction in the risk of developing TB mong people ltently infected with TB including by combting these nd other risk fctors will be essentil to chieve the End TB Strtegy milestones nd trgets. These findings reinforce the grounds for inclusion of socil protection, poverty llevition nd ction on other determinnts of TB under the bold policies nd systems pillr of the End TB Strtegy. As explined in Chpter 2, in 217 WHO hs developed TB-SDG monitoring frmework tht focuses ttention on 14 indictors (under seven SDGs) tht re ssocited with TB incidence. Monitoring of these indictors cn be used to identify key influences on the TB epidemic t ntionl level nd inform the multisectorl ctions required to end the TB epidemic. For SDG 3, the seven indictors selected for monitoring re: coverge of essentil helth services; percentge of totl helth expenditures tht re out-ofpocket; helth expenditure per cpit; HIV prevlence; prevlence of smoking; 1 Lonnroth K, Jrmillo E, Willims B, Dye C, Rviglione M. Tuberculosis: the role of risk fctors nd socil determinnts. In: Bls E & Kurup A (eds.), Equity, socil determinnts nd public helth progrmmes, WHO. 21( eng.pdf, ccessed 2 August 217). 2 Lonnroth K, Cstro KG, Chky JM, Chuhn LS, Floyd K, Glziou P et l. Tuberculosis control nd elimintion 21 5: cure, cre, nd socil development. Lncet. 21;375(9728): ( sciencedirect.com/science/rticle/pii/s ?vi%3dihub, ccessed 2 August 217). 3 Lienhrdt C, Glziou P, Uplekr M, Lonnroth K, Gethun H, Rviglione M. Globl tuberculosis control: lessons lernt nd future prospects. Nt Rev Microbiol. 212;1(6): ( v1/n6/full/nrmicro2797.html, ccessed 2 August 217). 4 Lonnroth K, Jrmillo E, Willims BG, Dye C, Rviglione M. Drivers of tuberculosis epidemics: the role of risk fctors nd socil determinnts. Soc Sci Med. 29;68(12): ( rticle/pii/s , ccessed 2 August 217) prevlence of dibetes; nd prevlence of lcohol use disorder. For SDGs 1, 2, 7, 8, 1 nd 11, the seven indictors selected for monitoring re: proportion of the popultion living below the interntionl poverty line; proportion of the popultion covered by socil protection floors/systems; prevlence of undernourishment; proportion of the popultion with primry relince on clen fuels nd technology; GDP per cpit; Gini index for income inequlity; 5 nd proportion of the urbn popultion living in slums. Collection nd reporting of dt for the 14 indictors does not require ny dditionl dt collection nd reporting efforts by NTPs. Nor does it require dt collection nd reporting efforts tht go beyond those to which countries hve lredy committed in the context of the SDGs. Dt re vilble from globl dtbses, primrily those mintined by the UN, WHO, the World Bnk nd UNAIDS (for further detils, see Annex 1). The most recent dt for five of the seven SDG 3 (helth) indictors re shown for the 3 high TB burden countries in Tble For ll of the indictors shown, lower level is more desirble. 7 The most recent dt for six of the seven selected SDG indictors beyond SDG 3 re shown in Fig. 7.6, this time for the 23 high TB burden countries for which dt for ll six indictors were vilble. 8 In this figure, the outer edge of the hexgon (1) is the idel vlue for ech indictor. Therefore, 5 The index cn tke vlues between nd 1, with representing perfect equlity nd 1 representing perfect inequlity. 6 Coverge of helth services is not included becuse methods to clculte this indictor re in development; helth expenditure per cpit is lso not shown, but dt re included in Annex 2. 7 The composite indictor of coverge for essentil helth services ws excluded becuse WHO hs not yet published its recommendtions for definition nd mesurement of the indictor. 8 GDP per cpit is not included becuse it is the only indictor tht is not mesured on scle of 1. However, the ltest vlue nd recent trends in this indictor re shown in the country profiles in Annex GLOBAL TUBERCULOSIS REPORT 217

144 TABLE 7.3 Sttus of selected SDG 3 indictors, 3 high TB burden countries, ltest vilble yer b. COUNTRY OUT-OF-POCKET HEALTH EXPENDITURE (% OF TOTAL EXPENDITURE ON HEALTH) b HIV PREVALENCE (% OF POPULATION AGED YEARS) SMOKING PREVALENCE (% OF MALE POPULATION AGED 15 YEARS) SMOKING PREVALENCE (% OF FEMALE POPULATION AGED 15 YEARS) DIABETES PREVALENCE (% OF POPULATION AGED 18 YEARS) ALCOHOL USE DISORDERS, 12 MONTH PREVALENCE (% OF POPULATION AGED 15 YEARS) Angol Bngldesh Brzil Cmbodi Centrl Africn Republic Chin Congo DPR Kore DR Congo Ethiopi Indi Indonesi Keny Lesotho Liberi Mozmbique Mynmr Nmibi Nigeri Pkistn Ppu New Guine Philippines Russin Federtion Sierr Leone South Afric Thilnd UR Tnzni Viet Nm Zmbi Zimbbwe Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion (see Annex 1, Tble A1.2). Missing vlues indicte dt not vilble in these dt sources. Out of pocket expenditure is ny direct outly by households, including grtuities nd in-kind pyments, to helth prctitioners nd suppliers of phrmceuticls, therpeutic pplinces, nd other goods nd services whose primry intent is to contribute to the restortion or enhncement of the helth sttus of individuls or popultion groups. It is prt of privte helth expenditure. better performnce corresponds to lrger shded-in region. To chieve this, the indictors proportion of the urbn popultion living in slums nd proportion of the popultion living below the interntionl poverty line were inverted. Tble 7.3 nd Fig. 7.6 show tht mny high TB burden countries, especilly those in the low-income ctegory, still fce significnt chllenges to chieve rnge of TB-relted SDG trgets. It is lso importnt to highlight tht vlues for poor popultions nd vulnerble groups most t risk of developing TB re likely to be worse thn ntionl verges. Exmples of high TB burden countries doing reltively well in terms of t lest some of the indictors include Brzil, Indonesi, South Afric, Thilnd nd Viet Nm. Monitoring of ll 14 indictors should stimulte more explortion of the fctors ffecting progress, interreltionships between indictors nd resulting ctions needed. This is one of the resons why the country profiles for high TB burden countries contined in Annex 2 include, for the first time in 217, full pge showing the sttus of nd recent trends in indictors included in the TB-SDG monitoring frmework. GLOBAL TUBERCULOSIS REPORT

145 FIG. 7.6 Sttus of selected SDG indictors beyond SDG 3 in selected high TB burden countries, ltest vilble yer Clen fuels Bngldesh Not in slums Income equlity Clen fuels Brzil Not in slums Income equlity Clen fuels Cmbodi Not in slums Income equlity Centrl Africn Republic Not in slums 1 75 Clen fuels 5 Income 25 equlity Clen fuels Congo Not in slums Income equlity Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Not in poverty Not in poverty Not in poverty Not in poverty Not in poverty Clen fuels Ethiopi Not in slums Income equlity Clen fuels Indi Not in slums Income equlity Clen fuels Indonesi Not in slums Income equlity Clen fuels Keny Not in slums Income equlity Clen fuels Lesotho Not in slums Income equlity Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Not in poverty Not in poverty Not in poverty Not in poverty Not in poverty Clen fuels Liberi Not in slums Income equlity Mozmbique Not in slums 1 75 Clen fuels 5 25 Income equlity Clen fuels Nmibi Not in slums Income equlity Clen fuels Nigeri Not in slums Income equlity Clen fuels Pkistn Not in slums Income equlity Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Not in poverty Not in poverty Not in poverty Not in poverty Not in poverty Clen fuels Philippines Not in slums Income equlity Sierr Leone Not in slums 1 75 Clen fuels 5 25 Income equlity Clen fuels South Afric Not in slums Income equlity Clen fuels Thilnd Not in slums Income equlity Clen fuels UR Tnzni Not in slums Income equlity Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Not in poverty Not in poverty Not in poverty Not in poverty Not in poverty Clen fuels Nutrition Viet Nm Not in slums Not in poverty Income equlity Socil protection Clen fuels Nutrition Zmbi Not in slums Not in poverty Income equlity Socil protection Clen fuels Nutrition Zimbbwe Not in slums Not in poverty Income equlity Socil protection Not in slums: Percentge of urbn popultion not living in slums. Income equlity: An reverse GINI index is shown i.e. is perfect inequlity nd 1 is perfect equlity. Socil protection: Percentge of popultion covered by socil protection nd lbour progrmmes. Not in poverty: Percentge of popultion living bove the interntionl poverty line. Nutrition: Percentge of popultion not undernourished. Clen fuels: Percentge of popultion with ccess to clen fuels nd technologies for cooking. Dt re shown for the high TB burden countries tht hd t lest one dt point for ll six indictors (23 of the 3 countries). Source: World Bnk Sustinble Development Gols Dtbse ( 134 GLOBAL TUBERCULOSIS REPORT 217

146

147 A child receives her dily TB mediction in New Delhi, Indi ANDREW AITCHISON / ALAMY STOCK PHOTO

148 CHAPTER 8. TB reserch nd development n KEY FACTS AND MESSAGES n Intensified reserch nd innovtion is the third pillr of the End TB Strtegy. The dignostic pipeline is reltively stgnnt. Few technologies emerged in 217 nd severl hve not demonstrted dequte performnce in field evlution studies. The next-genertion Xpert MTB/RIF Ultr crtridge hs been found to hve significntly better performnce (incresed sensitivity) thn the Xpert MTB/RIF crtridge for the detection of Mycobcterium tuberculosis. Following review of the evidence by n expert group, WHO recommendtions for the use of Xpert MTB/RIF s the initil dignostic test for ll dults nd children with signs nd symptoms of TB, nd for the testing of selected extrpulmonry specimens (cerebrospinl fluid, lymph nodes nd tissue specimens) now lso pply to the Ultr crtridge. The development nd evlution of the GeneXpert Omni instrument, which is intended s closeto-cre pltform tht uses either Xpert MTB/RIF or Xpert Ultr crtridges, hs been delyed. Field evlutions re scheduled to strt in 218. There re 17 drugs in Phse I, II or III trils for the tretment of drug-susceptible TB, multidrug-resistnt TB (MDR-TB) or ltent TB infection (LTBI). These drugs include eight new compounds: delpzolid, GSK , OPC , PBTZ169, pretomnid, Q23, SQ19 nd sutezolid. Two other drugs, bedquiline nd delmnid, hve lredy received ccelerted or conditionl regultory pprovl bsed on Phse IIb results. The seven repurposed drugs tht re undergoing further testing re clofzimine, linezolid, levofloxcin, moxifloxcin, nitzoxnide, rifmpicin (high dose) nd rifpentine. Vrious combintion regimens with new nd/or repurposed drugs re in Phse II or Phse III trils. There re 12 vccine cndidtes in clinicl trils: nine in Phse II or Phse III, nd three in Phse I. They include cndidtes to prevent the development of TB, nd cndidtes to help improve the outcomes of tretment for TB disese. WHO continues to promote TB reserch, bsed on the Globl Action Frmework for TB Reserch tht ws published in 215. Prticulr ttention hs been given to the development of ntionl TB reserch networks. Countries tht used the frmework in included Indi, Indonesi, Swzilnd nd Thilnd. A substntil increse in funding for TB reserch nd development will be needed to chieve the trgets set in the End TB Strtegy nd Sustinble Development Gols. Intensified reserch nd innovtion is one of the three pillrs of the WHO End TB Strtegy. 1 The two min components of this pillr re discovery, development nd rpid uptke of new tools, interventions nd strtegies nd reserch to optimize implementtion nd impct, nd promote innovtions (Chpter 2). Both components re fundmentl to chieving the globl TB trgets set in the End TB Strtegy nd the Sustinble Development Gols (SDGs). The 23 trgets re 9% reduction in the TB incidence rte nd n 8% reduction in the number of TB deths compred with levels in 215; such reductions cn only be chieved if there is mjor technologicl brekthrough by 225, so tht the rte t which TB incidence flls cn be drmticlly ccelerted compred with historic levels (Chpter 2). A substntil increse in investment in TB reserch nd development will be needed to chieve such brekthrough. The Stop TB Prtnership s Globl Pln to End TB, estimtes tht bout US$ 2 billion per yer is needed 1 World Helth Orgniztion. WHO End TB Strtegy: globl strtegy nd trgets for tuberculosis prevention, cre nd control fter 215. Genev: WHO; 215 ( ccessed 8 August 216). 2 The globl pln to end TB, Genev: Stop TB Prtnership; 215 ( ccessed 28 July 216). GLOBAL TUBERCULOSIS REPORT

149 n BOX 8.1 n Advncing TB reserch in the context of the WHO Ministeril Conference on Ending TB in the Er of the SDGs TB reserch nd development is one of the mjor topics of the WHO Globl Ministeril Conference on Ending TB in the Er of the SDGs, which will be held in the Russin Federtion in November 217. There will be pnel discussion on scientific reserch nd innovtions, covering issues such s how to ddress the persistently lrge funding gps for TB reserch nd development, the need for multisectorl nd multidisciplinry pproch to reserch, how to build institutionl cpcity t globl nd ntionl levels, enggement of communities nd how to reduce regultory brriers tht ffect the speed of uptke of tools. Commitments mde in the Ministeril Declrtion t the end of the conference will then be tken forwrd in the led-up to the United Ntions Generl Assembly high-level meeting on TB in 218. during the period , but funding between 25 nd 215 never exceeded US$.7 billion per yer. 1,2 The urgent need for incresed finncing for TB reserch will be one of the topics discussed t the 217 WHO Globl Ministeril Conference on Ending TB in the Er of the SDGs (Box 8.1). This chpter is not intended s n exhustive overview of current or recently completed TB reserch. As in previous globl TB reports, it focuses on providing n overview of progress in the development of new TB dignostics (Section 8.1), drugs (Section 8.2) nd vccines (Section 8.3). This includes presenttion nd description of the sttus of the pipelines s of August 217, bsed on recent publictions, communictions with the secretrits of the relevnt working groups of the Stop TB Prtnership, nd discussions with other stkeholders. The lst prt of the chpter (Section 8.4) discusses the role of multisectorl nd multidisciplinry reserch in optimizing the implementtion nd impct of vilble tools nd pproches, linked to the WHO Globl Action Frmework for TB Reserch tht ws published in New dignostics for TB This section strts by providing n overview of the TB dignostics pipeline, with prticulr ttention to developments in 217. It then describes dignostic tests, products nd methods relted to the detection of TB disese nd drug resistnce tht were reviewed by WHO in 217, or tht re scheduled for evlution in 218. Finlly, it discusses tests for identifiction of ltent TB infection (LTBI), with prticulr ttention to tests to predict progression from TB infection to ctive TB disese. 1 Tretment Action Group (215). 215 report on tuberculosis reserch funding trends, : decde of dt. New York: Tretment Action Group ( ccessed 8 August 217). 2 The globl pln to stop TB, Genev: Stop TB Prtnership; 21 ( ccessed 2 July 217). 3 World Helth Orgniztion. A globl ction frmework for TB reserch in support of the third pillr of WHO s End TB Strtegy. Genev: World Helth Orgniztion; 215 ( ccessed 8 August 217) An overview of the dignostics pipeline Reserch nd development of new dignostics for TB ppers to be stlling. Only few technologies successfully emerged from the pipeline in 217. Rpid nd robust point-of-cre dignostics, technologies to relibly detect LTBI nd ccurte biomrker tests to monitor tretment response remin elusive. This reflects serious underinvestment (especilly in bsic science) s well s persistent scientific nd technicl chllenges tht ffect the development of new TB dignostics. An overview of the pipeline for TB dignostics in August 217 is shown in Fig The list of technologies is not necessrily complete, but does reflect technologies tht hve been documented in recent reports published by the Tretment Action Group 4 nd Unitid. 5 Technologies under development include tests to detect TB, to detect drug resistnce mong confirmed TB cses, nd to detect TB nd drug resistnce simultneously. The pipeline remins similr to the one published in the 216 edition of the Globl TB report nd highlights the urgent need for new technologies to minimize brriers to helth cre ccess, ensure qulity testing for difficult-to-dignose groups, expnd the spectrum of drug-susceptibility testing, nd reduce costs of dignostic pltforms nd their mintennce. Dt on the performnce of Cepheid s close-to-cre pltform GeneXpert Omni (Omni) were expected to be vilble for WHO evlution in 217. Omni is described by the mnufcturer s smll, light nd durble instrument designed for simultneous testing for TB nd rifmpicinresistnt TB using either Xpert MTB/RIF crtridges or the next-genertion Xpert MTB/RIF Ultr crtridges. It is imed t fcilitting wider ccess to rpid moleculr testing for TB nd rifmpicin resistnce in decentrlized settings, ided by specific fetures such s built-in btteries nd use of crtridges tht incorporte ner-field communiction chip to llow cellulr trnsfer of dt. The development of Omni 4 Lessem E. The tuberculosis dignostics pipeline. Tretment Action Group; 217 ( Report-TB-Dignostics.pdf, ccessed 16 August 217). 5 Unitid. Tuberculosis dignostic technology lndscpe, 5th edition. Genev: World Helth Orgniztion; 217 ( Unitid-TB-Dignostics-Technology-Lndscpe.pdf, ccessed 16 August 217). 138 GLOBAL TUBERCULOSIS REPORT 217

150 FIG. 8.1 An overview of progress in the development of TB dignostics, August 217 TECHNOLOGIES IN DEVELOPMENT Moleculr detection of TB nd drug resistnce n Gendrive MTB/RIF ID, Epistem, UK n Xpert XDR-TB crtridge, Cepheid, USA n TruArry MDR-TB, Akkoni, USA n INFINITIMTB Assy, AutoGenomics, USA n FluoroType XDR-TB ssy, Hin Lifescience, Germny n MeltPro TB ssy, Zeesn Biotech, Chin n QuntuMDx, POC, UK ON THE MARKET (EVIDENCE FOR USE NOT SUBMITTED TO WHO FOR EVALUATION) Moleculr detection of TB nd drug resistnce n icubte System, icubte, USA n Genechip, TB drug resistnce rry, Cpitl Bio, Chin n EsyNAT TB Dignostic kit, Ustr Biotechnologies, Chin n Truelb/Truent MTB, Molbio/bigtec Dignostics, Indi TECHNOLOGIES ENDORSED BY WHO Moleculr detection of TB nd drug resistnce n Xpert MTB/RIF Ultr for detection of TB nd rifmpicin resistnce in pulmonry, extrpulmonry nd peditric smples, Cepheid, USA n Line probe ssys for the detection of Mycobcterium tuberculosis (MTB), isonizid nd rifmpicin resistnce in cid-fst bcilli smer positive sputum or MTB cultures (FL-LPA), Hin Lifescience, Germny nd Nipro, Jpn n Line probe ssys for the detection of resistnce to fluoroquinolones nd second-line injectble gents (SL-LPA), Hin Lifescience, Germny n TB LAMP for detection of TB, Eiken, Jpn Nonmoleculr technologies n Alere Determine TB-LAM, Alere, USA (TB detection in people seriously ill with HIV) n Inteferon gmm relese ssy (IGRAs) for the dignosis of ltent TB infection (LTBI) Oxford Immunotec, UK, Qigen, USA Culture-bsed technologies n Commercil liquid culture systems nd rpid specition n Culture-bsed phenotypic DST using 1% criticl proportion in LJ,7H1,7H11 nd MGIT medi. Microscopy n Light nd light-emitting diode microscopy (dignosis nd tretment monitoring) SCHEDULED FOR WHO EVALUATION IN 218/19 Moleculr detection of TB nd drug resistnce n Moleculr technologies for genotypic drug resistnce testing (including sequencing technologies) n FluoroType MTBDR, Hin Lifescience, Germny n m2 RelTime MTB System, Abbott, USA n BD Mx MDR-TB, Becton Dickinson, USA n GeneXpert Omni, Cepheid, USA Rdiology n Chest X-ry n Computer ided detection (CAD) This is not n exhustive list of technologies in development but includes ll those described in the TAG Tuberculosis Dignostics Pipeline Report 217. Lessem E. The Tuberculosis Dignostic Pipeline. New York. Tretment Action Group 216 ( ). hs, however, been delyed. Field evlutions re expected to strt in 218. Severl mnufcturers re developing centrlized testing pltforms suitble for high lbortory throughput. In principle, these should hve similr performnce to Xpert ssys, but with higher throughput nd potentilly lower unit cost (per smple tested). Performnce dt for these pltforms hve not yet been submitted to WHO for forml review, but exmples include: The RelTime pltform, developed by Abbott. This is lredy widely used in centrl lbortories for HIV-1 virl lod testing. Assys clled RelTime MTB (for detection of TB disese) nd RelTime MTB RIF/INH (for detection of resistnce to rifmpicin nd isonizid) hve been developed. FluoroType MTBDR, lunched by Hin Lifescience in erly 217. This pltform detects TB nd resistnce to rifmpicin nd isonizid simultneously, directly from sputum specimens. The technology is fully utomted, from DNA extrction to mplifiction nd detection. Pltforms being developed by Becton Dickinson nd Roche, which re expected to be redy for field evlution studies in 218. The pipeline lso includes three commercil technologies intended for use t lower levels of dignostic systems (s opposed to reference level): Epistem Genedrive (Epistem, United Kingdom); EsyNAT (Ustr Biotechnologies, Chin); nd Molbio TrueNAT (Molbio, Indi. Performnce dt for these tests remin limited, nd to dte only the Epistem Genedrive hs undergone multicentre evlution in different epidemiologicl settings. Evidence bout the performnce of these technologies from well-designed vlidtion studies is needed to enble WHO to review nd ssess their performnce TB dignostic tests, products nd methods reviewed by WHO in 217 In 217, WHO reviewed the next-genertion Xpert MTB/RIF Ultr crtridge, criticl concentrtions for performing drugsusceptibility testing (DST) using phenotypic methods, nd products for trnsporting specimens tht could potentilly improve the detection of Mycobcterium tuberculosis using culture-bsed nd moleculr methods. The min outcomes of these reviews re discussed below. GLOBAL TUBERCULOSIS REPORT

151 Xpert MTB/RIF Ultr crtridge The Ultr crtridge showed significntly better performnce (incresed sensitivity) thn the current Xpert MTB/RIF crtridge in detecting M. tuberculosis in specimens with low numbers of bcilli. This ws prticulrly the cse for smer-negtive, culture-positive specimens (e.g. those from people living with HIV), extrpulmonry specimens (notbly cerebrospinl fluid) nd specimens from children. However, the incresed sensitivity hs been offset by decrese in specificity, possibly due to the well-described limittions of the reference stndrd (culture) used s the comprtor for both versions of the Xpert crtridge. This reduced specificity my led to flse-positive results for TB disese (compred with culture), with the Ultr ssy detecting TB bcilli tht re not replicting. The ccurcy of the Ultr ssy in detecting rifmpicin resistnce ws similr to tht of the Xpert crtridge. Following review of the ltest evidence, 1 WHO recommendtions for the use of Xpert MTB/RIF 2 s the initil dignostic test for ll dults nd children with signs nd symptoms of TB, nd for the testing of selected extr pulmonry specimens (cerebrospinl fluid, lymph nodes nd tissue specimens) now lso pply to the Ultr ssy. Products for trnsporttion of smples Detection of M. tuberculosis nd testing for drug resistnce re fundmentl for ccurte dignosis nd tretment of TB. However, they re often hmpered by difficulties in trnsporting nd storing smples between remote loctions nd reference lbortories. Products for trnsporttion of smples tht improve the recovery nd detection of M. tuberculosis nd reduce culture contmintion rtes in the lbortory re highly desirble, s re products tht cn improve the detection of M. tuberculosis using moleculr tools. Four commercil trnsport products were ssessed by WHO in 217: OMNIgene SPUTUM (DNA Genotek, Ottw, Cnd); PrimeStore Moleculr Trnsport Medium (Longhorn Vccines nd Dignostics, Sn Antonio, United Sttes of Americ [USA]); FTA crd (Whtmn, GE Helthcre Life Sciences, Pittsburgh, USA); nd GENO CARD (Hin Lifescience GmbH, Nehren, Germny). The OMNIgene SPUTUM) product ws designed to retin the vibility of culture specimens; the other three im to 1 World Helth Orgniztion. WHO meeting report of technicl expert consulttion: non-inferiority nlysis of Xpert MTB/RIF Ultr compred to Xpert MTB/RIF (WHO/HTM/TB/217.4). Genev: World Helth Orgniztion; 217 ( en/, ccessed 16 August 217). 2 World Helth Orgniztion. Automted rel-time nucleic cid mplifiction technology for rpid nd simultneous detection of tuberculosis nd rifmpicin resistnce: Xpert MTB/RIF ssy for the dignosis of pulmonry nd extrpulmonry TB in dults nd children policy updte (WHO/HTM/ TB/213.16) Genev: World Helth Orgniztion; 213 ( iris/bitstrem/1665/112472/1/ _eng.pdf?u=1, ccessed 16 August 217). improve the moleculr yield of specimens without needing to preserve their vibility for culture. When compred with untreted specimens trnsported under mbient conditions, there ws insufficient evidence tht ny of the existing commercil trnsport products improved the performnce of TB dignostics, lrgely s result of poorly-designed studies nd significnt heterogeneity in the dt. Full detils re vilble in the meeting report. 3 Criticl concentrtions for culture-bsed drug-susceptibility testing DST is essentil to guide the choice of pproprite tretment for ptient, to confirm whether resistnce hs emerged when ptient does not hve stisfctory response to tretment, nd for surveillnce of resistnce to nti-tb drugs. Culturebsed phenotypic DST is the current reference method for M. tuberculosis, nd relies on the testing of so-clled criticl concentrtions of drugs, i.e. the lowest concentrtion of n nti-tb drug tht will inhibit the growth of t lest 95% of wild-type strins of M. tuberculosis. In 217, WHO commissioned systemtic review of studies on culture-bsed DST results for second-line nti-tb drugs. The min outcomes were chnges to the criticl concentrtions for the fluoroquinolones nd the estblishment of interim criticl concentrtions for bedquiline nd delmnid TB dignostic tests, products nd methods tht my be evluted by WHO in 218 In 218, there my be sufficient dt for WHO to review the performnce of centrlized high-throughput testing pltforms, the use of moleculr sequencing s reference stndrd for DST, nd tests for extensively drug-resistnt TB (XDR-TB). 5 Centrlized high-throughput testing pltforms If sufficient evidence becomes vilble, the centrlized highthroughput testing pltforms described in Section could be evluted in 218. WHO nd FIND hve developed two-step evlution process for this purpose. The first step includes verifiction of the ccurcy of the ssys in detecting M. tuberculosis s well s resistnce to rifmpicin nd isonizid, bsed on n externl evlution of stndrdized pnel of strins, conducted independently of the mnufcturers t one or more WHO TB suprntionl reference lbortories (SRLs). The second step is evlution of the clinicl vlidity of the ssys, bsed on testing of the pltforms in two or three reference lbortories in high TB burden settings, nd 3 World Helth Orgniztion. Technicl Expert Group meeting report: Smple trnsport products nd trget product profile (TPP) for solutions tht improve the recovery of mycobcteri with culture (WHO/HTM/TB/217.19). Genev: World Helth Orgniztion; World Helth Orgniztion. WHO meeting report of technicl expert consulttion: criticl concentrtions for TB medicines (WHO/HTM/ TB/217.22). Genev: World Helth Orgniztion; XDR-TB is defined s MDR-TB plus resistnce to t lest one fluoroquinolone nd second-line injectble. 14 GLOBAL TUBERCULOSIS REPORT 217

152 compring results with the reference stndrds of culture, phenotypic DST nd moleculr sequencing, s well s with Xpert MTB/RIF. Moleculr sequencing s reference stndrd for drugsusceptibility testing Drug resistnce in the M. tuberculosis complex my be exclusively due to muttions ffecting the bcteril genome. In 218, WHO expects to ssess evidence bout the ccurcy of genotypic DST compred with current phenotypic reference stndrds, nd to develop relted list of priority muttions (so-clled high-confidence muttions) to id in test development. WHO will lso consider whether the combintion of genotypic DST nd informed interprettion of the muttions cn replce phenotypic DST, t lest for certin key drugs such s rifmpicin nd pyrzinmide. Tests for XDR-TB Moleculr line probe ssys (LPAs) for second-line nti- TB drugs re currently the only rpid moleculr tests recommended by WHO to detect whether ptients with confirmed multidrug-resistnt (MDR) or rifmpicin-resistnt TB hve XDR-TB. 1 However, LPAs require sophisticted lbortory infrstructure nd equipment tht is normlly only vilble in centrlized lbortories. Hin Lifescience is developing rel-time ssy for the detection of resistnce to second-line injectble gents nd fluoroquinolones, using the new Fluorotype pltform. Cepheid plns to develop n XDR-TB crtridge to detect resistnce to isonizid, injectble gents nd fluoroquinolones s n lterntive to LPAs. If sufficient dt become vilble, WHO will evlute these tests using the sme two-step pproch described bove for centrlized high-throughput testing pltforms Tests for the identifiction of LTBI Identifying nd effectively treting or vccinting people with LTBI who hve no signs nd symptoms of TB disese will be necessry to chieve the 23 nd 235 trgets of the End TB Strtegy. The tests tht re currently vilble for the identifiction of LTBI re the tuberculin skin test (TST) nd interferon gmm relese ssys (IGRAs). These tests indirectly mesure TB infection by detecting memory T-cell response, signifying the presence of host sensitiztion to M. tuberculosis ntigens. 2 Test results show only whether or not n individul hs been exposed to M. tuberculosis, nd re poor predictors of whether 1 The use of moleculr line probe ssys for the detection of resistnce to second-line nti-tuberculosis drugs. Policy guidnce. WHO/HTM/TB/ Genev: World Helth Orgniztion. ( lp-mdr-dignostics/en/, ccessed 8 August 217) 2 Implementing tuberculosis dignostics. Policy frmework. WHO/HTM/ TB/ Genev: World Helth Orgniztion, 215. ( iris/bitstrem/1665/162712/1/ _eng.pdf?u=1&u=1, ccessed 8 August 217). the individul will progress to ctive TB disese in the future. 3 Without being ble to predict who is most likely to develop disese, lrge number of people would need to be treted to prevent one cse of ctive TB. This is mjor brrier to scling up existing tretment for LTBI. In 217, n expert meeting ws held to develop consensus round trget product profile (TPP) for test tht would ccurtely mesure the progression of LTBI to ctive disese. The meeting ws convened by WHO, on behlf of the New Dignostics Working Group of the Stop TB Prtnership. Prticipnts defined the key specifictions of the required product, including its intended use, performnce nd opertionl chrcteristics, nd pricing; they lso estblished frmework for future evlution of ny new tests tht re developed. Further detils re vilble in the meeting report New drugs nd drug regimens to tret TB The pipeline for new nti-tb drugs in August 217 is shown in Fig There re 17 drugs in Phse I, II or III trils. These include eight new compounds: delpzolid, GSK , OPC , PBTZ169, pretomnid, Q23, SQ19 nd sutezolid. Two other drugs, bedquiline nd delmnid, hve lredy received ccelerted or conditionl regultory pprovl bsed on Phse IIb results nd re now in Phse III trils. The seven repurposed drugs tht re undergoing further testing re clofzimine, linezolid, levofloxcin, moxifloxcin, nitzoxnide, rifmpicin (high dose) nd rifpentine. These 17 drugs re described in more detil in Section nd Section New TB drug regimens re lso being tested, nd these re described in Section New compounds Bedquiline WHO issued interim policy guidnce on the use of bedquiline for tretment of ptients with MDR-TB in 213, bsed on Phse IIb tril results. 5 There ws conditionl recommendtion to use bedquiline to strengthen the longer tretment regimens for MDR-TB tht re recommended by WHO. Following the vilbility of more evidence bout the use of bedquiline, WHO convened Guideline Development Group in 216. The min outcome of this review ws to mintin the sme conditionl recommendtion, until new systemtic review 3 Mtteelli A, Sulis G, Cpone S, D Ambrosio L, Migliori GB, Gethun H. Tuberculosis elimintion nd the chllenge of ltent tuberculosis. Presse Med. 217;46(2 Pt 2):e13-e21 ( rticle/pii/s ?vi%3dihub, ccessed 16 August 217). 4 World Helth Orgniztion. Consensus meeting report: development of trget product profile nd frmework for evlution for test of progression from tuberculosis infection to ctive disese (WHO/HTM/TB/217.18). Genev: World Helth Orgniztion; World Helth Orgniztion. The use of bedquiline in the tretment of multidrug-resistnt tuberculosis: interim policy guidnce (WHO/HTM/ TB/213.6). Genev: WHO; 213 ( bitstrem/1665/84879/1/ _eng.pdf, ccessed 8 August 217). GLOBAL TUBERCULOSIS REPORT

153 FIG. 8.2 The globl development pipeline for new nti-tb drugs nd regimens, August 217 Phse I Phse II Phse III GSK b OPC b Q23 b Delpzolid (LCB1-371) PBTZ169 b SQ19 b Sutezolid Levofloxcin Linezolid Nitzoxnide Rifmpicin (high dose) Rifpentine Bedquiline nd delmnid (ACTG 5343 DELIBERATE tril) Bedquiline Pretomnid Pyrzinmide regimen Bedquiline Pretomnid Moxifloxcin Pyrzinmide regimen Delmnid Linezolid Levofloxcin Pyrzinmide regimen (MDR-END tril) Bedquiline Delmnid Pretomnid Clofzimine Rifmpicin (high dose) Rifpentine Bedquiline Pretomnid Linezolid, with or without moxifloxcin or clofzimine for MDR-TB or XDR-TB (TB PRACTECAL tril) Bedquiline Pretomnid Linezolid (NiX-TB tril) Bedquiline with two optimised bckground regimens (orl, 9 months; with orl nd injectbles, 6 months) (STREAM tril) Bedquiline Linezolid with optimized bckground regimen for MDR-TB (NExT tril) Bedquiline nd delmnid with vrious existing regimens for MDR-TB nd XDR-TB (endtb tril) Rifpentine Moxifloxcin for drug-susceptible TB (TB Tril Consortium Study 31/A5349) b New drug compounds re listed first, followed by repurposed drugs nd then by regimens. New chemicl clss. Source: Adpted from the Stop TB Prtnership Working Group on New TB Drugs pipeline. More informtion on these products nd other ongoing projects cn be found t of evidence is wrrnted or results from the Phse III clinicl tril become vilble. 1 The sfety nd efficcy of bedquiline s prt of short MDR-TB regimens (i.e. 6 nd 9 months durtion), compred with the updted current stndrd of cre recommended by WHO (i.e. shortened regimen) is being investigted in the second stge of the Phse III STREAM tril. Recruitment strted in Mrch 216, 2 nd the first results re expected in 22. A study on the use of bedquiline to tret children with MDR-TB is being implemented in the Philippines, the Russin Federtion nd South Afric. Bedquiline is lso being used in trils of ll-orl tretment regimens (Section 8.2.3), nd investigtion of its use in tretment of drug-susceptible TB hs strted. Delmnid The follow-up stge of Phse III tril of the sfety nd efficcy of delmnid s n ddition to n optimized bckground regimen for the tretment of dults with MDR-TB ws recently completed. Finl results re expected by erly 218. The use of delmnid in ddition to n optimized bckground regimen to tret children with MDR-TB is being investigted in Phse I nd II trils. Following the results of two trils in cohorts of children nd dolescents with MDR- 1 Report of the Guideline Development Group Meeting on the use of bedquiline in the tretment of multidrug-resistnt tuberculosis, 216 revision (WHO/HTM/TB/217.1). Genev, WHO, iris/bitstrem/1665/254712/1/who-htm-tb eng.pdf 2 Moodley R, Godec TR, Tem ST. Short-course tretment for multidrugresistnt tuberculosis: the STREAM trils. Eur Respir Rev. 216;25(139):29 35 ( ccessed 16 August 217). TB ged 6 17 yers, WHO s interim guidnce on the use of delmnid ws updted to include recommendtions for its use in this ge group. 3 As with bedquiline, delmnid is being used in trils of ll-orl tretment regimens (Section 8.2.3). Studies of its use in the prevention of drug-resistnt TB mong contcts of people with MDR-TB re plnned. Delpzolid (LCB1-371) Delpzolid is new oxzolidinone developed by LegoChem BioSciences. It entered Phse II tril in the Republic of Kore in 217. GSK GSK is new oxborole compound developed by GlxoSmithKline. A Phse I tril strted in Mrch 217. OPC OPC is crbostyril developed by Otsuk tht is bctericidl ginst both growing nd intrcellulr bcilli. A single scending dose study will be completed in lte 217. A multiple scending dose/erly bctericidl ctivity (EBA) study of OPC lone nd in combintion with delmnid is plnned for World Helth Orgniztion. The use of delmnid in the tretment of multidrug-resistnt tuberculosis in children nd dolescents: Interim policy guidnce (WHO/HTM/TB/216.14). Genev: WHO; 216. ( publictions/delmnid_interim_policy/en/, ccessed 16 August 217) 142 GLOBAL TUBERCULOSIS REPORT 217

154 PBTZ169 PBTZ169 is benzothizinone developed by the Swiss Federl Institute of Technology (Lusnne) nd Innovtive Medicines for Tuberculosis (im4tb). A Phse I tril hs been completed; results re not yet published. A Phse II tril hs strted in the Russin Federtion. Pretomnid Pretomnid is nitroimidzole tht is being developed by the TB Allince (the Globl Allince for TB Drug Development). 1 It is currently being tested s prt of combintion regimens for the tretment of both drug-susceptible nd drug-resistnt TB, including XDR-TB (Section 8.2.3). Q23 Q23 is n imidzopyridine tht hs been developed by Qurient (Republic of Kore). 2 Single doses of vrious sizes re being tested in two Phse I trils. SQ19 SQ19 is drug discovered by scientists t Sequell Inc. (USA) nd the US Ntionl Institutes of Helth. A Phse IIb/III tril in which the drug ws dded to stndrd regimen for MDR-TB hs been completed in seven clinicl centres in the Russin Federtion; positive results in terms of sfety, efficcy nd tolerbility were reported in press relese in Mrch 217. A Phse II tril is being implemented in the USA. Sutezolid Sutezolid (PNU-148) is n oxzolidinone nd n nlogue of linezolid. Results from n EBA study presented in 212 showed significnt reduction in colony-forming unit counts compred with the bseline level fter 14 dys of tretment. In Jnury 217, the Medicines Ptent Pool nnounced tht it hs signed licence with Johns Hopkins University to fcilitte the clinicl development of sutezolid in combintion with other drugs. On World TB Dy 217, the TB Allince nd the Medicines Ptent Pool nnounced licensing greement for the clinicl development of sutezolid Approved drugs being tested for new purposes Clofzimine Clofzimine is riminophenzine tht is used to tret leprosy. Its use in MDR-TB tretment is being explored in preclinicl models of TB infection, to better understnd its nti-tb effects. Novrtis, the compny tht mnufctures the drug, hs withdrwn support for Phse II trils; however, clofzimine continues to be tested s prt of tretment regimens for MDR- TB tht re in Phse III trils. Levofloxcin Levofloxcin is being tested in the Phse II Opti-Q study. This is investigting the best dose of levofloxcin to use for tretment of MDR-TB in dults with smer- nd culturepositive pulmonry TB. Four doses re being tested (11, 14, 17, 2 mg/kg) s prt of n optimized bckground regimen. The tril is being implemented in Peru nd South Afric nd is scheduled for completion in lte 217. Linezolid Linezolid is n oxzolidinone with potent ctivity ginst TB. It hs been widely used in the tretment of drug-resistnt TB nd there is good evidence tht it improves culture conversion nd cure rtes when dded to tretment regimens. Since the medicine hs nrrow therpeutic window, nd the optiml dosing strtegy remins unknown, the TB Allince is implementing Phse II tril to evlute mycobctericidl ctivity, sfety, tolerbility, nd phrmcokinetics of 5 doses of linezolid in dults with pulmonry TB. Moxifloxcin Moxifloxcin is included in severl trils of new regimens for tretment of both drug susceptible nd drug-resistnt TB (Section 8.2.3). Nitzoxnide Nitzoxnide is n nti-prsitic drug. Its ctivity ginst M. tuberculosis is being tested in Phse II tril in Hiti. Rifmpicin (high dose) Findings from the multi-rm, multi-stge TB (MAMS-TB) tril of the PnACEA consortium were published in These showed tht 35 mg/kg of rifmpicin given over 12 weeks ws sfe, nd shortened the time to stble culture conversion from 62 to 48 dys. The other tril rms, which included vrious combintions of 1 mg/kg or 2 mg/kg of rifmpicin, moxifloxcin nd SQ19, did not chieve significnt improvements compred with the control rm. When ll the dt re tken into considertion, the tril suggests tht 35 mg/ kg dose of rifmpicin given for 12 weeks is likely to improve tretment outcomes. This tril is the first multi-rm dptive tril design to be successfully implemented in multiple sites in countries with high burden of TB. It my help to pve the wy for ccelerted testing of new TB tretment regimens t reduced cost. Rifpentine The effectiveness of rifpentine in the tretment of drugsusceptible TB is being studied in three trils. The TB Tril Consortium (TBTC) Study 31/A5349, which is investigting Pethe K, Bifni P, Jng J, Kng S, Prk S, Ahn S et l. Discovery of Q23, potent clinicl cndidte for the tretment of tuberculosis. Nt Med. 213;19(9): Boeree MJ, Heinrich N, Arnoutse R, Dicon AH, Dwson R, Rehl S et l. High-dose rifmpicin, moxifloxcin, nd SQ19 for treting tuberculosis: multi-rm, multi-stge rndomised controlled tril. Lncet Infect Dis. 217;17(1):39 49 ( pii/s ?vi%3dihub, ccessed 16 August 217). GLOBAL TUBERCULOSIS REPORT

155 the use of rifpentine with or without moxifloxcin to shorten the tretment of drug-susceptible pulmonry TB to 4 months, strted in 216. TBTC Study 35, Phse II study of the phrmcokinetics of new wter-dispersible peditric formultions of rifpentine, is scheduled to strt in two sites in South Afric in 218. TBTC Study 37 is Phse III tril of the sfety nd efficcy of 6 weeks of dily rifpentine for the tretment of LTBI in HIV-negtive people in settings with low burden of TB. It is being compred with loclly vilble 3 4 month rifmycin-bsed regimen New regimens for the tretment of drugsusceptible or drug-resistnt TB New combintions of drugs re being tested in Phse II or Phse III trils. ACTG A5343 DELIBERATE The ACTG A5343 DELIBERATE tril is testing the crdiotoxicity of regimens contining delmnid nd bedquiline lone nd in combintion in phrmcokinetic nd drug-drug interction studies. The tril is sponsored by NIH/NIAID. endtb The endtb tril strted in 217, to compre severl regimens for tretment of MDR-TB or XDR-TB with the current longer regimen recommended by WHO. The regimens being tested include bedquiline or delmnid (or both), moxifloxcin or levofloxcin, nd pyrzinmide plus linezolid or clofzimine (or both), in vrious combintions. MDR-END The MDR-END tril is investigting 9 12 month regimen of delmnid, linezolid, levofloxcin nd pyrzinmide for tretment of MDR-TB mong TB ptients without resistnce to fluoroquinolones. NeXT The NeXT tril is testing 6 9 month injection-free regimen of bedquiline, ethionmide or high-dose isonizid, linezolid, levofloxcin nd pyrzinmide for ptients with MDR-TB, compred with the short regimen of 12 months recommended by WHO. Recruitment strted in South Afric in 216. NiX-TB nd ZeNix The NiX-TB tril is investigting the sfety nd efficcy of 6-month combintion of bedquiline, pretomnid nd linezolid (ll orl gents) in ptients with XDR-TB nd tretment-intolernt MDR-TB. It is being implemented by the TB Allince in South Afric. The primry endpoint is bcteriologicl filure (relpse or clinicl filure) 6 months fter completion of tretment. A cure rte of 87% hs been reported for the first 15 ptients. A follow-on tril clled ZeNix will explore lower doses nd shorter durtions of linezolid to minimize toxicity. The TB Allince is lso in the process of implementing Phse IIc tril of bedquiline, pretomnid, moxifloxcin nd pyrzinmide (BPMZ), with primry endpoint of culture conversion t 2 months. A previous Phse IIb study of this BPMZ regimen showed lmost 1% culture conversion t 2 months in ptients with MDR-TB. In combintion, these two regimens could potentilly tret ll ptients with ctive TB with orl drugs only, within mximum of 6 months. STREAM The STREAM stge 1 tril is compring 9-month regimen for MDR-TB with longer regimens of months. 1 Ptients with rifmpicin-resistnt pulmonry TB nd no evidence of resistnce to fluoroquinolones or knmycin re eligible. The tril is being implemented in Ethiopi, Mongoli, South Afric nd Viet Nm, nd finl results re expected in 218. TB-PRACTECAL The TB-PRACTECAL tril is Phse II/III tril to evlute the sfety nd efficcy of 6-month regimens tht contin bedquiline, pretomnid nd linezolid, with or without moxifloxcin or clofzimine, for the tretment of dults with MDR-TB or XDR-TB. It is being implemented in Belrus, South Afric nd Uzbekistn. 8.3 New vccines to prevent TB The BCG vccine, first used in the 192s, remins the only licensed vccine for preventing TB. Despite high coverge of BCG vccintion s prt of childhood immuniztion progrmmes (Chpter 5), the slow decline in TB incidence globlly highlights the need for much more effective vccine tht provides protection ginst ll forms of TB in ll ge groups. The sttus of the pipeline for new TB vccines in August 217, including the nmes of vccine developers, is shown in Fig There re 12 vccines in Phse I, II or III trils. Their min chrcteristics re summrized below Phse I trils There re three vccine cndidtes in Phse I trils. Ad5 Ag85A Ad5 Ag85A is n denovirus serotype 5 vector expressing Ag85A. It hs been evluted for sfety nd immunogenicity in both BCG-nive nd previously BCG-immunized helthy volunteers in Cnd. Overll, intrmusculr dministrtion ws found to be sfe, well tolerted nd immunogenic in both 1 Nunn AJ, Rusen ID, Vn Deun A, Torre G, Phillips PP, Ching CY et l. Evlution of stndrdized tretment regimen of nti-tuberculosis drugs for ptients with multi-drug-resistnt tuberculosis (STREAM): study protocol for rndomized controlled tril. Trils. 214;15:353 ( biomedcentrl.com/rticles/1.1186/ , ccessed 16 August 217). 144 GLOBAL TUBERCULOSIS REPORT 217

156 FIG. 8.3 The globl development pipeline for new TB vccines, August 217 Phse I Phse II Phse IIb Phse III MTBVAC Biofbri, TBVI, Zrgoz RUTI Archivel Frm, S.L DAR-91 booster Drtmouth, GHIT Vcce Anhui Zhifei Longcom Ad5 Ag85A McMster, CnSino H56: IC31 SSI, Vlnev, Aers VPM12 SII, Mx Plnck, VPM, TBVI ChAdOx185A-MVA85A (ID/IM/Aerosol) University of Oxford H4: IC31 Snofi Psteur, SSI, Aers M72 / AS1E GSK, Aers ID93 + GLA-SE IDRI, Wellcome Trust, Aers TB / FLU-4L RIBSP n Virl Vector n Protein/Adjuvnt n Mycobcteril Whole Cell or Extrct n Mycobcteril Live Informtion ws self-reported by vccine sponsors, nd the Stop TB Prtnership Working Group on New TB Vccines helped to coordinte their feedbck. tril groups, with more potent immunogenicity observed in volunteers who hd been previously vccinted with BCG. A sfety nd immunogenicity study of erosol dministrtion in BCG-vccinted helthy volunteers hs strted. ChAdOx185A MVA85A (ID/IM/Aerosol) ChAdOx185A is simin denovirus nd MVA85A is recombinnt pox virus both express ntigen 85A. These cndidtes re being developed with the overll im of generting joint-heterologous prime-boost regimen delivered through both systemic nd mucosl routes. A Phse I tril of intrmusculr dministrtion of ChAdOx185A in BCG-vccinted dults in the United Kingdom, both lone nd s prt of prime-boost strtegy with MVA85A, hs been completed. Phse I trils of erosol dministrtion of ChAdOx185A in BCG-vccinted dults re scheduled to strt in lte 217. Two studies of erosol dministrtion of MVA85A in BCG-vccinted individuls hve been completed nd further study in people with LTBI is being implemented. MTBVAC MTBVAC is live strin of M. tuberculosis, ttenuted vi deletions of the phop nd fdd26 genes. The primry trget popultion is neontes (s BCG replcement vccine); the secondry trget popultion is dolescents nd dults (s booster vccine). A Phse Ib tril in neontes is due to be completed t the end of 217. Phse II trils in both trget popultions re expected to strt in Phse II nd Phse III clinicl trils There re currently nine vccines in Phse II or Phse III trils. DAR-91 booster DAR-91 is whole-cell, het-inctivted, nontuberculous mycobcteril vccine. It represents new sclble mnufcturing method for SRL172, cndidte vccine which showed some efficcy mong dults living with HIV in Phse II/III tril in the United Republic of Tnzni. It is now being tested in Phse IIb prevention of (estblished) infection tril mong BCG-primed dolescents, lso in the United Republic of Tnzni. The tril is scheduled for completion in 218. H4:IC31 H4:IC31 is BCG booster vccine tht contins fusion protein of Ag85B nd TB1.4, formulted with IC31 djuvnt. It is being tested in pre-proof-of-concept Phse II tril of prevention of (estblished) infection mong IGRA-negtive, HIV-negtive dolescents t high risk of cquiring M. tuberculosis infection. It is lso in Phse I/II tril in infnts. H56:IC31 H56:IC31 is n djuvnted subunit vccine tht combines three M. tuberculosis ntigens (Ag85B, ESAT-6 nd Rv266c) with the IC31 djuvnt. Three Phse I or I/II trils of sfety nd immunogenicity hve been completed. Two of these were in HIV-negtive, BCG-vccinted dults with nd without LTBI nd without history or ny evidence of TB disese. The other ws in HIV-negtive pulmonry TB ptients who hd recently completed tretment. The trils showed tht the vccine hd n cceptble sfety profile nd ws immunogenic t GLOBAL TUBERCULOSIS REPORT

157 n BOX 8.2 n The WHO Globl Action Frmework for TB Reserch: progress in Country level WHO hs developed toolkit to support countries to develop ntionl reserch pln. This includes n emphsis on the development or strengthening of ntionl TB reserch networks to drive efforts in TB reserch, incresing ntionl investment in helth reserch, nd multisectorl collbortion. Countries tht dopted this pproch in included Indi, Indonesi, Swzilnd nd Thilnd. Globl level The Tsk Force on Globl TB Reserch ws estblished in 216, to dvise WHO on how to support the globl TB reserch community to extend its rech nd impct. WHO subsequently convened TB Reserch Funders Forum to promote discussion mong funding gencies, ntionl TB progrmme mngers, dvoctes nd public privte prtnerships on how to invigorte impct-oriented reserch t country level. WHO continues to promote TB reserch by convening stkeholders to shre knowledge, contributing to the development of consensus-bsed gend tht ddresses priorities in high TB burden countries, nd fcilitting the development nd mintennce of regionl nd globl TB reserch networks. World Helth Orgniztion. A toolkit for developing ntionl TB reserch pln, in support of the third pillr of the End TB Strtegy. Genev: World Helth Orgniztion; 216 ( who.int/tb/publictions/tb_reserch_toolkit/en/, ccessed 2 July 217). ll studied doses. Anlysis of Phse Ib tril evluting the sfety nd immunogenicity of H4:IC31, H56:IC31 nd BCG revccintion in dolescents is underwy. ID93 + GLA-SE The ID93 + GLA-SE vccine comprises four M. tuberculosis ntigens ssocited with virulence (Rv268, Rv3619 nd Rv362) or ltency (Rv1813), nd the djuvnt GLA-SE. A Phse II tril in HIV-negtive TB ptients tht hve recently completed tretment for pulmonry TB disese ws recently completed in South Afric, in preprtion for Phse IIb tril tht will investigte prevention of recurrence of disese in the sme popultion. M72/AS1E M72/AS1E is subunit vccine tht pirs two M. tuberculosis ntigens (32A nd 39A) with n djuvnt (AS1E). It is being tested in Phse IIb efficcy tril in HIV-negtive dults infected with M. tuberculosis in Keny, South Afric nd Zmbi. The primry endpoint is the number of incident cses of ctive pulmonry TB disese not ssocited with HIV infection. Secondry endpoints include sfety nd immunogenicity. RUTI RUTI is non-live, polyntigenic vccine bsed on cellwll frgmented M. tuberculosis bcteri. It is intended s therpeutic vccine, to be used in conjunction with short intensive ntibiotic tretment. A Phse I study in helthy volunteers nd Phse II study in people with LTBI hve demonstrted good sfety profile nd found the vccine to be immunogenic t ll studied doses. The min trget for RUTI is MDR-TB, nd Phse II study in ptients with MDR- TB is being implemented. TB/FLU-4L TB/FLU-4L is mucosl vectored vccine bsed on n ttenuted repliction-deficient influenz virus vector expressing ntigens Ag85A nd ESAT-6. It ws designed s prophylctic boost vccine for infnts, dolescents nd dults. A Phse II tril in people with LTBI is being implemented. Vcce Vcce vccine is specified lyste tht hs been licensed by the Chin Food nd Drug Administrtion s n immunotherpeutic gent to help shorten TB tretment for ptients with drug-susceptible TB. A Phse III tril to ssess its efficcy nd sfety in preventing TB disese in people with LTBI is being implemented. It is the lrgest TB vccine tril undertken in the pst decde, involving 1 people ged yers. The tril is scheduled to be completed in 218. VPM12 VPM12 is live recombinnt vccine. A Phse II tril is being implemented in South Afric to ssess the sfety nd immunogenicity of the vccine in HIV-exposed nd unexposed neontes nd the preprtions for subsequent Phse III tril re underwy. A Phse II/III tril for prevention of TB recurrence in dults is expected to strt before the end of 217 in Indi. 8.4 Multisectorl nd multidisciplinry pproch to TB reserch The second component of the reserch pillr of the End TB Strtegy is to optimize implementtion nd impct, nd promote innovtions. This requires multisectorl nd multidisciplinry pproch. The WHO Globl Action Frmework for TB Reserch (GAF), published in 215, ws 146 GLOBAL TUBERCULOSIS REPORT 217

158 developed to support such n pproch. 1 It hs two min components: promoting TB reserch t country level to find wys to ddress locl brriers; nd ctlysing reserch t globl level through dvoccy, knowledge shring, reserch prioritiztion, nd support to interntionl networks for reserch nd cpcity-building. Exmples of wys in which WHO hs built on the GAF in t globl nd country levels re provided in Box 8.2. A good recent exmple of n interntionl network tht is promoting multisectorl nd multidisciplinry reserch to ddress top priority of the End TB Strtegy is the Socil Protection Action Reserch & Knowledge Shring (SPARKS) Network. This hs been estblished by the Krolinsk Institute in Sweden, the London School of Hygiene & Tropicl Medicine in the United Kingdom, nd WHO. SPARKS ims to ctlyse nd chmpion reserch on socil protection, nd the use of findings to inform multisectorl policy nd ction. The network will be used to shre knowledge nd to fcilitte collbortion mong reserch institutions, public helth prctitioners, interntionl orgniztions nd civil society. At the first SPARKS consulttion, held in 216, three-phse pln for collbortion ws developed, with focus on collbortive reserch involving ntionl TB progrmmes, cdemic institutions nd other prtners. 2 One of the prticipting countries is Brzil (Box 8.3). A second exmple of n interntionl inititive to improve TB prevention nd cre services is the Globl Tsk Force on Digitl Helth for TB. This ws estblished by WHO in 215, in collbortion with the Europen Respirtory Society. The tsk force ims to enhnce TB prevention nd cre through the use of electronic helth (e-helth) nd mobile helth (m-helth) technologies. The min focus to dte hs been the development of TPPs for nine priority digitl helth concepts nd products relted to ptient cre, surveillnce, progrmme mngement nd e-lerning t country level. 3 It is hoped tht the TPPs will motivte innovtors to invest time nd resources in ventures ligned with the End TB Strtegy. Digitl helth innovtions will need to be evluted in vriety of geogrphic, socil nd economic contexts nd in specific subpopultions to generte the evidence needed to inform globl guidnce, s well s dpttion nd use t country level. Such evlution nd ppliction will involve both the helth sector nd the field of informtion nd communiction technology. n BOX 8.3 n Minstreming multisectorl reserch gend in Brzil In April 217, the ntionl TB progrmme in Brzil orgnized workshop on socil protection nd TB reserch. Prticipnts included ntionl reserchers from the Brzilin Tuberculosis Reserch Network (Rede TB), dvoctes, stff from the ntionl TB progrmme, implementing prtners, stkeholders from outside the helth sector nd funding gencies. The focus ws on wys to optimize TB cre delivery for the poorest nd most vulnerble popultions in Brzil, by leverging the existing ntionl socil protection pltform. Reserch priorities tht were identified included obtining better understnding of the impct of socioeconomic nd demogrphic fctors on TB outcomes, identifying how such fctors contribute to opertionl nd implementtion gps in the progrmmtic mngement of TB, nd designing trgeted interventions tht will ddress these brriers to cre, nd will improve ptient helth nd socioeconomic outcomes. 1 World Helth Orgniztion. A globl ction frmework for TB reserch in support of the third pillr of WHO s End TB Strtegy. Genev: World Helth Orgniztion; 215 ( ccessed 8 August 217). 2 World Helth Orgniztion. Report from the first consulttion of the Helth nd Socil Protection Action Reserch & Knowledge Shring (SPARKS) Network (WHO/HTM/TB/ 217.1). 217 ( publictions/sprksreport/en/, ccessed 16 August 217). 3 Flzon D, Timimi H, Kurosinski P, Migliori GB, Vn Gemert W, Denkinger C et l. Digitl helth for the End TB Strtegy: developing priority products nd mking them work. Eur Respir J. 216;48(1):29 45 ( com/content/48/1/29.long, ccessed 16 August 217). GLOBAL TUBERCULOSIS REPORT

159 A ptient with MDR-TB in Dushnbe, Tjikistn WENDY MARIJNISSEN / MSF

160 ANNEX 1 The WHO globl TB dtbse GLOBAL TUBERCULOSIS REPORT

161 A.1 Dtbse contents The 217 globl TB report is bsed on dt collected nnully from countries nd territories, including 194 Member Sttes. These dt re stored in globl TB dtbse tht is mnged by the TB monitoring nd evlution unit of the Globl TB Progrmme, t WHO hedqurters. In 217, dt were collected on the following topics: TB cse notifictions nd tretment outcomes, including brekdowns by TB cse type, ge, sex, HIV sttus nd drug resistnce; lbortory dignostic services; monitoring nd evlution, including surveillnce nd surveys specificlly relted to drug-resistnt TB; TB preventive therpy; TB infection control; enggement of ll public nd privte cre providers in TB prevention nd cre; community enggement; the budgets of ntionl TB control progrmmes (NTPs); utiliztion of generl helth services (hospitliztion nd outptient visits) during tretment; nd NTP expenditures. A shortened version of the online questionnire ws used for high-income countries (tht is, countries with gross ntionl income per cpit of US$ in 215, s defined by the World Bnk) 1 nd/or low-incidence countries (defined s countries with n incidence rte of <2 cses per 1 popultion or <1 cses in totl in 215). Countries reported dt using dedicted website ( which ws opened for reporting in April 217. Countries in the Europen Union submitted dt on notifictions nd tretment outcomes to the TESSy system mnged by the Europen Centre for Disese Prevention nd Control (ECDC). Dt from TESSy were uploded into the globl TB dtbse. Additionl dt bout the provision of tretment for ltent TB infection to people newly enrolled in HIV cre nd ntiretrovirl therpy (ART) for HIV-positive TB ptients were collected by the Joint United Ntions Progrmme on HIV/AIDS (UNAIDS) nd the HIV deprtment in WHO. These dt were jointly vlidted by UNAIDS nd the WHO s Globl TB Progrmme nd HIV deprtment, nd uploded into the globl TB dtbse. Following review nd follow-up with countries, the dt used for the min prt of this report were those dt vilble on 14 August 217. The number of countries nd territories tht hd reported dt by 14 August 217 is shown in Tble A1.1. TABLE A1.1 Reporting of dt in the 217 round of globl TB dt collection COUNTRIES AND TERRITORIES WHO MEMBER STATES WHO REGION OR SET OF COUNTRIES NUMBER NUMBER THAT REPORTED DATA NUMBER NUMBER THAT REPORTED DATA Africn Region Region of the Americs Estern Mediterrnen Region Europen Region South-Est Asi Region Western Pcific Region GLOBAL Indictors in the Sustinble Development Gols ssocited with TB incidence were imported into the globl TB dtbse on 21 August 217. The dt sources used re shown in Tble A1.2. A.2 Accessing TB dt using the WHO Globl TB Progrmme website Most of the dt held in the globl TB dtbse cn be found by going to This web pge provides ccess to country profiles, comm-seprted vlue (CSV) dt files nd dt visulistions. A2.1 Country profiles Profiles cn be viewed nd downloded for ll 216 countries nd territories tht report TB dt to WHO ech yer, nd not just the 3 high burden countries shown in the printed version of the globl TB report. The profiles cn be generted on-demnd directly from the globl TB dtbse nd therefore my include updtes received fter publiction of the globl TB report. TB finncil profiles cn be viewed nd downloded for over 1 countries nd territories tht report detiled TB finncil dt to WHO. A2.2 CSV dt files These files re the primry resource for nyone interested in conducting their own nlyses of the records in the globl TB dtbse. Dt reported by countries, such s time series for cse notifictions nd tretment outcomes nd WHO s estimtes GLOBAL TUBERCULOSIS REPORT 217

162 TABLE A1.2 Dt sources for indictors in the Sustinble Development Gols ssocited with TB incidence SDG INDICATOR DISPLAY NAME IN PROFILE DATA SOURCE NAME AT SOURCE SOURCE URL Popultion living below the interntionl poverty line (% of popultion) Popultion covered by socil protection floors/systems (% of popultion) Prevlence of undernourishment (% of popultion) (lterntive) (lterntive) (lterntive) 3..1 (lterntive) (lterntive) (lterntive) HIV prevlence (% of popultion ged yers) Dibetes prevlence (% of popultion ged 18 yers) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) Smoking prevlence (% of popultion ged 15 yers) Helth expenditure per cpit, PPP (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of totl expenditure on helth) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Access to clen fuels nd technologies for cooking (% of popultion) (lterntive) (lterntive) GDP per cpit, PPP (constnt 211 interntionl $) GINI index (=perfect equlity, 1=perfect inequlity) Popultion living in slums (% of urbn popultion) UN SDG dtbse World Bnk World Bnk Proportion of popultion below the interntionl poverty line Coverge All Socil Protection nd Lbour (% of popultion) Prevlence of undernourishment (% of popultion) World Bnk Prevlence of HIV, totl (% of popultion ges 15 49) WHO-GHO Rised fsting blood glucose ( 7. mmol/l or on mediction) (gestndrdized estimte) WHO-GHO Alcohol use disorders (15+), 12 month prevlence (%) World Bnk World Bnk World Bnk Smoking prevlence, femles (% of dults) nd Smoking prevlence, mles (% of dults) Helth expenditure per cpit, PPP (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of totl expenditure on helth) Not vilble Not vilble Not vilble World Bnk World Bnk World Bnk World Bnk Access to clen fuels nd technologies for cooking (% of popultion) GDP per cpit, PPP (constnt 211 interntionl $) GINI index (World Bnk estimte) Popultion living in slums (% of urbn popultion) dtbse/?indictor= Direct links to CSV files: dt-coded.csv?trget=gho/ncd_ GLUC_4&filter=AGEGROUP:*;COUNTRY:*;SEX:FMLE nd dt-coded.csv?trget=gho/ncd_ GLUC_4&filter=AGEGROUP:*;COUNTRY:*;SEX:MLE Direct links to CSV files: dt/dt-coded.csv?trget=gho/ SA_1462&filter=COUNTRY:*;SEX:FMLE nd csv?trget=gho/sa_1462&filter=country:*;sex:mle nd GLOBAL TUBERCULOSIS REPORT

163 of TB disese burden, cn be downloded s comm-seprted vlue (CSV) files covering ll yers for which dt re vilble. These CSV files cn be imported into mny spredsheet, sttisticl nlysis nd dtbse pckges. A dt dictionry tht defines ech of the vribles vilble in the CSV files is lso vilble nd cn be downloded. The CSV files re generted on-demnd directly from the globl TB dtbse, nd therefore my include updtes received fter publiction of the globl TB report. A2.3 Dt visulistions There re severl interctive web pges tht cn be used to view mps, grphs nd underlying dt on TB cse notifictions, drug-resistnt TB cses, tretment outcomes nd WHO estimtes of TB incidence nd mortlity. A.3 Accessing TB dt using the WHO Globl Helth Observtory The WHO Globl Helth Observtory (GHO) t is WHO s portl, providing ccess to dt nd nlyses for monitoring the globl helth sitution. It includes dt repository. Dt from WHO s globl TB dtbse cn be viewed, filtered, ggregted nd downloded from within the GHO Dt Repository t The GHO dt tble heders include links to vrible nd indictor definitions. The dt cn be downloded in mny formts, including s CSV nd Excel files. There is lso n Appliction Progrmme Interfce (API) for nlysts nd progrmmers to use GHO dt directly in their softwre pplictions. See GLOBAL TUBERCULOSIS REPORT 217

164

165 A TB ptient tkes his tretment t helth clinic in the Western Cpe, South Afric SYDELLE WILLOW SMITH / MSF

166 ANNEX 2 Country profiles FOR 3 HIGH TB BURDEN COUNTRIES n 2 n n 1 n high TB burden countries bsed on bsolute number of incident cses high TB burden countries bsed on severity of disese burden (incidence per cpit)

167 Angol POPULATION MILLION Estimtes of TB burden, Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 18 (1 29) 64 (36 99) Mortlity (HIV+TB only) 6.9 (3.4 12) 24 (12 41) Incidence (includes HIV+TB) 17 (66 156) 37 (23 543) Incidence (HIV+TB only) 18 (8.5 3) 61 (29 14) Incidence (MDR/RR-TB) b 4.3 ( ) 15 (4.8 25) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 5.1 ( ) 35 (2 5) 4 (23 58) Mles 5.8 ( ) 6 (35 86) 66 (38 94) Totl 11 (6.3 16) 96 (55 136) 17 (66 156) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis <1% % with known HIV sttus 46% % pulmonry 93% % bcteriologiclly confirmed mong pulmonry 54% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (38 9) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.13.4) Incidence (Rte per 1 popultion per yer) Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 2 6 notified pulmonry TB cses (79 4 4) Estimted % of TB cses with MDR/RR-TB 2.6% (.1 5.1) 18% (.1 36) % notified tested for rifmpicin resistnce <1% 4% 452 MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 167, XDR-TB: Ptients strted on tretment d MDR/RR-TB: 334, XDR-TB: Tretment success rte nd cohort size Success Cohort New nd relpse cses registered in 215 Previously treted cses, excluding relpse, registered in 215 HIV-positive TB cses registered in 215 MDR/RR-TB cses strted on second-line tretment in % 249 XDR-TB cses strted on second-line tretment in 214 Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) 14 Funding source: 29% domestic, 19% interntionl, 52% unfunded Totl budget (US$ millions) Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed Funded domesticlly Funded interntionlly Unfunded 156 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

168 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

169 Bngldesh POPULATION MILLION Estimtes of TB burden, Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 66 (43 94) 4 (26 58) Mortlity (HIV+TB only).18 (.86.3).11 (.5.18) Incidence (includes HIV+TB) 36 ( ) 221 ( ) Incidence (HIV+TB only).5 (.25.84).31 (.15.52) Incidence (MDR/RR-TB) b 8.8 (4.8 13) 5.4 ( ) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 17 (12 22) 112 (79 144) 129 (91 167) Mles 19 (14 25) 212 (15 275) 232 (164 3) Totl 36 (26 47) 324 ( ) 36 ( ) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 2% % pulmonry 8% % bcteriologiclly confirmed mong pulmonry 72% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (47 85) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.11.29) Incidence (Rte per 1 popultion per yer) Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive 87 2% on ntiretrovirl therpy 69 79% Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 5 3 notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 1.6% ( ) 29% (22 36) % notified tested for rifmpicin resistnce 16% 62% MDR/RR-TB cses tested for resistnce to second-line drugs 139 Lbortory-confirmed cses MDR/RR-TB: 969, XDR-TB: 9 Ptients strted on tretment d MDR/RR-TB: 918, XDR-TB: 8 Tretment success rte nd cohort size Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses registered in % 72 MDR/RR-TB cses strted on second-line tretment in % 946 XDR-TB cses strted on second-line tretment in 214 % 3 Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 17% (16 19) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) 85 Funding source: 7% domestic, 51% interntionl, 43% unfunded Totl budget (US$ millions) Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed Funded domesticlly Funded interntionlly Unfunded 158 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

170 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

171 Brzil POPULATION MILLION Estimtes of TB burden, Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 5.4 ( ) 2.6 ( ) Mortlity (HIV+TB only) 1.9 ( ).9 ( ) Incidence (includes HIV+TB) 87 (74 1) 42 (36 48) Incidence (HIV+TB only) 11 (9.1 13) 5.2 ( ) Incidence (MDR/RR-TB) b 2.4 ( ) 1.1 (.9 1.4) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 4.9 ( ) 24 (2 27) 29 (24 33) Mles 5.5 ( ) 53 (45 61) 58 (5 67) Totl 1 (8.9 12) 76 (65 88) 87 (74 1) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 21% % with known HIV sttus 76% % pulmonry 87% % bcteriologiclly confirmed mong pulmonry 72% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (75 1) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.7.1) Incidence (Rte per 1 popultion per yer) Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 1 9 notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 1.5% ( ) 8% (5.1 11) % notified tested for rifmpicin resistnce 26% 35% MDR/RR-TB cses tested for resistnce to second-line drugs 165 Lbortory-confirmed cses MDR/RR-TB: 99, XDR-TB: 1 Ptients strted on tretment d MDR/RR-TB: 653, XDR-TB: 1 Tretment success rte nd cohort size Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses registered in % MDR/RR-TB cses strted on second-line tretment in % 793 XDR-TB cses strted on second-line tretment in % 72 Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) 67 Funding source: 81% domestic, <1% interntionl, 19% unfunded Totl budget (US$ millions) Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed Funded domesticlly Funded interntionlly Unfunded 16 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

172 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

173 Chin POPULATION MILLION Estimtes of TB burden, Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 5 (34 7) 3.6 (2.4 5) Mortlity (HIV+TB only) 1.8 (.7 3.4).13 (.5.24) Incidence (includes HIV+TB) 895 ( ) 64 (55 74) Incidence (HIV+TB only) 11 (6.9 15).76 ( ) Incidence (MDR/RR-TB) b 73 (56 89) 5.2 (4 6.4) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 47 (4 54) 245 (28 281) 292 ( ) Mles 53 (45 61) 55 ( ) 63 ( ) Totl 1 (85 115) 795 ( ) 895 ( ) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 43% % pulmonry 95% % bcteriologiclly confirmed mong pulmonry 31% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (75 1) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.4.8) Incidence (Rte per 1 popultion per yer) Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mon 58 notified pulmonry TB cses (47 69 ) Estimted % of TB cses with MDR/RR-TB 7.1% ( ) 24% (2 28) % notified tested for rifmpicin resistnce 13% 55% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 1 898, XDR-TB: 525 Ptients strted on tretment d MDR/RR-TB: 5 45, XDR-TB: 265 Tretment success rte nd cohort size Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses registered in % MDR/RR-TB cses strted on second-line tretment in % XDR-TB cses strted on second-line tretment in % 135 Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) 384 Funding source: 96% domestic, 3% interntionl, 1% unfunded Totl budget (US$ millions) Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed Funded domesticlly Funded interntionlly Unfunded 162 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

174 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

175 Democrtic People s Republic of Kore POPULATION MILLION Estimtes of TB burden, Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 11 (6.8 16) 43 (27 63) Mortlity (HIV+TB only).51 (.23.89).2 (.9.35) Incidence (includes HIV+TB) 13 ( ) 513 ( ) Incidence (HIV+TB only).28 (.14.46) 1.1 ( ) Incidence (MDR/RR-TB) b 5.7 ( ) 22 (13 32) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 6.9 ( ) 27 (23 3) 34 (29 38) Mles 7.7 ( ) 89 (77 11) 97 (84 11) Totl 15 (13 17) 116 (1 131) 13 ( ) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus % pulmonry 81% % bcteriologiclly confirmed mong pulmonry 5% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (76 99) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.5.12) Incidence (Rte per 1 popultion per yer) Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Ptients with known HIV-sttus who re HIV-positive on ntiretrovirl therpy Drug-resistnt TB cre, 216 Number (%) New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 4 6 notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 2.2% ( ) 16% (5.8 27) % notified tested for rifmpicin resistnce % 8% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 935, XDR-TB: Ptients strted on tretment d MDR/RR-TB: 814, XDR-TB: 19 Tretment success rte nd cohort size Success Cohort New nd relpse cses registered in 215 9% Previously treted cses, excluding relpse, registered in % HIV-positive TB cses registered in 215 MDR/RR-TB cses strted on second-line tretment in % 212 XDR-TB cses strted on second-line tretment in 214 Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 1% (99 1) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) 27 Funding source: 2% domestic, 3% interntionl, 49% unfunded Totl budget (US$ millions) Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed Funded domesticlly Funded interntionlly Unfunded 164 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

176 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

177 Democrtic Republic of the Congo POPULATION MILLION Estimtes of TB burden, Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 53 (31 8) 67 (39 11) Mortlity (HIV+TB only) 8.5 (4 15) 11 (5.1 19) Incidence (includes HIV+TB) 254 ( ) 323 (29 461) Incidence (HIV+TB only) 2 (13 29) 26 (17 37) Incidence (MDR/RR-TB) b 7.6 (3.9 11) 9.7 (4.9 15) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 15 (9.1 21) 82 (5 114) 97 (59 134) Mles 17 (1 24) 141 (86 196) 158 (96 22) Totl 32 (19 44) 222 (135 31) 254 ( ) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 54% % pulmonry 82% % bcteriologiclly confirmed mong pulmonry 81% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (36 79) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.13.4) Incidence (Rte per 1 popultion per yer) Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 3 6 notified pulmonry TB cses (2 3 5 ) Estimted % of TB cses with MDR/RR-TB 2.2% (1 3.5) 17% (9.6 24) % notified tested for rifmpicin resistnce 2% 6% MDR/RR-TB cses tested for resistnce to second-line drugs 223 Lbortory-confirmed cses MDR/RR-TB: 79, XDR-TB: 39 Ptients strted on tretment d MDR/RR-TB: 637, XDR-TB: 15 Tretment success rte nd cohort size Success Cohort New cses registered in % Previously treted cses registered in % HIV-positive TB cses registered in 215 MDR/RR-TB cses strted on second-line tretment in % 448 XDR-TB cses strted on second-line tretment in 214 Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 6.3% ( ) New cses Previously treted cses HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) 57 Funding source: 3% domestic, 48% interntionl, 49% unfunded Totl budget (US$ millions) Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed Funded domesticlly Funded interntionlly Unfunded 166 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

178 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

179 Ethiopi POPULATION MILLION Estimtes of TB burden, Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 26 (16 37) 25 (16 36) Mortlity (HIV+TB only) 4 ( ) 3.9 ( ) Incidence (includes HIV+TB) 182 ( ) 177 ( ) Incidence (HIV+TB only) 14 (9.6 19) 13 (9.4 18) Incidence (MDR/RR-TB) b 5.8 ( ) 5.7 (3 8.3) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 11 (7.5 15) 7 (48 93) 81 (55 18) Mles 12 (8.5 17) 88 (6 116) 1 (68 133) Totl 24 (16 31) 158 (17 29) 182 ( ) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 81% % pulmonry 68% % bcteriologiclly confirmed mong pulmonry 55% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (51 98) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.1.25) Incidence (Rte per 1 popultion per yer) Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 2 9 notified pulmonry TB cses (1 8 4 ) Estimted % of TB cses with MDR/RR-TB 2.7% (1.5 4) 14% (3.6 25) % notified tested for rifmpicin resistnce 42% 1% MDR/RR-TB cses tested for resistnce to second-line drugs 28 Lbortory-confirmed cses MDR/RR-TB: 7, XDR-TB: 2 Ptients strted on tretment d MDR/RR-TB: 7, XDR-TB: 2 Tretment success rte nd cohort size Success Cohort New cses registered in % Previously treted cses registered in 215 HIV-positive TB cses registered in 215 MDR/RR-TB cses strted on second-line tretment in 214 7% 557 XDR-TB cses strted on second-line tretment in 214 Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment 52% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment New cses Previously treted cses HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) 84 Funding source: 11% domestic, 45% interntionl, 43% unfunded Totl budget (US$ millions) Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed Funded domesticlly Funded interntionlly Unfunded 168 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

180 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

181 Indi POPULATION MILLION Estimtes of TB burden, Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 423 ( ) 32 (24 4) Mortlity (HIV+TB only) 12 (6.6 19).92 (.5 1.5) Incidence (includes HIV+TB) 2 79 ( ) 211 (19 345) Incidence (HIV+TB only) 87 (56 125) 6.6 ( ) Incidence (MDR/RR-TB) b 147 (95 199) 11 (7.2 15) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 17 (47 167) 897 ( ) 1 ( ) Mles 12 (52 188) 1 66 ( ) 1 78 ( ) Totl 227 (99 355) 2 56 ( ) 2 79 ( ) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 17% % with known HIV sttus 72% % pulmonry 84% % bcteriologiclly confirmed mong pulmonry 63% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (39 12) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.9.27) Incidence (Rte per 1 popultion per yer) Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 84 notified pulmonry TB cses (72 95 ) Estimted % of TB cses with MDR/RR-TB 2.8% (2 3.5) 12% (1 13) % notified tested for rifmpicin resistnce 2% 67% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: , XDR-TB: Ptients strted on tretment d MDR/RR-TB: , XDR-TB: Tretment success rte nd cohort size Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses registered in % MDR/RR-TB cses strted on second-line tretment in % XDR-TB cses strted on second-line tretment in % Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment 5% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 1.9% (1.7 2) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) 525 Funding source: 74% domestic, 26% interntionl, % unfunded Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. Estimtes of TB incidence nd mortlity for Indi re interim in nture, pending results from the ntionl TB prevlence survey plnned for 218/219. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded 17 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

182 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

183 Indonesi POPULATION MILLION Estimtes of TB burden, Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 11 (75 152) 42 (29 58) Mortlity (HIV+TB only) 13 (6.2 23) 5.1 ( ) Incidence (includes HIV+TB) 1 2 ( ) 391 ( ) Incidence (HIV+TB only) 45 (21 78) 17 (8 3) Incidence (MDR/RR-TB) b 32 (19 45) 12 (7.3 17) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 28 (17 39) 294 (179 41) 323 ( ) Mles 32 (19 44) 666 (45 928) 698 ( ) Totl 6 (36 83) 961 ( ) 1 2 ( ) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis <1% % with known HIV sttus 14% % pulmonry 92% % bcteriologiclly confirmed mong pulmonry 59% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (25 54) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.7.19) Incidence (Rte per 1 popultion per yer) Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 11 notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 2.8% ( ) 16% (1 2) % notified tested for rifmpicin resistnce 2% 176% MDR/RR-TB cses tested for resistnce to second-line drugs 1 6 Lbortory-confirmed cses MDR/RR-TB: 2 72, XDR-TB: 37 Ptients strted on tretment d MDR/RR-TB: 1 879, XDR-TB: 52 Tretment success rte nd cohort size Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses registered in 215 6% MDR/RR-TB cses strted on second-line tretment in % XDR-TB cses strted on second-line tretment in % 3 Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment 2% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 1.5% ( ) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) 185 Funding source: 29% domestic, 18% interntionl, 53% unfunded Totl budget (US$ millions) Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed Funded domesticlly Funded interntionlly Unfunded 172 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

184 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

185 Keny Estimtes of TB burden, 216 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 29 (16 45) 6 (33 93) Mortlity (HIV+TB only) 24 (14 36) 5 (3 75) Incidence (includes HIV+TB) 169 (13 25) 348 ( ) Incidence (HIV+TB only) 53 (32 79) 19 (66 162) Incidence (MDR/RR-TB) b 3 ( ) 6.2 ( ) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 1 (5.9 15) 46 (26 65) 56 (31 8) Mles 12 (6.7 17) 11 (57 145) 113 (64 162) Totl 22 (13 32) 147 (83 211) 169 (13 25) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 26% % with known HIV sttus 96% % pulmonry 83% % bcteriologiclly confirmed mong pulmonry 7% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (31 74) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.17.51) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) Incidence (Rte per 1 popultion per yer) POPULATION MILLION Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 1 3 notified pulmonry TB cses (91 1 6) Estimted % of TB cses with MDR/RR-TB 1.3% ( ) 9.4% (8.7 1) % notified tested for rifmpicin resistnce 26% 42% MDR/RR-TB cses tested for resistnce to second-line drugs 24 Lbortory-confirmed cses MDR/RR-TB: 326, XDR-TB: 9 Ptients strted on tretment d MDR/RR-TB: 326, XDR-TB: 7 Tretment success rte nd cohort size Success Cohort New nd relpse cses registered in % 8 31 Previously treted cses, excluding relpse, registered in % 224 HIV-positive TB cses registered in % MDR/RR-TB cses strted on second-line tretment in % 251 XDR-TB cses strted on second-line tretment in 214 1% 1 Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment 11% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 14% (13 15) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) 62 Funding source: 18% domestic, 41% interntionl, 41% unfunded Totl budget (US$ millions) Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed Funded domesticlly Funded interntionlly Unfunded 174 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

186 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

187 Mozmbique POPULATION MILLION Estimtes of TB burden, Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 22 (13 33) 75 (44 115) Mortlity (HIV+TB only) 33 (2 48) 114 (7 167) Incidence (includes HIV+TB) 159 (13 227) 551 ( ) Incidence (HIV+TB only) 72 (46 14) 249 (158 36) Incidence (MDR/RR-TB) b 7.6 (4.5 11) 26 (16 37) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 1 (6.2 14) 5 (3 7) 6 (37 84) Mles 12 (7.1 16) 87 (53 121) 98 (6 137) Totl 22 (13 3) 137 (83 191) 159 (13 227) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 94% % pulmonry 9% % bcteriologiclly confirmed mong pulmonry 45% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (32 7) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.19.54) Incidence (Rte per 1 popultion per yer) Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 3 4 notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 3.7% (2.4 5) 2% (2.1 37) % notified tested for rifmpicin resistnce 48% 55% MDR/RR-TB cses tested for resistnce to second-line drugs 868 Lbortory-confirmed cses MDR/RR-TB: 911, XDR-TB: 25 Ptients strted on tretment d MDR/RR-TB: 897, XDR-TB: 25 Tretment success rte nd cohort size Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses registered in % MDR/RR-TB cses strted on second-line tretment in 214 5% 439 XDR-TB cses strted on second-line tretment in 214 Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment 52% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 1% (91 1) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) 32 Funding source: 4% domestic, 96% interntionl, % unfunded Totl budget (US$ millions) Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed Funded domesticlly Funded interntionlly Unfunded 176 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

188 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

189 Mynmr POPULATION MILLION Estimtes of TB burden, Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 25 (16 35) 47 (3 66) Mortlity (HIV+TB only) 4.9 ( ) 9.3 (6.7 12) Incidence (includes HIV+TB) 191 ( ) 361 ( ) Incidence (HIV+TB only) 18 (13 24) 34 (25 45) Incidence (MDR/RR-TB) b 13 (8.8 18) 25 (17 34) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 11 (7.7 14) 58 (41 74) 68 (49 88) Mles 12 (8.7 16) 111 (79 142) 123 (88 157) Totl 23 (16 29) 168 (12 216) 191 ( ) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 83% % pulmonry 89% % bcteriologiclly confirmed mong pulmonry 41% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (55 98) TB ptients fcing ctstrophic totl costs, 216 6% TB cse ftlity rtio (estimted mortlity/estimted incidence), (.1.23) Incidence (Rte per 1 popultion per yer) Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 9 notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 5.1% (3.2 7) 27% (1 44) % notified tested for rifmpicin resistnce 15% 63% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 3 213, XDR-TB: Ptients strted on tretment d MDR/RR-TB: 2 537, XDR-TB: 5 Tretment success rte nd cohort size Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses registered in % MDR/RR-TB cses strted on second-line tretment in 214 8% XDR-TB cses strted on second-line tretment in 214 Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment 3% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 1.9% ( ) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) 78 Funding source: 16% domestic, 84% interntionl, <1% unfunded Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. Estimtes of TB incidence nd mortlity for Mynmr will be reviewed following completion of the 217/218 ntionl TB prevlence survey. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded 178 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

190 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

191 Nigeri POPULATION MILLION Estimtes of TB burden, Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 115 (67 176) 62 (36 95) Mortlity (HIV+TB only) 39 (23 58) 21 (12 31) Incidence (includes HIV+TB) 47 ( ) 219 ( ) Incidence (HIV+TB only) 63 (4 93) 34 (21 5) Incidence (MDR/RR-TB) b 2 (12 29) 11 (6.4 15) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 26 (16 36) 114 (7 158) 14 (86 194) Mles 3 (18 41) 237 ( ) 267 (164 37) Totl 56 (34 77) 352 ( ) 47 ( ) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 94% % pulmonry 95% % bcteriologiclly confirmed mong pulmonry 73% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (17 37) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.2.6) Incidence (Rte per 1 popultion per yer) Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 5 2 notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 4.3% ( ) 25% (19 31) % notified tested for rifmpicin resistnce 38% 71% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 1 686, XDR-TB: 5 Ptients strted on tretment d MDR/RR-TB: 1 251, XDR-TB: 4 Tretment success rte nd cohort size Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses registered in % MDR/RR-TB cses strted on second-line tretment in % 423 XDR-TB cses strted on second-line tretment in 214 % 2 Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment 29% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 18% (17 2) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) 336 Funding source: 9% domestic, 27% interntionl, 64% unfunded Totl budget (US$ millions) Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed Funded domesticlly Funded interntionlly Unfunded 18 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

192 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

193 Pkistn POPULATION MILLION Estimtes of TB burden, Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 44 (34 55) 23 (18 29) Mortlity (HIV+TB only) 2.1 ( ) 1.1 ( ) Incidence (includes HIV+TB) 518 ( ) 268 ( ) Incidence (HIV+TB only) 6.9 (3.2 12) 3.5 ( ) Incidence (MDR/RR-TB) b 27 (17 37) 14 (8.8 19) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 24 (15 34) 27 ( ) 231 ( ) Mles 27 (17 38) 26 ( ) 287 (175 4) Totl 51 (31 71) 467 (284 65) 518 ( ) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 4% % pulmonry 8% % bcteriologiclly confirmed mong pulmonry 48% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (48 11) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.6.14) Incidence (Rte per 1 popultion per yer) Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive 71 <1% on ntiretrovirl therpy 68 96% Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 15 notified pulmonry TB cses (12 18 ) Estimted % of TB cses with MDR/RR-TB 4.2% ( ) 16% (15 17) % notified tested for rifmpicin resistnce 3% 5% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 3 331, XDR-TB: 126 Ptients strted on tretment d MDR/RR-TB: 2 881, XDR-TB: 76 Tretment success rte nd cohort size Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % 8 91 HIV-positive TB cses registered in 215 MDR/RR-TB cses strted on second-line tretment in % XDR-TB cses strted on second-line tretment in % 78 Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) 18 Funding source: 7% domestic, 65% interntionl, 28% unfunded Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded 182 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

194 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

195 Philippines Estimtes of TB burden, 216 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 22 (22 22) 21 (21 22) Mortlity (HIV+TB only).3 ( 2.6).29 ( 2.5) Incidence (includes HIV+TB) 573 ( ) 554 ( ) Incidence (HIV+TB only) 6 (2.5 11) 5.9 (2.4 11) Incidence (MDR/RR-TB) b 3 (21 4) 3 (2 39) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 33 (16 5) 136 (68 25) 169 (84 255) Mles 37 (18 56) 366 (182 55) 43 (2 66) Totl 7 (35 16) 52 ( ) 573 ( ) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 13% % with known HIV sttus 19% % pulmonry 98% % bcteriologiclly confirmed mong pulmonry 37% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (37 1) TB ptients fcing ctstrophic totl costs, % TB cse ftlity rtio (estimted mortlity/estimted incidence), (.2.6) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) Incidence (Rte per 1 popultion per yer) POPULATION MILLION Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive 1 9 2% on ntiretrovirl therpy 82 81% Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 2 notified pulmonry TB cses (15 24 ) Estimted % of TB cses with MDR/RR-TB 2.6% ( ) 29% (2 38) % notified tested for rifmpicin resistnce 7% 67% MDR/RR-TB cses tested for resistnce to second-line drugs 432 Lbortory-confirmed cses MDR/RR-TB: 5 233, XDR-TB: 5 Ptients strted on tretment d MDR/RR-TB: 5 253, XDR-TB: 5 Tretment success rte nd cohort size Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses registered in % 277 MDR/RR-TB cses strted on second-line tretment in % 2 49 XDR-TB cses strted on second-line tretment in 214 % 7 Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment 49% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 5% ( ) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) e 14 Funding source: 19% domestic, 53% interntionl, 28% unfunded Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed. e The ntionl budget does not include the budgets of locl government units. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded 184 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

196 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

197 Russin Federtion POPULATION MILLION Estimtes of TB burden, b Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 12 (11 12) 8.2 ( ) Mortlity (HIV+TB only) 1.7 ( ) 1.2 ( ) Incidence (includes HIV+TB) 94 (61 135) 66 (42 94) Incidence (HIV+TB only) 18 (12 26) 13 (8.1 18) Incidence (MDR/RR-TB) c 63 (52 74) 44 (36 51) Estimted TB incidence by ge nd sex (thousnds), b yers > 14 yers Totl Femles 4.7 ( ) 25 (15 35) 3 (18 42) Mles 5.4 ( ) 59 (36 82) 65 (39 9) Totl 1 (6.1 14) 84 (51 118) 94 (61 135) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 7% % with known HIV sttus 87% % pulmonry 91% % bcteriologiclly confirmed mong pulmonry 51% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (68 15) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.1.21) Incidence (Rte per 1 popultion per yer) Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number d Estimted MDR/RR-TB cses mong 47 notified pulmonry TB cses (46 47 ) Estimted % of TB cses with MDR/RR-TB 27% (27 28) 65% (65 66) % notified tested for rifmpicin resistnce 4% 63% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: , XDR-TB: Ptients strted on tretment e MDR/RR-TB: , XDR-TB: Tretment success rte nd cohort size Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in 215 5% HIV-positive TB cses registered in % 694 MDR/RR-TB cses strted on second-line tretment in % 2 89 XDR-TB cses strted on second-line tretment in % 2 29 Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment 93% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 1% (1 1) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) Funding source: 1% domestic, % interntionl, % unfunded Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. UN Popultion Division estimtes re lower thn the popultion registered by the Federl Stte Sttistics Service of the Russin Federtion. b Rnges represent uncertinty intervls. c MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. d Includes cses with unknown previous TB tretment history. e Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded 186 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

198 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

199 South Afric Estimtes of TB burden, 216 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 23 (17 29) 41 (31 52) Mortlity (HIV+TB only) 11 (67 142) 181 (12 254) Incidence (includes HIV+TB) 438 (34 595) 781 ( ) Incidence (HIV+TB only) 258 ( ) 461 ( ) Incidence (MDR/RR-TB) b 19 (12 25) 34 (22 45) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 27 (18 36) 154 (13 26) 182 ( ) Mles 31 (2 41) 226 (15 31) 256 ( ) Totl 58 (38 77) 38 (253 57) 438 (34 595) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 69% % with known HIV sttus 96% % pulmonry 9% % bcteriologiclly confirmed mong pulmonry 67% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (4 78) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.17.43) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) Incidence (Rte per 1 popultion per yer) POPULATION MILLION Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 8 2 notified pulmonry TB cses (6 4 1 ) Estimted % of TB cses with MDR/RR-TB 3.4% ( ) 7.1% ( ) % notified tested for rifmpicin resistnce MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 19 73, XDR-TB: 967 Ptients strted on tretment d MDR/RR-TB: , XDR-TB: 628 Tretment success rte nd cohort size Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses registered in 215 8% MDR/RR-TB cses strted on second-line tretment in % XDR-TB cses strted on second-line tretment in % 61 Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment 51% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) 244 Funding source: 9% domestic, 1% interntionl, % unfunded Totl budget (US$ millions) Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed Funded domesticlly Funded interntionlly Unfunded 188 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

200 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

201 Thilnd POPULATION MILLION Estimtes of TB burden, Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 8.6 (7.2 1) 13 (1 15) Mortlity (HIV+TB only) 3.9 ( ) 5.7 ( ) Incidence (includes HIV+TB) 119 (7 18) 172 (12 261) Incidence (HIV+TB only) 1 (6.1 16) 15 (8.8 23) Incidence (MDR/RR-TB) b 4.7 (3 6.3) 6.8 ( ) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 4.2 ( ) 36 (19 52) 4 (21 58) Mles 4.7 ( ) 74 (4 18) 79 (42 115) Totl 8.9 (4.8 13) 11 (59 161) 119 (7 18) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) TB cse notifictions, 216 Totl cses notified Totl new nd relpse 68 4 % tested with rpid dignostics t time of dignosis 1% % with known HIV sttus 81% % pulmonry 84% % bcteriologiclly confirmed mong pulmonry 6% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (38 97) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.6.17) Incidence (Rte per 1 popultion per yer) Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 2 7 notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 2.2% ( ) 24% (16 32) % notified tested for rifmpicin resistnce 8% 18% MDR/RR-TB cses tested for resistnce to second-line drugs 499 Lbortory-confirmed cses MDR/RR-TB: 955, XDR-TB: 13 Ptients strted on tretment d MDR/RR-TB: 952, XDR-TB: 8 Tretment success rte nd cohort size Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in 215 7% 4 35 HIV-positive TB cses registered in % MDR/RR-TB cses strted on second-line tretment in % 414 XDR-TB cses strted on second-line tretment in 214 Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) 2 Funding source: 77% domestic, 18% interntionl, 6% unfunded Totl budget (US$ millions) Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed Funded domesticlly Funded interntionlly Unfunded 19 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

202 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

203 United Republic of Tnzni POPULATION MILLION Estimtes of TB burden, Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 28 (13 5) 51 (23 9) Mortlity (HIV+TB only) 27 (12 46) 48 (22 83) Incidence (includes HIV+TB) 16 (75 275) 287 ( ) Incidence (HIV+TB only) 54 (35 78) 98 (63 14) Incidence (MDR/RR-TB) b 2.6 ( ) 4.7 ( ) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 4.2 ( ) 48 (18 78) 52 (19 85) Mles 4.8 ( ) 13 (38 167) 17 (4 175) Totl 9 (3.3 15) 151 (56 246) 16 (75 275) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 8% % with known HIV sttus 97% % pulmonry 79% % bcteriologiclly confirmed mong pulmonry 54% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), 216 4% (24 86) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.14.66) Incidence (Rte per 1 popultion per yer) Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 83 notified pulmonry TB cses (42 1 2) Estimted % of TB cses with MDR/RR-TB 1.3% ( ) 6.2% ( ) % notified tested for rifmpicin resistnce 13% 58% MDR/RR-TB cses tested for resistnce to second-line drugs 97 Lbortory-confirmed cses MDR/RR-TB: 196, XDR-TB: Ptients strted on tretment d MDR/RR-TB: 158, XDR-TB: Tretment success rte nd cohort size Success Cohort New nd relpse cses registered in 215 9% Previously treted cses, excluding relpse, registered in 215 8% HIV-positive TB cses registered in % MDR/RR-TB cses strted on second-line tretment in % 143 XDR-TB cses strted on second-line tretment in 214 % 1 Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment 9% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 31% (28 34) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) 7 Funding source: 3% domestic, 39% interntionl, 58% unfunded Totl budget (US$ millions) Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed Funded domesticlly Funded interntionlly Unfunded 192 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

204 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

205 Viet Nm POPULATION MILLION Estimtes of TB burden, Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 13 (8.4 18) 14 (8.9 19) Mortlity (HIV+TB only).85 ( ).9 ( ) Incidence (includes HIV+TB) 126 (13 151) 133 (19 159) Incidence (HIV+TB only) 4.2 ( ) 4.4 ( ) Incidence (MDR/RR-TB) b 8.2 (6.1 1) 8.7 (6.5 11) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 7.3 ( ) 26 (21 3) 33 (27 39) Mles 8.2 ( ) 85 (69 11) 93 (75 11) Totl 15 (13 18) 11 (89 131) 126 (13 151) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 6% % with known HIV sttus 79% % pulmonry 81% % bcteriologiclly confirmed mong pulmonry 69% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (68 99) TB ptients fcing ctstrophic totl costs, % TB cse ftlity rtio (estimted mortlity/estimted incidence), (.7.16) Incidence (Rte per 1 popultion per yer) Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 5 5 notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 4.1% ( ) 26% (25 27) % notified tested for rifmpicin resistnce 19% 95% MDR/RR-TB cses tested for resistnce to second-line drugs 556 Lbortory-confirmed cses MDR/RR-TB: 3 84, XDR-TB: 4 Ptients strted on tretment d MDR/RR-TB: 2 45, XDR-TB: 28 Tretment success rte nd cohort size Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses registered in % MDR/RR-TB cses strted on second-line tretment in % XDR-TB cses strted on second-line tretment in 214 Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment 26% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 19% (18 21) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) 7 Funding source: 8% domestic, 28% interntionl, 63% unfunded Totl budget (US$ millions) Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed Funded domesticlly Funded interntionlly Unfunded 194 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

206 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

207 Cmbodi Estimtes of TB burden, 216 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 3.2 ( ) 2 (14 28) Mortlity (HIV+TB only).45 (.29.66) 2.9 ( ) Incidence (includes HIV+TB) 54 (35 78) 345 ( ) Incidence (HIV+TB only) 1.3 ( ) 8.5 (5.4 12) Incidence (MDR/RR-TB) b 1.2 ( ) 7.7 (3.4 12) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 3.2 ( ) 19 (12 27) 23 (14 31) Mles 3.6 (2.2 5) 28 (17 39) 32 (19 44) Totl 6.7 ( ) 48 (29 66) 54 (35 78) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 86% % pulmonry 67% % bcteriologiclly confirmed mong pulmonry 5% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (43 95) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.4.11) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) Incidence (Rte per 1 popultion per yer) POPULATION MILLION Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive 721 3% on ntiretrovirl therpy 78 98% Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 55 notified pulmonry TB cses (26 84) Estimted % of TB cses with MDR/RR-TB 1.8% ( ) 11% ( 23) % notified tested for rifmpicin resistnce 1% 7% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 11, XDR-TB: 1 Ptients strted on tretment d MDR/RR-TB: 11, XDR-TB: 1 Tretment success rte nd cohort size Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % 226 HIV-positive TB cses registered in 215 MDR/RR-TB cses strted on second-line tretment in % 11 XDR-TB cses strted on second-line tretment in 214 Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment 2% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 36% (33 39) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) 37 Funding source: 9% domestic, 39% interntionl, 52% unfunded Totl budget (US$ millions) Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed Funded domesticlly Funded interntionlly Unfunded 196 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

208 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

209 Centrl Africn Republic Estimtes of TB burden, 216 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 2.7 ( ) 59 (33 92) Mortlity (HIV+TB only) 2.5 (1.3 4) 54 (29 87) Incidence (includes HIV+TB) 19 (12 27) 47 ( ) Incidence (HIV+TB only) 6.2 ( ) 134 (73 215) Incidence (MDR/RR-TB) b.18 (.41) 4. ( 8.9) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 1.2 ( ) 5.9 ( ) 7.1 ( ) Mles 1.4 ( ) 1 (6.2 14) 12 (7 16) Totl 2.6 ( ) 16 (9.8 22) 19 (12 27) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 66% % pulmonry 81% % bcteriologiclly confirmed mong pulmonry 64% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (37 82) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.15.45) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) Incidence (Rte per 1 popultion per yer) POPULATION MILLION Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 11 notified pulmonry TB cses (12 21) Estimted % of TB cses with MDR/RR-TB.4% ( 1.6) 13% (8.9 17) % notified tested for rifmpicin resistnce % 34% 26 MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 57, XDR-TB: Ptients strted on tretment d MDR/RR-TB: 51, XDR-TB: Tretment success rte nd cohort size Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % 521 HIV-positive TB cses registered in % MDR/RR-TB cses strted on second-line tretment in % 21 XDR-TB cses strted on second-line tretment in 214 Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) 1.6 Funding source: 18% domestic, 65% interntionl, 17% unfunded Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded 198 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

210 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

211 Congo POPULATION MILLION Estimtes of TB burden, Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 3.1 ( ) 6 (34 93) Mortlity (HIV+TB only) 2.1 ( ) 41 (21 66) Incidence (includes HIV+TB) 19 (12 28) 378 (24 547) Incidence (HIV+TB only) 5.1 ( ) 1 (52 163) Incidence (MDR/RR-TB) b.64 (.39.9) 13 (7.5 18) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 1.3 ( ) 6.1 ( ) 7.3 (4.3 1) Mles 1.4 (.85 2) 11 (6.3 15) 12 (7.1 17) Totl 2.7 ( ) 17 (9.9 23) 19 (12 28) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 3% % with known HIV sttus 3% % pulmonry 74% % bcteriologiclly confirmed mong pulmonry 45% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (37 85) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.14.43) Incidence (Rte per 1 popultion per yer) Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 27 notified pulmonry TB cses (22 31) Estimted % of TB cses with MDR/RR-TB 2.8% ( ) 13% (8.9 17) % notified tested for rifmpicin resistnce % 74% 336 MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 29, XDR-TB: Ptients strted on tretment d MDR/RR-TB:, XDR-TB: Tretment success rte nd cohort size Success Cohort New nd relpse cses registered in % 9 87 Previously treted cses, excluding relpse, registered in % 196 HIV-positive TB cses registered in 215 2% 53 MDR/RR-TB cses strted on second-line tretment in 214 XDR-TB cses strted on second-line tretment in 214 Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) 2.2 Funding source: 88% domestic, 12% interntionl, % unfunded Totl budget (US$ millions) Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed Funded domesticlly Funded interntionlly Unfunded 2 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

212 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

213 Lesotho Estimtes of TB burden, 216 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 1.1 ( ) 49 (26 8) Mortlity (HIV+TB only) 5.2 ( ) 238 (148 35) Incidence (includes HIV+TB) 16 (1 23) 724 ( ) Incidence (HIV+TB only) 12 (7.3 17) 525 (332 76) Incidence (MDR/RR-TB) b 1.1 ( ) 49 (32 66) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 1.1 ( ) 5 (3 7) 6.1 ( ) Mles 1.2 ( ) 8.6 (5.2 12) 9.9 (6 14) Totl 2.3 ( ) 14 (8.3 19) 16 (1 23) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 91% % pulmonry 89% % bcteriologiclly confirmed mong pulmonry 56% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (32 71) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.21.63) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) Incidence (Rte per 1 popultion per yer) POPULATION MILLION Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 41 notified pulmonry TB cses (33 49) Estimted % of TB cses with MDR/RR-TB 4.8% ( ) 14% (9.2 18) % notified tested for rifmpicin resistnce MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB:, XDR-TB: Ptients strted on tretment d MDR/RR-TB: 238, XDR-TB: Tretment success rte nd cohort size Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % 299 HIV-positive TB cses registered in % MDR/RR-TB cses strted on second-line tretment in % 152 XDR-TB cses strted on second-line tretment in 214 Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) 4.7 Funding source: 17% domestic, 67% interntionl, 16% unfunded Totl budget (US$ millions) Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed Funded domesticlly Funded interntionlly Unfunded 22 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

214 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

215 Liberi POPULATION MILLION Estimtes of TB burden, Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 2.8 ( ) 6 (35 91) Mortlity (HIV+TB only).96 (.6 1.4) 21 (13 3) Incidence (includes HIV+TB) 14 (9.2 2) 38 (199 44) Incidence (HIV+TB only) 2.2 ( ) 48 (31 7) Incidence (MDR/RR-TB) b.43 (.46.82) 9.4 (1 18) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles.77 ( ) 4.4 ( ) 5.2 ( ) Mles.87 ( ) 8.2 (5 11) 9 (5.5 13) Totl 1.6 ( ) 13 (7.7 18) 14 (9.2 2) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) TB cse notifictions, 216 Totl cses notified 7 18 Totl new nd relpse 7 15 % tested with rpid dignostics t time of dignosis % with known HIV sttus 74% % pulmonry 69% % bcteriologiclly confirmed mong pulmonry 63% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), 216 5% (35 77) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.14.42) Incidence (Rte per 1 popultion per yer) Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy 39 47% Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 16 notified pulmonry TB cses (36 29) Estimted % of TB cses with MDR/RR-TB 2.6% (.1 5.1) 18% (.1 36) % notified tested for rifmpicin resistnce 24% 1% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 92, XDR-TB: Ptients strted on tretment d MDR/RR-TB: 75, XDR-TB: Tretment success rte nd cohort size Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % 43 HIV-positive TB cses registered in 215 MDR/RR-TB cses strted on second-line tretment in 214 XDR-TB cses strted on second-line tretment in 214 Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment 9% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 4.4% (4 4.8) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) 1.7 Funding source: 24% domestic, 76% interntionl, % unfunded Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded 24 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

216 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

217 Nmibi Estimtes of TB burden, 216 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB).75 ( ) 3 (2 44) Mortlity (HIV+TB only).87 ( ) 35 (25 48) Incidence (includes HIV+TB) 11 (8.5 14) 446 ( ) Incidence (HIV+TB only) 4.2 (2.7 6) 171 (11 244) Incidence (MDR/RR-TB) b.96 ( ) 39 (3 47) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles.87 ( ) 3.8 ( ) 4.7 ( ) Mles.99 ( ) 5.4 ( ) 6.4 (4.8 8) Totl 1.9 ( ) 9.2 (6.9 12) 11 (8.5 14) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 98% % pulmonry 82% % bcteriologiclly confirmed mong pulmonry 8% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), 216 8% (63 1) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.1.2) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) Incidence (Rte per 1 popultion per yer) POPULATION MILLION Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 48 notified pulmonry TB cses (41 56) Estimted % of TB cses with MDR/RR-TB 5% ( ) 12% (8.7 15) % notified tested for rifmpicin resistnce 3% 1% 387 MDR/RR-TB cses tested for resistnce to second-line drugs 54 Lbortory-confirmed cses MDR/RR-TB: 36, XDR-TB: 1 Ptients strted on tretment d MDR/RR-TB: 362, XDR-TB: 1 Tretment success rte nd cohort size Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in 215 6% 33 HIV-positive TB cses registered in % MDR/RR-TB cses strted on second-line tretment in 214 7% 266 XDR-TB cses strted on second-line tretment in % 6 Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 26% (24 28) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) 56 Funding source: 3% domestic, 18% interntionl, 52% unfunded Totl budget (US$ millions) Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed Funded domesticlly Funded interntionlly Unfunded 26 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

218 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

219 Ppu New Guine POPULATION MILLION Estimtes of TB burden, Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 3.6 (2.4 5) 44 (29 62) Mortlity (HIV+TB only).82 ( ) 1 (5.5 16) Incidence (includes HIV+TB) 35 (28 42) 432 ( ) Incidence (HIV+TB only) 3.6 (2 5.5) 44 (25 68) Incidence (MDR/RR-TB) b 1.9 ( ) 23 (15 32) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 1.8 ( ) 11 (8.7 13) 13 (1 15) Mles 2 ( ) 2 (16 24) 22 (18 27) Totl 3.8 (3 4.5) 31 (25 37) 35 (28 42) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 33% % pulmonry 57% % bcteriologiclly confirmed mong pulmonry 31% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (65 97) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.8.18) Incidence (Rte per 1 popultion per yer) Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive 699 7% on ntiretrovirl therpy % Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 1 2 notified pulmonry TB cses (79 1 5) Estimted % of TB cses with MDR/RR-TB 3.4% (1.7 5) 26% (15 36) % notified tested for rifmpicin resistnce MDR/RR-TB cses tested for resistnce to second-line drugs 21 Lbortory-confirmed cses MDR/RR-TB: 342, XDR-TB: 4 Ptients strted on tretment d MDR/RR-TB: 32, XDR-TB: 2 Tretment success rte nd cohort size Success Cohort New cses registered in % 4 11 Previously treted cses registered in % 661 HIV-positive TB cses registered in 215 MDR/RR-TB cses strted on second-line tretment in % 18 XDR-TB cses strted on second-line tretment in 214 4% 5 Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment New cses Previously treted cses HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) 11 Funding source: 27% domestic, 73% interntionl, % unfunded Totl budget (US$ millions) Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed Funded domesticlly Funded interntionlly Unfunded 28 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

220 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

221 Sierr Leone POPULATION MILLION Estimtes of TB burden, Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 3.4 (2 5.2) 47 (28 7) Mortlity (HIV+TB only) 1 ( ) 14 (9 2) Incidence (includes HIV+TB) 22 (14 32) 34 ( ) Incidence (HIV+TB only) 3.1 (2 4.5) 42 (27 61) Incidence (MDR/RR-TB) b.72 ( ) 9.7 (1.6 18) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 1.2 ( ) 7.9 (4.8 11) 9.1 (5.5 13) Mles 1.4 ( ) 12 (7.2 17) 13 (8.1 19) Totl 2.6 ( ) 2 (12 28) 22 (14 32) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % % with known HIV sttus 97% % pulmonry 94% % bcteriologiclly confirmed mong pulmonry 85% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (44 98) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.11.33) Incidence (Rte per 1 popultion per yer) Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 44 notified pulmonry TB cses (99 78) Estimted % of TB cses with MDR/RR-TB 2.6% (.1 5.1) 18% (.1 36) % notified tested for rifmpicin resistnce % 1% 6 MDR/RR-TB cses tested for resistnce to second-line drugs 13 Lbortory-confirmed cses MDR/RR-TB: 13, XDR-TB: Ptients strted on tretment d MDR/RR-TB:, XDR-TB: Tretment success rte nd cohort size Success Cohort New cses registered in % 8 17 Previously treted cses registered in % 227 HIV-positive TB cses registered in 215 MDR/RR-TB cses strted on second-line tretment in 214 XDR-TB cses strted on second-line tretment in 214 Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment 2% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment New cses Previously treted cses HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) 6.9 Funding source: 3% domestic, 97% interntionl, % unfunded Totl budget (US$ millions) Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed Funded domesticlly Funded interntionlly Unfunded 21 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

222 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

223 Zmbi Estimtes of TB burden, 216 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 4.8 ( ) 29 (17 44) Mortlity (HIV+TB only) 12 (7.9 18) 74 (47 17) Incidence (includes HIV+TB) 62 (4 89) 376 ( ) Incidence (HIV+TB only) 36 (23 52) 218 (14 312) Incidence (MDR/RR-TB) b 2.1 ( ) 13 (8.4 17) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 3.6 ( ) 2 (12 28) 24 (15 33) Mles 4 ( ) 34 (21 48) 38 (23 53) Totl 7.6 (4.6 11) 55 (33 76) 62 (4 89) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 93% % pulmonry 82% % bcteriologiclly confirmed mong pulmonry 5% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (43 95) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.16.43) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) Incidence (Rte per 1 popultion per yer) POPULATION MILLION Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 1 4 notified pulmonry TB cses (91 1 9) Estimted % of TB cses with MDR/RR-TB 1.1% ( ) 18% (12 25) % notified tested for rifmpicin resistnce <1% 7% 526 MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 18, XDR-TB: Ptients strted on tretment d MDR/RR-TB: 136, XDR-TB: Notified cses by ge group nd sex, Femles Mles 1 Tretment success rte nd cohort size Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses registered in % MDR/RR-TB cses strted on second-line tretment in % 68 XDR-TB cses strted on second-line tretment in 214 TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment 15% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment TB finncing, 217 Ntionl TB budget (US$ millions) 14 Funding source: 9% domestic, 52% interntionl, 4% unfunded Totl budget (US$ millions) Tretment success rte (%) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed Funded domesticlly Funded interntionlly Unfunded 212 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

224 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

225 Zimbbwe Estimtes of TB burden, 216 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 1.2 ( ) 7.2 (4.4 11) Mortlity (HIV+TB only) 4.4 (3 6.1) 27 (19 38) Incidence (includes HIV+TB) 34 (24 44) 28 ( ) Incidence (HIV+TB only) 23 (15 32) 139 (9 199) Incidence (MDR/RR-TB) b 1.9 ( ) 12 (8 16) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 1.5 (1 1.9) 13 (9 16) 14 (1 18) Mles 1.7 ( ) 18 (13 23) 19 (14 25) Totl 3.1 (2.2 4) 3 (22 39) 34 (24 44) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 1% % pulmonry 88% % bcteriologiclly confirmed mong pulmonry 58% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (62 11) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.11.24) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) Incidence (Rte per 1 popultion per yer) POPULATION MILLION Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV cre in new nd relpse TB ptients, 216 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 216 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 1 3 notified pulmonry TB cses (95 1 7) Estimted % of TB cses with MDR/RR-TB 4.6% (3 6.2) 14% (8.9 2) % notified tested for rifmpicin resistnce MDR/RR-TB cses tested for resistnce to second-line drugs 31 Lbortory-confirmed cses MDR/RR-TB: 572, XDR-TB: 5 Ptients strted on tretment d MDR/RR-TB: 397, XDR-TB: 5 Tretment success rte nd cohort size Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in 215 7% HIV-positive TB cses registered in % MDR/RR-TB cses strted on second-line tretment in % 381 XDR-TB cses strted on second-line tretment in 214 Notified cses by ge group nd sex, 216 Tretment success rte (%) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment 73% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 63% (58 69) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing, 217 Ntionl TB budget (US$ millions) 18 Funding source: <1% domestic, 1% interntionl, % unfunded Totl budget (US$ millions) Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed Funded domesticlly Funded interntionlly Unfunded 214 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

226 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (constnt 211 interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-ofpocket helth expenditure (% of totl expenditure on helth) GINI index ( = perfect equlity, 1 = perfect inequlity) Coverge of essentil helth services (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. b Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

227 A presumptive TB ptient seeks cre in Kbul, Afghnistn fter trvelling 2 miles through the Hindu Kush mountins MARC RIBOUD / WHO

228 ANNEX 3 Regionl nd globl profiles GLOBAL TUBERCULOSIS REPORT

229 WHO Africn Region POPULATION BILLION WHO MEMBER STATES 47 Estimtes of TB burden, 216 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 417 ( ) 41 (34 48) Mortlity (HIV+TB only) 32 ( ) 31 (27 36) Incidence (includes HIV+TB) 2 59 ( ) 254 ( ) Incidence (HIV+TB only) 764 (66 876) 75 (65 86) Incidence (MDR/RR-TB) b 93 (81 16) 9.1 (7.9 1) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 148 (91 25) 832 ( ) 98 ( ) Mles 167 (13 232) 1 45 ( ) 1 62 ( ) Totl 316 ( ) 2 28 ( ) 2 59 ( ) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % with known HIV sttus 82% % pulmonry 84% % bcteriologiclly confirmed mong pulmonry 66% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (44 55) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.24.33) TB/HIV cre in new nd relpse TB ptients, 216 Number Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 216 (%) f New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 4 notified pulmonry TB cses (36 44 ) Estimted % of TB cses with MDR/RR-TB 2.7% (2 3.5) 14% (8.4 2) % notified tested for rifmpicin resistnce 15% 29% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: , XDR-TB: 1 92 Ptients strted on tretment d MDR/RR-TB: , XDR-TB: 727 Tretment success rte nd cohort size Success Cohort New nd relpse e cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses, ll types, registered in 215 8% MDR/RR-TB cses strted on second-line tretment in % XDR-TB cses strted on second-line tretment in % 623 TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment 42% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 16% (16 17) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, 216 Tretment success rte (%) Notified, new nd relpse Incidence Incidence (HIV+TB only) Femles Mles New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB 15 TB finncing (low- nd middle-income countries), g,h 217 Ntionl TB budget (US$ millions) 1 38 Funding source: 26% domestic, 34% interntionl, 41% unfunded Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed. e Some countries reported on new cses only. f Clcultions exclude countries with missing numertors or denomintors. g Dt re not collected from ll Member Sttes. h Finncing indictors exclude funding for generl helthcre services provided outside NTPs. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded 218 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

230 WHO/PAHO Region of the Americs WHO MEMBER STATES 35 OTHER COUNTRIES AND TERRITORIES 11 Estimtes of TB burden, 216 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 17 (16 18) 1.7 ( ) Mortlity (HIV+TB only) 6 (6 7).63 (.56.7) Incidence (includes HIV+TB) 274 ( ) 27 (26 29) Incidence (HIV+TB only) 3 (28 33) 3 ( ) Incidence (MDR/RR-TB) b 12 (11 13) 1.2 ( ) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 16 (12 19) 85 (67 14) 11 (79 122) Mles 17 (14 21) 156 ( ) 173 (137 21) Totl 33 (26 4) 241 (19 292) 274 ( ) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % with known HIV sttus 8% % pulmonry 85% % bcteriologiclly confirmed mong pulmonry 77% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (75 87) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.8.9) TB/HIV cre in new nd relpse TB ptients, 216 Number Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 216 (%) f New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 8 1 notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 2.9% ( ) 13% (6.9 2) % notified tested for rifmpicin resistnce 34% 4% MDR/RR-TB cses tested for resistnce to second-line drugs 1 94 Lbortory-confirmed cses MDR/RR-TB: 3 715, XDR-TB: 112 Ptients strted on tretment d MDR/RR-TB: 3 59, XDR-TB: 15 Tretment success rte nd cohort size Success Cohort New nd relpse e cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses, ll types, registered in % MDR/RR-TB cses strted on second-line tretment in % XDR-TB cses strted on second-line tretment in % 15 TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment 3% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 68% (64 72) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, 216 Tretment success rte (%) POPULATION BILLION Notified, new nd relpse Incidence (HIV+TB only) Incidence Femles Mles New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing (low- nd middle-income countries), g,h 217 Ntionl TB budget (US$ millions) 285 Funding source: 67% domestic, 15% interntionl, 18% unfunded Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed. e Some countries reported on new cses only. f Clcultions exclude countries with missing numertors or denomintors. g Dt re not collected from ll Member Sttes. h Finncing indictors exclude funding for generl helthcre services provided outside NTPs. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

231 WHO Estern Mediterrnen Region WHO MEMBER STATES 21 OTHER COUNTRIES AND TERRITORIES 1 Estimtes of TB burden, 216 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 82 (69 95) 12 (1 14) Mortlity (HIV+TB only) 3 (2 5).45 (.27.68) Incidence (includes HIV+TB) 766 ( ) 114 (86 147) Incidence (HIV+TB only) 1 (6 15) 1.5 ( ) Incidence (MDR/RR-TB) b 41 (31 52) 6.2 ( ) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 39 (25 53) 294 (187 42) 333 ( ) Mles 43 (27 59) 389 ( ) 433 (276 59) Totl 82 (52 112) 684 ( ) 766 ( ) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % with known HIV sttus 16% % pulmonry 76% % bcteriologiclly confirmed mong pulmonry 53% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (52 9) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.8.15) TB/HIV cre in new nd relpse TB ptients, 216 Number Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy 72 67% Drug-resistnt TB cre, 216 (%) f New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 21 notified pulmonry TB cses (18 24 ) Estimted % of TB cses with MDR/RR-TB 4.2% ( ) 17% (14 19) % notified tested for rifmpicin resistnce 5.5% 55% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 4 713, XDR-TB: 152 Ptients strted on tretment d MDR/RR-TB: 4 73, XDR-TB: 94 Tretment success rte nd cohort size Success Cohort New nd relpse e cses registered in % Previously treted cses, excluding relpse, registered in 215 8% HIV-positive TB cses, ll types, registered in % 46 MDR/RR-TB cses strted on second-line tretment in % XDR-TB cses strted on second-line tretment in % 81 TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment 16% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 16% (15 17) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, 216 Tretment success rte (%) POPULATION BILLION Notified, new nd relpse Incidence (HIV+TB only) Incidence Femles Mles New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing (low- nd middle-income countries), g,h 217 Ntionl TB budget (US$ millions) 228 Funding source: 2% domestic, 55% interntionl, 24% unfunded Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed. e Some countries reported on new cses only. f Clcultions exclude countries with missing numertors or denomintors. g Dt re not collected from ll Member Sttes. h Finncing indictors exclude funding for generl helthcre services provided outside NTPs. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded 22 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

232 WHO Europen Region WHO MEMBER STATES 53 OTHER COUNTRIES AND TERRITORIES 1 Estimtes of TB burden, 216 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 26 (25 27) 2.8 ( ) Mortlity (HIV+TB only) 5 (4 6).55 (.43.69) Incidence (includes HIV+TB) 29 ( ) 32 (27 36) Incidence (HIV+TB only) 34 (26 42) 3.7 ( ) Incidence (MDR/RR-TB) b 122 (11 134) 13 (12 15) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 15 (1 19) 87 (62 112) 12 (73 132) Mles 17 (12 22) 177 (124 23) 194 ( ) Totl 31 (22 41) 264 ( ) 29 ( ) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % with known HIV sttus 84% % pulmonry 85% % bcteriologiclly confirmed mong pulmonry 64% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (66 88) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.9.13) TB/HIV cre in new nd relpse TB ptients, 216 Number Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 216 Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed. e Some countries reported on new cses only. f Clcultions exclude countries with missing numertors or denomintors. g Dt re not collected from ll Member Sttes. h Finncing indictors exclude funding for generl helthcre services provided outside NTPs. (%) f New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 71 notified pulmonry TB cses (71 72 ) Estimted % of TB cses with MDR/RR-TB 19% (12 26) 55% (43 67) % notified tested for rifmpicin resistnce 5% 65% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: , XDR-TB: Ptients strted on tretment d MDR/RR-TB: , XDR-TB: Tretment success rte nd cohort size Success Cohort New nd relpse e cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses, ll types, registered in % MDR/RR-TB cses strted on second-line tretment in % XDR-TB cses strted on second-line tretment in % 4 44 TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment 54% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 55% (52 58) TB finncing (low- nd middle-income countries), g,h 217 Ntionl TB budget (US$ millions) Funding source: 93% domestic, 5.1% interntionl, 2.1% unfunded Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, 216 Tretment success rte (%) Totl budget (US$ millions) POPULATION BILLION Notified, new nd relpse Incidence (HIV+TB only) Incidence Femles Mles New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

233 WHO South-Est Asi Region WHO MEMBER STATES 11 Estimtes of TB burden, 216 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 652 ( ) 33 (28 4) Mortlity (HIV+TB only) 35 (25 46) 1.8 ( ) Incidence (includes HIV+TB) 4 67 ( ) 24 ( ) Incidence (HIV+TB only) 163 (12 211) 8.3 (6.2 11) Incidence (MDR/RR-TB) b 214 ( ) 11 (8.4 14) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 178 (95 261) 1 44 ( ) 1 62 ( ) Mles 2 (17 293) 2 85 ( ) 3 5 ( ) Totl 378 (21 554) 4 3 ( ) 4 67 ( ) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % with known HIV sttus 56% % pulmonry 85% % bcteriologiclly confirmed mong pulmonry 61% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (42 85) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.1.22) TB/HIV cre in new nd relpse TB ptients, 216 Number Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 216 (%) f New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 117 notified pulmonry TB cses (15 13 ) Estimted % of TB cses with MDR/RR-TB 2.8% ( ) 13% (1 15) % notified tested for rifmpicin resistnce 15% 66% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: , XDR-TB: Ptients strted on tretment d MDR/RR-TB: 4 48, XDR-TB: Tretment success rte nd cohort size Success Cohort New nd relpse e cses registered in % Previously treted cses, excluding relpse, registered in % 9 84 HIV-positive TB cses, ll types, registered in % MDR/RR-TB cses strted on second-line tretment in 214 5% XDR-TB cses strted on second-line tretment in % 1 43 TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment 4.1% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 5.8% ( ) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, 216 Tretment success rte (%) POPULATION BILLION Notified, new nd relpse Incidence (HIV+TB only) Incidence Femles Mles New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing (low- nd middle-income countries), g,h 217 Ntionl TB budget (US$ millions) 956 Funding source: 52% domestic, 32% interntionl, 17% unfunded Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed. e Some countries reported on new cses only. f Clcultions exclude countries with missing numertors or denomintors. g Dt re not collected from ll Member Sttes. h Finncing indictors exclude funding for generl helthcre services provided outside NTPs. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded 222 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

234 WHO Western Pcific Region WHO MEMBER STATES 27 OTHER COUNTRIES AND TERRITORIES 9 Estimtes of TB burden, 216 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 13 (85 123) 5.4 ( ) Mortlity (HIV+TB only) 5 (3 7).26 (.16.39) Incidence (includes HIV+TB) 1 8 ( ) 95 (79 113) Incidence (HIV+TB only) 29 (23 36) 1.5 ( ) Incidence (MDR/RR-TB) b 119 (11 139) 6.3 ( ) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 99 (71 126) 477 (351 63) 576 ( ) Mles 111 (8 142) 1 12 ( ) 1 23 ( ) Totl 21 ( ) 1 59 ( ) 1 8 ( ) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % with known HIV sttus 42% % pulmonry 92% % bcteriologiclly confirmed mong pulmonry 38% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (64 92) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.5.8) TB/HIV cre in new nd relpse TB ptients, 216 Number Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 216 (%) f New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 88 notified pulmonry TB cses (76 1 ) Estimted % of TB cses with MDR/RR-TB 5.3% ( ) 25% (2 29) % notified tested for rifmpicin resistnce 14% 64% MDR/RR-TB cses tested for resistnce to second-line drugs 2 21 Lbortory-confirmed cses MDR/RR-TB: , XDR-TB: 618 Ptients strted on tretment d MDR/RR-TB: , XDR-TB: 344 Tretment success rte nd cohort size Success Cohort New nd relpse e cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses, ll types, registered in % MDR/RR-TB cses strted on second-line tretment in % XDR-TB cses strted on second-line tretment in 214 4% 216 TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment 41% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 9.9% (9.3 11) Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, 216 Tretment success rte (%) POPULATION BILLION Notified, new nd relpse Incidence (HIV+TB only) Incidence Femles Mles New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing (low- nd middle-income countries), g,h 217 Ntionl TB budget (US$ millions) 636 Funding source: 67% domestic, 18% interntionl, 15% unfunded Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed. e Some countries reported on new cses only. f Clcultions exclude countries with missing numertors or denomintors. g Dt re not collected from ll Member Sttes. h Finncing indictors exclude funding for generl helthcre services provided outside NTPs. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

235 Globl WHO MEMBER STATES 194 OTHER COUNTRIES AND TERRITORIES 22 Estimtes of TB burden, 216 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 1 3 ( ) 17 (16 19) Mortlity (HIV+TB only) 374 ( ) 5 ( ) Incidence (includes HIV+TB) 1 4 ( ) 14 ( ) Incidence (HIV+TB only) 1 3 ( ) 14 (12 15) Incidence (MDR/RR-TB) b 61 ( ) 8.1 ( ) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 493 (34 683) 3 22 ( ) 3 71 ( ) Mles 555 ( ) 6 14 ( ) 6 69 ( ) Totl 1 5 ( ) 9 36 ( ) 1 4 ( ) TB cse notifictions, 216 Totl cses notified Totl new nd relpse % with known HIV sttus 57% % pulmonry 85% % bcteriologiclly confirmed mong pulmonry 57% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (52 72) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.13.19) TB/HIV cre in new nd relpse TB ptients, 216 Number Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 216 (%) f New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses mong 345 notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 4.1% ( ) 19% (9.8 27) % notified tested for rifmpicin resistnce 16% 6% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: , XDR-TB: 8 14 Ptients strted on tretment d MDR/RR-TB: , XDR-TB: Tretment success rte nd cohort size Success Cohort New nd relpse e cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses, ll types, registered in % MDR/RR-TB cses strted on second-line tretment in % XDR-TB cses strted on second-line tretment in 214 3% 6 94 Mortlity (excludes HIV + TB) (Rte per 1 popultion per yer) Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, 216 Tretment success rte (%) POPULATION BILLION Notified, new nd relpse Incidence Incidence (HIV+TB only) Femles Mles TB preventive tretment, 216 % of HIV-positive people (newly enrolled in cre) on preventive tretment 38% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 13% (12 13) TB finncing (low- nd middle-income countries), g,h 217 Ntionl TB budget (US$ millions) Funding source: 59% domestic, 22% interntionl, 19% unfunded Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 216 nd ptients who were not lbortory-confirmed. e Some countries reported on new cses only. f Clcultions exclude countries with missing numertors or denomintors. g Dt re not collected from ll Member Sttes. h Finncing indictors exclude funding for generl helthcre services provided outside NTPs. Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 224 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

236

237 Lbortory technicins exmine sputum smer slides in Mseru, Lesotho SAM NUTTALL / WHO

238 ANNEX 4 TB burden estimtes, notifictions nd tretment outcomes FOR INDIVIDUAL COUNTRIES AND TERRITORIES, WHO REGIONS AND THE WORLD

239 Estimtes of incidence nd mortlity Estimted vlues re shown s best estimtes followed by lower nd upper bounds. The lower nd upper bounds re defined s the 2.5th nd 97.5th centiles of outcome distributions produced in simultions. For detils bout the methods used to produce these estimtes see the technicl ppendix t Estimtes re shown rounded to three significnt figures unless the displyed vlue is under 1, in which cse it is shown rounded to two significnt figures. Dt source Dt shown in this file were tken from the WHO globl TB dtbse on 6 October 217. Dt shown in the min prt of the report were tken from the dtbse on 14 August 217. As result, dt in this nnex my differ slightly from those in the min prt of the report. Downlodble dt This nnex is provided s reference for looking up figures when needed. It is not suitble for conducting nlyses or producing grphs nd tbles. Insted, downlod dt for ll countries nd ll yers s comm-seprted vlue (CSV) files from the WHO globl TB dtbse t See Annex 1 for more detils. Country notes Cribben Islnds Dt collection from Cribben Islnds tht re not Member Sttes of WHO ws resumed in 211 fter brek of few yers. This includes Arub, Curço, Puerto Rico nd Sint Mrten, which re Associte Members of the Pn Americn Helth Orgniztion, plus the territories of Anguill, Bermud, Bonire, Sint Eusttius nd Sb, British Virgin Islnds, Cymn Islnds, Montserrt nd Turks nd Cicos Islnds. Dt re not currently independently collected from the US Virgin Islnds. Denmrk Dt for Denmrk exclude Greenlnd. Europen Union/ Europen Economic Are countries Notifiction nd tretment outcome dt for Europen Union nd Europen Economic Are countries re provisionl. Frnce Dt from Frnce include dt from 5 overses deprtments (French Guin, Gudeloupe, Mrtinique, Myotte nd Réunion) nd exclude French territories of the Pcific. Indi Estimtes of TB incidence nd mortlity for Indi re interim in nture, pending results from the ntionl TB prevlence survey plnned for 218/219. Mynmr Estimtes of TB incidence nd mortlity for Mynmr will be reviewed following completion of the 217/218 ntionl TB prevlence survey. Russin Federtion UN Popultion Division estimtes re lower thn the popultion registered by the Federl Stte Sttistics Service of the Russin Federtion. United Sttes of Americ In ddition to the 51 reporting res, the USA includes territories tht report seprtely to WHO. The dt for these territories re not included in the dt reported by the USA. Definitions of cse types nd outcomes do not exctly mtch those used by WHO. 228 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

240 TABLE A4.1 TB incidence estimtes, 216 Incidence (including HIV) Incidence (HIV-positive) Incidence (MDR/RR-TB) Popultion (millions) Number (thousnds) Rte Number (thousnds) Rte Number (thousnds) Rte Afghnistn (42 93) 189 (122 27).28 (.18.41).82 ( ) 3.3 ( ) 9.5 (3.6 15) Albni 3.48 (.41.55) 16 (14 19) <.1 (<.1 <.1).21 (.13.29).12 (<.1.23).42 (<.1.78) Algeri (22 36) 7 (54 89).17 (.9.28).42 (.22.69).46 (.14.78) 1.1 ( ) Americn Smo < 1 <.1 (<.1 <.1) 8.4 ( ) ( ) <.1 (<.1 <.1) <.1 (<.1 <.1).46 (.24.69) Andorr < 1 <.1 (<.1 <.1) 6 ( ) ( ) ( ) Angol (66 156) 37 (23 543) 18 (8.5 3) 61 (29 14) 4.3 ( ) 15 (4.8 25) Anguill < 1 <.1 (<.1 <.1) 22 (14 31) ( ) ( ) Antigu nd Brbud < 1 <.1 (<.1 <.1) 3.4 ( ) ( ) ( <.1) <.1 (<.1 <.1) <.1 (<.1.11) Argentin (9.2 12) 24 (21 28).59 (.38.85) 1.4 ( ).44 (.29.58).99 ( ) Armeni ( ) 44 (34 56).74 (.48.11) 2.5 ( ).28 (.21.35) 9.6 (7.2 12) Arub < 1.16 (.14.19) 15 (13 18) <.1 (<.1 <.1).37 (.24.5) Austrli ( ) 6.1 ( ).29 (.25.34).12 (.1.14).63 (.4.86).26 (.16.36) Austri 9.71 (.61.82) 8.2 (7. 9.5).38 (.21.59).43 (.24.67).22 (<.1.36).26 (.11.41) Azerbijn ( ) 66 (51 84).13 (.83.18) 1.3 ( ) 2.4 (2. 2.9) 25 (2 3) Bhms < 1.1 (.88.12) 26 (22 3).41 (.27.59) 1 (6.8 15).13 (<.1.25) 3.3 ( ) Bhrin 1.18 (.15.2) 12 (11 14) <.1 (<.1.1).59 (.49.69) <.1 ( <.1).3 (.69) Bngldesh ( ) 221 ( ).5 (.25.84).31 (.15.52) 8.8 (4.8 13) 5.4 ( ) Brbdos < 1 <.1 (<.1 <.1) 1.2 (1. 1.4) <.1 (<.1 <.1) 1.2 ( ) ( ) ( ) Belrus ( ) 52 (37 69).4 (.26.57) 4.2 (2.7 6.) 3.4 ( ) 35 (28 43) Belgium ( ) 1 (8.5 12).89 (.73.11).78 (.64.93).24 (<.1.4).21 (<.1.35) Belize < 1.14 (.12.16) 38 (32 43).4 (.26.57) 11 (7. 15).11 (<.1.13) 2.9 ( ) Benin ( ) 59 (38 84).95 ( ) 8.7 (5.6 12).97 (<.1.19).89 (<.1 1.8) Bermud < 1 <.1 (<.1 <.1) 3.7 ( ) ( ) ( ) ( ) ( ) Bhutn < ( ) 178 ( ) <.1 (<.1.11).94 ( ).19 (.13.24) 23 (16 31) Bolivi (Plurintionl Stte of) (8.1 18) 114 (75 162).5 (.32.71) 4.6 ( ).47 (.23.7) 4.3 ( ) Bonire, Sint Eusttius nd Sb < 1 <.1 (<.1 <.1) 4.6 ( ) ( ) ( ) Bosni nd Herzegovin ( ) 32 (25 41) <.1 (<.1 <.1) <.1 (<.1 <.1) ( ) ( ) Botswn ( ) 326 (252 41) 4.4 ( ) 196 ( ).41 (.29.54) 18 (13 24) Brzil (74 1) 42 (36 48) 11 (9.1 13) 5.2 ( ) 2.4 ( ) 1.1 (.9 1.4) British Virgin Islnds < 1 ( ) ( ) ( ) ( ) Brunei Drusslm < 1.28 (.24.32) 66 (56 76) <.1 (<.1 <.1).82 ( ) ( ) ( ) Bulgri ( ) 27 (2 34) <.1 (<.1 <.1) <.1 (<.1 <.1).61 (.41.81).85 ( ) Burkin Fso (6.1 13) 51 (33 72).87 ( ) 4.7 (3. 6.7).3 (.18.41) 1.6 ( ) Burundi (8. 18) 118 (76 169) 1.5 ( ) 14 (9.1 2).42 (.27.58) 4 ( ) Cbo Verde < 1.74 ( ) 137 (88 195).6 (.38.87) 11 (7. 16).29 (<.1.48) 5.3 (1.6 9.) Cmbodi (35 78) 345 ( ) 1.3 ( ) 8.5 (5.4 12) 1.2 ( ) 7.7 (3.4 12) Cmeroon (31 68) 23 (131 29) 16 (1 24) 7 (44 1) 1.6 (1. 2.2) 6.8 ( ) Cnd ( ) 5.2 (4.4 6.).15 (.12.18).41 (.34.49).19 (<.1.31) <.1 (<.1 <.1) Cymn Islnds < 1 <.1 (<.1 <.1) 5.7 ( ) <.1 ( <.1) 1.1 ( ) ( ) ( ) Centrl Africn Republic 5 19 (12 27) 47 ( ) 6.2 ( ) 134 (73 215).18 (.41) 4 ( 8.9) Chd (14 32) 153 (99 219) 2.8 (1.8 4.) 2 (13 28).76 ( ) 5.3 ( ) Chile ( ) 16 (14 19).47 (.28.7) 2.6 ( ).58 (.37.78).32 (.21.44) Chin ( ) 64 (55 74) 11 (6.9 15).76 ( ) 73 (56 89) 5.2 (4. 6.4) Chin, Hong Kong SAR ( ) 69 (59 8).38 (.32.45).53 (.44.61).79 (.53.11) 1.1 ( ) Chin, Mco SAR < 1.41 (.35.48) 67 (58 78) <.1 (<.1 <.1).65 (.42.93).13 (<.1.21) 2.1 ( ) Colombi (12 2) 32 (25 41) 2.2 ( ) 4.4 ( ).58 (.4.77) 1.2 ( ) Comoros < 1.28 (.18.39) 35 (22 49) <.1 (<.1.13) 1.1 ( ).45 (<.1.81) 5.7 (1.1 1) Congo 5 19 (12 28) 378 (24 547) 5.1 ( ) 1 (52 163).64 (.39.9) 13 (7.5 18) Cook Islnds < 1 <.1 (<.1 <.1) 13 (11 15) ( ) <.1 (<.1 <.1) ( ) ( ) Cost Ric 5.46 (.35.58) 9.5 (7.3 12).39 (.25.56).81 ( ).1 (<.1.19).21 (<.1.39) Côte d'ivoire (23 52) 153 (99 22) 7.9 (5. 11) 33 (21 48) 2.1 ( ) 8.9 (4.6 13) Croti 4.52 (.44.6) 12 (1 14) <.1 (<.1 <.1) <.1 (<.1.13) ( ) ( ) Cub (.68.92) 6.9 (5.9 8.).69 (.44.98).6 (.39.86).25 (.1.39).21 (<.1.34) Curço < 1 <.1 (<.1 <.1) 2.9 ( ) ( ) ( ) ( ) ( ) Cyprus 1.66 (.56.76) 5.6 ( ) <.1 (<.1 <.1).2 (.11.31) ( ) ( ) Czechi (.45.61) 5 ( ) <.1 (<.1.15) <.1 (<.1.14).17 (<.1.26).16 (<.1.24) Democrtic People's Republic of Kore ( ) 513 ( ).28 (.14.46) 1.1 ( ) 5.7 ( ) 22 (13 32) Democrtic Republic of the Congo ( ) 323 (29 461) 2 (13 29) 26 (17 37) 7.6 (3.9 11) 9.7 (4.9 15) Denmrk 6.35 (.3.41) 6.1 ( ).11 (<.1.13).18 (.14.23) <.1 (<.1.16).15 (<.1.28) Djibouti < (2.4 4.) 335 ( ).17 (.13.21) 18 (13 22).17 (.93.25) 18 (9.8 27) Dominic < 1 <.1 (<.1 <.1) 7.8 (6.7 9.) <.1 (<.1 <.1) 1.6 (1. 2.2) ( ) ( ) Dominicn Republic ( ) 6 (46 77) 1.5 (1.1 2.) 14 (11 19).42 (.3.55) 4 ( ) Ecudor (5.3 12) 5 (33 72) 1.1 ( ) 6.5 ( ).71 (.43 1.) 4.4 ( ) Egypt (12 15) 14 (12 15).31 (.2.44) <.1 (<.1 <.1) 2.1 ( ) 2.2 ( ) El Slvdor ( ) 6 (46 76).26 (.17.37) 4.1 ( ).14 (.76.21) 2.2 ( ) Equtoril Guine ( ) 181 (159 25) 1.1 ( ) 91 (76 17).11 (.55.17) 9.2 (4.5 14) Rtes re per 1 popultion. Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

241 TABLE A4.1 TB incidence estimtes, 216 Incidence (including HIV) Incidence (HIV-positive) Incidence (MDR/RR-TB) Popultion (millions) Number (thousnds) Rte Number (thousnds) Rte Number (thousnds) Rte Eritre ( ) 74 (34 129).22 (.14.31) 4.4 ( ).14 (.28.26) 2.9 ( ) Estoni 1.22 (.18.25) 16 (14 19).23 (.15.33) 1.8 ( ).46 (.31.6) 3.5 ( ) Ethiopi ( ) 177 ( ) 14 (9.6 19) 13 (9.4 18) 5.8 ( ) 5.7 (3. 8.3) Fiji < 1.53 (.41.67) 59 (45 75).1 (<.1.12) 1.1 ( ) ( ) ( ) Finlnd 6.26 (.22.3) 4.7 (4. 5.4).1 (<.1.14).17 (.11.25) <.1 ( <.1) <.1 (.18) Frnce 65 5 ( ) 7.7 ( ).67 (.4 1.) 1 ( ).82 (.59.1).13 (<.1.16) French Polynesi < 1.57 (.49.66) 2 (18 24) <.1 (<.1 <.1) 1.8 (.4 3.2) Gbon (6.9 13) 485 ( ) 2 ( ) 12 (7 139).4 (.29.5) 2 (15 25) Gmbi ( ) 174 ( ).65 (.49.84) 32 (24 41).11 (.18.2) 5.4 ( ) Georgi (3. 4.3) 92 (77 19).77 (.64.91) 2 ( ).78 (.65.92) 2 (17 23) Germny ( ) 8.1 ( ).35 (.2.54).43 (.24.66).22 (.11.34).27 (.13.41) Ghn (21 75) 156 (75 265) 1 (4.7 17) 35 (17 61).84 ( ) 3 (.95 5.) Greece (.42.57) 4.4 ( ).39 (.22.6).35 (.2.54).12 (.28).1 (.25) Greenlnd < 1.67 (.57.77) 118 (11 137) <.1 (<.1 <.1) 4.9 ( ) Grend < 1 <.1 (<.1 <.1) 6.4 ( ) ( ) ( ) <.1 (<.1 <.1).44 (.24.65) Gum < 1.86 (.74.1) 53 (45 61) ( ) <.1 (<.1 <.1) <.1 ( <.1) 2.6 ( 6.1) Guteml 17 4 ( ) 24 (19 31).31 (.2.44) 1.9 ( ).23 (.15.31) 1.4 ( ) Guine (14 31) 176 ( ) 5.4 ( ) 43 (28 63).73 ( ) 5.9 (1.1 11) Guine-Bissu ( ) 374 ( ) 2.2 ( ) 12 (75 175).2 (.17.39) 11 (.93 21) Guyn < 1.72 (.55.91) 93 (71 118).17 (.11.25) 22 (14 32).46 (.3.62) 5.9 (3.9 8.) Hiti 11 2 (17 24) 188 ( ) 3.1 ( ) 28 (23 34).77 ( ) 7.1 (4.1 1) Hondurs ( ) 4 (3 5).31 (.24.4) 3.4 ( ).12 (.59.17) 1.3 ( ) Hungry 1.86 (.73.99) 8.8 (7.5 1).23 (.13.37).24 (.13.38).35 (.21.48).36 (.22.5) Icelnd < 1 <.1 (<.1 <.1) 2.1 ( ) ( ) ( ) ( ) ( ) Indi ( ) 211 (19 345) 87 (56 125) 6.6 ( ) 147 (95 199) 11 (7.2 15) Indonesi ( ) 391 ( ) 45 (21 78) 17 (8. 3) 32 (19 45) 12 (7.3 17) Irn (Islmic Republic of) 8 12 (8.9 15) 14 (11 18).35 (.23.5).44 (.28.62).2 (.12.29).25 (.14.36) Irq (14 18) 43 (37 48).16 (.12.2) <.1 (<.1 <.1) 1.2 ( ) 3.2 ( ) Irelnd 5.34 (.29.39) 7.1 ( ).23 (.13.36).5 (.28.77) <.1 (.11) <.1 (.22) Isrel 8.29 (.25.33) 3.5 (3. 4.1).21 (.13.3).25 (.16.36).24 (.11.38).3 (.13.46) Itly ( ) 6.1 ( ).41 (.24.63).69 (.4 1.1).14 (.95.19).24 (.16.32) Jmic 3.13 (.99.16) 4.5 ( ).55 (.41.72) 1.9 ( ) <.1 ( <.1) <.1 (.23) Jpn (17 23) 16 (14 18).89 (.73.11) <.1 (<.1 <.1).26 (.17.34).2 (.13.27) Jordn 9.53 (.41.67) 5.6 ( ) <.1 (<.1 <.1) <.1 (<.1 <.1).39 (.12.67).41 (.12.7) Kzkhstn (7.7 17) 67 (43 95).58 (.37.82) 3.2 ( ) 7 ( ) 39 (3 48) Keny (13 25) 348 ( ) 53 (32 79) 19 (66 162) 3 ( ) 6.2 ( ) Kiribti < 1.65 (.5.82) 566 ( ) <.1 (<.1 <.1) 2.4 ( ).4 (.21.58) 35 (19 51) Kuwit 4.96 ( ) 24 (2 27) <.1 (<.1 <.1).1 (<.1.11).26 (<.1.42).64 (.24 1.) Kyrgyzstn ( ) 145 (13 162).28 (.25.32) 4.8 ( ) 4.8 (4. 5.5) 8 (68 92) Lo People's Democrtic Republic 7 12 (7.7 17) 175 (113 25).71 (.45 1.) 11 (6.7 15).72 ( ) 11 (4.8 17) Ltvi 2.74 (.63.85) 37 (32 43).91 (.77.11) 4.6 ( ).9 (.66.11) 4.6 ( ) Lebnon 6.74 (.64.86) 12 (11 14) <.1 (<.1 <.1).1 (<.1.12).29 (<.1.5).48 (.14.83) Lesotho 2 16 (1 23) 724 ( ) 12 (7.3 17) 525 (332 76) 1.1 ( ) 49 (32 66) Liberi 5 14 (9.2 2) 38 (199 44) 2.2 ( ) 48 (31 7).43 (.46.82) 9.4 (1. 18) Liby ( ) 4 (25 58).56 (.34.82).88 ( ).12 (.4.2) 1.9 ( ) Lithuni ( ) 53 (46 62).5 (.42.59) 1.7 (1.5 2.).35 (.29.41) 12 (1 14) Luxembourg < 1.33 (.29.39) 5.8 (5. 6.7) <.1 (<.1 <.1).85 ( ) ( ) ( ) Mdgscr (38 84) 237 ( ) 1.4 ( ) 5.6 ( ).44 (.81.79) 1.8 ( ) Mlwi (15 46) 159 (85 256) 15 (9.9 22) 85 (55 121).4 (.13.67) 2.2 ( ) Mlysi (25 33) 92 (79 17) 1.7 (1.4 2.) 5.4 ( ).57 (.45.7) 1.8 ( ) Mldives < 1.21 (.16.27) 49 (38 62) <.1 (<.1 <.1).23 (.15.33) <.1 (.11).95 ( 2.6) Mli 18 1 (6.6 14) 56 (37 79) 1.4 (.9 2.) 7.8 (5. 11).38 (.1.66) 2.1 ( ) Mlt < 1.58 (.49.66) 13 (11 15).15 (.13.17) 3.5 (3. 4.1) ( ) ( ) Mrshll Islnds < 1.22 (.17.28) 422 ( ) ( ).39 (.27.52) ( ) ( ) Muritni ( ) 12 (66 146).22 (.84.42) 5.1 (2. 9.8).14 (.23.26) 3.3 (.53 6.) Muritius 1.28 (.18.4) 22 (14 31).37 (.23.53) 2.9 ( ) <.1 (.17).65 ( 1.3) Mexico (21 35) 22 (17 28) 3.7 ( ) 2.9 ( ).94 ( ).74 (.58.9) Micronesi (Federted Sttes of) < 1.19 (.14.24) 177 ( ) ( ).18 (.13.24).11 (<.1.16) 1 (5.1 15) Monco < 1 ( ) ( ) ( ) ( ) Mongoli (4.2 7.) 183 (14 231).12 (<.1.16).4 (.3.51).47 (.36.58) 15 (12 19) Montenegro < 1.1 (.86.12) 16 (14 18) ( ) <.1 (<.1 <.1) ( ) ( ) Montserrt < 1 ( ) ( ) ( ) ( ) Morocco (31 42) 13 (88 119).44 (.29.63) 1.3 ( ).64 (.38.9) 1.8 ( ) Mozmbique (13 227) 551 ( ) 72 (46 14) 249 (158 36) 7.6 (4.5 11) 26 (16 37) Mynmr ( ) 361 ( ) 18 (13 24) 34 (25 45) 13 (8.8 18) 25 (17 34) Nmibi 2 11 (8.5 14) 446 ( ) 4.2 (2.7 6.) 171 (11 244).96 ( ) 39 (3 47) Rtes re per 1 popultion. 23 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

242 TABLE A4.1 TB incidence estimtes, 216 Incidence (including HIV) Incidence (HIV-positive) Incidence (MDR/RR-TB) Popultion (millions) Number (thousnds) Rte Number (thousnds) Rte Number (thousnds) Rte Nuru < 1.13 (.11.15) 112 (96 129) <.1 (<.1 <.1) 14 (11 17) Nepl (39 5) 154 ( ).95 ( ) 3.3 ( ) 1.5 ( ) 5.1 ( ) Netherlnds 17 1 ( ) 5.9 ( ).34 (.28.4).2 (.17.24).29 (.13.45).17 (<.1.26) New Cledoni < 1.44 (.37.5) 16 (14 19) ( ) ( ) New Zelnd 5.34 (.29.39) 7.3 ( ) ( ) <.1 (<.1 <.1) <.1 (<.1.18).21 (<.1.39) Nicrgu ( ) 48 (36 6).14 (.1.17) 2.2 ( ).53 (.13.93).86 ( ) Niger (12 27) 93 (6 132).95 (.6 1.4) 4.6 ( ).66 ( ) 3.2 ( ) Nigeri ( ) 219 ( ) 63 (4 93) 34 (21 5) 2 (12 29) 11 (6.4 15) Niue < 1 ( ) 2 (17 23) ( ) ( ) Northern Mrin Islnds < 1.32 (.28.37) 59 (5 68) ( ) ( ) ( ) ( ) Norwy 5.32 (.27.37) 6.1 (5.2 7.).14 (<.1.21).27 (.18.39) <.1 (<.1.18).18 (<.1.34) Omn 4.4 (.34.46) 9 (7.7 1).14 (<.1.2).32 (.21.45) <.1 (<.1.15).18 (<.1.34) Pkistn ( ) 268 ( ) 6.9 (3.2 12) 3.5 ( ) 27 (17 37) 14 (8.8 19) Plu < 1.26 (.23.31) 123 (15 142) ( ) <.1 (<.1.1) ( ) ( ) Pnm ( ) 55 (42 7).25 (.16.36) 6.2 (4. 8.9).96 (.57.14) 2.4 ( ) Ppu New Guine 8 35 (28 42) 432 ( ) 3.6 (2. 5.5) 44 (25 68) 1.9 ( ) 23 (15 32) Prguy ( ) 42 (36 48).27 (.17.39) 4 ( ).84 (.36.13) 1.2 ( ) Peru (28 47) 117 (9 148) 2.2 ( ) 6.8 ( ) 3.5 ( ) 11 (9.1 13) Philippines ( ) 554 ( ) 6 (2.5 11) 5.9 (2.4 11) 3 (21 4) 3 (2 39) Polnd (6. 8.2) 18 (16 21).18 (.99.28).47 (.26.73).9 (.66.11).24 (.17.3) Portugl ( ) 2 (17 23).29 (.24.34) 2.8 ( ).28 (.17.4).27 (.16.39) Puerto Rico 4.75 (.64.86) 2 ( ) <.1 (<.1.1).24 (.2.28) <.1 (<.1 <.1).12 (.11.13) Qtr 3.58 (.5.67) 23 (19 26) ( ) ( ) <.1 (.18).3 (.72) Republic of Kore (36 42) 77 (71 82).77 ( ) 1.5 ( ) 2.4 ( ) 4.8 ( ) Republic of Moldov ( ) 11 (87 117).37 (.31.43) 9.2 (7.8 11) 2.3 ( ) 56 (47 65) Romni 2 15 (13 17) 74 (64 86).37 (.31.43) 1.9 ( ).89 (.75 1.) 4.5 ( ) Russin Federtion (61 135) 66 (42 94) 18 (12 26) 13 (8.1 18) 63 (52 74) 44 (36 51) Rwnd 12 6 (5. 7.1) 5 (42 59) 1.4 (.9 2.) 12 (7.5 17).14 (.89.19) 1.2 ( ) Sint Kitts nd Nevis < 1 ( ) ( ) ( ) ( ) ( ) ( ) Sint Luci < 1 <.1 (<.1 <.1) 1.9 ( ) <.1 (<.1 <.1).65 (.42.92) ( ) ( ) Sint Vincent nd the Grendines < 1 <.1 (<.1 <.1) 6.3 ( ) ( ) ( ) <.1 ( <.1) 3.2 ( 7.6) Smo < 1.15 (.13.17) 7.7 ( ) <.1 ( <.1).96 ( 2.7) Sn Mrino < 1 ( ) ( ) ( ) ( ) So Tome nd Principe < 1.2 (.19.2) 99 (96 11).37 (.24.53) 19 (12 26).1 (<.1.15) 5.1 ( ) Sudi Arbi ( ) 1 (8.9 12).79 (.66.94).25 (.2.29).13 (.11.16).41 (.33.48) Senegl (15 3) 14 (95 193) 1.4 ( ) 8.8 (5.9 12).44 (.28.61) 2.9 (1.8 4.) Serbi (1.4 2.) 19 (16 22).1 (<.1.14).11 (<.1.16).27 (.13.41).3 (.15.46) Seychelles < 1.14 (.12.16) 15 (13 17) <.1 (<.1 <.1) 1.1 ( ) ( ) ( ) Sierr Leone 7 22 (14 32) 34 ( ) 3.1 (2. 4.5) 42 (27 61).72 ( ) 9.7 (1.6 18) Singpore ( ) 51 (43 58).44 (.37.51).78 (.66.9).51 (.31.71).91 ( ) Sint Mrten (Dutch prt) < 1 ( ) ( ) ( ) ( ) Slovki 5.32 (.28.37) 5.9 ( ) ( ) <.1 ( <.1) <.1 (<.1 <.1) <.1 (<.1 <.1) Sloveni 2.14 (.12.16) 6.5 ( ) <.1 (<.1 <.1) <.1 (<.1 <.1) ( ) ( ) Solomon Islnds < 1.5 (.38.64) 84 (64 16).29 (.15.44) 4.9 ( ) Somli (25 55) 27 ( ).59 (.37.86) 4.1 (2.6 6.) 3.9 ( ) 27 (16 39) South Afric (34 595) 781 ( ) 258 ( ) 461 ( ) 19 (12 25) 34 (22 45) South Sudn (12 26) 146 (95 29) 2.2 ( ) 18 (11 26).66 (.43.9) 5.4 ( ) Spin (4. 5.5) 1 (8.7 12).34 (.29.41).74 (.62.88).23 (.16.3).5 (.33.66) Sri Lnk (9.9 18) 65 (48 84).2 (.15.27).1 (<.1.13).93 (.2).45 (.95) Sudn 4 32 (18 51) 82 (46 129).83 ( ) 2.1 (1.4 3.) 1.2 ( ) 3.1 ( ) Surinme < 1.14 (.11.18) 26 (2 32).36 (.28.46) 6.5 (5. 8.3).11 (<.1.19) 1.9 ( ) Swzilnd ( ) 398 ( ) 3.8 ( ) 28 ( ).66 (.34.98) 49 (25 73) Sweden 1.81 (.69.93) 8.2 (7. 9.5).48 (.27.74).49 (.28.75).37 (.21.53).38 (.21.54) Switzerlnd 8.66 (.56.76) 7.8 ( ).68 (.4.1).81 ( ).31 (.14.49).37 (.16.58) Syrin Arb Republic ( ) 21 (16 26) <.1 (<.1 <.1) <.1 (<.1 <.1).37 (.23.51) 2 ( ) Tjikistn ( ) 85 (65 18).25 (.16.35) 2.8 (1.8 4.) 2.6 ( ) 3 (24 36) Thilnd (7 18) 172 (12 261) 1 (6.1 16) 15 (8.8 23) 4.7 (3. 6.3) 6.8 ( ) The Former Yugoslv Republic of Mcedoni 2.33 (.25.42) 16 (12 2) ( ) <.1 (<.1 <.1) <.1 (.12).28 (.57) Timor-Leste (4.1 9.) 498 ( ).59 (.38.84) 4.6 (3. 6.6).21 (.13.28) 16 (1 22) Togo ( ) 46 (37 56).77 (.5 1.1) 1 (6.5 14).11 (.23.2) 1.5 (.3 2.7) Tokelu < 1 ( ) ( ) ( ) ( ) Tong < 1 <.1 (<.1.11) 8.6 ( ) ( ) ( ) <.1 (<.1 <.1).48 (.25.7) Trinidd nd Tobgo 1.25 (.21.28) 18 (15 21).47 (.3.67) 3.4 ( ) <.1 (<.1.11).66 (.5.81) Tunisi ( ) 38 (29 48).28 (.18.4).25 (.16.35).45 (.19.71).4 (.16.63) Turkey 8 14 (12 16) 18 (15 2).92 (.77.11).12 (.1.14).56 (.46.65).7 (.58.82) Turkmenistn ( ) 6 (46 76).18 (.84.31) 3.2 ( ).83 (.65 1.) 15 (11 18) Rtes re per 1 popultion. Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

243 TABLE A4.1 TB incidence estimtes, 216 Incidence (including HIV) Incidence (HIV-positive) Incidence (MDR/RR-TB) Popultion (millions) Number (thousnds) Rte Number (thousnds) Rte Number (thousnds) Rte Turks nd Cicos Islnds < 1 <.1 (<.1 <.1) 6.6 ( ) <.1 (<.1 <.1) 3.3 ( ) <.1 (<.1 <.1).16 (.1.22) Tuvlu < 1.23 (.2.27) 27 ( ) ( ) ( ) <.1 (<.1 <.1) 16 (1 22) Ugnd (49 127) 21 (118 36) 35 (2 54) 85 (49 131) 1.9 ( ) 4.7 (2.4 7.) Ukrine (25 55) 87 (56 124) 8.1 (5.2 12) 18 (12 26) 21 (16 26) 47 (37 58) United Arb Emirtes 9.74 (.63.85).79 (.68.92) <.1 (<.1 <.1) <.1 (<.1 <.1) <.1 (<.1 <.1) <.1 (<.1 <.1) United Kingdom of Gret Britin nd Northern Irelnd ( ) 9.9 (8.9 11).56 (.33.85).85 (.5 1.3).11 (.72.14).16 (.11.22) United Republic of Tnzni (75 275) 287 ( ) 54 (35 78) 98 (63 14) 2.6 ( ) 4.7 ( ) United Sttes of Americ (8.7 12) 3.1 ( ).56 (.47.65).17 (.15.2).18 (.13.22) <.1 (<.1 <.1) Uruguy 3 1 ( ) 29 (25 34).16 (.14.19) 4.6 (4. 5.4) ( ) ( ) US Virgin Islnds < 1 <.1 (<.1 <.1) 7.7 ( ) ( ) ( ) Uzbekistn (17 32) 76 (53 13) 1.2 (.8 1.7) 3.8 ( ) 1 (7.6 13) 32 (24 4) Vnutu < 1.15 (.12.2) 56 (43 72) ( ) ( ) Venezuel (Bolivrin Republic of) 32 1 (7.8 13) 32 (25 41) 1.2 ( ) 3.7 ( ).41 (.23.58) 1.3 ( ) Viet Nm (13 151) 133 (19 159) 4.2 ( ) 4.4 ( ) 8.2 (6.1 1) 8.7 (6.5 11) Wllis nd Futun Islnds < 1 ( ) ( ) ( ) ( ) West Bnk nd Gz Strip 5.49 (.38.62) 1 ( ) ( ) ( ) <.1 (<.1 <.1) <.1 (<.1 <.1) Yemen (12 15) 48 (42 54).91 (.59.13).33 (.21.47).36 (.18.55) 1.3 (.65 2.) Zmbi (4 89) 376 ( ) 36 (23 52) 218 (14 312) 2.1 ( ) 13 (8.4 17) Zimbbwe (24 44) 28 ( ) 23 (15 32) 139 (9 199) 1.9 ( ) 12 (8. 16) WHO regions Africn Region ( ) 254 ( ) 764 (66 876) 75 (65 86) 93 (81 16) 9.1 (7.9 1) Region of the Americs ( ) 27 (26 29) 3 (28 33) 3 ( ) 12 (11 13) 1.2 ( ) Estern Mediterrnen Region ( ) 114 (86 147) 9.9 (5.9 15) 1.5 ( ) 41 (31 52) 6.2 ( ) Europen Region ( ) 32 (27 36) 34 (26 42) 3.7 ( ) 122 (11 134) 13 (12 15) South-Est Asi Region ( ) 24 ( ) 163 (12 211) 8.3 (6.2 11) 214 ( ) 11 (8.4 14) Western Pcific Region ( ) 95 (79 113) 29 (23 36) 1.5 ( ) 119 (11 139) 6.3 ( ) Globl ( ) 14 ( ) 1 3 ( ) 14 (12 15) 61 ( ) 8.1 ( ) Rtes re per 1 popultion. 232 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

244 TABLE A4.2 Estimtes of TB mortlity, 216. Deths from TB mong HIV-positive people re officilly clssified s deths cused by HIV/AIDS in the Interntionl clssifiction of diseses. Popultion (millions) Mortlity (HIV-negtive people) Number (thousnds) Rte Mortlity (HIV-positive people) Number (thousnds) Rte Mortlity (HIV-negtive nd HIV-positive people) b Number (thousnds) Afghnistn (6.7 17) 33 (19 49).96 (.16.24).28 (<.1.71) 11 (6.8 17) 33 (2 49) Albni 3 <.1 (<.1.15).29 (.13.51) <.1 ( <.1) <.1 (<.1 <.1) <.1 (<.1.16).32 (.16.53) Algeri (2. 4.5) 7.7 (4.9 11).35 (.17.59) <.1 (<.1.15) 3.2 (2. 4.5) 7.8 (5. 11) Americn Smo < 1 ( <.1).69 (.42 1.) ( ) ( ) ( <.1).69 (.43 1.) Andorr < 1 ( ) ( ) ( ) ( ) ( ) ( ) Angol (1 29) 64 (36 99) 6.9 (3.4 12) 24 (12 41) 25 (16 36) 88 (57 126) Anguill < 1 <.1 (<.1 <.1) 9.2 (5.3 14) ( ) ( ) <.1 (<.1 <.1) 9.2 (5.3 14) Antigu nd Brbud < 1 ( ) ( ) ( ) ( ) ( ) ( ) Argentin 44.6 (.58.63) 1.4 ( ).64 (.31.11).15 (<.1.25).67 (.62.71) 1.5 ( ) Armeni 3.62 (.37.94) 2.1 ( ).15 (.11.21).52 (.36.7).77 (.51.11) 2.6 ( ) Arub < 1 <.1 (<.1 <.1) 1.3 ( ) ( ) ( ) <.1 (<.1 <.1) 1.3 ( ) Austrli (.47.48).2 (.2.2) <.1 (<.1 <.1) <.1 (<.1 <.1).52 (.51.54).22 (.21.22) Austri 9.71 (.71.72).82 (.81.83) <.1 (<.1.1) <.1 (<.1.11).77 (.74.81).89 (.85.93) Azerbijn 1.62 (.61.63) 6.4 ( ).28 (.2.36).28 (.2.37).65 (.64.66) 6.7 ( ) Bhms < 1 <.1 (<.1 <.1).21 (.21.21) <.1 (<.1 <.1) 1.7 ( ) <.1 (<.1.1) 1.9 ( ) Bhrin 1 <.1 (<.1 <.1).56 (.51.62) <.1 (<.1 <.1).1 (<.1.14) <.1 (<.1.1).67 (.6.73) Bngldesh (43 94) 4 (26 58).18 (.86.3).11 (<.1.18) 66 (43 94) 41 (26 58) Brbdos < 1 <.1 (<.1 <.1).72 (.71.72) <.1 ( <.1).22 (.15.3) <.1 (<.1 <.1).94 (.86 1.) Belrus 9.23 (.2.26) 2.4 ( ).13 (.86.17) 1.3 ( ).35 (.3.41) 3.7 ( ) Belgium (.41.43).37 (.36.38).14 (<.1.19).12 (<.1.17).56 (.5.61).49 (.44.54) Belize < 1 <.1 (<.1 <.1) 2.1 ( ) <.1 (<.1 <.1) 1.7 ( ).14 (.12.16) 3.7 ( ) Benin 11 1 ( ) 9.4 (5.6 14).33 (.21.47) 3 ( ) 1.3 ( ) 12 (8.3 17) Bermud < 1 ( ).31 (.19.45) ( ) ( ) ( ).31 (.19.45) Bhutn < 1.16 (.1.22) 2 (13 28) <.1 (<.1 <.1).2 (.15.27).16 (.1.22) 2 (13 28) Bolivi (Plurintionl Stte of) ( ) 8.6 (6.2 11).17 (.11.24) 1.6 (1. 2.2) 1.1 ( ) 1 (7.7 13) Bonire, Sint Eusttius nd Sb < 1 ( ).38 (.23.56) ( ) ( ) ( ).38 (.23.56) Bosni nd Herzegovin 4.14 (.12.15) 3.9 ( ) ( <.1) <.1 (<.1 <.1).14 (.12.15) 3.9 ( ) Botswn 2.49 (.32.7) 22 (14 31) 1.4 (1. 1.8) 62 (45 81) 1.9 ( ) 84 (65 15) Brzil ( ) 2.6 ( ) 1.9 ( ).9 ( ) 7.3 (6.5 8.) 3.5 ( ) British Virgin Islnds < 1 ( ) ( ) ( ) ( ) ( ) ( ) Brunei Drusslm < 1.25 (.21.29) 5.9 (5. 6.8).25 (.21.29) 5.9 (5. 6.8) Bulgri 7.12 (.12.13) 1.7 ( ) ( <.1) <.1 ( <.1).12 (.12.13) 1.7 ( ) Burkin Fso ( ) 8.7 (5.2 13).31 (.19.44) 1.6 (1. 2.4) 1.9 ( ) 1 (6.7 15) Burundi 11 2 ( ) 19 (12 29).52 (.33.75) 4.9 ( ) 2.6 ( ) 24 (16 34) Cbo Verde < 1.2 (.19.21) 3.7 ( ).32 (.2.48) 6 ( ).52 (.39.68) 9.7 (7.2 13) Cmbodi ( ) 2 (14 28).45 (.29.66) 2.9 ( ) 3.6 ( ) 23 (16 31) Cmeroon (3.9 1) 28 (17 43) 6.3 (4. 9.2) 27 (17 39) 13 (9.2 17) 55 (39 74) Cnd (.98.1).27 (.27.27).23 (.15.33) <.1 (<.1 <.1).12 (.11.13).34 (.31.36) Cymn Islnds < 1 ( ) ( ) ( ).2 (.11.32) ( ).2 (.11.32) Centrl Africn Republic ( ) 59 (33 92) 2.5 (1.3 4.) 54 (29 87) 5.2 ( ) 113 (76 158) Chd ( ) 31 (18 48) 1.3 ( ) 8.7 (4.2 15) 5.8 ( ) 4 (26 57) Chile (.34.35) 1.9 (1.9 2.).72 (.37.12).4 (.21.67).42 (.38.46) 2.3 ( ) Chin (34 7) 3.6 (2.4 5.) 1.8 (.7 3.4).13 (<.1.24) 52 (35 72) 3.7 ( ) Chin, Hong Kong SAR 7.16 (.16.17) 2.2 ( ) <.1 (<.1 <.1) <.1 (<.1.12).17 (.17.17) 2.3 ( ) Chin, Mco SAR < 1.34 (.21.5) 5.5 ( ) <.1 ( <.1) <.1 (<.1.11).34 (.21.5) 5.6 ( ) Colombi (.97.99) 2 (2. 2.).46 (.34.61).95 (.7 1.2) 1.4 ( ) 3 ( ) Comoros < 1.51 (.31.78) 6.5 ( ) <.1 (<.1 <.1).41 (.26.59).55 (.34.81) 6.9 (4.2 1) Congo ( ) 6 (34 93) 2.1 ( ) 41 (21 66) 5.1 ( ) 1 (67 141) Cook Islnds < 1 ( ) 1.1 ( ) ( ) ( ) ( ) 1.1 ( ) Cost Ric 5.42 (.4.45).87 (.82.93) <.1 (<.1.11).17 (.11.23).5 (.47.54) 1 ( ) Côte d'ivoire ( ) 23 (14 35) 2.8 ( ) 12 (7.5 17) 8.4 (5.8 11) 35 (24 48) Croti 4.27 (.26.27).63 (.63.64) <.1 ( <.1) <.1 (<.1 <.1).27 (.27.28).65 (.64.66) Cub (.38.41).34 (.33.36).11 (<.1.15) <.1 (<.1.13).5 (.46.54).43 (.4.47) Curço < 1 ( <.1).24 (.15.35) ( ) ( ) ( <.1).24 (.15.35) Cyprus 1 <.1 (<.1 <.1).42 (.41.42) ( <.1) <.1 (<.1 <.1) <.1 (<.1 <.1).45 (.43.47) Czechi (.56.57).54 (.53.54) <.1 (<.1 <.1) <.1 (<.1 <.1).58 (.57.59).55 (.54.56) Democrtic People's Republic of Kore (6.8 16) 43 (27 63).51 (.23.89).2 (<.1.35) 11 (6.8 16) 43 (27 63) Democrtic Republic of the Congo (31 8) 67 (39 11) 8.5 (4. 15) 11 (5.1 19) 61 (39 89) 78 (49 112) Denmrk 6.13 (.13.14).24 (.22.25) <.1 (<.1 <.1) <.1 (<.1 <.1).15 (.14.16).26 (.24.29) Djibouti < 1.33 (.21.47) 35 (22 5).35 (.25.46) 3.7 ( ).36 (.24.51) 39 (26 54) Dominic < 1 ( ).31 (.31.31) ( ).24 (.16.34) ( ).55 (.46.65) Dominicn Republic (.24 1.) 5.2 ( ).49 (.35.64) 4.6 (3.3 6.) 1 ( ) 9.8 (6.3 14) Rte b Rtes re per 1 popultion. All clcultions re mde before numbers re rounded. Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

245 TABLE A4.2 Estimtes of TB mortlity, 216. Deths from TB mong HIV-positive people re officilly clssified s deths cused by HIV/AIDS in the Interntionl clssifiction of diseses. Popultion (millions) Mortlity (HIV-negtive people) Number (thousnds) Rte Mortlity (HIV-positive people) Number (thousnds) Rte Mortlity (HIV-negtive nd HIV-positive people) b Number (thousnds) Ecudor 16.4 (.31.49) 2.4 (1.9 3.).34 (.22.49) 2.1 (1.3 3.).74 (.58.91) 4.5 ( ) Egypt (.27.3).3 (.28.31).11 (<.1.17) <.1 (<.1 <.1).3 (.28.31).31 (.29.33) El Slvdor 6.77 (.47.11) 1.2 ( ).53 (.37.72).84 ( ).13 (.95.17) 2.1 ( ) Equtoril Guine 1.19 (.13.26) 16 (11 21).37 (.28.46) 3 (23 38).56 (.45.67) 46 (37 55) Eritre 5.64 ( ) 13 (5.9 23).75 (.36.13) 1.5 ( ).72 ( ) 15 (7.2 24) Estoni 1.16 (.16.16) 1.2 ( ) <.1 (<.1 <.1).27 (.18.38).2 (.18.21) 1.5 ( ) Ethiopi (16 37) 25 (16 36) 4 ( ) 3.9 ( ) 3 (2 41) 29 (2 4) Fiji < 1.4 (.37.43) 4.4 ( ) <.1 (<.1 <.1).22 (.15.3).42 (.39.45) 4.7 (4.3 5.) Finlnd 6.31 (.3.31).56 (.55.56) <.1 (<.1 <.1) <.1 (<.1 <.1).32 (.31.33).58 (.57.6) Frnce (.39.43).63 (.6.67).11 (.56.18).17 (<.1.27).52 (.45.58).8 (.7.9) French Polynesi < 1 <.1 (<.1 <.1) 1.7 (1. 2.5) ( ) ( ) <.1 (<.1 <.1) 1.7 (1. 2.5) Gbon ( ) 76 (49 11).76 (.51 1.) 38 (26 53) 2.3 (1.6 3.) 114 (83 15) Gmbi 2.43 (.28.6) 21 (14 3).19 (.14.24) 9.1 (6.6 12).62 (.46.8) 3 (22 39) Georgi 4.19 (.13.26) 4.8 ( ).15 (.11.19).38 (.28.49).2 (.15.27) 5.2 ( ) Germny (.32.33).39 (.39.4).54 (.26.91) <.1 (<.1.11).38 (.34.41).46 (.42.5) Ghn 28 1 (4.6 18) 36 (16 64) 5.5 ( ) 2 (9.3 34) 16 (9.1 24) 56 (32 86) Greece (.53.57).49 (.48.51) <.1 (<.1.1) <.1 (<.1 <.1).61 (.57.65).55 (.51.58) Greenlnd < 1 <.1 (<.1 <.1) 9.7 (6. 14) ( ) ( ) <.1 (<.1 <.1) 9.7 (6. 14) Grend < 1 <.1 (<.1 <.1) 1.9 ( ) ( ) ( ) <.1 (<.1 <.1) 1.9 ( ) Gum < 1 <.1 (<.1.1) 4.3 ( ) ( ) <.1 (<.1 <.1) <.1 (<.1.1) 4.4 ( ) Guteml (.3.34) 1.9 ( ).64 (.45.86).39 (.27.52).38 (.36.41) 2.3 ( ) Guine ( ) 26 (16 4) 2 ( ) 16 (1 23) 5.3 ( ) 43 (3 57) Guine-Bissu (.8 2.1) 76 (44 116) 1.2 ( ) 66 (4 98) 2.6 ( ) 142 (99 192) Guyn < 1.14 (.12.17) 19 (15 22).36 (.26.48) 4.7 ( ).18 (.15.21) 23 (2 27) Hiti ( ) 8.4 (4.8 13).75 (.57.95) 6.9 ( ) 1.7 ( ) 15 (11 2) Hondurs 9.37 (.21.58) 4.1 ( ).66 (.47.87).72 (.52.95).44 (.27.64) 4.8 (3. 7.1) Hungry 1.72 (.71.73).74 (.72.75) <.1 (<.1 <.1) <.1 (<.1 <.1).75 (.73.78).77 (.75.8) Icelnd < 1 <.1 (<.1 <.1).61 (.59.64) ( ) ( ) <.1 (<.1 <.1).61 (.59.64) Indi ( ) 32 (24 4) 12 (6.6 19).92 (.5 1.5) 435 ( ) 33 (25 41) Indonesi (75 152) 42 (29 58) 13 (6.2 23) 5.1 ( ) 124 (87 166) 47 (33 64) Irn (Islmic Republic of) 8.85 (.83.88) 1.1 (1. 1.1).37 (.12.76) <.1 (<.1 <.1).89 (.85.93) 1.1 ( ) Irq ( ) 3.3 ( ) <.1 (<.1 <.1) <.1 (<.1 <.1) 1.2 ( ) 3.4 ( ) Irelnd 5.23 (.23.23).49 (.49.49) <.1 (<.1 <.1) <.1 (<.1.14).27 (.25.3).58 (.53.63) Isrel 8.15 (.15.16).19 (.18.19) <.1 (<.1 <.1) <.1 (<.1 <.1).18 (.17.2).23 (.21.24) Itly (.33.34).56 (.56.57).63 (.32.11).11 (<.1.18).4 (.36.44).67 (.61.73) Jmic 3 <.1 (<.1 <.1).25 (.25.25).12 (<.1.16).41 (.29.55).19 (.16.23).66 (.54.8) Jpn ( ) 2.4 ( ).14 (<.1.19) <.1 (<.1 <.1) 3.1 (3. 3.2) 2.4 ( ) Jordn 9.15 (.14.15).15 (.15.16) ( ) ( ).15 (.15.15).16 (.15.16) Kzkhstn (.4.48) 2.4 ( ).38 (.13.76).21 (<.1.42).47 (.42.53) 2.6 ( ) Keny (16 45) 6 (33 93) 24 (14 36) 5 (3 75) 53 (36 73) 19 (75 15) Kiribti < 1.35 (.22.51) 31 (19 45) <.1 ( <.1).54 (.38.74).36 (.23.52) 31 (2 45) Kuwit 4 <.1 (<.1 <.1).23 (.22.23) <.1 ( <.1) <.1 (<.1 <.1).1 (.1.1).24 (.24.25) Kyrgyzstn 6.43 (.42.44) 7.2 (7. 7.3).59 (.46.74).99 ( ).49 (.47.5) 8.2 ( ) Lo People's Democrtic Republic ( ) 43 (25 65).34 (.21.5) 5.1 ( ) 3.2 (2. 4.8) 48 (3 7) Ltvi 2.39 (.38.39) 2 (1.9 2.).15 (.11.2).78 (.58 1.).54 (.5.59) 2.8 (2.5 3.) Lebnon 6.61 (.37.89) 1 ( ) <.1 (<.1 <.1) <.1 (<.1 <.1).62 (.38.9) 1 ( ) Lesotho ( ) 49 (26 8) 5.2 ( ) 238 (148 35) 6.3 ( ) 287 (192 42) Liberi ( ) 6 (35 91).96 (.6 1.4) 21 (13 3) 3.7 ( ) 81 (54 112) Liby 6.61 (.35.95) 9.8 (5.6 15).25 (.15.38).4 (.24.6).64 (.38.97) 1 (6. 15) Lithuni 3.19 (.19.19) 6.4 ( ) <.1 (<.1.11).27 (.17.38).19 (.19.2) 6.7 ( ) Luxembourg < 1 <.1 (<.1 <.1).18 (.18.19) <.1 ( <.1).13 (<.1.22) <.1 (<.1 <.1).31 (.24.39) Mdgscr (7.9 2) 54 (32 82).61 ( ) 2.4 ( ) 14 (8.5 21) 56 (34 84) Mlwi ( ) 16 (8. 27) 6 ( ) 33 (18 54) 8.9 (5.6 13) 49 (31 71) Mlysi (.73 2.) 4.1 ( ).29 (.22.38).94 ( ) 1.6 (1. 2.3) 5.1 ( ) Mldives < 1.17 (.13.21) 3.9 ( ) ( ) ( ).17 (.13.21) 3.9 ( ) Mli ( ) 7.7 (4.6 11).43 (.28.61) 2.4 ( ) 1.8 ( ) 1 (6.8 14) Mlt < 1 <.1 (<.1 <.1).24 (.23.24) <.1 (<.1 <.1).58 (.43.75) <.1 (<.1 <.1).81 (.66.98) Mrshll Islnds < 1.25 (.16.35) 46 (3 66) ( ) <.1 (<.1.12).25 (.16.35) 46 (3 67) Muritni 4.89 ( ) 21 (12 31).9 (.34.17) 2.1 (.8 4.).98 ( ) 23 (14 34) Muritius 1.21 (.21.21) 1.6 ( ).17 (.11.25) 1.4 (.84 2.).38 (.31.46) 3 ( ) Mexico ( ) 1.7 ( ).77 (.55 1.).6 (.43.81) 3 ( ) 2.3 ( ) Micronesi (Federted Sttes of) < 1.2 (.13.29) 2 (13 28) ( ) <.1 (<.1 <.1).21 (.13.29) 2 (13 28) Rte b Rtes re per 1 popultion. All clcultions re mde before numbers re rounded. 234 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

246 TABLE A4.2 Estimtes of TB mortlity, 216. Deths from TB mong HIV-positive people re officilly clssified s deths cused by HIV/AIDS in the Interntionl clssifiction of diseses. Popultion (millions) Mortlity (HIV-negtive people) Number (thousnds) Rte Mortlity (HIV-positive people) Number (thousnds) Rte Mortlity (HIV-negtive nd HIV-positive people) b Number (thousnds) Monco < 1 ( ) ( ) ( ) ( ) ( ) ( ) Mongoli 3.61 (.39.87) 2 (13 29) <.1 (<.1 <.1) <.1 (<.1.11).61 (.39.87) 2 (13 29) Montenegro < 1 <.1 (<.1 <.1).19 (.17.2) ( ) ( <.1) <.1 (<.1 <.1).19 (.18.21) Montserrt < 1 ( ).58 (.58.58) ( ) ( ) ( ).58 (.58.58) Morocco ( ) 9.3 (6. 13).74 (.35.13).21 (.1.36) 3.4 ( ) 9.5 (6.2 13) Mozmbique (13 33) 75 (44 115) 33 (2 48) 114 (7 167) 54 (38 73) 189 ( ) Mynmr (16 35) 47 (3 66) 4.9 ( ) 9.3 (6.7 12) 3 (21 4) 56 (39 76) Nmibi 2.75 ( ) 3 (2 44).87 ( ) 35 (25 48) 1.6 ( ) 65 (5 83) Nuru < 1 <.1 (<.1 <.1) 13 (8.7 18) ( ) ( ) <.1 (<.1 <.1) 13 (8.7 18) Nepl ( ) 22 (16 3).27 (.15.44).95 (.5 1.5) 6.8 (4.9 9.) 23 (17 31) Netherlnds (.37.38).22 (.22.23) <.1 (<.1 <.1) <.1 (<.1 <.1).43 (.42.45).26 (.24.27) New Cledoni < 1 <.1 (<.1 <.1) 1.3 ( ) ( ) ( ) <.1 (<.1 <.1) 1.3 ( ) New Zelnd 5.1 (.1.11).22 (.22.23) ( ) ( ).11 (.1.11).23 (.22.23) Nicrgu 6.16 (.11.21) 2.6 ( ).28 (.2.38).46 (.32.62).19 (.14.24) 3 ( ) Niger 21 4 ( ) 2 (12 3).39 (.24.57) 1.9 ( ) 4.4 ( ) 21 (13 31) Nigeri (67 176) 62 (36 95) 39 (23 58) 21 (12 31) 154 (12 216) 83 (55 116) Niue < 1 ( ) 1.6 ( ) ( ) ( ) ( ) 1.6 ( ) Northern Mrin Islnds < 1 <.1 (<.1 <.1) 4.8 (3. 7.1) ( ) ( ) <.1 (<.1 <.1) 4.8 (3. 7.1) Norwy 5.13 (.13.13).25 (.24.26) <.1 (<.1 <.1) <.1 (<.1 <.1).15 (.14.17).29 (.27.32) Omn 4.31 (.23.42).71 (.51.95) <.1 (<.1 <.1) <.1 (<.1 <.1).34 (.25.44).76 (.56 1.) Pkistn (34 55) 23 (18 29) 2.1 ( ) 1.1 ( ) 46 (36 57) 24 (19 3) Plu < 1 <.1 (<.1 <.1) 1 (6.2 15) ( ) <.1 (<.1 <.1) <.1 (<.1 <.1) 1 (6.2 15) Pnm 4.22 (.2.25) 5.5 ( ).52 (.36.7) 1.3 ( ).27 (.25.3) 6.8 ( ) Ppu New Guine (2.4 5.) 44 (29 62).82 ( ) 1 (5.5 16) 4.4 ( ) 55 (39 73) Prguy 7.27 (.23.31) 4.1 ( ).44 (.32.57).65 (.47.85).32 (.28.36) 4.7 ( ) Peru ( ) 4.9 ( ).46 (.34.61) 1.5 ( ) 2 ( ) 6.3 ( ) Philippines (22 22) 21 (21 22).3 ( 2.6).29 ( 2.5) 22 (21 24) 22 (2 23) Polnd (.46.51) 1.3 ( ).27 (.13.47) <.1 (<.1.12).51 (.48.54) 1.3 ( ) Portugl 1.21 (.21.22) 2 (2. 2.1).45 (.29.64).43 (.28.62).26 (.24.28) 2.5 ( ) Puerto Rico 4.1 (.1.1).28 (.27.28) <.1 (<.1 <.1) <.1 (<.1 <.1).12 (.11.12).32 (.3.33) Qtr 3 <.1 (<.1 <.1).27 (.22.33) ( ) ( ) <.1 (<.1 <.1).27 (.22.33) Republic of Kore ( ) 5.1 ( ).82 (.33.15).16 (<.1.3) 2.7 ( ) 5.2 (5. 5.5) Republic of Moldov 4.26 (.24.27) 6.3 ( ).62 (.46.8) 1.5 (1.1 2.).32 (.29.34) 7.8 ( ) Romni 2 1 (1. 1.) 5.1 (5. 5.1).59 (.43.79).3 (.22.4) 1.1 (1. 1.1) 5.4 ( ) Russin Federtion (11 12) 8.2 ( ) 1.7 ( ) 1.2 ( ) 13 (12 15) 9.3 (8.6 1) Rwnd 12.2 (.73.38) 1.7 ( ).13 (.71.2) 1.1 (.6 1.7).33 (.18.52) 2.7 ( ) Sint Kitts nd Nevis < 1 <.1 (<.1 <.1) 2.4 ( ) ( ) ( ) <.1 (<.1 <.1) 2.4 ( ) Sint Luci < 1 <.1 (<.1 <.1) 2.2 ( ) ( ).1 (<.1.14) <.1 (<.1 <.1) 2.3 ( ) Sint Vincent nd the Grendines < 1 <.1 (<.1 <.1) 2 (2. 2.1) ( ) ( ) <.1 (<.1 <.1) 2 (2. 2.1) Smo < 1 <.1 (<.1 <.1).63 (.39.93) ( ) ( ) <.1 (<.1 <.1).63 (.39.93) Sn Mrino < 1 ( ) ( ) ( ) ( ) ( ) ( ) So Tome nd Principe < 1 <.1 (<.1.14) 3.9 ( ) <.1 (<.1 <.1) 1.6 ( ).11 (<.1.18) 5.5 (3. 8.8) Sudi Arbi ( ) 2.6 (2. 3.3).13 (.1.17) <.1 (<.1 <.1).86 ( ) 2.7 (2. 3.4) Senegl ( ) 25 (15 37).48 (.31.68) 3.1 (2. 4.4) 4.3 ( ) 28 (18 4) Serbi 9.84 (.73.96).96 ( ) <.1 (<.1 <.1) <.1 (<.1 <.1).86 (.75.98).98 ( ) Seychelles < 1 ( ).4 (.4.4) ( ) <.1 (<.1.1) ( ).47 (.45.5) Sierr Leone (2. 5.2) 47 (28 7) 1 ( ) 14 (9. 2) 4.5 (3. 6.3) 61 (41 85) Singpore 6.51 (.44.58).91 (.79 1.) <.1 (<.1 <.1).12 (<.1.17).58 (.51.65) 1 (.9 1.2) Sint Mrten (Dutch prt) < 1 ( ) ( ) ( ) ( ) ( ) ( ) Slovki 5.35 (.34.35).64 (.63.65) ( ) ( ).35 (.34.35).64 (.63.65) Sloveni 2.13 (.13.13).61 (.61.62) ( ) <.1 (<.1 <.1).13 (.13.13).62 (.61.63) Solomon Islnds < 1.55 (.36.79) 9.2 (5.9 13) ( ) ( ).55 (.36.79) 9.2 (5.9 13) Somli (6.3 16) 75 (44 115).31 (.19.46) 2.1 ( ) 11 (6.6 17) 77 (46 117) South Afric (17 29) 41 (31 52) 11 (67 142) 181 (12 254) 124 (89 165) 222 ( ) South Sudn 12 3 ( ) 24 (14 37).77 ( ) 6.3 (4. 9.1) 3.7 ( ) 31 (2 43) Spin (.28.29).61 (.61.62).53 (.35.75).11 (<.1.16).34 (.32.36).73 (.68.77) Sri Lnk ( ) 6 (4.3 8.) <.1 (<.1 <.1) <.1 (<.1 <.1) 1.3 (.9 1.7) 6 (4.3 8.) Sudn (3. 9.1) 14 (7.5 23).28 (.98.57).72 ( ) 5.9 ( ) 15 (8.2 24) Surinme < 1.11 (.11.12) 2 ( ) <.1 (<.1.1) 1.4 (1. 1.8).19 (.17.22) 3.5 (3. 3.9) Swzilnd 1.26 (.15.4) 19 (11 3) 1.1 ( ) 84 (53 123) 1.4 ( ) 14 (7 143) Sweden 1.25 (.25.25).25 (.25.26) <.1 (<.1.12) <.1 (<.1.13).32 (.28.37).33 (.28.38) Switzerlnd 8.2 (.2.21).24 (.24.25).1 (<.1.17).12 (<.1.21).31 (.25.37).37 (.3.45) Rte b Rtes re per 1 popultion. All clcultions re mde before numbers re rounded. Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

247 TABLE A4.2 Estimtes of TB mortlity, 216. Deths from TB mong HIV-positive people re officilly clssified s deths cused by HIV/AIDS in the Interntionl clssifiction of diseses. Popultion (millions) Mortlity (HIV-negtive people) Number (thousnds) Rte Mortlity (HIV-positive people) Number (thousnds) Rte Mortlity (HIV-negtive nd HIV-positive people) b Number (thousnds) Syrin Arb Republic (.22.23).12 (.12.13) <.1 ( <.1) ( <.1).23 (.23.24).13 (.12.13) Tjikistn 9.52 (.4.66) 6 ( ).51 (.36.69).58 (.41.79).57 (.45.71) 6.6 ( ) Thilnd (7.2 1) 13 (1 15) 3.9 ( ) 5.7 ( ) 13 (1 15) 18 (15 22) The Former Yugoslv Republic of Mcedoni 2.2 (.2.21).98 (.95 1.) ( ) ( <.1).2 (.2.21).98 (.95 1.) Timor-Leste ( ) 1 (59 15) <.1 (.35).29 ( 2.7) 1.3 ( ) 1 (59 151) Togo 8.32 (.21.44) 4.1 ( ).17 (.12.22) 2.2 ( ).48 (.36.62) 6.3 ( ) Tokelu < 1 ( ) ( ) ( ) ( ) ( ) ( ) Tong < 1 <.1 ( <.1).71 (.43 1.) ( ) ( ) <.1 ( <.1).71 (.43 1.) Trinidd nd Tobgo 1.23 (.23.23) 1.7 ( ) <.1 (<.1.1).55 (.4.73).3 (.28.33) 2.2 ( ) Tunisi (.21.58) 3.3 ( ) <.1 (<.1 <.1) <.1 (<.1 <.1).38 (.22.58) 3.3 ( ) Turkey 8.48 (.35.63).61 (.44.79).15 (.11.2) <.1 (<.1 <.1).5 (.37.65).62 (.46.81) Turkmenistn 6.43 (.38.48) 7.6 ( ).37 (.16.66).65 ( ).46 (.41.52) 8.2 ( ) Turks nd Cicos Islnds < 1 ( ).27 (.17.4) ( ).51 (.33.71) ( ).78 (.57 1.) Tuvlu < 1 <.1 (<.1 <.1) 17 (1 25) ( ) ( ) <.1 (<.1 <.1) 17 (1 25) Ugnd (5.8 17) 26 (14 41) 14 (8.3 22) 35 (2 53) 25 (17 35) 61 (41 84) Ukrine ( ) 9.5 ( ) 2 ( ) 4.6 (3. 6.4) 6.2 (5.5 7.) 14 (12 16) United Arb Emirtes 9.39 (.17.71).42 (.18.76) <.1 (<.1 <.1) <.1 (<.1 <.1).4 (.18.72).44 (.19.77) United Kingdom of Gret Britin nd Northern Irelnd (.35.36).54 (.53.54).78 (.38.13).12 (<.1.2).43 (.38.48).66 (.58.73) United Republic of Tnzni (13 5) 51 (23 9) 27 (12 46) 48 (22 83) 55 (32 83) 99 (58 15) United Sttes of Americ (.52.53).16 (.16.17).86 (.57.12) <.1 (<.1 <.1).61 (.58.65).19 (.18.2) Uruguy 3.53 (.49.58) 1.5 ( ).27 (.2.34).77 (.58 1.).8 (.72.88) 2.3 ( ) US Virgin Islnds < 1 ( ) ( ) ( ) ( ) ( ) ( ) Uzbekistn ( ) 5.9 ( ).35 (.23.49) 1.1 ( ) 2.2 ( ) 7 ( ) Vnutu < 1.26 (.17.36) 9.5 (6.3 13) ( ) ( ).26 (.17.36) 9.5 (6.3 13) Venezuel (Bolivrin Republic of) (.71.71) 2.2 ( ).25 (.18.33).79 (.57 1.).96 (.89 1.) 3 ( ) Viet Nm (8.4 18) 14 (8.9 19).85 ( ).9 ( ) 14 (9.2 19) 14 (9.7 2) Wllis nd Futun Islnds < 1 ( ) ( ) ( ) ( ) ( ) ( ) West Bnk nd Gz Strip 5 ( ) ( ) ( ) ( ) ( ) ( ) Yemen ( ) 6.9 ( ).26 (<.1.53) <.1 (<.1.19) 1.9 ( ) 7 (5. 9.4) Zmbi ( ) 29 (17 44) 12 (7.9 18) 74 (47 17) 17 (12 23) 13 (73 139) Zimbbwe ( ) 7.2 (4.4 11) 4.4 (3. 6.1) 27 (19 38) 5.6 ( ) 35 (25 45) WHO regions Africn Region ( ) 41 (34 48) 32 ( ) 31 (27 36) 737 ( ) 72 (64 81) Region of the Americs (16 18) 1.7 ( ) 6.2 ( ).63 (.56.7) 23 (22 24) 2.3 ( ) Estern Mediterrnen Region (69 95) 12 (1 14) 3 ( ).45 (.27.68) 85 (72 98) 13 (11 15) Europen Region (25 27) 2.8 ( ) 5.1 ( ).55 (.43.69) 31 (3 33) 3.4 ( ) South-Est Asi Region ( ) 33 (28 4) 35 (25 46) 1.8 ( ) 687 (576 87) 35 (3 41) Western Pcific Region (85 123) 5.4 ( ) 5 (3. 7.3).26 (.16.39) 18 (89 128) 5.7 ( ) Globl ( ) 17 (16 19) 374 ( ) 5 ( ) 1 67 ( ) 22 (21 24) Rte b Rtes re per 1 popultion. All clcultions re mde before numbers re rounded. 236 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

248 TABLE A4.3 Mesured percentge of TB cses with MDR/RR-TB, most recent yer vilble New TB cses Previously treted TB cses Yer Source Coverge Percentge Yer Source Coverge Percentge Afghnistn Albni 212 Surveillnce Ntionl 2.3 ( ) 212 Surveillnce Ntionl 6.7 (.17 32) Algeri 22 Survey Ntionl 1.4 ( ) 22 Survey Ntionl 9.1 ( 29) Americn Smo Andorr 216 Surveillnce Ntionl ( 84) 216 Surveillnce Ntionl ( ) Angol Anguill Antigu nd Brbud Argentin 25 Survey Ntionl 2.3 ( ) 25 Survey Ntionl 18 (9.5 27) Armeni 27 Survey Ntionl 11 (8. 14) 27 Survey Ntionl 47 (4 55) Arub Austrli 215 Surveillnce Ntionl 3.6 ( ) 215 Surveillnce Ntionl 24 (9.4 45) Austri 215 Surveillnce Ntionl 2.3 ( ) 216 Surveillnce Ntionl 18 (3.8 43) Azerbijn 213 Survey Ntionl 13 (1 16) 216 Surveillnce Ntionl 39 (37 42) Bhms 212 Surveillnce Ntionl 11 (2.4 29) 215 Surveillnce Ntionl 5 (1.3 99) Bhrin 216 Surveillnce Ntionl 2.3 ( ) 216 Surveillnce Ntionl 5 (1.3 99) Bngldesh 211 Survey Ntionl 1.6 ( ) 211 Survey Ntionl 29 (22 36) Brbdos 214 Surveillnce Ntionl ( 71) 214 Surveillnce Ntionl ( ) Belrus 216 Surveillnce Ntionl 38 (36 4) 216 Surveillnce Ntionl 72 (68 75) Belgium 215 Surveillnce Ntionl 1.6 ( ) 215 Surveillnce Ntionl 8.8 (1.9 24) Belize 213 Surveillnce Ntionl 1 (29 1) Benin 21 Survey Ntionl 1.2 ( 2.6) 216 Surveillnce Ntionl 6.6 (3.8 11) Bermud 216 Surveillnce Ntionl ( 84) 216 Surveillnce Ntionl ( ) Bhutn 216 Surveillnce Ntionl 11 (8.5 15) 216 Surveillnce Ntionl 18 (7.7 34) Bolivi (Plurintionl Stte of) 216 Surveillnce Ntionl 9.6 (7.2 12) Bonire, Sint Eusttius nd Sb 216 Surveillnce Ntionl ( 98) 216 Surveillnce Ntionl ( ) Bosni nd Herzegovin 216 Surveillnce Ntionl (.67) 216 Surveillnce Ntionl ( 6.8) Botswn 28 Survey Ntionl 3.6 ( ) 28 Survey Ntionl 13 (7.4 19) Brzil 28 Survey Sub-ntionl 1.5 ( ) 28 Survey Sub-ntionl 8 (5.1 11) British Virgin Islnds Brunei Drusslm 216 Surveillnce Ntionl ( 2.3) 216 Surveillnce Ntionl ( 52) Bulgri 216 Surveillnce Ntionl 1.2 ( ) 216 Surveillnce Ntionl 19 (11 29) Burkin Fso 217 Survey Ntionl 2.1 (1.2 3.) 217 Survey Ntionl 14 (8.5 2) Burundi Cbo Verde Cmbodi 27 Survey Ntionl 1.8 ( ) 27 Survey Ntionl 11 ( 23) Cmeroon Cnd 215 Surveillnce Ntionl.82 ( ) 215 Surveillnce Ntionl 6.3 (1.7 15) Cymn Islnds 216 Surveillnce Ntionl ( 71) 216 Surveillnce Ntionl ( ) Centrl Africn Republic 29 Survey Sub-ntionl.4 ( 1.6) Chd Chile 215 Surveillnce Ntionl 1.5 ( ) 215 Surveillnce Ntionl 5.6 (2.6 1) Chin 213 Survey Ntionl 7.1 ( ) 213 Survey Ntionl 24 (2 28) Chin, Hong Kong SAR 211 Surveillnce Ntionl 1.2 ( ) 211 Surveillnce Ntionl 3.4 ( ) Chin, Mco SAR 215 Surveillnce Ntionl 2.5 ( ) 215 Surveillnce Ntionl 16 (4.5 36) Colombi 25 Survey Ntionl 2.4 ( ) 212 Surveillnce Ntionl 14 (11 18) Comoros Congo Cook Islnds 216 Surveillnce Ntionl ( 84) 216 Surveillnce Ntionl ( ) Cost Ric 26 Survey Ntionl 1.9 ( 3.9) 212 Surveillnce Ntionl 9.1 (1.1 29) Côte d'ivoire 217 Survey Ntionl 4.6 ( ) 217 Survey Ntionl 22 (14 3) Croti 215 Surveillnce Ntionl ( 1.4) 216 Surveillnce Ntionl ( 37) Cub 212 Surveillnce Ntionl 2.2 ( ) 214 Surveillnce Ntionl 4.2 (.51 14) Curço 216 Surveillnce Ntionl ( 6) 216 Surveillnce Ntionl ( ) Cyprus 215 Surveillnce Ntionl ( 1) 215 Surveillnce Ntionl ( ) Czechi 215 Surveillnce Ntionl 2.2 (.9 4.6) 215 Surveillnce Ntionl 12 (2.4 3) Democrtic People's Republic of Kore 214 Survey Sub-ntionl 2.2 ( ) 214 Survey Sub-ntionl 16 (5.8 27) Democrtic Republic of the Congo 217 Survey Ntionl 2.2 (1. 3.5) 217 Survey Ntionl 17 (9.6 24) Denmrk 215 Surveillnce Ntionl 1.9 ( ) 215 Surveillnce Ntionl 4.5 (.12 23) Empty rows indicte n bsence of high-qulity survey or surveillnce dt. In the bsence of high-qulity ntionl dt, high-qulity sub-ntionl dt re used. Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

249 TABLE A4.3 Mesured percentge of TB cses with MDR/RR-TB, most recent yer vilble New TB cses Previously treted TB cses Yer Source Coverge Percentge Yer Source Coverge Percentge Djibouti 215 Survey Ntionl 4.3 ( ) 215 Survey Ntionl 35 (25 47) Dominic 213 Surveillnce Ntionl ( 98) 213 Surveillnce Ntionl ( ) Dominicn Republic 216 Surveillnce Ntionl 34 (28 41) Ecudor 22 Survey Ntionl 7.3 ( ) 212 Surveillnce Ntionl 28 (25 31) Egypt 211 Survey Ntionl 14 (12 16) 216 Surveillnce Ntionl 2 (17 24) El Slvdor 214 Surveillnce Ntionl 4.1 ( ) Equtoril Guine 216 Surveillnce Ntionl 29 (21 39) Eritre Estoni 216 Surveillnce Ntionl 14 (8.3 21) 216 Surveillnce Ntionl 54 (25 81) Ethiopi 25 Survey Ntionl 2.7 (1.5 4.) 25 Survey Ntionl 14 (3.6 25) Fiji 26 Surveillnce Ntionl ( 8.2) 26 Surveillnce Ntionl ( 98) Finlnd 216 Surveillnce Ntionl 1.6 ( ) 216 Surveillnce Ntionl ( 46) Frnce 214 Surveillnce Ntionl 1 ( ) 214 Surveillnce Ntionl 1 (7.1 15) French Polynesi 215 Surveillnce Ntionl ( 11) 215 Surveillnce Ntionl 5 (1.3 99) Gbon Gmbi Georgi 216 Surveillnce Ntionl 11 (9.3 12) 216 Surveillnce Ntionl 31 (27 35) Germny 215 Surveillnce Ntionl 2.2 ( ) 215 Surveillnce Ntionl 23 (16 3) Ghn 217 Survey Ntionl 1.5 (.7 2.3) 217 Survey Ntionl 7 (.6 13) Greece 21 Surveillnce Ntionl 1.5 (<.1 8.) 21 Surveillnce Ntionl 9.1 (.23 41) Greenlnd Grend Gum 216 Surveillnce Ntionl 4.9 (.6 17) 216 Surveillnce Ntionl ( ) Guteml 22 Survey Ntionl 4.2 ( ) 22 Survey Ntionl 29 (19 39) Guine Guine-Bissu Guyn 216 Surveillnce Ntionl 17 (8.2 3) Hiti Hondurs 24 Survey Ntionl 2.2 ( ) 24 Survey Ntionl 21 (9.2 32) Hungry 21 Surveillnce Ntionl 2.9 ( ) 21 Surveillnce Ntionl 8.1 (3.3 16) Icelnd 216 Surveillnce Ntionl ( 6) 216 Surveillnce Ntionl ( ) Indi 216 Survey Ntionl 2.8 (2. 3.5) 216 Survey Ntionl 12 (1 13) Indonesi 24, 26, 26, Multiple surveys 2.8 ( ) Multiple surveys 16 (1 2) Irn (Islmic Republic of) 214 Survey Ntionl 1.3 (.6 2.) 216 Surveillnce Ntionl 8.3 (5.9 11) Irq 213 Survey Ntionl 6.1 ( ) 213 Survey Ntionl 24 (14 34) Irelnd 215 Surveillnce Ntionl 1.1 (<.1 5.8) 215 Surveillnce Ntionl ( 31) Isrel 216 Surveillnce Ntionl 7.4 (3.5 14) 216 Surveillnce Ntionl ( 84) Itly 215 Surveillnce Ntionl 2.8 ( ) 215 Surveillnce Ntionl 13 (7.7 21) Jmic 213 Surveillnce Ntionl 1.7 (<.1 9.1) 213 Surveillnce Ntionl ( ) Jpn 22 Surveillnce Ntionl 1 ( ) 22 Surveillnce Ntionl 11 (8.2 14) Jordn 29 Surveillnce Ntionl 6.3 (2.4 13) 29 Surveillnce Ntionl 29 (3.7 71) Kzkhstn 215 Surveillnce Ntionl 26 (25 28) 215 Surveillnce Ntionl 44 (42 46) Keny 214 Survey Ntionl 1.3 ( ) 214 Surveillnce Ntionl 9.4 (8.7 1) Kiribti Kuwit 216 Surveillnce Ntionl 2.7 ( ) 216 Surveillnce Ntionl ( ) Kyrgyzstn 216 Surveillnce Ntionl 27 (25 29) 216 Surveillnce Ntionl 6 (57 63) Lo People's Democrtic Republic 216 Surveillnce Ntionl 12 (7.2 19) Ltvi 216 Surveillnce Ntionl 7.6 (5.2 11) 216 Surveillnce Ntionl 23 (15 33) Lebnon 23 Survey Ntionl 2.6 ( 5.4) 213 Surveillnce Ntionl 43 (9.9 82) Lesotho 214 Survey Ntionl 4.8 ( ) 214 Survey Ntionl 14 (9.2 18) Liberi Liby Lithuni 215 Surveillnce Ntionl 12 (1 15) 215 Surveillnce Ntionl 47 (41 53) Luxembourg 214 Surveillnce Ntionl ( ) 214 Surveillnce Ntionl ( ) Mdgscr 27 Survey Ntionl.49 ( 1.1) 27 Survey Ntionl 5.9 ( 15) Mlwi 211 Survey Ntionl.75 ( 1.6) 211 Survey Ntionl 6.4 ( ) Mlysi 214 Surveillnce Ntionl 1.5 ( ) 214 Surveillnce Ntionl 3.1 ( ) Mldives 216 Surveillnce Ntionl 1.7 (<.1 9.1) 216 Surveillnce Ntionl ( ) Empty rows indicte n bsence of high-qulity survey or surveillnce dt. In the bsence of high-qulity ntionl dt, high-qulity sub-ntionl dt re used. 238 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

250 TABLE A4.3 Mesured percentge of TB cses with MDR/RR-TB, most recent yer vilble New TB cses Previously treted TB cses Yer Source Coverge Percentge Yer Source Coverge Percentge Mli Mlt 216 Surveillnce Ntionl ( 11) 216 Surveillnce Ntionl ( ) Mrshll Islnds 214 Surveillnce Ntionl ( 4.4) 215 Surveillnce Ntionl ( 41) Muritni Muritius 216 Surveillnce Ntionl 2.7 ( ) 216 Surveillnce Ntionl ( 71) Mexico 29 Survey Ntionl 2.6 ( ) 29 Survey Ntionl 11 (9. 13) Micronesi (Federted Sttes of) Monco Mongoli 216 Survey Ntionl 5.6 ( ) 216 Survey Ntionl 18 (14 22) Montenegro 216 Surveillnce Ntionl ( 7.1) 216 Surveillnce Ntionl ( 41) Montserrt Morocco 214 Survey Ntionl 1 (.3 1.7) 216 Surveillnce Ntionl 11 (9.5 12) Mozmbique 27 Survey Ntionl 3.7 (2.4 5.) 27 Survey Ntionl 2 (2.1 37) Mynmr 213 Survey Ntionl 5.1 (3.2 7.) 213 Survey Ntionl 27 (1 44) Nmibi 215 Survey Ntionl 5 ( ) 215 Survey Ntionl 12 (8.7 15) Nuru Nepl 211 Survey Ntionl 2.2 ( ) 211 Survey Ntionl 15 (6.7 24) Netherlnds 216 Surveillnce Ntionl 2 ( ) 216 Surveillnce Ntionl 3 (6.7 65) New Cledoni 216 Surveillnce Ntionl ( 14) 216 Surveillnce Ntionl ( 98) New Zelnd 214 Surveillnce Ntionl 2.6 (.7 6.4) 214 Surveillnce Ntionl 2 (.51 72) Nicrgu 26 Survey Ntionl.94 ( 2.3) 21 Surveillnce Ntionl 12 (7.3 18) Niger Nigeri 21 Survey Ntionl 4.3 ( ) 21 Survey Ntionl 25 (19 31) Niue Northern Mrin Islnds 216 Surveillnce Ntionl ( 21) 216 Surveillnce Ntionl ( ) Norwy 215 Surveillnce Ntionl 2.6 (.7 6.4) 215 Surveillnce Ntionl 5.9 (.15 29) Omn 216 Surveillnce Ntionl 1.9 ( ) 216 Surveillnce Ntionl ( ) Pkistn 213 Survey Ntionl 4.2 ( ) 215 Surveillnce Ntionl 16 (15 17) Plu 216 Surveillnce Ntionl ( 2) 216 Surveillnce Ntionl ( ) Pnm 216 Surveillnce Ntionl 17 (8.9 29) Ppu New Guine 214 Survey Sub-ntionl 3.4 (1.7 5.) 214 Survey Sub-ntionl 26 (15 36) Prguy 28 Survey Ntionl.9 ( 2.2) 28 Survey Ntionl 15 ( 3) Peru 216 Surveillnce Ntionl 6.3 ( ) 216 Surveillnce Ntionl 24 (23 26) Philippines 212 Survey Ntionl 2.6 ( ) 212 Survey Ntionl 29 (2 38) Polnd 216 Surveillnce Ntionl.83 ( ) 216 Surveillnce Ntionl 4.4 ( ) Portugl 212 Surveillnce Ntionl.98 ( ) 212 Surveillnce Ntionl 6.9 (2.8 14) Puerto Rico 216 Surveillnce Ntionl ( 9.) 216 Surveillnce Ntionl 1 (2.5 1) Qtr 214 Surveillnce Ntionl 1.3 ( ) Republic of Kore 216 Surveillnce Ntionl 3.4 ( ) 216 Surveillnce Ntionl 11 (9.4 12) Republic of Moldov 216 Surveillnce Ntionl 26 (24 28) 216 Surveillnce Ntionl 56 (51 6) Romni 216 Surveillnce Ntionl 2.8 ( ) 216 Surveillnce Ntionl 17 (16 19) Russin Federtion 216 Surveillnce Ntionl 27 (27 28) 216 Surveillnce Ntionl 65 (65 66) Rwnd 215 Survey Ntionl 1.5 ( ) 216 Surveillnce Ntionl 5.1 ( ) Sint Kitts nd Nevis Sint Luci 213 Surveillnce Ntionl ( 52) 213 Surveillnce Ntionl ( ) Sint Vincent nd the Grendines 213 Surveillnce Ntionl 5 (1.3 99) 214 Surveillnce Ntionl ( 98) Smo 216 Surveillnce Ntionl 13 (.32 53) 216 Surveillnce Ntionl ( ) Sn Mrino So Tome nd Principe 212 Surveillnce Ntionl 88 (47 1) Sudi Arbi 21 Survey Ntionl 2.6 (2. 3.2) 21 Survey Ntionl 2 (14 26) Senegl 214 Survey Ntionl.9 ( ) 214 Survey Ntionl 19 (9.6 27) Serbi 213 Surveillnce Ntionl 1.1 ( ) 213 Surveillnce Ntionl 4.7 (1.3 11) Seychelles 216 Surveillnce Ntionl ( 52) 216 Surveillnce Ntionl ( 98) Sierr Leone Singpore 216 Surveillnce Ntionl 1.4 ( ) 216 Surveillnce Ntionl 2.3 ( ) Sint Mrten (Dutch prt) Slovki 212 Surveillnce Ntionl ( 2.6) 212 Surveillnce Ntionl 3.7 (<.1 19) Sloveni 216 Surveillnce Ntionl ( 3.9) 216 Surveillnce Ntionl ( 71) Solomon Islnds 213 Surveillnce Ntionl ( 41) Empty rows indicte n bsence of high-qulity survey or surveillnce dt. In the bsence of high-qulity ntionl dt, high-qulity sub-ntionl dt re used. Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

251 TABLE A4.3 Mesured percentge of TB cses with MDR/RR-TB, most recent yer vilble New TB cses Previously treted TB cses Yer Source Coverge Percentge Yer Source Coverge Percentge Somli 211 Survey Ntionl 8.7 (5.9 11) 211 Survey Ntionl 47 (23 71) South Afric 214 Survey Ntionl 3.4 ( ) 214 Survey Ntionl 7.1 ( ) South Sudn Spin 215 Surveillnce Ntionl 4.2 ( ) 215 Surveillnce Ntionl 18 (9.4 3) Sri Lnk 26 Survey Ntionl.54 ( 1.3) 216 Surveillnce Ntionl 3.1 ( ) Sudn 217 Survey Ntionl 2.9 ( ) 217 Survey Ntionl 13 (8.6 17) Surinme 216 Surveillnce Ntionl 6.1 (1.7 15) 216 Surveillnce Ntionl ( 41) Swzilnd 29 Survey Ntionl 8 (3.1 13) 29 Survey Ntionl 36 (29 44) Sweden 215 Surveillnce Ntionl 4 ( ) 216 Surveillnce Ntionl 16 (3.4 4) Switzerlnd 215 Surveillnce Ntionl 3.2 ( ) 215 Surveillnce Ntionl 26 (9.1 51) Syrin Arb Republic 23 Survey Ntionl 8 (4.9 11) 216 Surveillnce Ntionl 24 (16 35) Tjikistn 216 Surveillnce Ntionl 22 (21 24) 216 Surveillnce Ntionl 45 (4 5) Thilnd 212 Survey Ntionl 2.2 ( ) 212 Survey Ntionl 24 (16 32) The Former Yugoslv Republic of Mcedoni 216 Surveillnce Ntionl 1.3 ( ) 216 Surveillnce Ntionl ( 23) Timor-Leste Togo 216 Surveillnce Ntionl 5.4 ( ) Tokelu Tong Trinidd nd Tobgo Tunisi 216 Surveillnce Ntionl.93 ( ) 216 Surveillnce Ntionl 4.2 (.88 12) Turkey 216 Surveillnce Ntionl 2.9 ( ) 216 Surveillnce Ntionl 16 (13 19) Turkmenistn 213 Survey Ntionl 14 (11 17) 213 Survey Ntionl 38 (28 49) Turks nd Cicos Islnds Tuvlu Ugnd 211 Survey Ntionl 1.6 ( ) 211 Survey Ntionl 12 (3.4 21) Ukrine 216 Surveillnce Ntionl 27 (26 27) 216 Surveillnce Ntionl 47 (46 48) United Arb Emirtes 213 Surveillnce Ntionl ( 52) United Kingdom of Gret Britin nd Northern Irelnd 215 Surveillnce Ntionl 1.4 (.98 2.) 215 Surveillnce Ntionl 3.4 ( ) United Republic of Tnzni 27 Survey Ntionl 1.3 ( ) 216 Surveillnce Ntionl 6.2 ( ) United Sttes of Americ 216 Surveillnce Ntionl 1.5 ( ) 216 Surveillnce Ntionl 5.6 ( ) Uruguy 216 Surveillnce Ntionl (.69) 216 Surveillnce Ntionl 6 (1.3 17) US Virgin Islnds Uzbekistn 211 Survey Ntionl 24 (18 3) 211 Survey Ntionl 63 (5 75) Vnutu 26 Surveillnce Ntionl ( 12) Venezuel (Bolivrin Republic of) Viet Nm 212 Survey Ntionl 4.1 ( ) 216 Surveillnce Ntionl 26 (25 27) Wllis nd Futun Islnds West Bnk nd Gz Strip Yemen 211 Survey Ntionl 2.3 ( ) 211 Survey Ntionl 18 (8.7 28) Zmbi 28 Survey Ntionl 1.1 ( ) 28 Survey Ntionl 18 (12 25) Zimbbwe 216 Survey Ntionl 4.6 (3. 6.2) 216 Survey Ntionl 14 (8.9 2) Empty rows indicte n bsence of high-qulity survey or surveillnce dt. In the bsence of high-qulity ntionl dt, high-qulity sub-ntionl dt re used. 24 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

252 TABLE A4.4 TB cse notifictions, 216 Totl cses notified Notified % tested with rpid dignostics t time of dignosis New nd relpse cses % with known HIV sttus % pulmonry % bcteriologiclly confirmed mong pulmonry Afghnistn Albni Algeri Americn Smo Andorr Angol Anguill Antigu nd Brbud * 1 67 Argentin Armeni Arub Austrli Austri Azerbijn * 8 61 Bhms Bhrin Bngldesh Brbdos * 1 1 Belrus Belgium Belize Benin * 9 91 Bermud Bhutn Bolivi (Plurintionl Stte of) * Bonire, Sint Eusttius nd Sb Bosni nd Herzegovin Botswn Brzil British Virgin Islnds Brunei Drusslm Bulgri Burkin Fso Burundi * Cbo Verde * 9 85 Cmbodi Cmeroon Cnd Cymn Islnds Centrl Africn Republic * Chd * Chile Chin Chin, Hong Kong SAR Chin, Mco SAR Colombi * 83 8 Comoros * Congo Cook Islnds * 1 1 Cost Ric Côte d'ivoire * Croti Cub Curço Cyprus Czechi * Democrtic People's Republic of Kore Democrtic Republic of the Congo * Denmrk * Includes cses for which the tretment history is unknown. Among ll notified cses, not just new nd relpse cses. Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

253 TABLE A4.4 TB cse notifictions, 216 Totl cses notified Notified % tested with rpid dignostics t time of dignosis New nd relpse cses % with known HIV sttus % pulmonry % bcteriologiclly confirmed mong pulmonry Djibouti * Dominic Dominicn Republic Ecudor Egypt * El Slvdor Equtoril Guine Eritre Estoni Ethiopi * Fiji Finlnd * 75 8 Frnce * 71 7 French Polynesi Gbon Gmbi * Georgi Germny Ghn * Greece Greenlnd Grend Gum * 96 6 Guteml Guine Guine-Bissu * Guyn Hiti * 9 8 Hondurs Hungry Icelnd Indi Indonesi < Irn (Islmic Republic of) * Irq Irelnd Isrel Itly Jmic Jpn Jordn Kzkhstn Keny Kiribti * Kuwit Kyrgyzstn Lo People's Democrtic Republic * Ltvi Lebnon Lesotho * Liberi Liby Lithuni Luxembourg Mdgscr * Mlwi * Mlysi Mldives * 46 1 Mli * Includes cses for which the tretment history is unknown. Among ll notified cses, not just new nd relpse cses. 242 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

254 TABLE A4.4 TB cse notifictions, 216 Totl cses notified Notified % tested with rpid dignostics t time of dignosis New nd relpse cses % with known HIV sttus % pulmonry % bcteriologiclly confirmed mong pulmonry Mlt Mrshll Islnds * Muritni Muritius Mexico Micronesi (Federted Sttes of) * Monco Mongoli Montenegro Montserrt Morocco Mozmbique * 9 45 Mynmr * Nmibi * 82 8 Nuru Nepl * Netherlnds New Cledoni New Zelnd Nicrgu Niger * Nigeri * Niue Northern Mrin Islnds Norwy Omn Pkistn * 8 48 Plu Pnm Ppu New Guine * Prguy Peru * 8 82 Philippines Polnd Portugl * Puerto Rico Qtr Republic of Kore Republic of Moldov Romni * Russin Federtion Rwnd Sint Kitts nd Nevis Sint Luci Sint Vincent nd the Grendines 7 6 >1 1 1 Smo Sn Mrino So Tome nd Principe Sudi Arbi Senegl Serbi Serbi (without Kosovo) Kosovo Seychelles Sierr Leone Singpore * Sint Mrten (Dutch prt) Slovki Sloveni * Includes cses for which the tretment history is unknown. Among ll notified cses, not just new nd relpse cses. Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

255 TABLE A4.4 TB cse notifictions, 216 Totl cses notified Notified % tested with rpid dignostics t time of dignosis New nd relpse cses % with known HIV sttus % pulmonry % bcteriologiclly confirmed mong pulmonry Solomon Islnds * Somli South Afric South Sudn Spin Sri Lnk * 7 71 Sudn * Surinme Swzilnd * Sweden Switzerlnd Syrin Arb Republic Tjikistn * Thilnd * 84 6 The Former Yugoslv Republic of Mcedoni Timor-Leste Togo * Tokelu Tong Trinidd nd Tobgo Tunisi * 4 81 Turkey Turkmenistn Turks nd Cicos Islnds Tuvlu * 8 88 Ugnd * Ukrine United Arb Emirtes United Kingdom of Gret Britin nd Northern Irelnd United Republic of Tnzni * United Sttes of Americ Uruguy US Virgin Islnds Uzbekistn * Vnutu Venezuel (Bolivrin Republic of) Viet Nm Wllis nd Futun Islnds West Bnk nd Gz Strip Yemen Zmbi * 82 5 Zimbbwe * WHO regions Africn Region Region of the Americs Estern Mediterrnen Region Europen Region South-Est Asi Region Western Pcific Region Globl * Includes cses for which the tretment history is unknown. Among ll notified cses, not just new nd relpse cses. 244 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

256 TABLE A4.5 Tretment outcomes by TB cse type, 215 nd tretment outcomes for MDR/RR-TB nd XDR-TB cses, 214 New nd relpse, 215 cohort Previously treted, excluding relpse, 215 cohort HIV-positive TB, 215 cohort MDR/RR-TB, 214 cohort XDR-TB, 214 cohort Cohort (Number) Success (%) Cohort (Number) Success (%) Cohort (Number) Success (%) Afghnistn Albni Algeri Cohort (Number) Success (%) Cohort (Number) Success (%) Americn Smo Andorr 4 1 Angol Anguill Antigu nd Brbud* 2 5 Argentin Armeni Arub Austrli Austri Azerbijn* Bhms Bhrin Bngldesh Brbdos Belrus Belgium Belize Benin Bermud Bhutn Bolivi (Plurintionl Stte of) Bonire, Sint Eusttius nd Sb Bosni nd Herzegovin Botswn Brzil British Virgin Islnds* Brunei Drusslm Bulgri Burkin Fso Burundi Cbo Verde Cmbodi Cmeroon Cnd Cymn Islnds 7 1 Centrl Africn Republic Chd Chile Chin Chin, Hong Kong SAR Chin, Mco SAR Colombi Comoros Congo Cook Islnds* Cost Ric Côte d'ivoire Croti Cub Curço Cyprus Czechi Democrtic People's Republic of Kore Democrtic Republic of the Congo* * Relpses included in the previously treted cohort. Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

257 TABLE A4.5 Tretment outcomes by TB cse type, 215 nd tretment outcomes for MDR/RR-TB nd XDR-TB cses, 214 New nd relpse, 215 cohort Previously treted, excluding relpse, 215 cohort HIV-positive TB, 215 cohort MDR/RR-TB, 214 cohort XDR-TB, 214 cohort Cohort (Number) Success (%) Cohort (Number) Success (%) Cohort (Number) Success (%) Cohort (Number) Success (%) Cohort (Number) Denmrk Djibouti* Dominic 8 88 Dominicn Republic Ecudor Success (%) Egypt El Slvdor Equtoril Guine Eritre Estoni Ethiopi* Fiji Finlnd Frnce French Polynesi Gbon Gmbi* Georgi Germny Ghn Greece Greenlnd Grend 5 8 Gum Guteml Guine Guine-Bissu Guyn Hiti Hondurs Hungry Icelnd 7 1 Indi Indonesi Irn (Islmic Republic of) Irq Irelnd Isrel Itly Jmic Jpn Jordn Kzkhstn Keny Kiribti Kuwit Kyrgyzstn Lo People's Democrtic Republic Ltvi Lebnon Lesotho Liberi Liby Lithuni Luxembourg Mdgscr* Mlwi Mlysi * Relpses included in the previously treted cohort. 246 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

258 TABLE A4.5 Tretment outcomes by TB cse type, 215 nd tretment outcomes for MDR/RR-TB nd XDR-TB cses, 214 New nd relpse, 215 cohort Previously treted, excluding relpse, 215 cohort HIV-positive TB, 215 cohort MDR/RR-TB, 214 cohort XDR-TB, 214 cohort Cohort (Number) Success (%) Cohort (Number) Success (%) Cohort (Number) Success (%) Cohort (Number) Success (%) Cohort (Number) Mldives Mli Success (%) Mlt Mrshll Islnds Muritni Muritius Mexico Micronesi (Federted Sttes of) Monco Mongoli Montenegro Montserrt Morocco Mozmbique Mynmr Nmibi Nuru 9 89 Nepl Netherlnds New Cledoni New Zelnd Nicrgu Niger Nigeri Niue Northern Mrin Islnds 27 1 Norwy Omn Pkistn Plu Pnm Ppu New Guine* Prguy Peru* Philippines Polnd Portugl Puerto Rico* Qtr Republic of Kore Republic of Moldov Romni Russin Federtion Rwnd Sint Kitts nd Nevis 1 1 Sint Luci Sint Vincent nd the Grendines Smo Sn Mrino So Tome nd Principe Sudi Arbi Senegl Serbi Seychelles 8 88 Sierr Leone* Singpore Sint Mrten (Dutch prt) 2 1 Slovki * Relpses included in the previously treted cohort. Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

259 TABLE A4.5 Tretment outcomes by TB cse type, 215 nd tretment outcomes for MDR/RR-TB nd XDR-TB cses, 214 New nd relpse, 215 cohort Previously treted, excluding relpse, 215 cohort HIV-positive TB, 215 cohort MDR/RR-TB, 214 cohort XDR-TB, 214 cohort Cohort (Number) Success (%) Cohort (Number) Success (%) Cohort (Number) Sloveni Success (%) Cohort (Number) Success (%) Cohort (Number) Solomon Islnds Somli Success (%) South Afric South Sudn* Spin Sri Lnk Sudn* Surinme Swzilnd Sweden Switzerlnd Syrin Arb Republic Tjikistn Thilnd The Former Yugoslv Republic of Mcedoni Timor-Leste Togo* Tokelu Tong Trinidd nd Tobgo Tunisi Turkey Turkmenistn Turks nd Cicos Islnds* Tuvlu Ugnd Ukrine United Arb Emirtes United Kingdom of Gret Britin nd Northern Irelnd United Republic of Tnzni United Sttes of Americ Uruguy US Virgin Islnds Uzbekistn Vnutu Venezuel (Bolivrin Republic of) Viet Nm Wllis nd Futun Islnds* West Bnk nd Gz Strip Yemen Zmbi Zimbbwe WHO regions Africn Region Region of the Americs Estern Mediterrnen Region Europen Region South-Est Asi Region Western Pcific Region Globl * Relpses included in the previously treted cohort. 248 GLOBAL TUBERCULOSIS REPORT 217 Dt for ll countries nd yers cn be downloded from

260 TABLE A4.6 Collbortive TB/HIV ctivities in 3 high TB/HIV burden countries, for WHO regions nd globlly, 216 Number % s % of notified TB ptients with known HIV sttus s % of notified HIVpositive TB ptients % provided with TB preventive tretment Angol 18 (8.5 3) (9.2 33) 17 Botswn 4.4 ( ) (47 79) (38 64) Brzil 11 (9.1 13) (58 81) (24 34) Cmeroon 16 (1 24) (35 8) (32 73) Centrl Africn Republic 6.2 ( ) (21 61) (16 47) Chd 2.8 (1.8 4.) (41 92) Chin 11 (6.9 15) (3 67) (27 59) 2.7 Congo 5.1 ( ) (6.2 2) ( ) Democrtic Republic of the Congo 2 (13 29) (29 63) (21 47) Ethiopi 14 (9.6 19) (42 82) 88 5 (37 72) Ghn 1 (4.7 17) (16 6) (7. 26) Guine-Bissu 2.2 ( ) (16 37) (7.8 18) Indi 87 (56 125) (32 7) (31 69) Indonesi 45 (21 78) (5.6 21) ( ) Keny 53 (32 79) (29 71) (28 68) Lesotho 12 (7.3 17) (3 68) (25 58) Liberi 2.2 ( ) (26 59) (12 28) Mlwi 15 (9.9 22) (39 87) (38 84) Mozmbique 72 (46 14) (3 67) 94 4 (28 64) 52 Mynmr 18 (13 24) (46 83) (27 48) Nmibi 4.2 (2.7 6.) (56 >1) (53 >1) Nigeri 63 (4 93) (16 37) (13 3) Ppu New Guine 3.6 (2. 5.5) (13 35) (12 32) 9.2 South Afric 258 ( ) (38 77) (34 68) 51 Swzilnd 3.8 ( ) (49 >1) (46 >1) Thilnd 1 (6.1 16) (43 >1) (28 74) 14 Ugnd 35 (2 54) (34 89) 9 46 (3 8) 7.5 United Republic of Tnzni 54 (35 78) (28 62) (25 56) 8.5 Zmbi 36 (23 52) (42 93) 83 5 (35 77) Zimbbwe 23 (15 32) (57 >1) 86 7 (49 >1) WHO regions Estimted HIVpositive incident TB cses Number (thousnds) Notified TB ptients with known HIV sttus HIV-positve TB ptients s % of estimted HIV-positive incident TB cses HIV-positive TB ptients on ntiretrovirl therpy (ART) s % of estimted HIV-positive incident TB cses Of people newly enrolled in HIV cre Africn Region 764 (66 876) (41 54) (35 47) Region of the Americs 3 (28 33) (63 74) (39 45) Estern Mediterrnen Region 9.9 (5.9 15) (9.3 23) (4.8 12) Europen Region 34 (26 42) (61 98) 66 5 (4 64) South-Est Asi Region 163 (12 211) (3 52) (24 43) Western Pcific Region 29 (23 36) (32 5) (26 4) Globl 1 3 ( ) (42 52) (35 44) % notified s TB cse For new nd relpse cses only, lthough some countries report on ll cses. Dt for ll countries nd yers cn be downloded from GLOBAL TUBERCULOSIS REPORT

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262 MR ws here Levenoonebehind ISBN ENDTB