GLOBAL REPORT TUBERCULOSIS

Transcription

1 GLOBAL REPORT TUBERCULOSIS 216

2 GLOBAL TUBERCULOSIS REPORT :: 216

3 WHO Librry Ctloguing-in-Publiction Dt Globl tuberculosis report Tuberculosis - epidemiology. 2.Tuberculosis, Pulmonry prevention nd control. 3.Tuberculosis economics. 4.Tuberculosis, Multidrug-Resistnt. 5.Annul Reports. I.World Helth Orgniztion. ISBN (NLM clssifiction: WF 3) World Helth Orgniztion 216 All rights reserved. Publictions of the World Helth Orgniztion re vilble on the WHO website ( or cn be purchsed from WHO Press, World Helth Orgniztion, 2 Avenue Appi, 1211 Genev 27, Switzerlnd (tel.: ; fx: ; emil: bookorders@who.int). Requests for permission to reproduce or trnslte WHO publictions whether for sle or for non-commercil distribution should be ddressed to WHO Press through the WHO website ( html). 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 the World Helth Orgniztion 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 the World Helth Orgniztion 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 the World Helth Orgniztion 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 the World Helth Orgniztion be lible for dmges rising from its use. Designed by minimum grphics Cover designed by Irwin Lw Printed in Switzerlnd WHO/HTM/TB/216.13

4 :: Contents Abbrevitions Acknowledgements Executive summry 1 Chpter 1. Introduction 5 Chpter 2. A new er of globl TB monitoring 6 Chpter 3. TB disese burden 15 Chpter 4. Dignosis nd tretment: TB, HIV-ssocited TB nd drug-resistnt TB 54 Chpter 5. TB prevention services 82 Chpter 6. Universl helth coverge, socil protection nd ddressing socil determinnts: Implictions for TB 9 Chpter 7. TB finncing 18 Chpter 8. TB reserch nd development 122 iv v Annexes 1. Access to the WHO globl TB dtbse Country profiles for 3 high TB burden countries Regionl profiles for 6 WHO regions TB burden estimtes, notifictions nd tretment outcomes for individul countries nd territories, WHO regions nd the world 179 GLOBAL TUBERCULOSIS REPORT 216 :: iii

5 :: Abbrevitions DSM AE AIDS ART ATP BCG BRICS CC CFR CHOICE CI CRS DST EQA FIND GAF GDP GHE GIS Globl Fund GTB HBC HIV IGRA IHME LAMP LPA LTBI MDG MDR ctive TB drug-sfety monitoring nd mngement dverse event cquired immunodeficiency syndrome ntiretrovirl therpy denosine triphosphte Bcille-Clmette-Guérin Brzil, the Russin Federtion, Indi, Chin, South Afric criticl concentrtion cse ftlity rtio CHOosing Interventions tht re Cost- Effective (WHO) confidence intervl creditor reporting system drug susceptibility testing externl qulity ssessment Foundtion for Innovtive New Dignostics Globl Action Frmework for TB Reserch gross domestic product government helth expenditures geogrphic informtion system The Globl Fund to Fight AIDS, TB nd Mlri Globl TB Progrmme high burden country humn immune-deficiency virus interferon gmm relese ssys Institute of Helth Metrics nd Evlution loop-medited isotherml mplifiction line probe ssy ltent TB infection Millennium Development Gol multidrug-resistnt MDR/RR-TB RR-TB cses including MDR-TB cses M:F MSF NGO mle to femle (rtio) Médecins Sns Frontières nongovernmentl orgniztion NHI NTP OBR OECD OOP PAF PMDT POC P:N PPM RR SAE SDG SHA SNP SRL SSI STD TB TBTC TBVI TDR TNF TST UCS UHC UN UNAIDS US USAID VR WHO WRD XDR-TB ntionl helth insurnce ntionl TB progrmme optimized bckground regimen Orgnistion for Economic Co-opertion nd Development out-of-pocket popultion ttributble frction progrmmtic mngement of drugresistnt TB point-of-cre prevlence to notifiction (rtio) public privte mix rifmpicin-resistnt serious dverse event Sustinble Development Gol System of helth ccounts single nucleotide polymorphism Suprntionl Reference Lbortory Sttens Serum Institute sexully trnsmitted disese tuberculosis TB Tril Consortium Tuberculosis Vccine Inititive Specil Progrmme for Reserch nd Trining in Tropicl Diseses tumour necrosis fctor tuberculin skin test Universl Coverge Scheme (Viet Nm) universl helth coverge United Ntions Joint United Ntions Progrmme on HIV/ AIDS United Sttes US Agency for Interntionl Development vitl registrtion World Helth Orgniztion WHO-recommended rpid dignostic extensively drug-resistnt TB iv :: GLOBAL TUBERCULOSIS REPORT 216

6 :: Acknowledgements This globl TB report ws produced by core tem of 18 people: Lur Anderson, Hnnh Monic Dis, Dennis Flzon, Ktherine Floyd, Inés Grci Ben, Christopher Gilpin, Philippe Glziou, Yohhei Hmd, Avinsh Knchr, Irwin Lw, Christin Lienhrdt, Andrew Sirok, Chrlmbos Sismnidis, Ln Syed, 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 WHO 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 Ann Den, Hnnh Monic Dis, Dennis Flzon, Inés Grcí Ben, Mede Gegi, Yohhei Hmd, Avinsh Knchr, Andre Pntoj, Linh Nguyen, Andrew Sirok, Ln Syed, 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 followup nd vlidtion of dt for ll Europen countries. Victori Bendud, Josephine Dy nd Tvi Erkkol from 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 Victori Bendud from UNAIDS, long with UNAIDS regionl nd country strtegic informtion dvisers. Mny people contributed to the nlyses, preprtion of figures nd tbles, nd writing required for the min chpters of the report. Chpter 1 (Introduction) nd Chpter 2 (A new er of globl TB monitoring) were prepred by Ktherine Floyd. Chpter 3 (TB disese burden) ws prepred by Ktherine Floyd, Philippe Glziou, Irwin Lw, Chrlmbos Sismnidis nd Mtteo Zignol, with contributions from Lur Anderson, Ann Den, Peter Dodd nd Helen Jenkins. 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 nd the preprtion of figures nd tbles ws led by Hzim Timimi; other chpter contributors included Hnnh Monic Dis, Ktherine Floyd, Yohhei Hmd, Avinsh Knchr, Knut Lönnroth, Ln Syed nd Mukund Uplekr. Chpter 5 (TB prevention services) ws prepred by Yohhei Hmd, Avinsh Knchr nd Hileyesus Gethun, with contributions from Ktherine Floyd nd Philippe Glziou. The production of Chpter 6 (Universl helth coverge, socil protection nd socil determinnts) ws led by Din Weil, with contributions from Amy Collins, Jhnvi Curlin, Inés Grci Ben, Corneli Hennig, Knut Lönnroth, Andrew Sirok, Szbolcs Szigeti, Mukund Uplekr nd Mrtin vn den Boom. Chpter 7 (TB finncing) ws prepred by Ktherine Floyd, Inés Grci Ben nd Andrew Sirok. Chpter 8 (TB reserch nd development) ws prepred by Christin Lienhrdt (new TB drugs nd new TB vccines) nd Christopher Gilpin (new TB dignostics), with input from Ktherine Floyd, Nebit Gebreselssie nd Krin Weyer. 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 Cherise Scott nd Mel Spigelmn (new TB drugs) nd Jonthn Dniels (new TB vccines) for their reviews of nd input to Chpter 8. Annex 1, which explins how to use the online 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. The online technicl ppendix tht explins the methods used to estimte the burden of disese cused by TB ws prepred by Philippe Glziou, Chrlmbos Sismnidis nd Mtteo Zignol. We thnk Colin Mthers nd Dniel Hogn of the WHO Mortlity nd Burden of Disese tem for their creful review. 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 TB mortlity dt extrcted from the WHO Mortlity Dtbse, nd Julin Dher nd Mry Mhy (UNAIDS) for providing epidemiologicl dt tht were used to estimte HIV-ssocited TB mortlity. The entire report ws edited by Hilry Cdmn, who we thnk for her excellent work. We lso thnk, s usul, Sue Hobbs for her excellent work on the design nd lyout of this report. Her contribution, s lwys, ws very highly pprecited. GLOBAL TUBERCULOSIS REPORT 216 :: v

7 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 Smih Bghddi, Hendrik Bekedm, Mirth Del Grndo, Khurshid Alm Hyder, Dniel Kibug, Rfel López Olrte, André Ndongosieme, Nobu Nishikiori, Mrtini Oktvis, Kefs Smson, Krm Shh, Achuthn Nir Sreenivs, Ann Volz, Lungten Wngchuk nd Henriette Wembnym for their mjor 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, Smuel Herms Andrinriso, Jvier Armburu, Augusto D Cruz Cludin, Ayodele Awe, Nyé Bh, Mrie Ctherine Broun, Bbou Bzie, Sirimn Cmr, Mlng Coly, Dvi Kokou Mwule, Ev De Crvlho, Noel Djemdji, Sithembile Dlmini-Nqeketo, Ismel Hssen Endris, Louis Gnd, Boingotlo Gsennelwe, Crolin Crdoso d Silv Gomes, Ptrick Hzngwe, Corneli Hennig, Télesphore Hounsou, Jen Irgen, Moses Jeuronlon, Michel Jose, Joel Kngngi, Kss Hilu, Nzuzi Ktondi, Khelifi Houri, Dniel Kibug, Hillry Kipruto, Aristide Désiré Komngoy Nzonzo, Ktherine Lo, Shrmil Lreef-Jh, Mwendweli Mboshe, Leonrd Mbemb, Mbumb Ngimbi Richrd, Julie Mugbekzi, Christine Musnhu, Ahmd NssuriI, Andre 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, Klpesh Rhevr, Richrd Oleko Rehn, Kefs Smson, Bbtunde Snni, Simkoko Neem Gideon, Susn Zimb-Tembo, Trore Tieble, Dest Tiruneh, Hubert Wng, Henriette Wembnym, Addislem Yilm, Assefsh Zehie. WHO Region of the Americs Jen Seme Fils Alexndre, Monic Alonso Gonzlez, Angel Mnuel Alvrez, Miguel Angel Argón, Denise Arkki, Pedro Avedillo, Crlos Ayl, Eldonn Boisson, Gustvo Brets, Mrgrette Bury, Dvid Chvrri, Betriz Cohenc, Mirth Del Grndo, This dos Sntos, Mrcos Espinl, Ingrid Grcí, Yitdes Gebre, Mssimo Ghidinelli, Guillermo Gonzlvez, Percy Hlkyer, Frnklin Hernndez, Kthryn Vogel Johnston, Sndr Jones, Frncisco Leon Brvo, Rfel Lopez Olrte, Fbio Moherdui, Roberto Montoy, Romeo Montoy, Alin Perez, Enrique Perez, Soledd Pérez, Giovnni Rvsi, Kti Romero, Jen Mrie Rwngbwob, Hns Sls, Alb Lidi Sánchez, Alfonso Tenorio, Jorge Victori, Mrcelo Vil, Ann Volz. WHO Estern Mediterrnen Region Mohmed Abdel Aziz, Rehb Abdelhi, Ali Akbr, Smih Bghddi, Mi Eltigny Mohmmed, Qutbuddin Kkr, Ali Rez Aloudel, Sindni Ireneus Sebit, Syed Krm Shh, Bshir Suleimn, Rhim Tghizdeh. WHO Europen Region Andrei Ddu, Msoud Dr, Jmshid Gdoev, Sliy Krymbev, Vlintsin Rusovich, Bogdn Shcherbk-Verln, Szbolcs Szigeti, Gzmend Zhuri. WHO South-Est Asi Region Mohmmd Akhtr, Vikrunnes Begum, Hendrik Bekedm, Mri Regin Christin, Anupm Hzrik, Md Khurshid Alm Hyder, Nvrtnsingm Jnkn, Setiwn Jti Lksono, Prth Prtim Mndl, Gimpolo Mezzbott, O Hyng Song, Mrtini Oktvi, Ikushi Onozki, Pnt Sushil Dev, Mlik Prmr, Rnjni Rmchndrn, Mukt Shrm, Achuthn Nir Sreenivs, Ddng Supriydi, Ugyen Wngchuk, Keshv Yogi. WHO Western Pcific Region Shll Ahmdov, Lepiti Hnsell, Corneli Hennig, Tom Hitt, Tuhid Islm, Nrntuy Jdmb, Ridh Jebenini, Nobuyuki Nishikiori, Ktsunori Osug, Khnh Phm, Fbio Scno, Jcques Sebert, Ynni Sun, Mthid Thongseng, Subhsh Ydv, Rjendr-Prsd Ydv. vi :: GLOBAL TUBERCULOSIS REPORT 216

8 Ntionl respondents who contributed to reporting nd verifiction of dt WHO Africn Region Abderrmne Abdelrhim, Jen Louis Aben Foe, Felix Kwmi Afutu, Gbriel Akng, Arlindo Amrl, Angonou Séverin, Rdo Andrinsolo, Aw Boubcr, Mrth Awet, Georges Bksw Ntmbwe, Bllé Boubkr, Adm Mrie Bngour, Jorge Noel Brreto, Wilfried Bekou, Serge Bisut Fuez, Frnk Ade Bonsu, Chi Khttry, Evngelist Chiskitw, Ctherine Thoms Cooper, Abdoul Krim Coulibly, Coulibly Adjobi Ftou Tiépé, Isis Dmbe, Abdoulye Dillo, Aw Helene Diop, Mrie Srr Diouf, Sicelo Smuel Dlmini, Themb Dlmini, Antoine De Pdoue Etoundi Evoun, Alfred Etwom, Jun Eyene Acuresil, Lelis Fekdu, Lynd Fory, Gilberto Frot, Evriste Gsn, Rhw Tekle Gebreyesus, Abu George, Nthizniye Gérrd, Belineh Girm, Boukoulmé Hing, Georges Hermn, Hinikoye Aou Him Oumrou, Adm Jllow, Lou Joseph, Mdou Kne, Knyerere Henry Shrdreck, Nthn Kpt, Clr Chol Kspo, Jmes Ktt, Dedeh Kesselly, Botshelo Tebogo Kgwdir, Sidney Kololo, Aristide Désiré Komngoy-Nzonzo, Bkry Konté, Ptrick Konwloh, Koukou Jcquemin, Kuye Oluwtoyin Joseph, Joseph Lsu, Gertrude Ly Ofli, Llng Mm, Mhoumbou Jocelyn, Lerole Dvid Mmetj, Ivn Mnhic, Tseliso Mrt, Josue Mrtins, Msini Enos, Snele Msuku, Fri Mvhung, Amnuel Hdgu Mebrhtu, Agnès Pscline Mezene, Ptrick Migmbi, Louine Morel, Isidore Moyeng, Mpung Jmes Upile, Frnk Mugbe Rwbinumi, Clifford Munyndi, Betrice Mutyob, Lindiwe Mvusi, Fulgence Ndyikengurukiye, Euphrsie Ndihokubwyo, Thddée Ndikumn, Jcques Ndion-Ngndziens, Norbert Ndjek, Fith Ngri, Lourenço Nhocun, Emmnuel Nkiligi, Okemb-OkombiI Frnck Hrdin, Seydou Mohmed Ouedrogo, Oumr Abdelhdi, Emile Rkotondrmnnn, Mrtin Rkotonjnhry, Thto Rleting, Aduli Gomes Rodrigues, Rujeedw Mohmmed Fezul, Smey Agbenyegn, Hmdi Smi, Chrles Sndy, Kebb D Snneh, Tndogo Soudogo, Sizib Nichols, Alihlss Sofine, Addislem Tefer, Celstino Frncisco Teixeir, Albertin Thoms, Thusoyone Titi Tsholofelo, Eric Ismël Zoungrn. WHO Region of the Americs Rosmond Adms, Srit Aguirre Grcí, Shluddin Ahmed, Vlentin Antoniet Alrcon Guizdo, Xochil Alemán de Cruz, Mirin Alvrez, Aish Andrewin, A. Alister Antoine, Denise Arkki, Christopher Archibld, Crlos Alberto Mrcos Ayl Lun, Ptrici Brtholomy, Beltrme Soledd, Mri Bermudez, Mrtín Cstellnos Joy, Jorge Cstillo Crbjl, Cedeño Uglde Annbell, Gemm Chery, Krolyn April Chong Cstillo, Eric Commiesie, Mriel Contrer, Yren Cruz, Crlos Vitl Cruz Lesge, Ofeli Cuevs, Clr De l Cruz, Nild De Romero, Dy-Jun DeRoz, Mercedes Espñ Cedeño, Fernndez Hugo, Cecili Ruth Figuero Benites, Gret Frnco, Victor Gllnt, Julio Gry Rmos, Mrgrit Godoy, Roscio Gomez, Angel Grhm, Tny Green Dougls, Dorothe Hzel, Mri Henry, Tni Herrer, Olg T Joglr, Din Khn, Adm Lnger, Athelene Linton, Cecili Lyons de Arngo, Andre Y Mldondo Svedr, Mrvin Mnznero, Belkys Mrcelino, Antonio Mrrero Figuero, M. de Lourdes Mrtínez O, Timothy McLughlin-Munroe, Angelic Medin, Mry Mercedes, Leilwti Mohmmed, Jeetendr Mohnlll, Ernesto Moreno Nrnjo, Frncis Morey, Willy Morose, Denis Dnny Mosqueir Sls, Slivi Yolnd Nzr, Alice Neymour, Cheryl Peek-Bll, Toms Portillo, Ird Potter, Robert Prtt, Mnohr Singh Rjmnickm, Norm Lucreci Rmirez Sgstume, Dottin Rmoutr, Ann Esther Reyes Godoy, Pul Ricketts, Andres Rincon, Feros Roche, Mri Rodriguez, Adlberto Rodriguez, Mrcel Rojs Diz, Myrin Román, Arelisbel Ruiz Guido, Hild Mrí Slzr Bolños, Mritz Smyo Peláez, Krl Mrí Sánchez Mendoz, Nestor Segovi, Silv Tpi Guido Jonnthn, Jon Simon, Nicol Skyers, Ntli Sos, Din Sotto, Stijnberg Deborh, Surez Alvrez Lourdes, Jckurlyn Sutton, Meliss Vldez, Dniel Vázquez, An Mrí Vinuez, Dorothe Bergen Weichselberger, Iynn Wellington, Smuel Willims, Oritt Zchrih. WHO Estern Mediterrnen Region Trig Abdll Abdllrhim, Mohmmd Abouzeid, Soni Abu Loz, Ndi Abu Sbrh, Khwj Leeq Ahmd, Ahmdi Shhnz, Al Hmdn Khlood, Mohmed Redh Al Lwti, Al Sidi Ftmh, Bdr Albri, Rft Al-Hkeem, Abdulbri Al-Hmmdi, Nd Almrzouqi, Esm Al-Sberi, Reem Alsifi, Lyth Al-Slihi, Kifh Alshqeldi, Ftm Alyquobi, Smer Amin, Wgdy Amin, Ngi Awd, Bhnsy Smir, Slh Ben Mnsour, Molk Bouin, Swsen Boussett, Wlid Doud, Rchid Fourti, Mohmed Furjni, Aml Gll, Dhikryet Gmr, Assi Hissm Mohmed, Hw Hssn Guessod, Slm Hudi, Bshrt Khn, Syed Doud Mhmoodi, Nsehi Mhshid, Piro Yssir, Ejz Qdeer, Mohmmd Khlid Seddiq, Sghir Mohmmed, Mohemmed Tben, Ycoub Him. WHO Europen Region Ntvn Alikhnov, Slihdjn Alimov, Ekkehrdt Altpeter, Srh Anderson, Delphine Antoine, Trude Mrgrete Arnesen, Andrei Astrovko, Zz Avlini, Velimir Bereš, Yn Bestrshnov, Snježn Brčklo, Bonit Brodhun, Rikke Bruun de Neergrd, Ros Cno Portero, Dniel Chemtob, Domnic Ion Chiotn, An Ciobnu, Nico Ciorn, Thierry Comolet, Rdmil Curcic, Stefni D Amto, Edit Dvidviciene, Hyk Dvtyn, Ptrick De Smet, Gerrd de Vries, Rquel Durte, Mlden Duronjić, Lnfrnco Fttorini, Len Fiebig, Lyly Gbbsov, Viktor Gsimov, Mjlind Gjocj, Biljn Grbvčević, Genndy Gurevich, Jen Pul Guthmnn, Wlter Hs, Armen Hyrpetyn, Peter Helbling, Biljn Ilievsk-Poposk, GLOBAL TUBERCULOSIS REPORT 216 :: vii

9 Zhumgli Ismilov, Srh Jckson, Andrz Jkelj, Jerker Jonsson, Erhn Kbskl, Olim Kbirov, Kdyrov Abdullt, Dzmitry Klimuk, Mri Korzeniewsk-Koseł, Mitj Kosnik, Meve Llor, Yn Levin, Jen Lorenzi, Stevn Lucic, Mliukov Ekterin, Kml Mnsinho, Frncesco Mrglino, Lilii Msiuk, Donik Mem, Violet Mihilovic-Vucinic, Vldimir Milnov, Alvrd Mirzoyn, Uch Nnv, Ntli Nizov, Zdenk Novkov, Jon O Donnell, Anlit Pce Ascik, Clr Plm Jordn, Nrgiz Prpiev, Sbine Pfeiffer, Georget Gild Popescu, Asliddin Rdzbov, Jérôme Robert, Krin Rønning, Kzimierz Roszkowski-Śliż, Gérrd Scheiden, Firuz Shripov, Cthrine Slorbk, Erik Slump, Hnn Soini, Ivn Solovic, Petr Svetin Sorli, Sergey Sterlikov, Shhnoz Usmonov, Tonk Vrlev, Piret Viiklepp, Jiri Wllenfels, Mryse Wnlin, Pierre Weicherding, Brit Askelnd Winje, Aysegul Yildirim, Mj Zkosk, Hsn Žutić. WHO South-Est Asi Region Aminth Aroosh, Si Thu Aung, Rtn Bhttri, Endng Budi Hstuti, Choe Tong Chol, Tshering Dorji, Devesh Gupt, Md. Qumrul Islm, Suksont Jittimnee, Sirinph Jittimnee, Pusprj Joshi, Ahmdul Hsn Khn, Biksh Lmichhne, Constntino Lopes, Md. Mojibur Rhmn, Chwetsn Nmwt, Nirup Pllewtte, Kirnkumr Rde, Chewng Rinzin, Priydhrshini Smrsinghe, SKM Sulistyo, Asik Sury, Phurp Tenzin, Jnk Thilkrtne, Md. Ashrf Uddin, Dhmmik Vidngm, Htet Myet Win Mung. WHO Western Pcific Region Mohd Rotpi Abdullh, Pul Ai, Kzunri Asnum, Zirwtul Adilh Aziz, Rfidh Bhrudin, Christin Brej, Mohmed Nim bin Abdul Kdir, Urnchimeg Borgil, Srh Brown, Bukbuk Ris, Jocelyn Cbrles, Kwok-chiu Chng, Phonenly Chittmny, Chou Kuok Hei, Nese Ituso Conwy, Alice M. Cuenc, Jne Dowbobo, Myleen Jck Ekiek, Jenny Eveni, Fni Sen, Florence Flment, Ludovic Floury, Fonu Louise, Ann Mrie Celin Grfin, Donn Me Gviol, Glynn-Robinson Ann, Jmes Hofschneider, Dniel Houillon, Noel Itogo, Kng He-Young, Seiy Kto, Khin Mr Kyi Win, Frnçois Ludon, Chi-chiu Leung, Leo Lim, Liz Lopez, Henri-Pierre Mllet, Alice D. Mnlo, Mo Tn Eng, Andre McNeill, Mei Jin, Serfi Mo, Grizeld V. L. Mokoi, Nguyen Binh Ho, Nguyen Viet Nhung, Nou Chnly, Connie Olikong, Josephine O Mlln, Prk Ok, Penitni Sosi, Si S. Penitni, Ynjindulm Purevsuren, Mrcelin Rbulimn, Asmh Rzli, Berek Reiher, Bernrd Rouchon, Fetui Selu, Slmo, Lmek Sle, Temilo Seono, Hidekzu Shimd, Grnt Storey, Phnnsinh Sylvnh, Neti Tmru, Edwin Tngro, Kyw Thu, Tieng Sivnn, Alfred Tongnibei, Kzuhiro Uchimur, Frnk Underwood, Yee Tng Wng, Wng Lixi, Justin Wong, Du Xin, Lure Yen Ki Sun, Zhng Hui. viii :: GLOBAL TUBERCULOSIS REPORT 216

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11 Globl ctions nd investments fll fr short of those needed to end the globl TB epidemic.

12 :: Executive Summry Bckground The Sustinble Development Gols (SDGs) for 23 were dopted by the United Ntions in 215. One of the trgets is to end the globl TB epidemic. The WHO End TB Strtegy, pproved by the World Helth Assembly in 214, clls for 9% reduction in TB deths nd n 8% reduction in the TB incidence rte by 23, compred with 215. This globl TB report is the first to be produced in the er of the SDGs nd the End TB Strtegy. It provides n ssessment of the TB epidemic nd progress in TB dignosis, tretment nd prevention efforts, s well s n overview of TB-specific finncing nd reserch. It lso discusses the broder gend of universl helth coverge, socil protection nd other SDGs tht hve n impct on helth. Dt were vilble for 22 countries nd territories tht ccount for over 99% of the world s popultion nd TB cses. Min findings nd messges Sttus of the TB epidemic nd MDR-TB crisis The TB epidemic is lrger thn previously estimted, reflecting new surveillnce nd survey dt from Indi. However, the number of TB deths nd the TB incidence rte continue to fll globlly nd in Indi. In 215, there were n estimted 1.4 million new (incident) TB cses worldwide, of which 5.9 million (56%) were mong men, 3.5 million (34%) mong women nd 1. million (1%) mong children. People living with HIV ccounted for 1.2 million (11%) of ll new TB cses. Six countries ccounted for 6% of the new cses: Indi, Indonesi, Chin, Nigeri, Pkistn nd South Afric. 1 Globl progress depends on mjor dvnces in TB prevention nd cre in these countries. Worldwide, the rte of decline in TB incidence remined t only 1.5% from 214 to 215. This needs to ccelerte to 4 5% nnul decline by 22 to rech the first milestones of the End TB Strtegy. In 215, there were n estimted 48 new cses of multidrug-resistnt TB (MDR-TB) nd n dditionl 1 people with rifmpicin-resistnt TB (RR-TB) who were lso newly eligible for MDR-TB tretment. 2 Indi, Chin nd the Russin Federtion ccounted for 45% of the combined totl of 58 cses. There were n estimted 1.4 million TB deths in 215, nd n dditionl.4 million deths resulting from TB disese mong people living with HIV. 3 Although the number of TB deths fell by 22% between 2 nd 215, TB remined one of the top 1 cuses of deth worldwide in 215. TB cre nd prevention results TB tretment verted 49 million deths globlly between 2 nd 215, but importnt dignostic nd tretment gps persist. In 215, 6.1 million new TB cses were notified to ntionl uthorities nd reported to WHO. Notified TB cses incresed from , mostly due to 34% increse in notifictions in Indi. However, globlly there ws 4.3 million gp 4 between incident nd notified cses, with Indi, Indonesi nd Nigeri ccounting for lmost hlf of this gp. 5 The crisis of MDR-TB detection nd tretment continues. In 215, of the estimted 58 people newly eligible for MDR-TB tretment, only 125 (2%) were enrolled. Five countries ccounted for more thn 6% of the gp: Indi, Chin, the Russin Federtion, Indonesi nd Nigeri. 5 Globlly, the MDR-TB tretment success rte ws 52% in In 215, 55% of notified TB ptients hd documented HIV test result. The proportion of HIV-positive TB ptients on ntiretrovirl therpy (ART) ws 78%. Access to TB preventive tretment needs to be expnded. A totl of 91 people living with HIV were strted on such tretment in 215, s well s 87 children under five (7% of those eligible). TB finncing, universl helth coverge, socil protection nd socil determinnts US$ 6.6 billion ws vilble for TB cre nd prevention in low nd middle-income countries in 216, of which 84% ws from domestic sources. Nonetheless, ntionl TB progrmmes (NTPs) in low-income countries continue to rely on interntionl donors for lmost 9% of their finncing. Investments in low nd middle-income countries fll lmost US$ 2 billion short of the US$ 8.3 billion needed in 216. This nnul gp will widen to US$ 6 billion in 22 if current funding levels do not increse. Improvements re lso needed in overll helth finncing. Government expenditures on helth in 214 were less thn the WHO benchmrk of t lest 6% of gross domestic product (GDP) in 15 countries. Out-of-pocket expenditures exceeded 45% of totl helth expenditures in 46 countries, including 11 of the 3 high TB burden countries. TB reserch nd development Despite some progress in the pipeline for new dignostics, drugs nd regimens, nd vccines, TB reserch nd development remins severely underfunded. GLOBAL TUBERCULOSIS REPORT 216 :: 1

13 Additionl highlights from the report A new er of globl TB monitoring The End TB Strtegy hs three high-level indictors: the TB incidence rte, the bsolute number of TB deths nd the percentge of TB ptients nd their households tht experience ctstrophic costs s result of TB disese. Trgets for these indictors hve been set for 23 nd 235, with ccompnying milestones for 22 nd 225. The 22 milestones of the End TB Strtegy re 35% reduction in the bsolute number of TB deths nd 2% reduction in the TB incidence rte, compred with levels in 215; nd tht no TB-ffected households fce ctstrophic costs. WHO hs defined three lists of high burden countries for the period , for TB, TB/HIV nd MDR-TB. Ech list includes 3 countries. TB disese burden Upwrd revisions to estimtes of the burden of TB disese in Indi for the period follow ccumulting evidence tht previous estimtes were too low. This evidence includes household surveys, stte-wide TB prevlence survey, studies of nti-tb drug sles in the privte sector, notifiction dt nd new nlysis of mortlity dt. Since Indi ccounts for more thn one qurter of the world s TB cses nd deths, these revisions hve hd mjor impct on globl estimtes. Estimtes for Indi re considered interim, pending ntionl TB prevlence survey scheduled for 217/218. The proportion of TB cses living with HIV ws highest in the WHO Africn Region (31%), nd exceeded 5% in prts of southern Afric. In ddition to ccelerting the nnul decline in TB incidence, reching the 22 milestone for 35% reduction in TB deths requires reducing the globl proportion of people with TB who die from the disese (the cse ftlity rtio or CFR) from 17% in 215 to 1% by 22. The CFR in 215 vried 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. If everyone with TB hd timely dignosis nd high-qulity tretment, the CFR would be low in ll countries. Ntionl notifiction nd vitl registrtion systems (with stndrd coding of cuses of deth) of high coverge nd qulity re needed in ll countries. In the interim, ntionl TB prevlence surveys will continue to provide the best method for directly mesuring the burden of TB disese nd identifying ctions required to reduce tht burden in n importnt subset of countries. In recent yers, there hs been enormous progress in implementing such surveys, with 22 completed between 29 nd August 216. Dignosis nd tretment: TB, HIV-ssocited TB nd drug-resistnt TB The globl mle:femle (M:F) rtio for notifictions ws 1.7, vrying from 1. in Pkistn to 3.1 in Viet Nm mong the 3 high TB burden countries. 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 6.3% of the new cses tht were notified in 215. In 215, 3% of the 3.4 million new bcteriologiclly confirmed nd previously treted TB cses notified globlly were reported to hve hd drug susceptibility testing for rifmpicin, with coverge of 24% for new TB ptients nd 53% for previously treted TB ptients. The only WHO-recommended rpid dignostic test for detection of TB nd rifmpicin resistnce currently vilble is the Xpert MTB/RIF ssy. Of the 48 countries in t lest one of the three new lists of high burden countries, 15 hd dopted ntionl lgorithms positioning Xpert MTB/ RIF s the initil dignostic test for ll people with signs nd symptoms of pulmonry TB by the end of 215. These countries ccounted for 1% of the estimted globl number of incident TB cses in 215. In 215, the gp of 4.3 million between notifictions of new cses nd the estimted number of incident cses 4 reflects mixture of underreporting of detected TB cses (especilly in countries with lrge privte sectors) nd underdignosis (especilly in countries where there re mjor geogrphic or finncil brriers to ccessing cre). Ten countries ccounted for 77% of the totl estimted gp: Indi, Indonesi, Nigeri, Pkistn, South Afric, Bngldesh, the Democrtic Republic of the Congo, Chin, the United Republic of Tnzni nd Mozmbique. 5 In the Africn Region where the burden of HIVssocited TB is highest, 81% of notified TB ptients hd documented HIV test result. The proportion of known HIV-positive TB ptients on ART ws bove 9% in Indi, Keny, Mlwi, Mozmbique, Nmibi nd Swzilnd. The ltest tretment outcome dt show tretment success rte of 83% for TB (214 cohort), 52% for MDR- TB (213 cohort) nd 28% for extensively drug-resistnt TB (XDR-TB; 213 cohort). At lest 23 countries in Afric nd Asi hve introduced shorter regimens for tretment of MDR-TB or RR-TB. These hve chieved high tretment success rtes (87 9%) under opertionl reserch conditions. A stndrdised regimen of 9 12 months is recommended by WHO for ll ptients (excluding pregnnt women) with pulmonry MDR/RR-TB tht is not resistnt to second-line drugs. As prt of efforts to improve outcomes for MDR/XDR- TB, t lest 7 countries hd strted using bedquiline nd 39 countries hd introduced delmnid by the end of :: GLOBAL TUBERCULOSIS REPORT 216

14 TB prevention services South Afric ccounted for the lrgest shre (45%) of people living with HIV who received TB preventive tretment for ltent TB infection (LTBI) in 215, followed by Mlwi, Mozmbique nd Keny. Ten countries reported dt for the first time, including Keny. Despite this progress, 21 of the 3 high TB/HIV burden countries did not report dt. The rtio of the TB notifiction rte mong helth-cre 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 16 countries, the number of TB cses per 1 helth-cre workers ws more thn double the notifiction rte in the generl dult popultion in 215. BCG vccintion should be provided s prt of ntionl childhood immuniztion progrmmes ccording to country s TB epidemiology. In 215, 163 countries reported providing BCG vccintion s stndrd prt of these progrmmes; 12 reported coverge of bove 9%. Universl helth coverge, socil protection nd ddressing socil determinnts: Implictions for TB In some high TB burden settings, emerging helth finncing schemes, including ntionl helth insurnce, could led to mjor reductions in out-of-pocket expenditures in lowincome popultions. Thilnd nd rnge of countries in the Region of the Americs re good pthfinding exmples. Building on estblished pproches to privte enggement in TB cre could help to ddress the burgeoning privte sector in helth-cre delivery, especilly in Asi. This includes combintion of provider incentives nd regultion, nd ppliction of innovtive institutionl intermediries nd communictions technologies. Such levers cn help to ssure the qulity of services provided. Socil protection cn be dvnced through better models of cre nd socil benefits. Mny low- nd middleincome countries hve finnced socil nd economic support for TB ptients, but these support pckges need to be better documented nd evluted. For overll impct nd sustinbility, using ntionl socil protection pltforms is priority. WHO-recommended bseline ntionl surveys re underwy to ssess the nture nd severity of TB ptient costs, nd to improve service delivery nd socil protection ccordingly. One country survey ws conducted in 215, eight begn in 216 nd ten re plnned for The vilble evidence bout links between ending TB nd ending poverty needs to be used to dvocte for poverty elimintion nd ction on relted risk fctors, such s noncommunicble disese prevention, food security, nd housing. TB finncing The BRICS countries (Brzil, the Russin Federtion, Indi, Chin nd South Afric), which collectively ccount for bout 5% of the world s TB cses, rely mostly or exclusively (the exception is Indi) on domestic funding. In other countries with high TB burden, interntionl donor funding domintes, ccounting for 75% of reported funding for NTPs in the group of 25 high TB burden countries outside BRICS, 87% of funding in low-income countries nd 6% of funding in lower middle-income countries. The single lrgest source of interntionl donor funding is the Globl Fund to Fight AIDS, Tuberculosis nd Mlri. Interntionl donor funding for TB flls fr short of donor contributions for HIV nd mlri. The ltest dt from the Orgnistion for Economic Co-opertion nd Development (OECD) creditor reporting system show totls of US$ 5.4 billion for HIV/AIDS, US$ 1.7 billion for mlri nd US$.7 billion for TB in 214. The cost per ptient treted is usully in the rnge of US$ 1 1 for drug-susceptible TB nd US$ 2 2 for MDR-TB. TB reserch nd development At lest US$ 2 billion per yer is needed for TB reserch nd development. Funding during the decde never exceeded US$.7 billion per yer. In 216, four dignostic tests were reviewed nd recommended by WHO: the loop-medited isotherml mplifiction test for TB (known s TB-LAMP), two line probe ssys (LPAs) for the detection of resistnce to the firstline nti-tb drugs isonizid nd rifmpicin, nd n LPA for the detection of resistnce to second-line nti-tb drugs. A next-genertion crtridge clled Xpert Ultr nd new dignostic pltform clled GeneXpert Omni re in development; ssessment of both by WHO is expected in 217. There re nine drugs in dvnced phses of clinicl trils for the tretment of drug-susceptible TB, drug-resistnt TB or LTBI. These re bedquiline, delmnid, linezolid, PBTZ169, pretomnid, Q23, rifmpicin (high-dose), rifpen tine nd sutezolid. There re 13 vccine cndidtes in clinicl trils, including cndidtes for prevention of TB infection nd cndidtes for prevention of TB disese in people with LTBI. 1 Countries re listed in descending order of their number of cses. 2 MDR-TB is defined s resistnce to rifmpicin nd isonizid. WHO recommends tht ll ptients with rifmpicin-resistnt TB (RR-TB) re treted with second-line MDR-TB regimen. Cses of MDR-TB nd RR-TB re collectively referred to s MDR/RR-TB in this report. 3 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). 4 i.e. 1.4 million minus 6.1 million. 5 Countries re listed in descending order of the size of their gp. 6 This is the ltest yer for which tretment outcome dt re currently vilble. GLOBAL TUBERCULOSIS REPORT 216 :: 3

15 :: Box 1.1 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 2 3 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. Dignostic tests for TB disese include: sputum smer microscopy. This ws developed more thn 1 yers go. Sputum smples re exmined under microscope to see if bcteri re present. In the current cse definitions recommended by WHO, one positive result is required for dignosis of smer-positive pulmonry TB; rpid moleculr tests. The only rpid test for dignosis of TB currently recommended by WHO is the Xpert MTB/RIF ssy (Cepheid, Sunnyvle USA). It ws initilly recommended (in 21) for dignosis of pulmonry TB in dults. Since 213, it hs lso been recommended for children nd specific forms of extrpulmonry TB. The test hs much better ccurcy thn microscopy; nd culture methods. These re the current reference stndrd but 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 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 215, for exmple, 57% of the pulmonry cses reported to WHO were bcteriologiclly confirmed. There re lso tests for TB tht is resistnt to first 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 deth rte from TB is high. Studies of the nturl history of TB disese in the bsence of tretment with nti-tb drugs (tht were conducted before drug tretments becme vilble) found tht bout 7% of people with sputum smer-positive pulmonry TB died within 1 yers, 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 new 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 new 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. A stndrdised shorter MDR-TB regimen of 9 12 months is now recommended for ll ptients (excluding pregnnt women) with pulmonry MDR/ RR-TB tht is not resistnt to second-line drugs. The cost of shortened drug regimen is bout US$ 1 per person. New TB drugs hve begun to emerge from the pipeline, nd combintion regimens tht include new compounds re 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 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 13 TB vccines in Phse I, Phse II or Phse III trils. 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). b Defined s resistnce to isonizid nd rifmpicin, the two most powerful nti-tb drugs. 4 :: GLOBAL TUBERCULOSIS REPORT 216

16 Chpter 1 :: Introduction Tuberculosis (TB) hs existed for millenni nd remins mjor globl helth problem. It cuses ill-helth in millions of people ech yer nd in 215 ws one of the top 1 cuses of deth worldwide, rnking bove HIV/AIDS s one of the leding cuses of deth from n infectious disese. 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. The best estimte is tht there were 1.4 million TB deths in 215, nd n dditionl.4 million deths resulting from TB disese mong HIV-positive people. 2 In terms of cses, the best estimtes for 215 re tht there were 1.4 million new TB cses (including 1.2 million mong HIV-positive people), of which 5.9 million were mong men, 3.5 million mong women nd 1. million mong children. Overll, 9% of cses were dults nd 1% children, nd the mle:femle rtio ws 1.6:1. 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 of the disese t globl, regionl nd country levels. This is done in the context of recommended globl TB strtegies nd trgets endorsed by WHO s Member Sttes nd broder development gols set by the United Ntions (UN). As usul, the 216 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 3 used since 29. In 216, this system ws opened for reporting t the end of Mrch. Following the My dedline for reporting nd subsequent review nd follow-up of submitted dt between June nd August, dt were vilble for 22 countries nd territories tht ccount for more thn 99% of the world s popultion nd estimted TB cses; this included 183 of WHO s 194 Member Sttes. Other sources of dt used in 216 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 HIV-positive 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. This is the first globl TB report to be produced in the post-215 er of the Sustinble Development Gols (SDGs) nd the End TB Strtegy, which hve superseded the Millennium Development Gols (2 215) nd the Stop TB Strtegy (26 215), respectively. The SDGs were dopted by the UN in September 215 nd cover the period The End TB Strtegy spns 2-yer timefrme ( ) nd ws unnimously endorsed by WHO s Member Sttes t the 214 World Helth Assembly. 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. In this new context, the structure nd content of the globl TB report hve been reshped. Chpter 2 provides n overview of the SDGs, the End TB Strtegy nd new lists of high burden countries (for TB, TB/HIV nd drug-resistnt TB) tht will be given prticulr ttention in the period The remining six chpters of the report cover TB disese burden; dignosis nd tretment of TB, HIV-ssocited TB nd drug-resistnt TB; TB prevention services; universl helth coverge, socil protection nd socil determinnts from the TB perspective; TB finncing; nd TB reserch nd development. The report lso hs four nnexes. Annex 1 explins how to ccess the online WHO globl TB dtbse nd provides further detils bout the 216 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 profiles for WHO s six regions. 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 In 215, there were n estimted 1.1 million deths due to HIV, including.4 million deths from TB mong HIV-positive people (see unids.org). 2 When n HIV-positive person dies from TB disese, the underlying cuse is clssified s HIV in the interntionl clssifiction of diseses system GLOBAL TUBERCULOSIS REPORT 216 :: 5

17 Chpter 2 :: A new er of globl TB monitoring 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 MDG6 ws to hlt nd reverse TB incidence. The Stop TB Prtnership, estblished in 21, dopted this trget nd set two dditionl trgets: tht TB prevlence nd TB mortlity rtes should be hlved 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. WHO published its ssessment of whether the 215 globl TB trgets for reductions in TB incidence, prevlence nd mortlity were chieved in October The ssessment indicted tht the MDG trget ws chieved on worldwide bsis, in ech of WHO s six regions nd in 16 of the 22 countries tht were clssified by WHO s high TB burden countries during the period Globlly, the TB mortlity rte fell by 47% between 199 nd 215, with most of tht improvement occurring fter 2. The trget of 5% reduction ws met in four WHO regions the Region of the Americs, the Estern Mediterrnen Region, the South-Est Asi Region nd the Western Pcific Region nd in 11 high TB burden countries. Globlly, TB prevlence fell by 42% between 199 nd 215. The trget of 5% reduction ws chieved in three WHO regions the Region of the Americs, the South-Est Asi Region nd the Western Pcific Region nd in nine high TB burden countries. The MDGs (2 215) hve now been superseded by the Sustinble Development Gols (SDGs), which hve n end dte of 23. Similrly, WHO s Stop TB Strtegy hs been replced by the End TB Strtegy, which covers the period With the Globl tuberculosis report 216 being the first such report in the post-215 er, this chpter provides n overview of both the SDGs (Section 2.1) nd the End TB Strtegy (Section 2.2), including the indictors tht will be used to monitor progress. For the first 5 yers of this new er (216 22), WHO hs lso defined updted lists of high burden countries (HBCs) for TB, TB/HIV nd multidrug-resistnt TB (MDR-TB). The updted lists re presented nd explined in Section World Helth Orgniztion. Globl tuberculosis report 215. Genev: WHO; 215 ( bitstrem/1665/19112/1/ _eng.pdf, ccessed 27 July 216). 2.1 The Sustinble Development Gols The SDGs were dopted by ll UN Member Sttes in September 215, t the UN Generl Assembly. 2 The 17 gols 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. SDG3 is to Ensure helthy lives nd promote well-being for ll t ll ges, nd it includes 13 trgets (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 (UN- AIDS) for the post-215 er, 3 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. SDG3 lso includes trget (Trget 3.8) relted to universl helth coverge (UHC). 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. 4 Indictors for Trget 3.8 include coverge of trcer interventions for prevention nd tretment (including TB tretment coverge), 5 nd finncil coverge provided by helth insurnce or public helth system. Across the SDG indictor frmework s whole, the definitions of mny indictors include much greter emphsis on within-country disggregtion compred with the MDGs. This includes disggregtion by ge, sex, geog- 2 United Ntions. Sustinble Development Gols ( sustinbledevelopment.un.org/topics/ sustinbledevelopmentgols, ccessed 27 July 216). 3 World Helth Orgniztion. Accelerting progress on HIV, tuberculosis, mlri, heptitis nd neglected tropicl diseses: A new gend for Genev: WHO; 215 ( bout/structure/orgnigrm/htm/progress-hiv-tb-mlri-ntd/en/, ccessed 27 July 216). 4 World Helth Orgniztion/World Bnk Group. Trcking universl helth coverge: first globl monitoring report. Genev: WHO; 215 ( bitstrem/1665/174536/1/ _eng.pdf?u=1, ccessed 28 July 216). 5 There re mny different prevention nd tretment interventions. In this context, few interventions re selected to ct s trcers for progress towrds UHC for ll interventions. 6 :: GLOBAL TUBERCULOSIS REPORT 216

18 :: Box 2.1 The Sustinble Development Gols Gol 1. End poverty in ll its forms everywhere Gol 2. End hunger, chieve food security nd improved nutrition nd promote sustinble griculture Gol 3. Ensure helthy lives nd promote well-being for ll t ll ges Gol 4. Ensure inclusive nd equitble qulity eduction nd promote lifelong lerning opportunities for ll Gol 5. Achieve gender equlity nd empower ll women nd girls Gol 6. Ensure vilbility nd sustinble mngement of wter nd snittion for ll Gol 7. Ensure ccess to ffordble, relible, sustinble nd modern energy for ll Gol 8. Promote sustined, inclusive nd sustinble economic growth, full nd productive employment nd decent work for ll Gol 9. 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 GLOBAL TUBERCULOSIS REPORT 216 :: 7

19 :: Box 2.2 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 new-borns 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 noncommunicble diseses through prevention nd tretment nd promote mentl helth nd wellbeing 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 non-communicble 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 rphy (e.g. urbn versus rurl), welth (e.g. bottom 4%, or bottom versus top income quintiles) nd employment sttus. Some indictors lso give prticulr ttention to specific subpopultions, such s pregnnt women, people with disbilities, victims of work injuries nd migrnts. Disggregtion is intended to inform nlysis of within-country inequlities nd ssocited ssessments of equity, s bsis for identifying prticulr res or subpopultions where progress is lgging nd greter ttention is needed. This is n importnt considertion for the TB community, given the influence of socio-economic sttus nd ccess to helth cre on TB epidemiology. Chpter 3 of this report includes exmples of within-country nlyses of TB dt; it lso illustrtes cross-country inequities in ccess to TB dignosis nd tretment using the cse ftlity rtio (CFR), one of the top 1 indictors for monitoring implementtion of the End TB Strtegy (see Section 2.2). 2.2 The End TB Strtegy In 212, in nticiption of the end of the ers of the MDGs nd Stop TB Strtegy, WHO s Globl TB Progrmme initited the development of post-215 globl TB strtegy. Following 2 yers of consulttions, the proposed strtegy ws discussed t the 214 World Helth Assembly, where it ws unnimously endorsed by ll Member Sttes. 1 Tht strtegy is now known s the End TB Strtegy. 2 The End TB Strtegy t glnce is shown in Box 2.3. It covers the period nd the overll gol is to End the globl TB epidemic, defined s round 1 new cses per 1 popultion per yer. This is the level found in countries considered to hve low burden of TB in 215 (Chpter 3). The End TB Strtegy hs 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: 1 World Helth Assembly. Globl strtegy nd trgets for tuberculosis prevention, cre nd control fter 215 (WHA67.1, Agend item 12.1). Genev: World Helth Assembly; 214 ( ebwh/pdf_files/wha67/a67_r1-en.pdf, ccessed 28 July 216). 2 Uplekr M, Weil D, Lonnroth K, Jrmillo E, Lienhrdt C, Dis HM, et l. WHO s new End TB Strtegy. Lncet. 215;385(9979): ( ccessed 28 July 216). 8 :: GLOBAL TUBERCULOSIS REPORT 216

20 :: Box 2.3 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% (pproximtely 1 per 1 popultion) % % % % 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). GLOBAL TUBERCULOSIS REPORT 216 :: 9

21 :: FIG. 2.1 Projected incidence nd mortlity curves tht re required to rech End TB Strtegy trgets nd milestones, % reduction 1.5 Incidence rte per 1 popultion per yer % reduction 8% reduction Deths (millions) % reduction 75% reduction 25 TARGET FOR 235 = 9% REDUCTION % reduction TARGET FOR 235 = 95% REDUCTION 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 Stop TB Prtnership hs developed Globl Pln to End TB, , 1 which focuses on the ctions nd funding needed to rech these 22 milestones. More detils bout this pln re provided in Chpter 7. 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. This indictor is good trcer for progress towrds UHC. If UHC is in plce, then people with TB should be ble to ccess high-qulity dignosis nd tretment with finncil protection; tht is, they should not fce ctstrophic costs. UHC is lso fundmentl to chieving the trgets for reductions in TB cses nd deths, for two resons. First, reching the milestones for reductions in 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 1 The Globl Pln to End TB, Genev: Stop TB Prtnership; 215 ( ccessed 28 July 216). 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 t ntionl level historiclly 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 (nd of broder socil nd economic development). Second, the globl proportion of people with TB who die from the disese (i.e. the 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 cross nd within countries is included in Chpter 3. 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 for exmple, post-exposure vccine or short, efficcious nd sfe tretment for ltent TB infection (LTBI) so tht the risk of developing TB disese mong the pproximtely 2 3 billion people who re lredy infected with Mycobcterium tuberculosis is substntilly reduced. The trjectories of TB incidence nd TB deths tht re required to rech End TB Strtegy milestones nd trgets re shown in Fig. 2.1, nd the ltest sttus of the development pipelines for new dignostics, drugs nd vccines is presented in Chpter 8. This report includes estimtes of trends in TB incidence nd mortlity for the period (Chpter 3). In contrst to previous globl TB reports, estimtes of TB prevlence re not shown for ll countries. This is becuse (unlike the er of the MDGs nd Stop TB Strtegy) TB prev- 1 :: GLOBAL TUBERCULOSIS REPORT 216

22 :: TABLE 2.1 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 CHAPTER OF THIS REPORT WHERE INDICATOR IS FEATURED 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 drugsusceptible 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 6 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 TB ptients with DST results for t lest rifmpicin, divided by the totl number of notified (new nd retretment) cses 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 highperformnce surveillnce system, notifictions pproximte incidence. Chpter 3, Chpter 6 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 cre; 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 216 :: 11

23 :: FIG. 2.2 Countries in the three TB high-burden country lists tht will be 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-burden countries for TB 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. lence is no longer high-level indictor for which globl trget hs been set. However, ntionl TB prevlence surveys remin importnt for ssessing TB disese burden nd trends (through repet surveys) in mny countries, nd cn lso inform estimtes of TB incidence. For these resons, results from recent ntionl TB prevlence surveys re included in Chpter 3. 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, ptient-centred TB cre nd prevention; bold policies nd supportive systems; 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 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): ( ccessed 28 July 216). The 1 indictors re defined nd explined in n ppendix. shown in Tble 2.1. The chpter of this report in which vilble dt for ech indictor cn be found is lso explined in the tble. Dt for 5 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 nd their households nd ssessment of whether these re ctstrophic (indictor 3 in Tble 2.1) requires periodic surveys of representtive smple of TB ptients; further detils re provided in Chpter 6. For the other four indictors (numbered 4, 5, 6 nd 8 in Tble 2.1), 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 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 15 August 216). 12 :: GLOBAL TUBERCULOSIS REPORT 216

24 TABLE 2.2 :: The three TB high-burden country lists tht will be 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 Kzkhstn Keny Indonesi 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 % globl totl 84% 3.1% 87% 4.8% 84% 5.4% 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 End TB Strtegy. 1 In ddition, the Globl TB Progrmme hs begun working with pilot group of countries in the Africn Region on collection of dt using this pproch. For the first time, this report includes chpters relted to TB prevention (Chpter 5) nd UHC nd socil protection (Chpter 6), reflecting the much greter prominence of these topics in the End TB Strtegy compred with previous globl TB strtegies. 1 World Helth Orgniztion. Implementing the end TB strtegy: the essentils. Genev: WHO, 216 ( publictions/215/the_essentils_to_end_tb/en/). See in prticulr prt II, section Lists of high-burden countries to be 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 lists for TB, TB/HIV nd MDR-TB were in use. The TB HBC list (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 their replcement with the SDGs, nd the lst yer of the Stop TB Strtegy nd its replcement with the GLOBAL TUBERCULOSIS REPORT 216 :: 13

25 End TB Strtegy, it ws n idel time to revisit these three HBC lists. Following wide consulttion process, 1 WHO hs defined three new HBC lists for the period : one for TB, one for MDR-TB nd one for TB/HIV (Fig. 2.2, Tble 2.2). 2 Ech list contins 3 countries (Tble 2.2). These re defined s the top 2 in terms of bsolute numbers of cses, plus the dditionl 1 countries tht hve the most severe burden in terms of incidence rtes per cpit, do not pper in the top 2 nd meet minimum threshold in terms of 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 87 92% of the globl burden, with lmost ll 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 one-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. As in the 215 globl TB report, 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. 1 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 ( who.int/tb/publictions/globl_report/high_tb_ burdencountrylists pdf?u=1, ccessed 28 July 216). 2 As explined in the lst row of Tble 2.2, 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 216

26 Chpter 3 :: TB disese burden :: KEY FACTS AND MESSAGES Globl trgets nd milestones for reductions in the burden of TB disese in the period hve been set s prt of the Sustinble Development Gols (SDGs) nd WHO s End TB Strtegy. The first milestones of the End TB Strtegy, set for 22, re 35% reduction in the bsolute number of TB deths nd 2% reduction in the TB incidence rte, compred with levels in 215. To rech these milestones, the TB incidence rte needs to be flling by 4 5% per yer globlly by 22 nd the proportion of people with TB who die from the disese (the cse ftlity rtio or CFR) needs to be reduced to 1% globlly by 22. A substntil ccelertion in the current rte of progress in reducing the burden of TB disese, bsed on ll elements of the End TB Strtegy, is required to bring these milestones within rech. Globlly, the bsolute number of TB deths (excluding TB deths mong HIV-positive people b ) nd the TB incidence rte hve fllen since 2. The number of TB deths fell from 1.8 million in 2 to 1.4 million in 215. However, the globl rte of decline in the TB incidence rte ws only 1.5% from 214 to 215 nd the CFR in 215 ws 17%. TB is one of the top 1 cuses of deth worldwide nd cused more deths thn HIV in 215. Worldwide in 215, there were n estimted 1.4 million incident TB cses. An estimted 62% of these cses were mle, nd 9% of cses were dults. Six countries ccounted for 6% of the globl totl: Indi, Indonesi, Chin, Nigeri, Pkistn nd South Afric. The rte of progress in these countries will hve mjor influence on whether or not the 22 globl milestones re chieved. Estimtes of the burden of TB disese in Indi hve been revised substntilly upwrds for the period 2 215, compred with those published in previous reports. This follows ccumulting evidence from surveys nd routinely collected TB notifiction dt tht previous estimtes of cses nd deths were too low. As the country with the highest burden of TB disese in the world, these revisions hve hd mjor impct on the globl estimtes. The estimtes for Indi re still considered s interim, pending ntionl TB prevlence survey scheduled for 217/218. An estimted 11% of incident TB cses in 215 were HIVpositive. The proportion ws highest in countries in the WHO Africn Region, nd exceeded 5% in prts of southern Afric. In ddition to the 1.4 million TB deths mong HIVnegtive people, there were.4 million deths from TB mong HIV-positive people b in 215. Vrition in the CFR in 215, from under 5% in few countries to more thn 2% in most countries in the WHO Africn Region, shows considerble inequlities mong countries in ccess to TB dignosis nd tretment tht need to be ddressed. If everyone with TB hd timely dignosis nd ccess to high-qulity tretment, the CFR would be low in ll countries. Following WHO guidnce issued in My 216, ll cses of rifmpicin-resistnt TB (RR-TB), including those with multidrug-resistnt TB (MDR-TB), should be treted with second-line MDR-TB tretment regimen. Globlly in 215, there were n estimted 48 new cses of MDR-TB nd n dditionl 1 people with rifmpicin-resistnt TB who were lso newly eligible for MDR-TB tretment; Indi, Chin nd the Russin Federtion ccounted for 45% of these cses. Until ntionl notifiction nd vitl registrtion systems (with stndrd coding of cuses of deth) of high coverge nd qulity re present in ll countries, ntionl TB prevlence surveys will continue to provide the best method for directly mesuring the burden of TB disese nd identifying ctions required to reduce tht burden in n importnt subset of countries. In recent yers, there hs been enormous progress in implementing such surveys, with 22 completed between 29 nd August 216. In this report, estimtes of TB incidence were derived from prevlence surveys for 2 countries with 62% of the world s TB cses. The CFR cn be pproximted s the number of TB deths divided by the number of incident cses in the sme yer. b 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 216 :: 15

27 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 SDG3 includes trget to end the globl TB epidemic by 23, with TB incidence (per 1 popultion) 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 (~1/1 popultion) This chpter is structured in six mjor sections. Section 3.1 nd Section 3.2 present the ltest WHO estimtes of TB incidence nd mortlity between 2 nd 215. These sections lso 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 the ltest sttus of progress in globl surveillnce of resistnce to nti-tb drugs nd estimtes of the incidence of multidrug-resistnt TB (MDR-TB) nd rifmpicinresistnt TB (RR-TB). Section 3.4 discusses ntionl TB prevlence surveys. Although TB prevlence is no longer n indictor for which globl trget hs been set, 2 in mny countries, ntionl TB prevlence surveys still provide the best method for estimting the burden of TB disese 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 1 World Helth Orgniztion. WHO End TB Strtegy: globl strtegy nd trgets for tuberculosis prevention, cre nd control fter 215. Genev: WHO; 215 ( en/, ccessed 8 August 216). 2 This is in contrst to the ers of the Millennium Development Gols nd Stop TB Strtegy, when trget of hlving prevlence between 199 nd 215 ws set. contribute to monitoring of progress towrds SDG nd End TB Strtegy trgets. Finlly, Section 3.5 nd Section 3.6 cover disggregted estimtes of disese burden (TB incidence nd mortlity by ge nd sex), nd wht cn be lerned from disggregted nlysis (by ge, sex nd loction) of TB surveillnce nd survey dt. This is in line with the incresing emphsis on the importnce of withincountry 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 215 globl TB report is provided in Box 3.2; further detils for Indi re 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. 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 where these criteri re not yet met, 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 3.4). 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 ccess to helth cre. A TB surveillnce checklist developed by the WHO Globl Tsk Force on TB Impct Mesurement (Box 3.1) 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 214 estimtes in this report nd the 214 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 under-reporting through inventory studies. Genev: WHO; 212 ( int/tb/publictions/inventory_studies/en/, ccessed 15 August 216). 16 :: GLOBAL TUBERCULOSIS REPORT 216

28 :: Box 3.1 The WHO Globl Tsk Force on TB Impct Mesurement Progress to dte 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 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. Notifiction dt re consistently reported to WHO by bout 2 countries nd territories ech yer. In 215, direct mesurements of TB mortlity from ntionl or smple VR systems were vilble for 128 countries. Between 29 nd the end of 215, totl of 19 ntionl TB prevlence surveys were completed. When surveys in the Philippines nd Viet Nm in 27 re included, 16 of the 22 globl focus countries hd competed survey ccording to screening nd dignostic methods recommended by WHO by the end of 215. Comprehensive reviews of methods used by WHO to produce estimtes of TB incidence, prevlence nd mortlity were undertken between June 28 nd October 21, nd in meeting of the Tsk Force dedicted to this topic in April 215. WHO published its ssessment of whether 215 globl TB trgets for reductions in TB incidence, prevlence nd mortlity were chieved in its 215 globl TB report, using the methods greed in April 215. Looking forwrd: mndte nd 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. b 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 consensusbsed 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 drug-resistnce surveys mortlity surveys 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 projections of disese burden 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 does recognize tht indirect estimtes will continue to 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 res of work 1 3), including the disggregted nlyses tht re now given much greter ttention in the SDGs nd End TB Strtegy. In the next 5 yers, 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; c n up-to-dte summry is provided in the ltest brochure bout its work. d World Helth Orgniztion Globl Tsk Force on TB Impct Mesurement. Methods to be used for WHO s definitive ssessment of whether 215 globl TB trgets re met: report of the 3rd meeting of the TB estimtes subgroup. Genev: WHO; 215 ( impct_mesurement_tskforce/meetings/globl_consulttion_ meeting_report.pdf, ccessed 24 August 216). All bckground documents re vilble t impct_mesurement_tskforce/meetings/consulttion_pril_215_tb_ estimtes_subgroup/en/ b For further detils, plese see Bckground Document 1 tht ws prepred for the April 216 meeting of the Tsk Force, vilble t tb/dvisory_bodies/impct_mesurement_tskforce/meetings/tf6_ bckground_1_mndte_strtegic_res_work.pdf?u=1 c d pdf?u=1 GLOBAL TUBERCULOSIS REPORT 216 :: 17

29 :: Box 3.2 Updtes to estimtes of TB disese burden in this report nd nticipted updtes Updtes in this report 1. Interim updte for Indi Estimtes for Indi hve been updted following n ccumulting body of evidence tht indicted tht previously published estimtes were too low. The updted estimtes re interim in nture. A more definitive ssessment will follow the completion of ntionl TB prevlence survey scheduled for 217/218. Further detils re provided in Box New dt from ntionl TB prevlence surveys Between October 214 nd August 215, finl results from surveys in Mongoli nd Ugnd becme vilble. The postsurvey estimte of TB prevlence in Ugnd ws consistent with pre-survey estimtes, but ws more precise nd hd vlues locted towrds the upper end of the previously published uncertinty intervl. In Mongoli, TB prevlence ws higher thn nticipted. More detils re provided in Section Newly reported dt nd updted estimtes from other gencies New VR dt were reported to WHO between mid-215 nd mid-216, nd some countries mde corrections to historicl dt. Updted estimtes of the burden of disese cused by HIV were obtined from UNAIDS in July 216. 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 South Afric, estimtes of TB mortlity (HIV-negtive) were bsed on estimtes from the Institute of Helth Metrics nd Evlution (IHME), Wshington University, USA; these estimtes use dt from the ntionl VR system, djusted for widespred miscoding of deths cused by HIV nd TB,,b For Indi, estimtes of TB mortlity (HIV-negtive) were lso bsed on estimtes from IHME, following the Institute s extensive nlysis of vilble mortlity dt (see lso Box 3.3). 4. Deths due to TB sequele For the first time in 216, deths ttributed to TB sequele (ICD-1 codes B9.*) re included in HIV-negtive TB mortlity estimtes for countries reporting VR dt to WHO. The proportion of overll TB deths tht were clssified s deths from TB sequele vries widely between countries (Fig. B3.2.1) s result of vrition in certifiction prctices (i.e. wht is written on deth certifictes) or coding (i.e. which code is selected). 5. In-depth epidemiologicl reviews t country level A regionl workshop on TB epidemiology nd TB mortlity ws held in Lim, Peru in June 216. Methods to estimte TB incidence were reviewed nd ltered in most countries, shifting to the high-income method bsed on lrger stndrd djustment fctor (using fctor of [1, 1.5] except in Brzil, where the stndrd fctor lredy used for highincome countries ws pplied). A ntionl TB epidemiology workshop ws held in Chin in April 216, to review options for estimting TB disese burden. Estimtes of TB incidence in re now bsed on notifictions djusted by stndrd fctor to ccount for underreporting nd underdignosis, with the stndrd djustment [1, 1.3] bsed on tht lredy used for high-income countries (see lso Section 3.1). Mortlity estimtes re derived from the smple VR system, s before. :: FIG. B3.2.1 Deths from TB sequele s proportion of the totl number of reported TB deths, countries reporting ntionl VR dt (using the most recent yer of dt reported to WHO) Proportion of TB deths from TB sequele (%) No dt Not pplicble 18 :: GLOBAL TUBERCULOSIS REPORT 216

30 :: Box 3.2 Updtes to estimtes of TB disese burden in this report nd nticipted updtes 6. Indirect prevlence estimtes re no longer presented Ntionl TB prevlence surveys will continue to provide the best method for mesuring the burden of TB disese nd relted ssessment of ctions needed to reduce tht burden in lrge number of countries specificlly, those with high burden of TB tht do not yet hve helth, ntionl notifiction nd VR systems of the qulity nd coverge required to provide relible nd routine mesurements of the number of TB cses nd deths. Results from these surveys will continue to be fetured in globl TB reports. However, indirect estimtes of prevlence for other countries re no longer presented. Prevlence is not n indictor in the SDGs or high-level indictor of the End TB Strtegy, nd no globl trget hs been set (in contrst to the er of the MDGs nd Stop TB Strtegy, when trget of hlving prevlence between 199 nd 215 ws set). Furthermore, indirect estimtes of prevlence suffer from considerble uncertinty, becuse they re derived from estimtes of incidence nd ssumptions bout disese durtion. 7. Time series of TB burden estimtes strt with the yer 2 Series of TB estimtes published in this report strt with the yer 2. In previous reports, estimtes strted in 199, becuse this ws the bseline for the 215 globl trgets set in the context of the MDGs. TB dt for the period were of reltively poor qulity in mny countries, becuse stndrdized systems for recording nd reporting cses were often introduced only fter the mid-199s, in ssocition with the introduction of the DOTS strtegy (WHO s recommended globl TB strtegy from the mid- 199s until the end of 25). The qulity nd coverge of TB dt since 2 re comprtively much improved, nd estimtes re generlly more robust. 8. Estimtes of the burden of drug-resistnt TB Previous WHO globl TB reports hve focused on the burden of MDR-TB. In this report, estimtes re of the burden of RR-TB (TB resistnt to rifmpicin, with or without resistnce to other drugs) including MDR-TB, nd re referred to s MDR/RR-TB. This updte is becuse the ltest WHO guidnce on tretment of drug-resistnt TB (n updte issued in My 216, see Chpter 4, Box 4.3) recommends tht ll people with RR-TB (not only those with MDR-TB) should be treted with n MDR-TB tretment regimen. Estimtes of the burden of MDR/RR-TB re thus needed to ssess progress in detection nd tretment coverge for drug-resistnt TB. Globl nd ntionl estimtes of the incidence of MDR/RR-TB re presented in this chpter; in ddition, Chpter 4 includes estimtes of the number of cses of MDR/RR-TB mong notified cses of pulmonry TB (i.e. the number of cses tht could be detected if ll notified TB cses were tested for drug resistnce). Methods used to produce the estimtes of the incidence of MDR/RR-TB fetured in this report re those greed following n expert review during the April 216 meeting of the WHO Globl Tsk Force on TB Impct Mesurement. c 9. Country-level estimtes of TB incidence disggregted by ge nd sex In line with the SDG nd End TB Strtegy requirements for higher levels of dt grnulrity nd corresponding estimtes, country-level estimtes of TB incidence disggregted by ge (children nd dults) nd sex re shown (see Annex 2 nd 3). Estimtes of TB incidence in children (ged <15 yers) re bsed on methods previously used t globl level, in which estimtes bsed on cse notifictions djusted for underdetection nd underreporting d re combined with estimtes derived from dynmic modelling. e Updtes nticipted in the ner future Updtes to estimtes of disese burden re expected towrds the end of 216 or in erly 217 for Bngldesh, Keny nd the Philippines, following the completion of ntionl TB prevlence surveys. Estimtes of TB incidence in Indonesi, the Philippines, Thilnd nd Viet Nm my be updted following the implementtion of inventory studies to mesure underreporting of detected TB cses. Estimtes of TB burden in Indi will be further updted once results from the ntionl TB prevlence survey re vilble. Updtes to childhood TB mortlity (primrily for the 14 yer ge group nd, where possible, further disggregted for those ged 4 nd 5 14 yers) re expected by erly 217, bsed on systemtic review nd met-nlysis to inform CFRs for children f nd mthemticl model estimting TB mortlity in children s function of TB incidence nd CFRs. g 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 ( ncbi.nlm.nih.gov/pubmed/ , ccessed 24 August 216). b 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). c For further detils, plese see Bckground Document 3b prepred for the April 216 meeting of the Tsk Force, vilble t tb/dvisory_bodies/impct_mesurement_tskforce/meetings/tf6_ bckground_3b_drtb_burden.pdf?u=1 / d 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): ( pubmed/246718, ccessed 24 August 216). e 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 ( pubmed/ , ccessed 24 August 216). f Jenkins H et l. Mortlity mong children dignosed with tuberculosis: Systemtic review nd met-nlysis. Submitted for publiction. g Dodd P et l. The globl burden of tuberculosis mortlity in children. Under development. GLOBAL TUBERCULOSIS REPORT 216 :: 19

31 :: Box 3.3 Updted nd interim estimtes of TB disese burden in Indi nd plns for ntionl TB prevlence survey in 217/218 The estimtes of TB disese burden in Indi published in the globl TB reports were bsed on the outcomes of ntionl consensus workshop held in Delhi in April 211. This report includes estimtes for Indi tht hve been revised substntilly upwrds compred with those published in , following ccumulting evidence tht the TB disese burden in Indi is higher thn ws estimted t tht time. The revised estimtes of TB incidence (bsolute numbers) re bsed on extrpoltion of the results from prevlence survey in one stte (Gujrt). This survey used methods recommended by WHO nd is the lrgest s well s the only stte-wide prevlence survey implemented in Indi to dte. It ws ssumed tht the ntionl prevlence of TB disese is the sme s the prevlence in Gujrt, with incidence then estimted using stndrd methodologicl pproch recently reviewed by the WHO Globl Tsk Force on TB Impct Mesurement. The trend in TB incidence is estimted s in globl reports published ; tht is, using results from repet tuberculin surveys (2, 21) nd (to lesser extent) trends in TB notifictions in the districts where the Revised Ntionl TB Control Progrmme first implemented the DOTS strtegy. The revised estimtes of TB mortlity re derived from those published by IHME, b fter djustment for differences between WHO nd IHME estimtes of the totl number of deths ech yer. These updted estimtes of TB burden in Indi re considered interim estimtes, pending results from ntionl TB prevlence survey tht is scheduled to strt in 217 (see lso Section 3.4). The revised estimtes, nd how they compre with those published in the 215 globl TB report, cn be summrized s follows: The updted estimte of incidence (new TB cses per yer) is 2.8 million cses in 215 (217 per 1 popultion), nd 2.9 million (223 per 1 popultion) in 214. These figures cn be compred with notifictions of 1.7 million new nd relpse cses in 215 (127 per 1 popultion) nd 1.6 million new nd relpse cses in 214 (124 per 1 popultion). These figures suggest tht 56% of incident cses were officilly reported in 214 nd 59% in 215. In the 215 globl TB report, the estimte for 214 ws tht there were 2.2 million incident cses (167 per 1 popultion), with n estimted 74% of incident cses officilly reported. The updted estimte of the number of TB deths (excluding those in HIV-positive people, which re clssified s deths due to HIV/AIDS in ICD-1) is 478 in 215 (36 per 1 popultion), nd 483 (37 per 1 popultion) in 214. In the 215 globl TB report, the estimte for 214 ws 22 (17 per 1 popultion). Estimted trends in TB incidence nd mortlity remin similr to those published in previous yers, with incidence flling by 2% per yer over nd mortlity flling by 3.3% per yer over the sme period. The six sources of evidence tht the burden of TB is higher thn estimted in April 211 re summrized below. 1. Household survey in 3 districts of numbers of people on TB tretment, 211 Strting in 211, TB project tht imed to increse civil society s support to the NTP in Indi nd to engge communities nd community-bsed cre providers ws implemented in 374 out of 65 districts. c The 374 districts were selected bsed on suspected low TB cse detection or limited ccess of popultions to helth services. Funding for the project ws from the Globl Fund to Fight AIDS, Tuberculosis nd Mlri (Globl Fund). In smple of 3 of the 374 districts, the number of people on TB tretment bsed on self-reporting ws ssessed using dtset compiled s prt of survey of knowledge, ttitudes nd prctices conducted from Jnury to Mrch 211. Of the self-reported cses, 54% hd not been officilly reported to ntionl uthorities. The number of undetected cses could not be ssessed becuse of the study design. For comprison, the estimte published in the 215 globl TB report ws tht 59% of incident cses were officilly reported in 21 (with the gp of 41% including both unreported nd undetected cses). 2. Results from stte-wide prevlence survey in Gujrt stte In 211, prevlence survey ws conducted in Gujrt. This ws the country s first stte-wide survey (other surveys hve been conducted in districts tht were not ntionlly representtive). Results were shred with WHO in 215, nd indicted prevlence (djusted for ll ges nd ll forms of TB) of 39 cses per 1 popultion. This is much higher thn the ntionl estimte published by WHO in the 215 globl TB report of 25 prevlent cses per 1 popultion. Gujrt is mong the welthiest sttes in Indi, nd given the link between overll levels of income nd the burden of TB disese it seems unlikely tht TB prevlence in Gujrt would be higher thn the ntionl verge. 3. A district level household nd fcility survey (DLHS-4) A survey in estimted prevlence bsed on interview screening t 592 cses per 1. However, this method for estimting prevlence is not recommended in the WHO hndbook on TB prevlence surveys. 2 :: GLOBAL TUBERCULOSIS REPORT 216

32 :: Box 3.3 Updted nd interim estimtes of TB TB prevlence survey in 217/ A study of sles of nti-tb drugs, 214 A study of sles of nti-tb drugs in 214 ws published in 216. d The study indicted tht there were 17.8 million ptient-months of TB tretment in the privte sector, twice s mny s in the public sector. The uthors noted tht if 4 6% of privte-sector TB dignoses re correct, nd if privte-sector TB tretment lsts on verge 2 6 months, then bout 2.2 million (rnge 1.2 million to 5.3 million) TB cses were treted in the privte sector in 214. e This is 2 3 times higher thn the level ssumed when the April 211 workshop on TB disese burden estimtes (mentioned bove) ws held. 5. A lrge increse in ntionl cse notifictions in Indi implemented policy of mndtory TB notifiction in 212 nd hs lso rolled out ntionl web-bsed reporting system since 212. In 214, the number of notified cses incresed by 29% compred with 213, nd the number of notified cses in 215 ws 34% higher thn the level of 213. Most of the increse is relted to improved coverge of notifictions from the privte sector in smll number of districts. 6. Anlyses of TB mortlity by IHME IHME hs used lrge body of cuse-of-deth dt from VR nd verbl utopsy surveys, including dt tht re not yet ccessible to WHO, to estimte TB mortlity in Indi. The estimted number of TB deths is much higher thn previously published WHO estimtes. Glziou P, Sismnidis C, Pretorius C, Floyd K. Methods used by WHO to estimte the Globl burden of TB disese. rxiv preprint rxiv: ;( ccessed 24 August 216). b c Stynryn S, Nir SA, Chdh SS, Shivshnkr R, Shrm G, Ydv S et l. From where re tuberculosis ptients ccessing tretment in Indi? Results from cross-sectionl community bsed survey of 3 districts. PLoS One. 211;6(9):e2416. d Arinminpthy N, Btr D, Khprde S, Vulnm T, Mheshwri N, Shrm L et l. The number of privtely treted tuberculosis cses in Indi: n estimtion from drug sles dt. Lncet Infect Dis. 216;16: ( pdfs/journls/lninf/piis (16) pdf, ccessed 25 August 216). e This is consistent with n erlier study of drug sles in 28 nd 29. See Wells WA, Ge CF, Ptel N, Oh T, Grdiner E, Kimerling ME. Size nd usge ptterns of privte TB drug mrkets in the high burden countries. PLoS One. 211;6(5):e doi: /journl. pone defines the stndrds tht need to be met for notifiction dt to provide direct mesure of TB incidence. 1 By August 216, totl of 42 countries, including 19 of the 3 high TB burden countries (listed in Tble 3.2) 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): 1. Cse notifiction dt combined with expert opinion bout cse-detection gps. Expert opinion, elicited in 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 74 countries tht ccounted for 22% of the estimted globl number of incident cses in 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 co-infection on the distribution of disese durtion. This method is used for 2 countries, 19 of which hve ntionl survey dt nd one Indi tht hs survey in one stte. The 2 countries ccounted for 62% of the estimted globl number of incident cses in Notifictions in high-income countries djusted by stndrd fctor to ccount for underreporting nd underdignosis. This method is used for 118 countries: ll high-income countries except the Netherlnds nd the United Kingdom, plus selected upper-middle income countries with low levels of underreporting, including Brzil nd Chin. For three countries (Frnce, Republic of Kore nd Turkey) the djustment ws country specific, bsed on results from studies of underreporting. These 118 countries ccounted for 15.5% of the estimted globl number of incident cses in 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 215. Further detils bout these methods re provided in the online technicl ppendix 2 nd in bckground documents prepred for the globl review of methods used to produce TB burden estimtes tht ws held in April 215 (Box 3.1). 3 1 World Helth Orgniztion. Stndrds nd benchmrks for tuberculosis surveillnce nd vitl registrtion systems: checklist nd user guide. Genev: WHO; 214 ( publictions/stndrdsndbenchmrks/en/, ccessed 24 August 216). 2 The online technicl ppendix is vilble t 3 All bckground documents re vilble t dvisory_bodies/impct_mesurement_tskforce/meetings/ consulttion_pril_215_tb_estimtes_subgroup/en/ GLOBAL TUBERCULOSIS REPORT 216 :: 21

33 :: Box 3.4 Inventory studies to mesure the underreporting of detected TB cses: progress to dte The ccurte understnding nd mesurement of TB incidence, one of the high-level indictors consistently used by the globl helth community since 2, is pivotl to monitoring progress ginst interntionl trgets set for TB in the End TB Strtegy nd the SDGs, nd for ssessing whether investments in TB cre nd prevention ctully work. Although the level of nd trends in TB incidence could be directly mesured through popultion cohort studies, ntionl cohort studies re too expensive nd imprcticl to implement. In settings with stte-of-the-rt routine surveillnce systems where most, if not ll, new TB cses re dignosed nd registered, TB cses notified to the NTP provide good proxy for TB incidence. More often thn not, however, cse-detection gps plgue ntionl TB surveillnce systems t different stges in the ptient cscde, including gps in dignosis, tretment nd reporting. TB inventory studies re customized nd more cost-effective lterntive to popultion cohort studies tht could inform the extent of such gps. TB inventory studies hve two brod study objectives, one involving the direct mesurement of TB underreporting nd the other, under certin conditions, the estimtion of TB incidence through cpture recpture nlysis. There hs been growing interest in nd implementtion of ntionl inventory studies to mesure TB underreporting in the pst 1 yers (Fig. B3.4.1) often in combintion with cpture recpture nlysis in countries including the Netherlnds, b the United Kingdom, c French Guin, d Egypt, e Yemen, f Irq, g Pkistn h nd Keny. i Hypothesis-generting investigtions to ssess the level of TB cse-detection gps were lso completed in Indi (cross-sectionl survey of households), j Indonesi k nd Viet Nm (nested within ntionl prevlence survey mong dults). l Bsed on these studies, the level of TB underreporting found ws context-dependent, nd rnged from bout 15% in Europen countries, 2% in Afric nd 3% in the WHO Estern :: FIG. B3.4.1 Countries in which inventory studies of the underreporting of detected TB cses hve been implemented since 2 (sttus in August 216),b Pkistn is currently undertking second inventory study focussing on children with TB. b Nigeri is plnning to undertke subntionl level study (in metropolitn Lgos). At lest one study completed Study plnned Study ongoing Not pplicble Mediterrnen Region, to 5% in countries in Asi with lrge privte sector. These dt hve ll informed ntionl estimtes of TB disese burden reported by WHO. Results from TB inventory studies provide the pltform nd evidence to mke progrmmtic chnges to better ddress the TB epidemic. The Europen Centre for Disese Prevention nd Control cknowledges the vlue of inventory studies for providing evidence bout the performnce of surveillnce systems in Europe, nd UNITAID nd the Globl Fund re lredy supporting the implementtion of ntionl TB inventory studies in Asi, including some studies with prticulr focus on children. Strengthening ntionl TB surveillnce systems nd the dt they produce is the only credible wy to ensure the robust nd routine monitoring of progress towrds globl trgets for TB. Inventory studies re n importnt tool, one of the few vilble tody, for chieving tht gol for TB surveillnce. As countries begin working towrds the new TB incidence trgets set within the SDGs nd the End TB Strtegy, incresed commitment from NTPs nd funding gencies to conducting nd funding TB inventory studies is required. World Helth Orgniztion. Assessing tuberculosis under-reporting through inventory studies. Genev: WHO; 212 ( publictions/inventory_studies/en/, ccessed 15 August 216). b vn Hest NAH, Smit F, Brs HWM, De Vries G, De Hs PEW, Westenend PJ et l. Completeness of notifiction of tuberculosis in The Netherlnds: how relible is record-linkge nd cpture-recpture nlysis? Epidemiology nd Infection. 27;135(6): c vn Hest NAH, Story A, Grnt AD, Antoine D, Crofts JP, Wtson JM. Record-linkge nd cpture-recpture nlysis to estimte the incidence nd completeness of reporting of tuberculosis in Englnd Epidemiology nd Infection. 28;136(12): d Guernier V, Guegn J-F, Depris X. An evlution of the ctul incidence of tuberculosis in French Guin using cpture-recpture model. Microbes nd Infection. 26;8(3): e Bssili A, Grnt AD, El-Mohgzy E, Gll A, Glziou P, Seit A et l. Estimting tuberculosis cse detection rte in resource-limited countries: cpture-recpture study in Egypt. The Interntionl Journl of Tuberculosis nd Lung Disese. 21;14(6): f Bssili A, Al-Hmmdi A, Al-Absi A, Glziou P, Seit A, Abubkr I et l. Estimting the tuberculosis burden in resource-limited countries: cpture-recpture study in Yemen. The Interntionl Journl of Tuberculosis nd Lung Disese. 213;17(4): g Huseynov S, Hshim DS, Tben MR, Hrris R, Bssili A, Abubkr I et l. Estimting tuberculosis burden nd reporting in resource-limited countries: cpture-recpture study in Irq. The Interntionl Journl of Tuberculosis nd Lung Disese. 213;17(4): h Ftim R, Hrris RJ, Enrson DA, Hinderker SG, Qdeer E, Ali K et l. Estimting tuberculosis burden nd cse detection in Pkistn. The Interntionl Journl of Tuberculosis nd Lung Disese. 214;18(1):55 6. i Tollefson D, Ngri F, Ndish M, Gethi D, Kipruto H, Cin K, Bloss E. Underreporting of sputum smer-positive tuberculosis cses in Keny. Interntionl Journl of Tuberculosis nd Lung Disese. (Under peer review). j Stynryn S, Nir SA, Chdh SS, Shivshnkr R, Shrm G, Ydv S et l. From where re tuberculosis ptients ccessing tretment in Indi? Results from cross-sectionl community bsed survey of 3 districts. PLoS One. 211;6(9):e2416 ( pubmed/ , ccessed 24 August 216). k Ministry of Helth. Report of Indonesi Ntionl TB prevlence survey Ministry of Helth, Republic of Indonesi, Jkrt, 215. l Ho NB, Cobelens FGJ, Sy DN, Nhung NV, Borgdorff MW, Tiemersm EW. Dignosis nd tretment of tuberculosis in the privte sector, Vietnm. Emerging Infectious Diseses. 211;17(3): :: GLOBAL TUBERCULOSIS REPORT 216

34 :: FIG. 3.1 Strengthening ntionl TB surveillnce (sttus in August 216) Countries in which checklist of stndrds nd benchmrks hs been completed since Jnury 213 Countries in which n epidemiologicl review hs been undertken since July 212 Countries covered by regionl or countryspecific workshop focused on nlysis nd use of TB dt since October 215 Plnned for 216 Completed Not pplicble GLOBAL TUBERCULOSIS REPORT 216 :: 23

35 :: FIG. 3.2 Min methods used to estimte TB incidence Min method Cse notifictions, expert opinion Prevlence survey Cse notifictions, stndrd djustment Cpture recpture No dt Not pplicble In the first method, cse notifiction dt re combined with expert opinion bout cse detection gps (under-reporting nd under-dignosis), nd trends re estimted using either mortlity dt, repet surveys of the nnul risk of infection or exponentil interpoltion using estimtes of cse detection gps for three yers. For ll high-income countries except the Netherlnds nd the United Kingdom, notifictions re djusted by stndrd mount or mesure of underreporting from inventory studies, to ccount for cse detection gps. In Indi, results from subntionl prevlence survey for the stte of Gujrt were used. For further detils bout ll four methods, see text Estimtes of TB incidence in 215 Globlly in 215, there were n estimted 1.4 million incident cses of TB (rnge, 8.7 million to 12.2 million), 1 equivlent to 142 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). As explined in Box 3.2, estimtes of TB incidence hve been revised upwrds for the period 2 215, compred with those published in the 215 globl TB report. This follows ccumulting evidence tht the burden of TB disese in Indi is considerbly higher thn previously estimted (Box 3.3), nd more minor upwrd revisions for the Democrtic People s Republic of Kore nd the Philippines. The updted estimtes for Indi should be considered interim in nture, pending more definitive ssessment tht will follow completion of ntionl TB prevlence survey, which is scheduled to strt in 217. Most of the estimted number of cses in 215 occurred in Asi (61%) 2 nd the WHO Africn Region (26%); smller proportions of cses occurred in the Estern Mediterrnen Region (7%), the Europen Region (3%) nd the Region 1 Here nd elsewhere in the report, Rnge refers to the 95% uncertinty intervl. 2 Asi refers to the WHO regions of South-Est Asi nd the Western Pcific. of the Americs (3%). The 3 high TB burden countries 3 ccounted for 87% of ll estimted incident cses worldwide. The six countries tht stood out s hving the lrgest number of incident cses in 215 were (in descending order) Indi, Indonesi, Chin, Nigeri, Pkistn nd South Afric (combined, 6% of the globl totl). Of these, Chin, Indi nd Indonesi lone ccounted for 45% of globl cses in 215. The nnul number of incident TB cses reltive to popultion size (the incidence rte) vried widely mong countries in 215, from under 1 per 1 popultion in most high-income countries to 15 3 in most of the 3 high TB burden countries (Fig. 3.3), nd bove 5 in few countries including Lesotho, Mozmbique nd South Afric (Tble 3.3). An estimted 11% (rnge, 9 14%) of the incident TB cses in 215 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, nd exceeded 5% in prts of southern Afric (Fig. 3.4). Estimtes of the incidence of zoonotic TB re shown in Box 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 216

36 :: TABLE 3.2 Estimted epidemiologicl burden of TB in 215 for 3 high TB burden countries, WHO regions nd globlly. Numbers in thousnds. HIV-NEGATIVE TB MORTALITY HIV-POSITIVE TB MORTALITY b TOTAL TB INCIDENCE HIV-POSITIVE TB INCIDENCE POPULATION BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL Angol Bngldesh c Brzil Cmbodi Centrl Africn Republic Chin Congo DPR Kore DR Congo Ethiopi Indi d 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 Globl Numbers for mortlity shown to two significnt figures. Numbers for incidence shown to two significnt figures if under 1 nd to three significnt figures otherwise. b Deths mong HIV-positive TB cses re clssified s HIV deths ccording to ICD-1. c Estimtes of TB incidence nd mortlity for Bngldesh will be reviewed once finl results from the 215/216 ntionl TB prevlence survey re vilble. d Estimtes of TB incidence nd mortlity for Indi re interim in nture, pending results from the ntionl TB prevlence survey plnned for 217/218. GLOBAL TUBERCULOSIS REPORT 216 :: 25

37 :: TABLE 3.3 Estimted epidemiologicl burden of TB in 215 for 3 high TB burden countries, WHO regions nd globlly. Best estimtes re followed by the lower nd upper bounds of the 95% uncertinty intervl. Rtes per 1 popultion except where indicted. 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 b 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 Globl Deths mong HIV-positive TB cses re clssified s HIV deths ccording to ICD-1. b Estimtes of TB incidence nd mortlity for Bngldesh will be reviewed once finl results from the 215/216 ntionl TB prevlence survey re vilble. c Estimtes of TB incidence nd mortlity for Indi re interim in nture, pending results from the ntionl TB prevlence survey plnned for 217/ :: GLOBAL TUBERCULOSIS REPORT 216

38 :: FIG. 3.3 Estimted TB incidence rtes, 215 Estimted new TB cses (ll forms) per 1 popultion per yer No dt Not pplicble :: FIG. 3.4 Estimted HIV prevlence in new nd relpse TB cses, 215 HIV prevlence in new TB cses ll ges (%) No dt Not pplicble GLOBAL TUBERCULOSIS REPORT 216 :: 27

39 :: Box 3.5 Incidence nd mortlity due to zoonotic TB Mycobcterium bovis is the cusl gent of bovine TB in cttle nd zoonotic TB in people. Bovine TB hs mjor impct on livestock productivity, nd on the livelihoods of poor nd mrginlised communities. The most common route of trnsmission to people is through the consumption of unpsteurized diry products. In 215, there were n estimted 149 cses of zoonotic TB (Tble B3.5.1). This ws clculted by pplying the regionl proportions of ll TB cses tht re estimted to be cused by M. bovis to estimtes of TB incidence in 215. A stndrd devition of 5% reltive to the best estimte of ech regionl proportion ws ssumed when propgting uncertinty. Given the bsence of routine reporting in most countries where bovine TB is endemic, these proportions were drwn from scientific studies,b tht lck regionl representtiveness. As result, estimtes hve lrge uncertinty rnge. Mortlity (excluding TB deths in HIVpositive people) ws similrly estimted bsed on the sme proportions, but this time ws pplied to ggregted estimtes of TB mortlity by WHO region, nd reduced by fctor of 2% to ccount for higher proportion of extrpulmonry TB cses mong those with M. bovis, nd ssocited lower CFR. There is need to strengthen surveillnce of zoonotic TB to better quntify the burden of disese. One of the mjor brriers for dignosis is tht the most commonly used lbortory procedures do not differentite the M. tuberculosis complex into the species of M. bovis nd M. tuberculosis. Zoonotic TB lso presents tretment chllenge. It more often occurs in extrpulmonry sites nd is inherently resistnt to pyrzinmide, one of the drugs in the stndrd first-line nti-tb tretment regimen. In the context of WHO s End TB Strtegy, which clls for dignosis nd tretment of every TB cse, zoonotic TB must be better ddressed. This requires holistic pproch tht links the humn nd niml helth sectors to reduce the risk of TB trnsmission t the humn niml interfce. :: TABLE B3.5.1 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. REGION INCIDENCE MORTALITY Afric 76 3 ( ) 1 ( ) Americs 84 ( ) 46 (12 98) Estern Mediterrnen 749 ( ) 639 ( ) Europe 129 (35 284) 13 (28 225) South-Est Asi Western Pcific 47 4 ( ) 228 (62 55) 15 9 ( ) 286 (77 63) Globl 149 ( ) 13 4 ( ) World Helth Orgniztion. WHO estimtes of the globl burden of foodborne diseses. Genev: WHO, Foodborne diseses burden epidemiology reference group ; 215 ( foodsfety/publictions/foodborne_disese/fergreport/en/, ccessed 24 August 216). b Muller B, Durr S, Alonso S, Httendorf J, Lisse CJ, Prsons SD et l. Zoonotic Mycobcterium bovis-induced tuberculosis in humns. Emerg Infect Dis. 213;19(6): ( pubmed/ , ccessed 24 August 216) 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. 3.5, Fig. 3.6). Globlly, the verge rte of decline in the TB incidence rte ws 1.4% per yer in 2 215, nd 1.5% between 214 nd 215. 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. 3.7 nd for the 3 high TB burden countries in Fig The fstest declines re in the WHO Europen Region (3.3% per yer from 214 to 215). 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%), the United Republic of Tnzni (6.8%), Ethiopi (6.7%), Nmibi (6.2%), Keny (5.%) nd the Russin Federtion (4.2%). 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 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 cuses of deth re ccurtely coded ccording to ICD-1. Smple VR systems covering representtive res 1 World Helth Orgniztion. Interntionl sttisticl clssifiction of diseses nd helth relted problems (The) ICD-1. Genev: WHO; :: GLOBAL TUBERCULOSIS REPORT 216

40 :: FIG. 3.5 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 2 TB deths mong HIV-negtive people All TB cses Millions 5 Notifictions of new nd relpse cses Millions 1.5 TB deths mong HIV-positive people HIV-positive TB cses :: FIG. 3.6 Globl trends in estimted TB incidence nd mortlity rtes, The blck line show notifictions of new nd relpse cses, for comprison with estimtes of the totl incidence rte. Shded res represent uncertinty intervls. TB incidence TB mortlity (HIV-negtive) 2 3 Rte per 1 popultion per yer All TB cses Notifictions of new nd relpse cses Rte per 1 popultion per yer 2 1 HIV-positive TB cses of the country (e.g. s in Chin) provide n interim solution. Mortlity surveys cn lso be used to estimte deths cused by TB. In 215, most countries with high burden of TB lcked ntionl 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 from ecologicl modelling bsed on 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 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 Europen Region nd the 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 128 countries (Fig. 3.9), which collectively ccounted for 52% of the estimted number of TB deths (mong HIV-negtive people) globlly in 215. The WHO Africn GLOBAL TUBERCULOSIS REPORT 216 :: 29

41 :: FIG. 3.7 Regionl trends in estimted TB incidence rtes (log scle) 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. Afric The Americs Estern Mediterrnen Rte per 1 popultion per yer (log scle) Europe South-Est Asi Western Pcific Region is the prt of the world in which there is the gretest need to introduce or strengthen VR system 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 1 nd in bckground documents prepred for the globl review of methods used to produce TB burden estimtes tht ws held in April 215 (Box 3.1) Estimtes of TB mortlity in 215 Estimtes of the number of deths cused by TB re shown globlly, for the six WHO regions nd for the 3 high TB burden countries in Tble 3.2. There were n estimted 1.4 million (rnge, 1.2 million to 1.6 million) deths from TB mong HIV-negtive people in 215 nd n dditionl.39 million (rnge,.32 million to.46 million) deths from TB mong HIV-positive people. TB is one of the top 1 cuses of deth worldwide, nd cused more deths thn HIV/ AIDS in 215 (Fig. 3.1, Fig. 3.11). 2 About 84% of TB deths mong HIV-negtive people occurred in the WHO Africn Region nd South-Est Asi Region in 215; these regions ccounted for 86% of the 1 The online technicl ppendix is vilble t 2 WHO Globl Helth Observtory dt repository, vilble t pps.who.int/gho/dt/node.min.ghecod?lng=en (ccessed 27 July 216). combined totl of TB deths in HIV-negtive nd HIV-positive people. Indi nd Nigeri ccounted for 48% of globl TB deths mong HIV-negtive people nd for 43% of the combined totl TB deths in HIV-negtive nd HIV-positive people. Estimtes of TB mortlity rtes (per 1 popultion) 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 19 in 215, nd 24 when TB deths mong HIV-positive people were included. There ws considerble vrition mong countries (Fig. 3.12), rnging from less thn one TB deth per 1 popultion in mny high-income countries to more thn 4 deths per 1 popultion in much of the WHO Africn Region nd in five high TB burden countries in Asi (Bngldesh, Cmbodi, the Democrtic People s Republic of Kore, 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 1.8 million in 2 to 1.4 million in 215 (Fig. 3.5). The TB 3 :: GLOBAL TUBERCULOSIS REPORT 216

42 :: FIG. 3.8 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 Indi b 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 incidence for Bngldesh will be reviewed once finl results from the 215/216 ntionl TB prevlence survey re vilble. b Estimtes of TB incidence for Indi re interim in nture, pending results from the ntionl TB prevlence survey plnned for 217/218. GLOBAL TUBERCULOSIS REPORT 216 :: 31

43 :: FIG. 3.9 Countries (in red) for which TB mortlity in HIV-negtive people is estimted using mesurements from vitl registrtion systems nd/or mortlity survey Not pplicble mortlity rte (per 1 popultion) fell by 34% between 2 nd 215 (Fig. 3.6), nd by 2.7% between 214 nd 215. Rtes hve lso been flling in ll six of the WHO regions (Fig. 3.13). Since 21, the fstest verge rtes of decline in the mortlity rte hve been in the WHO Estern Mediterrnen nd Europen regions (6.5% nd 6.2% per yer, respectively) nd slowest in the WHO Africn Region (2.2% per yer). Trends in mortlity rtes in the 3 high TB burden countries vry mrkedly (Fig. 3.14), rnging from substntil reductions since 2 (e.g. Chin, Ethiopi, Mynmr, Pkistn the Philippines nd the Russin Federtion) to increses in Congo nd the Democrtic People s Republic of Kore The cse ftlity rtio 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 215, 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 HIV-negtive nd HIV-positive people) 1 ws 17% nd vried widely mong countries (Fig. 3.15), 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 The CFR ws clculted bsed on the combined totl of deths in HIV-negtive nd HIV-positive people for the purpose of crosscountry comprisons, in prticulr to illustrte the high CFRs in Africn countries tht 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. At the subntionl level, CFRs cn lso be restricted to HIV-negtive TB deths, depending on the country nd its HIV burden. 32 :: GLOBAL TUBERCULOSIS REPORT 216

44 :: FIG. 3.1 Top cuses of deth worldwide in 212.,b,c,d Deths from TB mong HIV-positive people re shown in grey. d Ischemic hert disese Stroke Lower respirtory infections :: FIG Globl trends in the estimted number of deths cused by TB nd HIV (in millions), ,b Shded res represent uncertinty intervls. 2 Totl TB deths (in HIV-negtive nd HIV-positive people ) Chronic obstructive pulmonry disese TB Millions 1 HIV deths TB deths in HIV-negtive people Trchel, bronchus, lung cncer Dirrhel diseses TB deths in HIV-positive people Dibetes mellitus HIV/AIDS Rod injury Millions (212) For HIV/AIDS, the ltest estimtes of the number of deths in 215 tht hve been published by UNAIDS re vilble t en/resources/documents/216/hiv_estimtes_with_uncertinty_ bounds_ For TB, the estimtes for 215 re those published in this report. b Deths from TB mong HIV-positive people re officilly clssified s deths cused by HIV/AIDS in the Interntionl Clssifiction of Diseses. Estimtes of cuses of deth will be updted by WHO before the end of 216. b This is the ltest yer for which estimtes for ll cuses re currently vilble. See WHO Globl Helth Observtory dt repository, vilble t (ccessed 28 July 216). c For HIV/AIDS, the ltest estimtes of the number of deths in 212 tht hve been published by UNAIDS re vilble t org/ en/resources/documents/216/hiv_estimtes_with_uncertinty_ bounds_ For TB, the estimtes for 212 re those published in this report. d Deths from TB mong HIV-positive people re officilly clssified s deths cused by HIV/AIDS in the Interntionl Clssifiction of Diseses. :: FIG. 3.1b Estimted number of deths from HIV/AIDS nd TB in 215. Deths from TB mong HIV-positive people re shown in grey.,b TB HIV/AIDS Millions (215) For HIV/AIDS, the ltest estimtes of the number of deths in 215 tht hve been published by UNAIDS re vilble t en/resources/documents/216/hiv_estimtes_with_uncertinty_ bounds_ For TB, the estimtes for 215 re those published in this report. b Deths from TB mong HIV-positive people re officilly clssified s deths cused by HIV/AIDS in the Interntionl Clssifiction of Diseses 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 give n estimte of the 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. 1 Estimtes re conservtive becuse they do not ccount for the impct of TB control or 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 215, TB tretment lone verted n estimted 39 million deths mong HIV-negtive people (Tble 3.4). Among HIV-positive people, TB tretment supported by ART verted n dditionl 9.6 million deths. 1 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 GLOBAL TUBERCULOSIS REPORT 216 :: 33

45 :: FIG Estimted TB mortlity rtes in HIV-negtive people, 215 Estimted TB deths per 1 popultion No dt Not pplicble :: FIG Regionl trends in estimted TB mortlity rtes (log scle), TB mortlity rtes in HIV-negtive people re shown in blue nd 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 :: GLOBAL TUBERCULOSIS REPORT 216

46 :: FIG Trends in estimted TB mortlity rtes, 2 215, 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.,b 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 Bngldesh will be reviewed once finl results from the 215/216 ntionl TB prevlence survey re vilble. b Estimtes of TB mortlity for Indi re interim in nture, pending results from the ntionl TB prevlence survey plnned for 217/218. GLOBAL TUBERCULOSIS REPORT 216 :: 35

47 :: FIG Estimtes of the cse ftlity rtio (CFR), (including HIV-negtive nd HIV-positive people), 215 CFR (%) No dt Not pplicble :: TABLE 3.4 Cumultive number of deths verted by TB nd TB/HIV interventions (in millions), globlly nd by WHO region HIV-NEGATIVE PEOPLE HIV-POSITIVE PEOPLE TOTAL WHO REGION BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL Afric The Americs Estern Mediterrnen Europe South-Est Asi Western Pcific Globl Drug-resistnt 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 155 countries worldwide (8% of 194 WHO Member Sttes), which collectively hve more thn 95% of the world s popultion nd TB cses. This includes 83 countries tht hve continuous surveillnce systems bsed on routine dignostic drug-susceptibility testing (DST) of Mycobcterium tuberculosis isoltes obtined from ll TB ptients, nd 72 countries tht rely on epidemiologicl surveys of bcteril isoltes collected from representtive smples of ptients (Fig. 3.16). Surveys conducted 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 3 high MDR-TB burden countries (which comprise totl of 4 countries, given 36 :: GLOBAL TUBERCULOSIS REPORT 216

48 :: FIG Dt sources vilble to estimte levels of TB drug resistnce Source of dt Surveillnce Survey No dt Not pplicble :: FIG Globl coverge of surveillnce dt on drug resistnce, Yer of most recent dt Ongoing survey in 216 No dt Subntionl dt only Not pplicble GLOBAL TUBERCULOSIS REPORT 216 :: 37

49 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 countries, the dt for Sierr Leone re from before the yer 2, nd five countries (Brzil, Centrl Africn Republic, Democrtic People s Republic of Kore, Ppu New Guine nd the Russin Federtion) rely on drug-resistnce surveillnce dt gthered from subntionl res only. In 215, the first-ever drug resistnce survey ws completed in Djibouti, nd repet surveys were completed in Keny, Lesotho, Nmibi, Romni, Rwnd nd South Afric. In 216, drug resistnce surveys were ongoing in 11 countries, with the first ntionwide surveys in seven countries (Burkin Fso, the Democrtic Republic of the Congo, Ghn, Indi, Indonesi, Lo People s Democrtic Republic nd Sudn) nd repet surveys in four countries (Chin, Côte d Ivoire, Swzilnd nd Zimbbwe) Estimtes of the disese burden cused by MDR/RR-TB In previous globl TB reports, estimtes of the burden of drug-resistnt TB hve focused on MDR-TB (defined s resistnce to rifmpicin nd isonizid, the two most effective nti-tb drugs). In My 216, WHO issued guidnce 2 tht people with TB resistnt to rifmpicin, with or without resistnce to other drugs, should be treted with n MDR- TB tretment regimen. This includes ptients with MDR-TB s well s ny other ptient with TB resistnt to rifmpicin (referred to in this report s MDR/RR-TB). Following tht guidnce, estimtes of the burden of MDR/RR-TB re required for ssessing progress in detection of cses with drug-resistnt TB nd tretment coverge. Globlly in 215, n estimted 3.9% (95% confidence intervl [CI]: %) of new cses nd 21% (95% CI: 15 28%) of previously treted cses hd MDR/RR-TB (Tble 3.5). The proportions of new nd previously treted TB cses with MDR/RR-TB t the country level re shown in Fig nd Fig There were n estimted 58 (rnge, ) incident cses of MDR/RR-TB in 215, with cses of MDR-TB ccounting for 83% of the totl (Tble 3.5). The number of MDR-TB incident cses (48 ) is in line with the estimte published in 215. The countries with the lrgest numbers of MDR/RR-TB cses (45% of the globl totl) re Chin, Indi nd the Russin Federtion (Fig. 3.2). There were bout 25 (rnge, ) deths from MDR/RR-TB in 215. The best estimte is slightly higher thn estimtes of deths from MDR-TB published in recent globl TB reports, due to the inclusion of deths from ll cses with RR-TB (nd not only those with MDR-TB). 1 For full list of the high TB burden nd high MDR-TB burden countries, see Chpter 2. 2 World Helth Orgniztion. WHO tretment guidelines for drugresistnt tuberculosis (216 updte) (WHO/HTM/TB/216.4). Genev: WHO; 216 ( drug-resistnt-tb/mdrtbguidelines216.pdf,). 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 WHO-recommended dignostic tests. Globlly in 215, there were n estimted 34 (rnge, ) MDR/RR-TB cses mong notified TB ptients. Country-specific estimtes re presented nd discussed in Chpter Trends in drug resistnce Of the 4 countries with high TB or MDR-TB burden (or both), only 2 hve repeted survey t lest once to evlute trends in drug resistnce. Among these countries, eight hve t lest 3 yers of dt: Belrus, Kzkhstn, Mynmr, Peru, Republic of Moldov, Tomsk Oblst in the Russin Federtion, Thilnd nd Viet Nm. For these settings, 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 re shown in Fig 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 second-line nti-tb drugs nd pyrzinmide By the end of 215, extensively drug-resistnt TB (XDR- TB) 3 hd been reported by 117 WHO Member Sttes. Of these, 88 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 9.5% (95% CI: %), similr to estimtes for previous yers (9.7% in 214 nd 9.% in 213). Among the 4 countries with high TB or MDR-TB burden, 21 hve surveillnce dt on resistnce to secondline nti-tb drugs, but only six hve estblished ntionl continuous surveillnce system for second-line drug resistnce mong ptients with MDR-TB. The proportion of MDR-TB cses with resistnce to ny fluoroquinolone for which testing ws done including ofloxcin, levofloxcin nd moxifloxcin ws 21.% (95% CI: %). A totl of 51% (3 7%) of ptients with MDR-TB hve resistnce to fluoroquinolone or second-line injectble gent, or both. Levels of resistnce to fluoroquinolones nd pyrzinmide mong ll TB cses hve been studied in multicountry surveillnce project; results re summrized in Box XDR-TB is defined s MDR-TB plus resistnce to t lest one fluoroquinoline nd second-line injectble gent. 38 :: GLOBAL TUBERCULOSIS REPORT 216

50 :: TABLE 3.5 Estimted incidence of MDR/RR-TB in 215 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 BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL NUMBER (IN 1s) UNCERTAINTY INTERVAL UNCERTAINTY (IN 1s) RATE b INTERVAL % OF MDR AMONG MDR/RR-TB 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 High MDR/RR-TB burden countries Afric The Americs Estern Mediterrnen Europe South-Est Asi Western Pcific Globl Best estimtes re for the ltest vilble yer. b Rtes re per 1 popultion. GLOBAL TUBERCULOSIS REPORT 216 :: 39

51 :: FIG Percentge of new TB cses with MDR/RR-TB Percentge of cses >18 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 the yer 21 re not shown. :: FIG Percentge of previously treted TB cses with MDR/RR-TB Percentge of cses >5 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 the yer 21 re not shown. The high percentges of previously treted TB cses with MDR-TB in Bhms, Bhrin, Belize, Bonire Sint Eusttius nd Sb, French Polynesi nd So Tomé nd Principe refer to only smll number of notified cses (rnge: 1-8 notified previously treted TB cses). 4 :: GLOBAL TUBERCULOSIS REPORT 216

52 :: FIG. 3.2 Estimted incidence of MDR/RR-TB in 215, for countries with t lest 1 incident cses. Ares tht re not pplicble re in grey. Russin Federtion 6 Chin 7 Number of incident cses Indi :: Box 3.6 Resistnce to pyrzinmide nd fluoroquinolones: summry of results from the first surveys in five countries The combintion of pyrzinmide plus fourth-genertion fluoroquinolone (moxifloxcin or gtifloxcin) is considered essentil in novel rifmpicin-spring regimens for the tretment of TB nd in shorter regimens for the tretment of MDR-TB. Understnding the bckground prevlence t popultion level of resistnce to these drugs is importnt to ssess the fesibility of introducing new nd shorter regimens in TB control progrmmes. Although levels of resistnce to rifmpicin nd isonizid re monitored in most TB-endemic countries through drug-resistnce surveys, testing for susceptibility to fluoroquinolones nd pyrzinmide is not routinely performed s prt of surveillnce efforts. Therefore, popultionrepresenttive surveillnce dt on levels of resistnce to these drugs re limited. To strt to ddress this knowledge gp, multicountry project ws coordinted by WHO in five countries Azerbijn, Bngldesh, Belrus, Pkistn nd South Afric enrolling more thn 5 ptients. Results from this project were published in My 216 nd summry is provided here. Levels of resistnce vried substntilly mong settings ( %). In ll settings, pyrzinmide resistnce ws significntly ssocited with rifmpicin resistnce (.5 4.2% mong rifmpicin-susceptible cses nd % mong rifmpicin-resistnt cses). Resistnce rnged from 1.% to 16.6% for ofloxcin, from.5% to 12.4% for levofloxcin nd from.9% to 14.6% for moxifloxcin when tested t.5 µg/ ml. High levels of ofloxcin resistnce were found in Pkistn. Resistnce to moxifloxcin nd gtifloxcin when tested t 2 µg/ml ws low in ll countries. Cross-resistnce ws high between ofloxcin nd levofloxcin (87%) nd between ofloxcin nd moxifloxcin (72%) when tested t.5 µg/ ml. Cross-resistnce ws very low between ofloxcin nd moxifloxcin nd gtifloxcin when tested t 2 µg/ml. The presence of rifmpicin resistnce, which currently is esily identified becuse of the wide vilbility of new rpid moleculr technology, should prompt ttention to the possibility of the simultneous presence of resistnce to pyrzinmide nd, in some settings, the erlier genertion fluoroquinolones. Resistnce to the ltest genertion fluoroquinolones t the clinicl brekpoint is still uncommon, finding tht supports current WHO recommendtions to use moxifloxcin or gtifloxcin in the tretment of MDR-TB. Zignol M, Den AS, Alikhnov N, Andres S, Cbibbe AM, Cirillo DM et l. Popultion-bsed resistnce of Mycobcterium tuberculosis isoltes to pyrzinmide nd fluoroquinolones: results from multicountry surveillnce project. Lncet Infect Dis. 216;16: ( ccessed 24 August 216). GLOBAL TUBERCULOSIS REPORT 216 :: 41

53 :: 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 TB cses per 1 popultion. The red line shows the number of MDR-TB cses mong new TB ptients per 1 popultion. Belrus Kzkhstn Mynmr % per yer -7% per yer % per yer 1-5% per yer 1-2% per yer 1 8% per yer TB nd MDR-TB cses per 1 popultion (log scle) Peru Republic of Moldov Tomsk Oblst, Russin Federtion % per yer -4% per yer % per yer 1 1 % per yer Thilnd Viet Nm 1 1 4% per yer 1% per yer % per yer 1 5% per yer 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 post-215. 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 215. Furthermore, indirect estimtes of prevlence suffer from considerble uncertinty, becuse they re derived from incidence nd ssumptions bout disese durtion. Hence, indirect estimtes of TB prevlence re not presented in this chpter. 1 These developments notwithstnding, in n importnt 1 WHO will continue to produce indirect estimtes of TB prevlence. These cn be provided upon request to tbdt@who.int. subset of countries with lrge proportion of the world s TB burden, ntionl TB prevlence surveys will 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 relted ssessment of ctions needed to reduce tht burden. This group of countries cn be brodly defined s those with reltively high burden of TB (bout 15 incident cses per 1 popultion) 2 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. In ddition, results from ntionl TB prevlence surveys cn inform estimtes of TB incidence nd mortlity, nd thus contribute to monitoring 2 In low- nd medium-burden countries, smple sizes nd costs for surveys become prohibitively lrge. 42 :: GLOBAL TUBERCULOSIS REPORT 216

54 :: FIG Globl progress in implementing ntionl surveys of the prevlence of TB disese, ctul (2 216) nd expected (217) 2 Chin Cmbodi 23 Mlysi 24 Indonesi 25 Eritre b 26 Thilnd 27 Viet Nm Philippines 28 Bngldesh b 29 Mynmr 21 Chin 211 Pkistn Cmbodi Ethiopi Lo PDR 212 Thilnd UR Tnzni Rwnd Nigeri Gmbi 213 Mlwi Ghn Sudn 214 Indonesi Zmbi Zimbbwe 215 Bngldesh Ugnd Keny Mongoli 216 Philippines DPR Kore 217 Viet Nm Mynmr South Afric Mozmbique Nepl In 27, 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 for the period up to the end of 215. In Afric, these countries included Ethiopi, Ghn, Keny, Mlwi, Mli, Mozmbique, Nigeri, Rwnd, Sierr Leone, South Afric, Ugnd, UR Tnzni nd Zmbi. In Asi, these countries included Bngldesh, Cmbodi, Chin, Indonesi, Mynmr, Pkistn, Philippines, Thilnd nd Viet Nm. b The ntionl survey 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. of progress towrds SDG nd End TB Strtegy trgets. For these resons, the sttus of progress in implementtion of ntionl TB prevlence surveys, nd summries of key results, will continue to be fetured in globl TB reports. There hs lredy been substntil progress in the number of countries tht hve implemented ntionl TB prevlence survey. This ws prticulrly the cse during the period , when 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). The Tsk Force hs retined ntionl TB prevlence surveys in selected countries 1 within its strtegic res of work 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 b) countries 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 lso 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. Countries in which surveys hve been implemented since 2 or re plnned in the ner future re shown in Fig nd Fig Between 29 nd August 216, n unprecedented number of ntionl TB prevlence surveys were completed: 22 in totl, of which 12 were in Africn countries nd 1 in Asin countries. A mjor development in 216 ws decision to implement ntionl TB prevlence survey in Indi (Box 3.3). Results in terms of the number of cses detected in surveys nd prevlence per 1 popultion re shown for surveys implemented since 29 in Tble 3.6. All of these surveys used the screening nd dignostic methods recommended in WHO s hndbook on ntionl TB prevlence surveys. 2 A comprison of estimtes of TB prevlence before nd fter the implementtion of ntionl survey is shown for the 19 countries tht completed survey (nd finlized results) between 29 nd August 216 in Fig Post-survey prevlence estimtes were lmost lwys more precise (i.e. hd nrrow uncertinty intervls). For 12 countries, estimtes were within the 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. Estimtes of TB incidence tht hve been derived from prevlence survey re shown in Fig This comprison shows tht post-survey estimtes of TB incidence sometimes hve wider uncertinty intervls. This occurred when pre-survey estimtes of incidence were bsed on cse notifiction dt nd expert opinion (i.e. method 1 s explined in Section 3.1 nd s shown in Fig. 3.1); in severl countries, uncertinty (bsed on the rnge of plusible incidence vlues elicited from experts) ws understted. This demonstrtes nd reinforces the importnce of direct mesurements of TB disese burden s opposed to indirect estimtes tht rely on expert opinion, s emphsized by the WHO Globl Tsk Force on TB Impct Mesurement since its estblishment in 26 (Box 3.1). A recent nd more detiled presenttion nd discussion of results nd lessons lernt from ntionl TB prevlence surveys is vilble on the Tsk Force website. 3 Exmples of how survey dt cn provide importnt insights into the distribution of TB disese by ge, sex nd loction, s well s differences in detection nd reporting of cses by ge nd sex, re provided in Section World Helth Orgniztion. Tuberculosis prevlence surveys: hndbook (WHO/HTM/TB/21.17). Genev: WHO; 211 (www. who.int/tb/dvisory_bodies/impct_mesurement_tskforce/ resources_documents/thelimebook/, ccessed 24 August 216). 3 tskforce/meetings/tf6_p6_prevlence_surveys_29_215. pdf?u=1 GLOBAL TUBERCULOSIS REPORT 216 :: 43

55 :: 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 216) No survey plnned Survey plnned b Survey ongoing c One survey completed d Repet survey plnned Repet survey ongoing 1 repet survey completed e Not pplicble Screening methods include field chest X-ry; culture is used to confirm dignosis. For current surveys ongoing in Bngldesh, Keny nd the Philippines, culture nd Xpert MTB/RIF re used to confirm dignosis. b A country hs submitted t lest drft survey protocol nd budget pln to the WHO Globl Tsk Force on TB Impct Mesurement. c Countries were implementing field opertions in August 216 or were undertking dt clening nd nlysis. d 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. e A repet ntionl survey is one in which prticipnts were screened with chest X-ry, nd culture exmintion ws used to dignose TB cses. :: FIG Estimtes of TB prevlence (ll ges, ll forms of TB) for 19 countries, before (in blue) nd fter (in red) survey results from ntionl TB prevlence surveys becme vilble. Pnels re ordered ccording to the before-fter difference. Asi Afric Lo PDR Indonesi Mongoli Cmbodi Thilnd Chin Pkistn Mynmr UR Tnzni Mlwi Ghn Nigeri Zmbi Ugnd Rwnd Sudn Zimbbwe Ethiopi Gmbi Prevlence per 1 popultion (log scle) 44 :: GLOBAL TUBERCULOSIS REPORT 216

56 :: TABLE 3.6 Number of TB cses found in ntionl TB prevlence surveys implemented , nd ssocited estimtes of the prevlence of pulmonry TB in dults (ged 15 yers) COUNTRY MAIN YEAR(S) OF SURVEY NUMBER OF SMEAR- POSITIVE CASES NUMBER OF BACTERIOLOGICALLY CONFIRMED CASES PREVALENCE PER 1 POPULATION: SMEAR-POSITIVE CASES PREVALENCE PER 1 : BACTERIOLOGICALLY CONFIRMED CASES BEST ESTIMATE 95% CONFIDENCE INTERVAL BEST ESTIMATE 95% CONFIDENCE INTERVAL Cmbodi Chin Ethiopi Gmbi Ghn Indonesi Lo PDR Mlwi Mongoli Mynmr Nigeri Pkistn Rwnd Sudn UR Tnzni b Thilnd c Ugnd Zmbi Zimbbwe Estimtes bsed upon the use of robust stndrd errors with missing vlue imputtion nd inverse probbility weighting for ll countries except for Cmbodi, Mynmr nd UR Tnzni which used cluster level model of nlysis without imputtion. b Lbortory chllenges ment tht it ws only possible to directly estimte the prevlence of smer-positive (s oppose to bcteriologiclly confirmed) TB. c Dt excludes clusters from the cpitl city, Bngkok. :: FIG Estimtes of TB incidence (ll ges, ll forms of TB) for 13 countries tht implemented ntionl TB prevlence survey in the period , before (in blue) nd fter (in red) survey results becme vilble Asi Afric Nigeri Mongoli UR Tnzni Mlwi Ghn Thilnd Ugnd Zmbi Sudn Indonesi Rwnd Gmbi Zimbbwe Incidence per 1 popultion per yer (log scle) GLOBAL TUBERCULOSIS REPORT 216 :: 45

57 :: FIG Globl nd regionl estimtes of TB incidence disggregted by ge nd sex Globl Adults Children Regionl AFR Femle children EMR AMR EUR SEAR WPR Mle children Femle Femle dults Mle Mle dults The totl re represents globl TB incidence nd ll rectngles re proportionl to their shre of totl TB incidence. 3.5 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 disggregted by ge nd sex were produced by ssuming tht the mle to femle (M:F) rtio of notified cses (with dults nd children considered seprtely) ws the sme s the rtio for incident cses. This ssumption is resonble for children (defined s people ged under 15 yers), 1 but is recognized to be problemtic for some countries, given evidence from recent prevlence surveys tht cse detection nd reporting gps re often lrger for dult men compred with dult women (Section 3.6.1). Resulting estimtes my thus understte the burden of TB in men compred with women. For 113 countries, (ll of which were middle- or highincome countries in 215), estimtes of TB deths mong HIV-negtive dults were produced using ge nd sex-disggregted mortlity dt from VR systems. For countries without VR dt, estimtes were produced using n imputtion model tht included risk fctors known to be ssocited with TB mortlity. TB deths mong HIV-positive people were disggregted by ge nd sex using the ssumption tht the M:F nd children:dult rtios re similr to the corresponding rtios of AIDS deths estimted by the Joint United Ntions Progrmme on HIV/AIDS (UN- AIDS). 1 Adults re defined s those ged 15 yers becuse this is consistent with the ge ctegories for which notifiction dt re reported, nd with the cut-off used in current guidelines to define people eligible to prticipte in TB prevlence survey. Detils of the methods used re provided in the online technicl ppendix TB incidence disggregted by ge nd sex Estimtes of TB incidence re shown for mles nd femles, both in totl nd by ge group (dults nd children), in Fig Globlly in 215, there were n estimted 6.4 million (rnge, 5.7 million to 7.2 million) incident cses of TB mong mles, of which 5.9 million (rnge, 5.3 million to 6.7 million) were dults nd.47 million (rnge,.42 million to.53 million) were children. There were 4. million (rnge, 3.1 million to 4.9 million) incident cses of TB in femles, of which 3.5 million (rnge, 2.7 million to 4.4 million) were dults nd.48 million (rnge,.41 million to.56 million) were children. These numbers correspond to 62% of cses being mles nd 38% femles, nd 9% of cses being dults nd 1% children. Further brekdowns by HIV sttus re not possible, becuse dt on the HIV sttus of TB cses by ge nd sex re not vilble. The M:F rtio of incident TB cses for ll ges rnged from 1.1 in the WHO Estern Mediterrnen Region to 2. in the Western Pcific Region. Similr M:F rtios were estimted for dults, wheres for children the M:F rtio rnged from.9 in the WHO Estern Mediterrnen Region to 1.1 in the Western Pcific Region. Most of the estimted cses mong mles in 215 were in Asi (63%) nd the WHO Africn Region (25%), 3 wheres for femles the percentges were 58% for Asi nd 28% for the WHO Africn Region, respectively. For children, the top three regions were the WHO South-Est Asi Region with 4% of incident TB cses in 215, followed by the Africn Region with 31% nd the Western Pcific Region with 14%. 2 The online technicl ppendix is vilble t 3 Asi refers to the WHO Regions of South-Est Asi nd the Western Pcific. 46 :: GLOBAL TUBERCULOSIS REPORT 216

58 :: TABLE 3.7 HIV-negtive nd HIV-positive TB mortlity by ge (children nd dults), globlly nd for WHO regions, 215 HIV-NEGATIVE WHO REGION BEST ESTIMATE TOTAL 14 YEARS MALE 15 YEARS FEMALE 15 YEARS 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 Globl HIV-POSITIVE WHO REGION BEST ESTIMATE TOTAL 14 YEARS MALE 15 YEARS FEMALE 15 YEARS 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 Globl :: FIG The ge distribution of dult TB cses detected in prevlence surveys implemented Asi Afric 8 Cmbodi Rte per 1 popultion Lo PDR Pkistn Indonesi Mynmr Thilnd Chin UR Tnzni Zimbbwe Mlwi Nigeri Zmbi Ghn Ugnd Gmbi Rwnd Sudn Ethiopi Age group (yers) Age group (yers) GLOBAL TUBERCULOSIS REPORT 216 :: 47

59 :: FIG The mle:femle rtio of dult TB cses detected in prevlence surveys implemented Smer-positive Ugnd Rwnd Gmbi Chin Mongoli Thilnd Mynmr Indonesi Lo PDR Nigeri Cmbodi Zmbi Sudn Pkistn Mlwi Zimbbwe Ghn Ethiopi UR Tnzni Sex rtio (mle:femle) Bcteriologiclly confirmed Sex rtio (mle:femle) Lbortory chllenges during the survey in UR Tnzni ment tht it ws only possible to directly estimte the prevlence of smer-positive (s oppose to bcteriologiclly confirmed) TB TB mortlity disggregted by ge nd sex Estimtes of TB mortlity disggregted by ge nd sex re shown in Tble 3.7. 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 215, there were n estimted.86 million (rnge,.77 million to.95 million) deths from TB mong HIV-negtive men. There were n dditionl.35 million (rnge,.27 million to.45 million) deths from TB mong HIV-negtive women, nd.17 million (rnge,.15 to.19 million) mong children. These numbers correspond to 62% of deths being in men, 25% in women, nd 13% in children. Higher numbers of TB deths mong men re consistent with the estimte tht 62% of incident cses were mong men in 215, nd with evidence from prevlence surveys tht show tht TB disese ffects men more thn women (Fig. 3.28) nd tht cse detection nd reporting gps re higher mong men (Fig. 3.29). The WHO South-Est Asi nd Africn regions ccounted for more thn 8% of TB deths mong HIV-negtive people. TB mortlity mong HIV-positive people There were n estimted.2 million (rnge,.18 million to.23 million) TB deths mong HIV-positive men,.14 million (rnge,.12 million to.17 million) mong HIVpositive women nd.4 million (rnge,.3 million to.5 million) mong HIV-positive children in 215 (Tble 3.7). The WHO Africn Region ccounted for 75% of these deths, where the M:F rtio ws close to one. The M:F rtio in other regions vried from bout 2 to Disggregted nlysis of TB surveillnce nd survey dt Disggregted nlysis of ntionl TB surveillnce nd survey dt is importnt to understnd how the TB epidemic vries geogrphiclly nd which popultion groups re most ffected. The results cn be used to inform ntionl nd locl response efforts, including strtegic lloction of resources. The importnce of such within-country nlyses nd disggregtion of key indictors is emphsized within the End TB Strtegy nd the SDGs (Chpter 2). This section showcses exmples of such nlyses TB prevlence survey dt disggregted by ge, sex nd loction Results from ntionl TB prevlence surveys (Section 3.4) provide representtive dt bout the distribution of TB disese by ge (in dults) nd sex. The prevlence of disese per 1 popultion for three ge groups found in surveys implemented in is shown in Fig In Asi nd some Africn countries (e.g. Ghn, Mlwi, Rwnd, the United Republic of Tnzni nd Zimbbwe), prevlence increses with ge. In severl Africn countries (e.g. Ethiopi, Gmbi, Nigeri, Sudn, Ugnd nd Zmbi), however, prevlence per 1 popultion peks mong those ged yers. The M:F rtio of cses for the sme set of surveys is shown in Fig These show systemticlly higher burden of TB disese mong men, with rtios rnging from 1.5 (in Ethiopi) to 6. (in Rwnd) 48 :: GLOBAL TUBERCULOSIS REPORT 216

60 :: FIG The prevlence:notifiction (P:N) rtio of dult TB cses in prevlence surveys implemented Nigeri Mongoli Lo PDR Sudn UR Tnzni Pkistn Ugnd Mlwi Ghn Zimbbwe Indonesi Mynmr Zmbi Thilnd Cmbodi Chin Rwnd Ethiopi Gmbi P:N rtio The P:N rtio is for smer-positive TB, except for Ugnd nd Zimbbwe where it is bsed on bcteriologiclly confirmed TB. Notifiction dt re from the min yer of the survey (shown in Fig. 3.22). :: FIGURE 3.29b The prevlence to notifiction (P:N) rtio by sex for dult TB cses in prevlence surveys implemented Nigeri Mongoli Lo PDR Sudn UR Tnzni Pkistn Ugnd Mlwi Ghn Zimbbwe Indonesi Mynmr Zmbi Thilnd Cmbodi Chin Rwnd Ethiopi Gmbi Mle Femle P:N rtio The P:N rtio is for smer-positive TB, except for Ugnd nd Zimbbwe where it is bsed on bcteriologiclly confirmed TB. Notifiction dt re from the min yer of the survey (shown in Fig. 3.22). for smer-positive TB, nd from 1.2 (in Ethiopi) to 4.5 (in Viet Nm) for bcteriologiclly confirmed TB. The rtio of prevlence to notifiction (P:N) cn be used to ssess detection nd reporting gps (Fig. 3.29), nd vrition in these gps by ge nd sex (Fig. 3.29b). The P:N rtios from surveys implemented in indicte tht women re probbly ccessing vilble dignostic nd tretment services more effectively thn men. The higher disese burden in men, combined with lrger detection nd reporting gps, lso suggests tht strtegies to improve ccess to nd use of helth services mong men re required. Due to smple-size requirements, fesibility nd budget restrictions, most of the ntionl TB prevlence surveys crried out since 2 produced single ntionl estimte of high sttisticl precision. However, there cn still be vlue in subntionl estimtes, especilly for hypothesis building, nd to identify potentil priority res for further evidence genertion nd subsequent ction. In Nigeri, the ntionl TB progrmme (NTP) identified sttes tht hd high levels of TB prevlence but lrge gps in surveillnce systems in terms of the ctul number of cses being detected, treted nd notified (Fig. 3.3) The cse ftlity rtio disggregted by ge, sex nd loction n exmple from Brzil As explined in Section 3.2.4, the CFR is the proportion of people with TB who die from the disese, nd it is n importnt indictor for monitoring progress towrds SDG nd End TB Strtegy milestones set for 22 nd 225. :: FIG. 3.3 Sctter-plot of stte-level dult, pulmonry TB prevlence nd cse notifiction rtes in Nigeri (212) TB cse notifiction per 1 popultion TB prevlence per 1 popultion Source: NTP dtbse nd first ntionl TB prevlence survey, Nigeri. 1 GLOBAL TUBERCULOSIS REPORT 216 :: 49

61 :: FIG The verge vlue nd rnge (minimum mximum) in the CFR by stte in Brzil, Algos Tocntins Rio de Jneiro Pernmbuco Goiás Rio Grnde do Sul Mrnhão Sergipe Bhi Piuí Mins Geris Ampá Espirito Snto Mto Grosso do Sul Pr Brsil Rio Grnde do Norte Príb Cer Prná Mto Grosso Distrito Federl Amzons São Pulo Rorim Rondôni Snt Ctrin Acre 4 8 CFR (%) 12 Reching the milestones for reductions in the number of TB deths requires the CFR t globl level to fll to 1% by 22 nd to 6.5% by 225. The CFR is one of the top priority indictors for monitoring implementtion of the End TB Strtegy (Chpter 2). In countries with ntionl notifiction nd VR systems of sufficient qulity nd coverge, the number of TB deths mesured using ntionl VR dt divided by the number of notified new nd relpse cses in the sme time period provides good pproximtion of the CFR. Since notifiction nd VR dt re vilble for subntionl res nd re disggregted by ge nd sex, the CFR cn then be estimted for subntionl res nd subpopultions (in ddition to the globl nd ntionl estimtes discussed in Section 3.2.4). This is useful becuse it cn help to identify withincountry inequlities nd inequities in ccess to TB dignosis nd tretment. If everyone hd similr nd good ccess to dignosis nd tretment, for exmple, the CFR should be low for ll res nd subpopultions. Brzil is n exmple of high TB burden country tht hs both VR system (clled SIM) of ntionl coverge 1 nd notifible disese surveillnce system (clled SINAN) tht 1 is thought to cpture most incident cses of TB (the best estimte is 87%, s shown in the country profile for Brzil in Annex 2). It thus provides good exmple of how CFRs cn be ssessed t subntionl level nd for subpopultions. The distribution of the CFR in Brzil by stte in the yers is shown in Fig b. There ws two-fold difference in the verge CFR between the stte with the highest verge CFR (Algos, 11.3%) nd the stte with the lowest verge CFR (Acre, 5.7%). The distribution of the CFR by sex in 214 is shown in Fig. 3.31c. The CFR ws higher mong mles thn femles, lthough there ws considerble overlp between the two distributions. 2 The reltionship between the CFR nd ge in 214 is shown in Fig. 3.31d. This shows positive reltionship between ge nd the CFR, with mrked differences between those ged yers nd those ged over 6 yers. The vrition in the CFR estimted in Brzil probbly reflects combintion of differences in cse detection, the qulity of cre nd the coverge of reporting. These cn be further explored through record-linkge studies using the 2 The violin plots shown in Fig. 3.31c-d re similr to box plots, but they lso show the probbility density of the dt t different vlues. 5 :: GLOBAL TUBERCULOSIS REPORT 216

62 :: FIG. 3.31b The verge CFR by stte in Brzil, :: FIG. 3.31c The distribution of stte CFRs by sex in Brzil, 214. Horizontl segments denote the verge. 12 CFR (%) 8 CFR (%) N 4 Mle Femle These violin plots re used to visulise the distribution of the dt nd its probbility density. It is combintion of box plot nd density plot tht is rotted nd plced on ech side, to show the distributionl shpe of the dt. The boundries nd nmes shown nd the designtions used on this mp do not imply the expression of ny opinion whtsoever on the prt of the World Helth Orgniztion concerning the legl sttus of ny country, territory, city or re or of its uthorities, or concerning the delimittion of its frontiers or boundries. :: FIG. 3.31d The distribution of stte CFRs by ge in Brzil, 214. Horizontl segments denote the verge CFR (%) Age group These violin plots re used to visulise the distribution of the dt nd its probbility density. It is combintion of box plot nd density plot tht is rotted nd plced on ech side, to show the distributionl shpe of the dt. GLOBAL TUBERCULOSIS REPORT 216 :: 51

63 :: Box 3.7 Promoting the nlysis nd use of disggregted dt for policy, plnning nd progrmmtic ction :: FIG. B Subntionl TB notifictions (new nd relpse, 215) from Ghn, Guine, Nigeri nd Sierr Leone Guine Ghn N Notifiction rte per 1 popultion Sierr Leone Nigeri The boundries nd nmes shown nd the designtions used on this mp do not imply the expression of ny opinion whtsoever on the prt of the World Helth Orgniztion concerning the legl sttus of ny country, territory, city or re or of its uthorities, or concerning the delimittion of its frontiers or boundries. Strong TB surveillnce systems llow the TB epidemic to be trcked t ntionl level, nd for subntionl res nd specific popultion groups, using routinely collected dt. The results cn be used to inform ntionl nd locl response efforts, including strtegic lloction of resources. As prt of efforts to improve the vilbility nd fcilitte the nlysis of disggregted TB surveillnce dt by ge, sex nd loction, pilot workshop ws held in My 216 with the NTPs of 16 countries in west Afric.,b In TB epidemiologicl reviews (Fig. 3.1b), common finding ws tht historicl subntionl dt were stored in multiple seprte spredsheets tht mde it difficult to use the vilble dt. In response to this finding, preprtions for the workshop included the development of stndrd pltformc for sfegurding nd nlysing subntionl notifiction nd tretment outcome dt. This pltform ws developed using the DHIS2 softwre,d which is open source nd is lredy used for collecting, mnging, visulizing nd exploring helth nd other dt in mny countries. The stndrd pltform ws designed to be suitble for compiltion of TB dt from recording nd reporting systems tht use either the 26 or the 213 versions of the WHO reporting frmework,e,f nd cn be used to conduct the nlyses recommended in the WHO hndbook for understnding nd using TB dt.g For the pilot workshop in west Afric, dt entry focused on the first dministrtive level (e.g. province). However, the pltform cn lso cpture dt t lower levels, such s districts or individul helth fcilities. Subntionl popultion estimtes, if vilble disggregted by ge nd sex, cn lso be entered. This requires coordintion with ntionl census gencies, unless lredy vilble (s my be the cse in countries using DHIS s their helth mngement informtion system). Geogrphic informtion system (GIS) 52 :: GLOBAL TUBERCULOSIS REPORT 216 shpe-files cn lso be imported into the pltform, llowing for genertion of mps for vilble surveillnce indictors. Exmples of the nlyses tht cn be generted re shown in Fig. B The estblishment of this DHIS2 pltform could lso provide the bsis for prospective collection of ggregte-level dt for countries still using pper-bsed TB surveillnce system or for countries tht re in the process of trnsitioning to ntionl cse-bsed TB surveillnce solution. The next multi-country workshop is scheduled for centrl nd est Africn countries towrds the end of 216, nd is expected to be followed by further workshops in other prts of the world. b c d e f g For further detils, plese see Bckground Document 2b prepred for the April 216 meeting of the Tsk Force, vilble t tb/dvisory_bodies/impct_mesurement_tskforce/meetings/tf6_ bckground_3b_drtb_burden.pdf?u=1 The 16 countries were Benin, Burkin Fso, Cpe Verde, Gmbi, Ghn, Guine Conkry, Guine Bissu, Ivory Cost, Liberi, Mli, Muritni, Niger, Nigeri, Senegl, Sierr Leone nd Togo. They re prt of the West Afric Reserch Network for TB tht hs been estblished by the Specil Progrmme for Reserch nd Trining in Tropicl Diseses (TDR) TB_26.373_eng.pdf 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 15 August 215). World Helth Orgniztion. Understnding nd using tuberculosis dt. Genev: WHO Globl Tsk Force on TB Impct Mesurement; 214 ( dt/en/, ccessed 24 August 216).

64 SIM nd SINAN cse-bsed dtbses, followed by ctions s pproprite to ddress gps in detection, tretment or reporting TB cse notifiction nd tretment outcome dt disggregted by ge, sex nd loction Dt on TB cse notifictions nd the tretment outcomes of notified cses re routinely collected in most countries, nd for the pst decde bout 2 countries nd territories hve reported ntionl dt to WHO in nnul rounds of globl TB dt collection (Chpter 1 nd Chpter 4). This hs been fcilitted by stndrd recording nd reporting frmework tht ws first developed by WHO in the mid- 199s, with subsequent updtes in 26 nd most recently in Most (98%) countries tht reported 215 notifiction dt to WHO were ble to disggregte notifictions of new nd relpse (incident) cses by ge nd sex; these dt re shown in Chpter 4 (see in prticulr Fig. 4.2) s well s in Annex 2 nd Annex 4. 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 (Fig. 3.1). Moreover, s prt of the WHO Globl Tsk Force on TB Impct Mesurement s fifth strtegic res of work for (Box 3.1), incresed ttention is being given to the nlysis nd use of subntionl dt. This hs strted with n inititive to provide pltform tht llows sfegurding of subntionl TB cse notifiction nd tretment outcome dt for s mny yers s possible, while t the sme time fcilitting nlysis nd use of dt to inform policy, plnning, budgeting nd resource mobiliztion. The pltform hs been built using the open source DHIS2 softwre, 2 nd its use ws piloted s prt of the preprtions for nd implementtion of regionl workshop for 16 countries in West Afric in My 216. Its use will be expnded to other countries lter in 216 nd in 217. Further detils, including exmples of the nlyses tht cn be produced, re provided in Box 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 15 August 215). The document vilble online includes few updtes mde in GLOBAL TUBERCULOSIS REPORT 216 :: 53

65 Chpter 4 :: Dignosis nd tretment: TB, HIVssocited TB nd drug-resistnt TB :: KEY FACTS AND MESSAGES In 215, 6.4 million people with TB were notified to ntionl TB progrmmes (NTPs) nd reported to WHO. Of these, just over 6.1 million hd n incident episode (new or relpse) of TB. The number of new nd relpse TB cses notified nd the notifiction rte per 1 popultion incresed globlly in , mostly explined by 34% increse in notifictions in Indi. In 215, 3% of the 3.4 million new bcteriologiclly confirmed nd previously treted TB cses notified globlly were reported to hve hd DST for rifmpicin, with coverge of 24% for new TB ptients nd 53% for previously treted TB ptients. Globlly, cses of multidrug-resistnt TB or rifmpicin-resistnt TB (MDR/RR-TB) were detected nd notified in 215, nd were enrolled on tretment. Despite increses in notifictions of TB nd MDR/RR-TB, big detection nd tretment gps remin. In 215, the gp between notifictions of new nd relpse cses nd the best estimte of the number of incident cses ws 4.3 million, reflecting mixture of underreporting of detected TB cses (especilly in countries with lrge privte sectors) nd underdignosis (especilly in countries where there re mjor geogrphic or finncil brriers to ccessing cre). The gp between the number of MDR/RR-TB cses strted on tretment nd the number of notified cses estimted to hve MDR/RR-TB ws 25 (455 if compred with the estimted incidence of MDR/RR-TB). From globl perspective, closing detection nd tretment gps requires progress in prticulr subset of countries. Ten countries ccount for 77% of the totl estimted gp between incidence nd notifictions, with Indi, Indonesi nd Nigeri lone ccounting for lmost hlf of the totl. Five countries ccount for over 6% of the gp between enrolments on MDR-TB tretment in 215 nd the estimted number of incident MDR/RR-TB cses in 215: Chin, Indi, Indonesi, Nigeri nd the Russin Federtion. The globl mle:femle (M:F) sex rtio for notifictions ws 1.7, vrying from 1. in Pkistn to 3.1 in Viet Nm mong the high TB burden countries. 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 6.3% of the new nd relpse cses tht were notified in 215. Globlly in 215, 55% of notified TB ptients hd documented HIV test result, n 18-fold increse in testing coverge since 24. In the Africn Region where the burden of HIV-ssocited TB is highest, 81% of TB ptients hd documented HIV test result. The proportion of known HIV-positive TB ptients on ntiretrovirl therpy (ART) ws 78% globlly, nd bove 9% in Indi, Keny, Mlwi, Mozmbique, Nmibi nd Swzilnd. The only 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 6.2 million in 215, up from 55 in 211. Of the 48 countries in t lest one of the new lists of high burden countries, 15 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 215. These countries ccounted for 1% of the estimted globl number of incident TB cses in 215. The ltest tretment outcome dt show tretment success rtes of 83% for TB (214 cohort), 52% for MDR/RR-TB (213 cohort) nd 28% for XDR-TB (213 cohort). At lest 23 countries in Afric nd Asi hve introduced shorter regimens for tretment of MDR/RR-TB, which hve chieved high tretment success rtes (87 9%) under opertionl reserch conditions. A stndrdised shorter MDR-TB regimen of 9 12 months is now recommended in WHO guidnce issued in My 216 for ll ptients (excluding pregnnt women) with pulmonry MDR/RR-TB tht is not resistnt to second-line drugs. As prt of efforts to improve outcomes for MDR/XDR-TB, t lest 7 countries hd strted using bedquiline nd 39 countries hd used delmnid by the end of :: GLOBAL TUBERCULOSIS REPORT 216

66 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 those with TB re promptly dignosed nd effectively treted. Ptient-centred cre nd prevention, bcked by bold policies nd supportive systems (including universl helth coverge, UHC), re pillrs one nd two of the End TB Strtegy (Box 4.1). This chpter provides the ltest dt reported to WHO on the dignosis nd tretment of TB, HIV-ssocited TB nd drug-resistnt TB. Section 4.1 presents nd discusses dt for 215 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 in 215. 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 (presented in more detil in Chpter 3). Section 4.3 provides the most recent dt on tretment outcomes, for new nd relpse TB ptients, TB ptients coinfected with HIV, nd ptients with multidrug-resistnt TB (MDR-TB) 1 or rifmpicin-resistnt TB (RR- TB). 2 It lso contins informtion bout the use of shorter MDR-TB regimens for tretment of MDR/RR-TB (i.e. RR-TB cses including those with MDR-TB) nd the use of new nti-tb drugs for tretment of extensively drug-resistnt TB (XDR-TB). 3 Throughout the chpter, dt re presented t globl, regionl nd country levels, giving prticulr ttention to high burden countries (HBCs). 4 Further country-specific detils for ll of the indictors covered in this chpter re provided in Annex 2, Annex 4 nd t Cse notifictions nd testing coverge TB cse notifictions nd bcteriologicl confirmtion In 215, 6.4 million people with TB were notified to ntionl TB progrmmes (NTPs) nd reported to WHO (Tble 4.1). 1 MDR-TB is defined s resistnce to t lest isonizid nd rifmpicin, the two most powerful first-line nti-tb medicines. 2 WHO recommends n MDR-TB tretment regimen for ptients with RR-TB. This includes ptients with MDR-TB s well s ny other ptient with TB resistnt to rifmpicin (MDR/RR-TB). 3 XDR-TB is defined s MDR-TB plus resistnce to t lest one fluoroquinolone nd second-line injectble gent, the two most importnt clsses of medicines in the MDR-TB regimen. 4 For n explntion of how the three lists of HBCs (for TB, HIVssocited TB nd MDR-TB) fetured in this chpter were defined, see Chpter 2. :: Box 4.1 Pillrs one nd two of the End TB Strtegy The first pillr of the End TB Strtegy is Integrted, ptient-centred cre nd prevention. It hs four components: erly dignosis of TB including universl drugsusceptibility 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 the first pillr is the topic of Chpter 5. The second pillr of the End TB Strtegy is bold policies nd supportive systems. It 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 the second pillr re primrily discussed in Chpter 6. For n overview of ll spects of the End TB Strtegy, see Chpter 2 (Box 2.3). Of these, just over 6.1 million hd new (incident) episode of TB (shown s the totl of new nd relpse cses), nd n dditionl hd been previously dignosed with TB but their tretment ws chnged to retretment regimen (nd they were re-registered s retretment cse). 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, before incresing in (Fig. 4.1). The increse since 213 is mostly explined by incresed notifictions in Indi (+34% between 213 nd 215), following the introduction of ntionl policy of mndtory notifiction, nd the rollout of ntionwide web-bsed nd cse-bsed reporting system (clled Nikshy ) tht fcilittes reporting of detected cses by cre providers in the public nd privte sectors. Further detils bout trends in notifictions nd comprisons with underlying estimtes of TB incidence re provided in Section GLOBAL TUBERCULOSIS REPORT 216 :: 55

67 :: TABLE 4.1 Notifictions of TB, TB/HIV nd MDR/RR-TB cses, globlly nd for WHO regions, 215 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 % 23% Europe % 14% South-Est Asi % 17% Western Pcific % 8% Globl % 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), 2 215, globlly nd for WHO regions. Shded res represent uncertinty bnds. Rte per 1 popultion per yer Afric The Americs Estern Mediterrnen Europe South-Est Asi Western Pcific Globl The distribution of notified cses in 215 by ge nd sex is shown globlly nd for WHO regions in Fig The globl mle:femle (M:F) sex rtio for notifictions ws 1.7. Among the 3 high TB burden countries, the rtio rnged from 1. in Pkistn to 3.1 in Viet Nm. Results from ntionl TB prevlence surveys of dults show higher M:F rtios (for exmple, M:F rtio of 4.5 in Viet Nm), indicting tht notifiction dt understte the shre of the TB burden ccounted for by men in some countries (see Section in Chpter 3 for further detils). Children (ged <15 yers) ccounted for 6.3% 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. Elsewhere, nd most noticebly in the WHO Africn Region, notifiction rtes were highest mong younger dults. In severl estern Europen countries s well s four high TB burden countries Chin, Ppu New Guine, 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 relible helth cre services, or differentil reporting prctices. Extrpulmonry TB represented 15% of the 6.1 million incident cses tht were notified, rnging from 8% in the WHO Western Pcific Region to 23% in the Estern Medi- 56 :: GLOBAL TUBERCULOSIS REPORT 216

68 :: FIG. 4.2 New nd relpse TB cse notifiction rtes by ge nd sex in 215, 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 mke up 85% of reported cses. :: FIG. 4.3 Percentge of new nd relpse TB cses tht were children (ged <15), 215 Percentge No dt Not pplicble 214 dt were used for 17 countries. GLOBAL TUBERCULOSIS REPORT 216 :: 57

69 :: FIG. 4.4 Percentge of new nd relpse pulmonry TB cses with bcteriologicl confirmtion, 2 215, globlly nd for WHO regions Afric The Americs Estern Mediterrnen Europe Percentge bcteriologiclly confirmed 2 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 ws lso vilble. terrnen Region. Of the 5.2 million new nd relpse pulmonry TB ptients notified globlly in 215, 3. million (57%) were bcteriologiclly confirmed 1 (Tble 4.1). The remining ptients were dignosed cliniclly; tht is, bsed on symptoms, chest X-ry bnormlities or suggestive histology. Although the percentge of cses with bcteriologicl confirmtion worldwide hs remined stble over the pst 6 yers, there hve been improvements in the WHO Africn Region (56% to 64%), Europen Region (52% to 6%) nd Region of the Americs (71% to 78%) (Fig. 4.4). In contrst, there ws fll (from 54% to 38%) in the WHO Western Pcific Region, influenced by decline in bcteriologicl confirmtion of notified cses in Chin in recent yers. There is considerble vrition mong countries in the percentge of new nd relpse pulmonry TB ptients tht re bcteriologiclly confirmed (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. Most clinicl fetures of TB nd bnormlities on X-ry or histology results generlly ssocited with TB hve low specificity, which my led to flse dignoses of TB, nd hence to people being enrolled on TB tretment unnecessrily. PPM inititives nd schemes re integrl components 1 A bcteriologiclly confirmed cse is one from whom biologicl specimen is positive by smer microscopy, culture or WHOrecommended rpid dignostic, such s Xpert MTB/RIF. of ntionl TB strtegies, nd hve prticulr relevnce to HBCs in Asi nd Afric. The contribution of PPM to totl notifictions is shown in Tble 4.2 for countries tht hve been collecting nd reporting dt for severl yers. In these countries, public public mix interventions contributed 5 56% of totl notifictions in 215, nd publicprivte mix interventions contributed 6 48% of totl cse notifictions HIV testing for TB ptients nd screening for TB mong people living with HIV In 215, 3.4 million notified TB ptients hd documented HIV test result, equivlent to 55% of notified TB cses. This represented n 18-fold increse in testing coverge since 24, when WHO first requested countries to report dt (Fig. 4.6). In 215, the percentge of TB ptients with known HIV sttus ws highest in the WHO Africn Region (81%) nd the Americs (82%). The level of testing in the 3 high TB/HIV burden countries verged 64%, but vried considerbly from 11% in Indonesi to bove 75% in 18 countries (Fig. 4.7). Globlly, 15% of TB ptients with n HIV test result were HIV-positive. Among WHO regions, the highest figure ws in the Africn Region (36%). Overll, the percentge of TB ptients testing HIV-positive hs been flling globlly since 28 (Fig. 4.8). A totl of HIV-positive TB ptients were reported by NTPs in 215 (Tble 4.1). Systemtic screening for TB mong people living with HIV is recommended by WHO s n essentil component of the HIV cre pckge. In 215, 86 countries reported 58 :: GLOBAL TUBERCULOSIS REPORT 216

70 :: FIG. 4.5 Percentge of new nd relpse pulmonry TB cses with bcteriologicl confirmtion, 215 Percentge No dt Not pplicble 214 dt were used for 15 countries. :: TABLE 4.2 Contribution of public-public mix nd public-privte mix b to notifictions of TB cses in selected countries, 215 Contribution of public-public mix to notifictions of TB cses in selected countries, 215 COUNTRY NUMBER OF TB CASES NOTIFIED BY NON-NTP PUBLIC SECTOR CARE PROVIDERS IN 215 CONTRIBUTION OF NON- NTP PUBLIC SECTOR CARE PROVIDERS TO TOTAL CASE NOTIFICATIONS IN 215 (%) Chin Egypt Indi Indonesi Irn Irq Nigeri Philippines Sri Lnk Swzilnd Thilnd Viet Nm Contribution of public-privte mix b to notifictions of TB cses in selected countries, 215 COUNTRY NUMBER OF TB CASES NOTIFIED BY PRIVATE SECTOR CARE PROVIDERS IN 215 CONTRIBUTION OF PRIVATE SECTOR CARE PROVIDERS TO TOTAL NOTIFICATIONS IN 215 (%) Bngldesh Ethiopi Indi Indonesi Irn Keny Mlwi Mynmr Nigeri Pkistn Philippines UR Tnzni Includes ll contributions from non-ntp providers of cre in the public sector, including public hospitls, public medicl colleges, prisons/detention centres, militry fcilities, rilwys nd public helth insurnce orgniztions. b Privte sector providers include privte individul nd institutionl providers, corporte/business sector providers, mission hospitls, nongovernmentl orgniztions nd fith-bsed orgniztions. GLOBAL TUBERCULOSIS REPORT 216 :: 59

71 :: FIG. 4.6 Percentge of new nd relpse TB cses with documented HIV sttus, , globlly nd for WHO regions 1 Afric The Americs Estern Mediterrnen Europe 8 6 Percentge with documented sttus South-Est Asi Western Pcific Globl The clcultion is for ll cses in yers prior to 215. :: FIG. 4.7 Percentge of new nd relpse TB cses with documented HIV sttus, 215 Percentge No dt Not pplicble Dt for the Russin Federtion re for new TB ptients in the civilin sector only. 6 :: GLOBAL TUBERCULOSIS REPORT 216

72 :: FIG. 4.8 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. dt bout the number of TB cses notified from mong those newly enrolled in HIV cre (up from 59 countries in 213 nd 76 in 214). In totl, (1%) of the lmost 2.3 million people who were newly enrolled in HIV cre in 215 were notified s TB cses during the sme yer; dt for the 12 high TB/HIV burden countries tht reported dt re shown in Tble 4.3. Improvements in the coverge nd qulity of dt for this indictor re necessry to trck the impct of HIV cre, especilly ntiretrovirl therpy (ART), on the burden of TB in people living with HIV Rpid testing for TB Use of rpid tests fcilittes erly detection of TB. One of the 1 priority indictors for monitoring implementtion of the End TB Strtegy (shown in Chpter 2, Tble 2.1) is the percentge of new nd relpse TB cses tested with WHO-recommended rpid dignostic (WRD) t the time of dignosis. This nd other indictors relted to lbortory strengthening ctivities re prt of the Frmework of indictors nd trgets for lbortory strengthening under the End TB Strtegy developed in 216 (Box 4.2). In this first yer of reporting, 113 of 191 reporting countries nd territories indicted tht their routine surveillnce system cptures dt on the percentge of new nd relpse TB cses tested with WRD t the time of dignosis. However, further vlidtion of the dt s well s refinements to reporting systems re needed to improve dt ccurcy. The only WRD currently vilble for detection of TB nd rifmpicin resistnce is the Xpert MTB/RIF ssy (developed by Cepheid, USA). The originl WHO recommendtions in 21 prioritized its use s the initil dignostic test in individuls suspected of hving MDR-TB or HIV-ssocited TB, nd most HBCs hve dopted the originl WHO recommendtions into ntionl policy (Tble 4.4). A policy updte in 213 expnded the recommended :: TABLE 4.3. Number of people newly enrolled in HIV cre in 215 who were lso notified s TB cse in 215, 12 high TB/HIV burden countries tht reported dt NUMBER OF PEOPLE NEWLY ENROLLED IN HIV CARE IN 215 (A) NUMBER NOTIFIED AS A TB CASE IN 215 (B) NOTIFIED TB CASES AS A PERCENTAGE OF THOSE NEWLY ENROLLED IN HIV CARE (B A) Centrl Africn Republic % Chin % DR Congo % Ghn % Indi % Indonesi % Keny % Liberi % Mlwi % Mozmbique % Mynmr % South Afric % Totl % uses of the ssy, to include its use for the dignosis of TB in children, on selected specimens for the dignosis of extrpulmonry TB, nd for ll people suspected of hving pulmonry TB s replcement for microscopy (conditionl recommendtions). A growing number of countries hve lredy dopted ntionl lgorithms positioning Xpert MTB/RIF s the initil dignostic test for ll people suspected of hving pulmonry TB. Among the 48 countries in one or more of three new lists of HBCs, 15 hd dopted such lgorithms by the end of 215 (Tble 4.4). In 215, these 15 countries ccounted for 11% of globl notifictions of pulmonry TB cses nd 1% of the estimted globl number of incident TB cses. Between 21 nd 215, cumultive totl of 4672 GeneXpert instruments comprising modules were procured in the public sector in 122 of the 145 countries eligible for concessionl pricing. In 215, 6.2 million test crtridges were procured by eligible countries, up from 55 in 211. Of these, 45% (2.8 million) went to South Afric, but this percentge hs fllen from high of 63% in 213, reflecting incresing doption of the technology in other prts of the world. South Afric ccounted for 2% of the totl cumultive number of modules procured by the end of 215. Despite the significnt scle-up in procurement of crtridges globlly, instlled instruments re still underused in mny countries. Outside South Afric, the number of procured crtridges in 215 compred to the totl number of instrument modules reflects n verge rtio of only 1. test per module per working dy. GLOBAL TUBERCULOSIS REPORT 216 :: 61

73 :: Box 4.2 Strengthening the cpcity nd qulity of dignostic testing A well-equipped nd stffed, qulity-ssured lbortory network with n efficient specimen referrl system is n essentil requirement for ny NTP in the post-215 er. Strengthening TB lbortories involves not only deploying modern dignostics, but lso ensuring widespred ptient ccess with fst turnround time nd high-qulity dignosis. A WHO Frmework of indictors nd trgets for lbortory strengthening under the End TB Strtegy ws lunched in 216. It is intended to serve s guide for ll countries, with monitoring t globl level on progress towrds reching trgets. The indictors mesure the cpcity of progrmmes to detect ptients ccurtely nd rpidly using WRDs, provide universl DST, nd ensure qulity of testing t ech level of the lbortory network. Country cpcity for dignostic testing ws previously monitored ccording to indictors nd globl trgets describing numbers of microscopy centres per 1 popultion nd culture/dst lbortories per 5 million popultion. These trgets re no longer recommended, given the displcement of these technologies by new WRD technology in dignostic lgorithms nd the need for countryspecific trgets considering epidemiology nd ptient ccess (urbn or rurl popultions, specimen referrl systems, etc.). Recommended methods for setting country-specific trgets for numbers of tests nd fcilities for ech of the min dignostic technologies microscopy, WRDs (including Xpert MTB/RIF), culture nd DST hve been developed, nd re contined in n nnex to the frmework. Ensuring qulity of testing is criticl for ll dignostic methods. A comprehensive externl qulity ssessment (EQA) progrmme for smer microscopy should be implemented tht includes slide rechecking or pnel testing :: FIG. B4.2.1 The WHO TB Suprntionl Reference Lbortory Network Boston, USA Atlnt, USA Mexico City, Mexico Gudeloupe, Frnce Cotonou, Benin Stockholm, Sweden Copenhgen, Denmrk Rig, Ltvi Moscow, Russin Federtion Antwerp, Belgium Yekterinburg, Russin Federtion Novosibirsk, Russin Federtion London, UK Borstel, Germny Guting, Germny Prgue, Czech Republic Miln, Itly Zgreb, Croti Porto, Portugl Rome, Itly Brcelon, Spin Seoul, Republic of Kore Tokyo, Jpn Le Hmm, Algeri Ciro, Egypt New Delhi, Indi Chenni, Indi Kmpl, Ugnd Krchi, Pkistn (or both), nd regulr supervision visits. Of the 15 countries nd territories tht reported dt on the number of smer microscopy centres undergoing EQA in 215, only 62 (41%) indicted the existence of scheme tht covered ll centres in the country, with further 21 (14%) covering t lest 9% of centres. EQA progrmmes for Xpert MTB/RIF should include monitoring of key performnce indictors (t lest monthly, idelly using remote monitoring system tht receives dt vi connectivity solution), pnel testing nd regulr supervision visits; 54 of 114 reporting countries nd territories (47%) indicted hving comprehensive scheme in 215. Qulity-ssured DST is lso importnt to ensure ccurte detection of drug resistnce to inform tretment decisions nd to void flse dignoses. Of the 123 countries nd territories globlly reporting DST cpcity, 73 (59%) indicted tht ll of their DST lbortories hd demonstrted proficiency by pnel testing in 215. Estblishing comprehensive qulity mngement system in lbortories llows for the necessry ctivities to be crried out t the right time nd by the ppropritely trined people; for the necessry equipment nd consumbles to be in stock; nd for ll mnuls, guidelines, forms nd stndrd operting procedures to be in plce, so tht processes re crried out correctly. In 215, 78 of 153 responding countries nd territories (51%) indicted tht forml qulity mngement system towrds chieving ccredittion ws being implemented in ll lbortories conducting culture, line probe ssys (LPAs) or DST. As key prtner in strengthening the cpcity nd qulity of TB dignostic testing globlly, the WHO TB Suprntionl Reference Lbortory (SRL) Network comprises 36 lbortories tht provide benchmrk for proficiency testing, nd cn lso provide long-term technicl ssistnce to prtner countries under the frmework of collbortive Hong Kong, Chin SAR Bngkok, Thilnd greements (Fig. B4.2.1). In 216, the Centre for Tuberculosis t the Ntionl Institute for Communicble Diseses in Johnnesburg, South Afric becme the newest member of the network nd the third SRL in the WHO Africn Region. The numbers of fcilities by country in 215 tht were performing microscopy, Xpert MTB/RIF, culture, LPA, first nd second line DST cn be downloded from Sntigo, Chile Johnnesburg, South Afric Buenos Aires, Argentin Brisbne, Austrli Adelide, Austrli Suprntionl Reference Lbortory Suprntionl Reference Lbortory Coordinting Centre Cndidte Suprntionl Reference Lbortory Ntionl Centre of Excellence 62 :: GLOBAL TUBERCULOSIS REPORT 216

74 :: TABLE 4.4 Ntionl guidnce in plce on use of Xpert MTB/RIF in high burden countries, 215 YES NO HIGH TB BURDEN HIGH TB/HIV BURDEN HIGH MDR-TB BURDEN ALL PEOPLE PRESUMED TO HAVE TB NATIONAL POLICY STIPULATING XPERT MTB/RIF AS THE INITIAL DIAGNOSTIC TEST FOR: PEOPLE AT RISK OF HIV- ASSOCIATED TB PEOPLE AT RISK OF DRUG- RESISTANT TB CHILDREN PRESUMED TO HAVE TB EXTRA- PULMONARY TB USING SELECTED SPECIMENS Angol Azerbijn Bngldesh Belrus Botswn Brzil Cmbodi Cmeroon Centrl Africn Republic Chd Chin Congo DPR Kore DR Congo Ethiopi Ghn Guine-Bissu Indi Indonesi Kzkhstn Keny Kyrgyzstn Lesotho Liberi Mlwi Mozmbique Mynmr Nmibi Nigeri Pkistn Ppu New Guine Peru Philippines Republic of Moldov Russin Federtion Sierr Leone Somli South Afric Swzilnd Tjikistn Thilnd Ugnd Ukrine UR Tnzni Uzbekistn Viet Nm Zmbi Zimbbwe High TB burden countries 2% 8% 93% 77% 7% High TB/HIV burden countries 23% 8% 97% 77% 6% High MDR-TB burden countries 33% 83% 97% 8% 77% The 48 countries shown in the tble re the countries tht re in one or more of the three lists of high TB, TB/HIV nd MDR-TB burden countries (see lso Chpter 2, Figure 2.3 nd Tble 2.2). GLOBAL TUBERCULOSIS REPORT 216 :: 63

75 :: Box 4.3 The WHO tretment guidelines for drugresistnt tuberculosis 216 updte In My 216, WHO revised its policy recommendtions for the tretment of drug-resistnt TB. The min chnges in the 216 recommendtions were s follows: A shorter MDR-TB tretment regimen is now recommended for ptients (other thn pregnnt women) with pulmonry RR or MDR-TB tht is not resistnt to second-line drugs. b All RR-TB cses re to be treted with MDR-TB regimen, regrdless of isonizid susceptibility. The design of longer MDR-TB regimens uses different regrouping of component medicines, bsed on current evidence on their effectiveness nd sfety. Clofzimine nd linezolid re now recommended s core secondline medicines in the MDR-TB regimen, wheres p-minoslicylic cid is n dd-on gent. Mcrolides re no longer indicted for MDR-TB regimens. Specific recommendtions re mde on the tretment of children with MDR/RR-TB bsed on first-ever met-nlysis of individul-level peditric ptient dt for tretment outcomes. Evidence-informed recommendtions on the role of prtil resection surgery re now included. No new evidence on the role of bedquiline nd delmnid ws vilble t the time of the 216 updte nd therefore no chnges were mde to the interim policy on the use of these new medicines. Both of these medicines hve now been ssigned to specific subgroup of dd-on gents. The Globl TB Progrmme in WHO is ctively engged with NTPs, technicl nd funding prtners, the Globl Drug-resistnt TB Inititive ( mdrtb/), the Globl Lbortory Inititive ( org/wg/gli/) nd Regionl Green Light Committees to support countries to revise their ntionl guidnce, strengthen lbortory cpcity, implement DSM (see Box 4.2 nd Box 4.6), nd ddress brriers to the importtion nd use of new medicines nd novel regimens. c World Helth Orgniztion. WHO tretment guidelines for drugresistnt tuberculosis (216 updte) (WHO/HTM/TB/216.4). Genev: WHO; 216 ( ccessed 15 August 216). b Frequently sked questions bout the implementtion of the new WHO recommendtion on the use of the shorter MDR-TB regimen under progrmmtic conditions ( c Médecins Sns Frontières/Stop TB Prtnership. Out of step 215: TB policies in 24 countries: survey of dignostic nd tretment prctices. Genev: MSF/Stop TB Prtnership; 215 ( msfccess.org/sites/defult/files/msf_ssets/tb/docs/tb_ report_out_of_step_eng_215.pdf, ccessed 15 August 216) Drug susceptibility testing nd detection of drug-resistnt TB Drug-resistnt TB thretens globl TB control nd remins mjor public helth concern in mny countries. All RR-TB cses including those with MDR-TB re eligible for tretment with second-line medicines (Box 4.3). 1 Cses of MDR-TB ccount for 83% of the worldwide totl of MDR/ RR-TB cses, with the proportion vrying by region nd country (e.g. from 67% to 91% mong the WHO regions). Further detils re provided in Chpter 3 (see in prticulr Tble 3.5). Universl ccess to DST, s clled for in the End TB Strtegy, cn be defined s DST for t lest rifmpicin for ll TB cses, plus DST for t lest fluoroquinolones nd secondline 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 (see lso Section 4.1.3), which cn detect RR-TB. Drug susceptibility testing for first-line drugs nd detection of MDR/RR-TB Progress in DST coverge since 29, when WHO intensified efforts to trck progress in the progrmmtic response to drug-resistnt TB, 2 is shown in Fig In 215, 3% of the 3.4 million new bcteriologiclly confirmed nd previously treted TB cses notified globlly were reported to hve hd DST for rifmpicin, with coverge of 24% for new TB ptients nd 53% for previously treted TB ptients. These figures represent smll increse in DST coverge for rifmpicin since 214 (22% of new nd previously treted TB cses) nd mjor progress since 29 (4.9%). The WHO Europen Region is the only prt of the world where DST coverge hs remined comprtively stble t high level (bout 6 7%; 69% in 215). DST coverge vried substntilly between countries, even within the sme region, nd mong the 3 high MDR-TB burden countries (Fig. 4.1). Globlly, cses of MDR/RR-TB were detected nd notified in 215 (Tble 4.1). This ws only slight increse from 214 (Fig. 4.11), lthough the ggregte globl figure concels country vrition (Fig. 4.12). Between 214 nd 215, the number of reported MDR/RR-TB cses incresed by more thn 2% in four of the 3 high MDR-TB burden countries (Chin, Nigeri, Philippines nd Ukrine), but lso fell by more thn 2% in seven of those countries. 3 The decline or stgntion in detection despite high 1 World Helth Orgniztion. WHO tretment guidelines for drugresistnt tuberculosis (216 updte) (WHO/HTM/TB/216.4). Genev: WHO; 216 ( drug-resistnt-tb/tretment/resources/en/, ccessed 15 August 216). 2 This ws done in ssocition with ministeril conference for high MDR-TB burden countries held in Beijing, Chin in April Country nd regionl time trends for the min TB indictors for drug-resistnt TB cn be ccessed t Reports?op=vs&pth=/WHO_HQ_Reports/G2/PROD/EXT/ DRTB_chrts 64 :: GLOBAL TUBERCULOSIS REPORT 216

76 :: FIG. 4.9 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 8 South-Est Asi Western Pcific Globl Among new lbortory confirmed nd retretment cses; test results in cses with previous history unknown not included. b The brupt increse in coverge in the Africn region in 215 is lrgely due to improved differentition by tretment history of reports from South Afric. :: FIG. 4.1 Percentge of bcteriologiclly confirmed TB cses tested for RR-TB, 215 Percentge No dt Not pplicble Among new lbortory confirmed nd retretment cses; test results in cses with previous history unknown not included. Vlues for 214 were used in countries without 215 dt by the reporting dedline. GLOBAL TUBERCULOSIS REPORT 216 :: 65

77 :: FIG 4.11 Globl number of MDR/RR-TB cses detected (pink) nd number enrolled on MDR-TB tretment (green) , compred with estimtes for 215 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 :: Box 4.4 Updted WHO policy guidnce on TB dignostics WHO convened Guideline Development Groups in 216 to review the evidence on the performnce nd utility of four TB dignostic technologies. The following recommendtions hve been issued: For ptients with confirmed rifmpicin-resistnt TB or MDR-TB, the Genotype MTBDRsl (Hin LifeScience, Germny) second-line LPA my be used s the initil test, insted of phenotypic culture-bsed DST, to detect resistnce to fluoroquinolones nd the secondline injectble drugs (conditionl recommendtion). This test llows quick trige of confirmed MDR/RR-TB ptients into either the shorter MDR-TB regimen or the conventionl longer regimen. Two new first-line LPAs the MTBDRplus Version 2 (Hin LifeScience, Germny) nd the Nipro NTM+MDRTB detection kit 2 (Nipro Corp., Jpn) demonstrted equivlence to the MTBDRplus Version 1 ssy. These new LPAs re now lso recommended for the detection of TB nd for resistnce to rifmpicin nd isonizid. A moleculr ssy bsed on loop-medited isotherml mplifiction (TB-LAMP), Loopmp TM MTBC Detection Kit (Eiken Chemicl Compny Ltd, Jpn) my be used s replcement for microscopy for the dignosis of pulmonry TB in dults with signs nd symptoms of TB (conditionl recommendtion). TB-LAMP my lso be used s follow-on test to microscopy in dults with signs nd symptoms of pulmonry TB, especilly when further testing of sputum smer-negtive specimens is necessry. Informtion bout technologies in the pipeline is provided in Chpter 8. A comprehensive list of existing WHO policy documents on TB dignostics is vilble t: policy_sttements nd incresing DST coverge could be due to more ccurte reporting of lbortory test results (e.g. de-dupliction of repeted counts of lbortory results for multiple specimens for the sme individul ptient) nd other improvements to reporting of dt. Wider use of electronic cse-bsed systems to mnge MDR-TB ptient dt could help to further improve the completeness nd ccurcy of reporting. By 215, 23 of the 3 high MDR-TB burden countries reported tht ntionl cse-bsed electronic registers were in plce (16 of which covered ll TB ptients). These systems vry from surveillnce dtbses to more elborte clinicl cse-mngement registers with links to lbortory informtion systems. The MDR/RR-TB cses notified globlly in 215 (Tble 4.1) mount to bout 4% of the estimted totl of 34 MDR/RR-TB cses tht could hve been detected hd DST been provided to ll pulmonry TB ptients notified in 215, nd bout 23% of the 58 estimted incident cses of MDR/RR-TB in 215 (Fig. 4.11). The proportion of MDR/RR-TB cses estimted to exist mong notified pulmonry TB cses tht were detected nd reported vried from 21% to 64% in the six WHO regions. Among the 3 high MDR-TB burden countries, the proportion rnged from under 1% in the Democrtic People s Republic of Kore nd Somli to bove 75% in Kzkhstn, Peru, South Afric nd Ukrine (Fig. 4.12). Evidence of progress in DST coverge notwithstnding, dignostic DST must be further expnded to close detection gps. Nine countries with more thn 5 notified TB cses in 215 reported no cpcity to perform phenotypic DST (Afghnistn, Burkin Fso, Chd, Congo, Ppu New Guine, Sierr Leone, Somli, South Sudn nd Yemen). Hence, there is need for continued strengthening of lbortory cpcity nd wider uptke of new rpid dignostics (Box 4.2, Box 4.4), s well s incresed deployment of digitl helth technologies (especilly connected dignostics 1 ), to improve the completeness of reporting from lbortory nd tretment centres. 1 World Helth Orgniztion. Digitl helth for the End TB Strtegy: n gend for ction (WHO/HTM/TB/215.21). Genev: WHO; 215 ( helth_endtbstrtegy.pdf, ccessed 8 August 216). 66 :: GLOBAL TUBERCULOSIS REPORT 216

78 :: FIG Number of MDR/RR-TB cses detected (pink) nd enrolled on MDR-TB tretment (green) compred with estimted number of MDR/RR-TB cses mong notified pulmonry TB cses in 215 (uncertinty intervl shown in red), 3 high MDR-TB burden countries Angol Azerbijn Bngldesh Belrus Chin DPR Kore DR Congo Ethiopi Indi Indonesi Kzkhstn Keny Kyrgyzstn Mozmbique Mynmr Number of cses Nigeri Pkistn Ppu New Guine Peru Philippines Republic of Moldov Russin Federtion Somli South Afric Tjikistn Thilnd Ukrine Uzbekistn Viet Nm Zimbbwe GLOBAL TUBERCULOSIS REPORT 216 :: 67

79 :: FIG Number of ptients with lbortory-confirmed XDR TB strted on tretment in 215 Number of ptients No dt Not pplicble Drug susceptibility testing for second-line drugs nd detection of XDR-TB Among MDR/RR-TB ptients notified in 215, 36% were reported to hve hd DST for both fluoroquinolones nd second-line injectble gents. Coverge ws lowest in the WHO Western Pcific nd South-Est Asi regions. In 215, 7579 XDR-TB cses were reported to hve been detected by 74 countries. Tretment of XDR-TB ptients ws reported by 58 countries nd territories (Fig. 4.13). Globlly, 7234 ptients with XDR-TB were enrolled on tretment (more thn twice the level in 214). Most of the cses in 215 were notified by Indi (213), Ukrine (126), the Russin Federtion (125) nd South Afric (719). 4.2 Tretment coverge The Sustinble Development Gols (SDGs) include trget to Achieve universl helth coverge, including finncil risk protection, ccess to qulity essentil helthcre services nd ccess to sfe, effective, qulity nd ffordble essentil medicines nd vccines for ll (Chpter 2, Box 2.2). Indictors for Trget 3.8 of SDG3 include prevention nd tretment coverge of trcer interventions, 1 one of which is TB tretment. TB tretment coverge is lso one of the 1 priority indictors for monitoring progress in implementtion of the End TB Strtegy (Chpter 2, Tble 2.1). This is becuse, s highlighted in the introduction to this chpter, universl 1 There re mny different prevention nd tretment interventions. In this context, few interventions re selected to ct s trcers for progress towrds UHC for ll interventions. coverge of pproprite dignosis nd tretment is fundmentl requirement for chieving the milestones nd trgets of the End TB Strtegy. 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 (Tble 2.1). In this section, the number of notified new nd relpse cses in 215 is used s proxy for the number of cses detected nd treted. As discussed further below, however, there re lso 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 be strted on 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 215 (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 59% (rnge, 5 7%) 2 in 215, up from 54% (rnge, 46 65%) in 21 nd 36% (rnge, 3 43%) in 2. Three WHO 2 Here nd elsewhere in the report, rnge refers to the 95% uncertinty intervl. 68 :: GLOBAL TUBERCULOSIS REPORT 216

80 :: FIG Cse notifiction rtes (new nd relpse cses, ll forms) (blck) compred with estimted TB incidence rtes (green), 2 215, 3 high TB burden countries. Shded res represent uncertinty bnds. Angol Bngldesh Brzil Cmbodi Centrl Africn Republic Chin Congo DPR Kore DR Congo Ethiopi Indi b 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 incidence for Bngldesh will be reviewed once finl results from the 215/216 ntionl TB prevlence survey re vilble. b Estimtes of TB incidence for Indi re interim in nture, pending results from the ntionl TB prevlence survey plnned for 217/218. GLOBAL TUBERCULOSIS REPORT 216 :: 69

81 :: FIG Estimted TB tretment coverge (new nd relpse ptients s percentge of estimted TB incidence) in 215, 3 high TB burden countries, WHO regions nd globlly Russin Federtion Chin Brzil Philippines DPR Kore Nmibi Ppu New Guine Viet Nm Keny Zimbbwe Ethiopi Mynmr Angol Pkistn South Afric Sierr Leone Cmbodi Indi Zmbi Bngldesh b Congo Centrl Africn Republic Thilnd DR Congo Lesotho Liberi Mozmbique UR Tnzni Indonesi Nigeri Western Pcific The Americs 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 217/218. b Estimtes of TB incidence for Bngldesh will be reviewed once finl results from the 215/216 ntionl TB prevlence survey re vilble. regions chieved higher levels of bove 75%: the Region of the Americs, nd the Europen nd Western Pcific regions. Among the 3 high TB burden countries, the highest levels of tretment coverge in 215 (>8%) were in Brzil, Chin, the Philippines nd the Russin Federtion. The lowest levels, with best estimtes of 5% or less, were in the Democrtic Republic of the Congo, Indonesi, Mozmbique, Nigeri nd the United Republic of Tnzni. Globlly in 215, there ws gp of bout 4.3 million cses between the 6.1 million new nd relpse cses tht were notified, nd the estimted 1.4 million incident TB cses in the sme yer (Fig. 4.1). Although notifictions hve incresed in recent yers, especilly in Indi (Section 4.1.1), the size of this gp is lrger thn indicted in previous globl TB reports following n upwrd revision to estimted TB incidence in Indi for 215 nd previous yers (for further detils, see Chpter 3 nd in prticulr Box 3.3). However, using the entire updted time-series of estimtes of TB incidence s shown in Fig. 4.1, 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 77% of the totl estimted gp between incidence nd notifictions (Fig. 4.16), nd Indi, Indonesi nd Nigeri lone ccount 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, especilly those without policies on mndtory notifiction nd other mesures to ensure reporting of detected cses by ll cre providers nd lrge privte helth sectors, levels of underreporting my be high. Underdignosis of people with TB. This cn occur for resons such s poor geogrphicl nd finncil ccess to helth cre; filure to recognize TB signs nd symptoms, nd to test for TB when people do present to helth fcilities; nd dignostic tests tht re not good enough to ensure ccurte identifiction of ll cses. 1 Time trends in countries nd regions re shown in Annex 2 nd Annex 3, respectively. 7 :: GLOBAL TUBERCULOSIS REPORT 216

82 :: FIG The ten countries with the lrgest gps between notifictions of new nd relpse (incident) TB cses nd the best estimtes of TB incidence, 215 Pkistn Chin Bngldesh Indi Indonesi Nigeri UR Tnzni DR Congo South Afric Mozmbique The ten countries, rnked in order of the size of the gp between notified cses nd the best estimte of TB incidence in 215, re Indi, Indonesi, Nigeri, Pkistn, South Afric, Bngldesh, DR Congo, Chin, UR Tnzni nd Mozmbique. Estimtes of TB incidence for Indi re interim in nture, pending results from the ntionl TB prevlence survey plnned for 217/218. :: FIG. 4.16b 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, 215 Pkistn Russin Federtion Ukrine Chin Mynmr Philippines Indi Indonesi Nigeri DR Congo The ten countries, rnked in order of the size of the gp between number of ptients strted on MDR-TB tretment nd the best estimte of MDR/RR-TB incidence in 215, re Indi, Chin, Russin Federtion, Indonesi, Nigeri, Pkistn, Philippines, Ukrine, Mynmr nd DR Congo. GLOBAL TUBERCULOSIS REPORT 216 :: 71

83 Overestimtion of the level of TB incidence. In this report, estimtes of TB incidence for 74 countries with 22% 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). Also, the 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 evidence bout the resons for such gps, nd ctions to ddress them re being tken or re plnned. In Indi, vrious dt sources point to lrge underreporting of detected TB cses (see lso Chpter 3, Box 3.3). These include two studies of sles of nti-tb drugs in the privte sector; the recent upsurge in notifictions tht followed ntionl policy of mndtory notifiction, s well s efforts to increse enggement with ll cre providers nd to fcilitte reporting vi ntionl web-bsed reporting system; nd comprison of household survey dt on self-reported TB tretment with notifiction dt in the sme survey res. 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 nd intensified enggement with public nd privte hospitls where mny people with TB were being treted. 1 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, demonstrting high levels of underdignosis nd need to strengthen ccess to dignostic nd tretment services. 2 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 under wy in Chin, Indonesi (s follow-on from the levels of underreporting indicted by the ntionl TB prevlence survey), Nigeri (metropolitn Lgos), the Philippines 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. 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), linking the supply of first-line drugs to notifiction of cses (s in Brzil), fcilitting reporting vi online web-bsed systems with limited dt entry requirements (s in Indi), nd wider implementtion of PPM schemes nd inititives (Tble 4.2). Even in the countries shown in Tble 4.2, PPM implementtion is often not ntionwide, nd its contribution to notifictions my come from smll proportion of providers tht willingly collborte with NTPs, or from prts of the country only. In Indi, for exmple, the big increse in notifictions tht occurred in ws from smll subset of districts. Chpter 6 provides further discussion of PPM, including the role of whole-of-government pproch, nd innovtive pproches to engging privte prctitioners tht re being tested in Bngldesh, Indi, Indonesi, Pkistn nd Mynmr. Recent ntionl TB prevlence surveys 4 hve lso shown tht, in both Afric nd Asi, detection nd reporting gps re systemticlly higher for men thn for women (for further detils, see Section in 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 (see lso Chpter 5). 5,6 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 up systemtic screening. However, this is expected to become more prominent prt of ntionl progrmme monitoring nd evlution efforts in future. Engging communities could lso dd vlue to efforts to improve cse detection nd ptient support (Box 4.5). 1 For further detils, see Box 2.4 in World Helth Orgniztion. Globl tuberculosis report 215 (WHO/HTM/TB/215.22). Genev: WHO; 215 ( bitstrem/1665/19112/1/ _eng.pdf, ccessed 27 July 216). 2 For further detils, see Box 2.2 in World Helth Orgniztion. Globl tuberculosis report 214 (WHO/HTM/TB/214.8). Genev: WHO; 214 ( bitstrem/1665/13794/1/ _eng.pdf, ccessed 15 August 216). 3 For guide to inventory studies, see World Helth Orgniztion. Assessing tuberculosis under-reporting through inventory studies. Genev: WHO; 212 ( inventory_studies/en/, ccessed 15 August 216). 4 meetings/tf6_p6_prevlence_surveys_29_215.pdf 5 World Helth Orgniztion. Systemtic screening for ctive tuberculosis: principles nd recommendtions (WHO/HTM/ TB.213.4). Genev: WHO; 213 ( tbscreening/en/, ccessed 15 August 216). The dt requested in the globl monitoring done by WHO focus on screening mong people living with HIV nd close contcts. 6 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 :: GLOBAL TUBERCULOSIS REPORT 216

84 :: Box 4.5 Community contributions to TB notifictions nd tretment support Enggement of communities, nongovernmentl nd civil society orgniztions is t the hert of the End TB Strtegy. Community-bsed TB ctivities cover wide rnge of ctivities tht contribute to the detection, referrl nd tretment of people with drug-susceptible, drug-resistnt nd HIV-ssocited TB. They re conducted outside the premises of forml helth fcilities (e.g. hospitls, helth centres nd clinics) in community-bsed structures (e.g. schools, plces of worship, congregte settings nd mrkets) nd homesteds. Community helth workers nd community volunteers crry out community-bsed TB ctivities. They cn be prt of the public helth services or nongovernmentl or other civil society orgniztions. ENGAGE-TB is n pproch to integrting community-bsed TB ctivities into the work of these orgniztions. Of the 114 countries tht were sked to respond to questions bout the contributions of communities to TB notifictions :: FIG. B4.5.1 Percentge of bsic mngement units in which there is community enggement or provision of tretment dherence support, 215 nd tretment support in WHO s 216 round of globl TB dt collection, 49 reported dt for t lest one indictor. Of the 49 countries, 6% (29/49) reported ntionwide coverge of community enggement in cse notifiction or community-bsed tretment support (Fig. B4.5.1). 4 out of 49 countries (82%) reported dt on the contribution of community referrls to TB notifictions; 41 out 49 (86%) reported on the proportion of TB ptients receiving community-bsed tretment support; nd 34 out of 49 (69%) reported informtion bout the tretment success rte mong TB ptients who received tretment support in the community. There re mny countries in which community-bsed TB ctivities re routine component of TB services, but where it is not yet possible to quntify this contribution. Of the 65 (out of 114) countries tht were sked to report but did not submit ny dt on notifictions, more thn hlf (33/65) nonetheless stted tht community-bsed ctivities re implemented. In these 33 countries, the men coverge of community-bsed ctivities is 79% of bsic mngement units while totl of 19 countries reported countrywide implementtion of community-bsed ctivities. Efforts to support countries to incorporte community enggement indictors into their routine monitoring nd evlution systems continue. Percentge No dt Not pplicble 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 ( int/tb/publictions/212/engge_tb_ policy/en/, ccessed 15 August 216) Tretment coverge of ntiretrovirl therpy for HIV-positive TB cses WHO recommends ART for ll HIV-positive TB ptients within the first 8 weeks of strting TB tretment. 1 The number of notified HIV-positive TB ptients on ART hs grown in recent yers (Fig. 4.8, Fig. 4.17) nd reched in 215, equivlent to 78% of the notified TB 1 World Helth Orgniztion. Consolidted guidelines on the use of ntiretrovirl drugs for treting nd preventing HIV infection. Recommendtions for public helth pproch. 2nd edition. Genev: WHO; 216. ( ccessed 26 August 216) ptients known to be HIV-positive (Tble 4.1). This ws n increse from 36% in 25, when dt on provision of ART to HIV-positive TB ptients were first collected t globl level. 2 In the 3 high TB/HIV burden countries, 8% of the TB ptients known to be HIV-positive were on ART nd in six of these countries (Indi, Keny, Mlwi, Mozmbique, Nmibi nd Swzilnd) the figure ws more thn 9%. 2 There my be discrepncies in dt on provision of ART to HIVpositive TB ptients tht re reported by ntionl TB progrmmes nd ntionl HIV progrmmes. These discrepncies hve reduced in recent yers nd re mostly resolved through follow-up nd vlidtion efforts. GLOBAL TUBERCULOSIS REPORT 216 :: 73

85 :: 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 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 :: GLOBAL TUBERCULOSIS REPORT 216

86 :: 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 215, 3 high TB/HIV burden countries, WHO regions nd globlly Nmibi Keny Ugnd Swzilnd South Afric Zimbbwe Mlwi Botswn Ethiopi Zmbi Cmeroon Indi Thilnd Mozmbique Lesotho UR Tnzni Chin Brzil Mynmr Chd DR Congo Nigeri Ghn Ppu New Guine Guine-Bissu Liberi Congo Indonesi Angol Centrl Africn Republic No dt Afric The Americs Western Pcific South-Est Asi Europe Estern Mediterrnen Globl Tretment coverge (%) In contrst, there were nine high TB/HIV burden countries (Brzil, Chd, Chin, Congo, Ghn, Guine-Bissu, Indonesi, Liberi, nd Mynmr) in which less thn 5% of HIV-positive TB ptients were strted on ART in 215. ART tretment coverge for people with TB cn lso be ssessed by compring the number of HIV-positive TB ptients on ART with the estimted number of HIV-positive incident TB cses (Fig. 4.18). This comprison revels lrger gps. Globlly in 215, the number of HIV-positive TB ptients on ART ws 33% of the estimted globl number of incident HIV-positive TB cses. There ws considerble vrition mong the high TB/HIV burden countries nd only four chieved ART coverge of more thn 5% (Keny, Nmibi, Swzilnd nd Ugnd). Improvements re needed in the detection of TB mong HIV-positive people, the coverge of HIV testing mong TB ptients, nd the enrolment of HIV-positive TB ptients on ART Tretment coverge for MDR/RR-TB Trends in the number of ptients enrolled on MDR-TB tretment globlly nd in the 3 high MDR-TB countries since 29 re shown in Fig nd Fig The number of people enrolled on tretment globlly ws in 215, n increse of 13% from in 214. There ws 14% increse in enrolments between 214 nd 215 in the 3 high MDR-TB burden countries, with increments mounting to more thn 1 ptients in Chin, Indi, the Philippines, the Russin Federtion nd Ukrine. Globlly, the ptients strting second-line MDR-TB tretment in 215 represented bout 37% of the 34 MDR/RR-TB cses estimted to hve existed mong pulmonry TB ptients notified in 215 (Fig. 4.19), nd 2% of the incidence estimte (Fig. 4.11). Five countries ccounted for over 6% of the gp between enrolments on MDR-TB tretment in 215 nd the estimted number of incident MDR/RR-TB cses in 215: Chin, Indi, Indonesi, Nigeri nd the Russin Federtion (Fig. 4.16b). The number of cses strting MDR-TB tretment in 215 ws equivlent to 95% of the MDR/RR-TB ptients notified in tht yer (Tble 4.1). The rtio exceeded 9% in 19 high MDR-TB burden countries, nd the WHO Europen nd South-Est Asin regions, nd ws lowest in the GLOBAL TUBERCULOSIS REPORT 216 :: 75

87 :: FIG Estimted MDR/RR-TB tretment coverge for MDR/RR-TB (ptients strted on tretment for MDR-TB s percentge of the estimted number of MDR/RR-TB cses mong notified pulmonry TB cses) in 215, 3 high MDR TB burden countries, WHO regions nd globlly Kzkhstn South Afric Belrus Peru Ukrine Russin Federtion Azerbijn Republic of Moldov Tjikistn Kyrgyzstn Viet Nm Zimbbwe Uzbekistn Indi Philippines Keny Mynmr Mozmbique Thilnd Ppu New Guine Pkistn Ethiopi Bngldesh Indonesi Nigeri DR Congo Chin Angol Somli DPR Kore Europe The Americs Afric South-Est Asi Estern Mediterrnen Western Pcific Globl Tretment coverge (%) Africn Region (Fig. 4.19). In 215, enrolments outstripped notifictions of MDR/RR-TB in eight high MDR-TB burden countries (Fig. 4.12). This my be cused by empiricl tretment of TB ptients considered t risk of hving MDR/ RR-TB but for whom lbortory-confirmed dignosis ws missing, incomplete reporting of lbortory dt, or enrolment of witing lists of people with MDR/RR-TB who were detected before 215. The rtio of enrolled to dignosed cses ws below 6% in two high MDR-TB burden countries in 215: Chin (59%) nd Nigeri (53%). These low rtios show tht progress in detection is fr outstripping cpcity to provide tretment; they my lso reflect weknesses in dt collection systems. Tretment coverge will not improve globlly unless there is n intensifiction of efforts in the countries with the lrgest burden, prticulrly Chin nd the Russin Federtion, but lso Indi where the rte of increse in enrolments hs slowed. In mny countries, one of the resons for indequte ccess to tretment of drug-resistnt TB is tht the network for the progrmmtic mngement of drug-resistnt TB (PMDT) is too centrlized. Hospitl-bsed models of cre continue to dominte in mny countries, nd hold bck wider use of decentrlized mbultory cre, chnge of direction tht could expnd popultion ccess to PMDT (see lso Chpter 6). In ddition, gps for pllitive nd end-oflife cre re evident. In 215, only 34 countries (including 16 of the 3 high MDR-TB burden countries) reported tht such services were provided within the scope of their NTPs. 4.3 Tretment outcomes This section highlights the ltest results of tretment for people who strted TB tretment on first-line regimen in 214, nd people tht strted second-line regimen for MDR/RR-TB in Tretment outcomes for new nd relpse TB ptients The definitions of TB tretment outcomes for new nd relpse cses of TB tht re recommended by WHO re provided in n updted recording nd reporting frmework 76 :: GLOBAL TUBERCULOSIS REPORT 216

88 issued in Mrch 213 nd updted in Most new nd relpse cses do not hve MDR/RR-TB; however, in some prts of the world, especilly countries of the former Soviet Union, more thn 2% of new nd relpse cses do so (Chpter 3). Universl ccess to DST is required to ensure tht ll people with TB receive pproprite tretment, s discussed in Section 4.1. Dt on tretment outcomes in 214 for new nd relpse cses of TB re shown for the world, the six WHO regions nd the 3 high TB burden countries in Fig. 4.2, nd trends globlly nd in the six WHO regions since 2 re shown in Fig Globlly, the tretment success rte for the 5.9 million new nd relpse cses tht were treted in the 214 cohort ws 83%. This ws reduction from 87% for the 213 cohort, which cn be explined by dt for Indi. From 213 to 214, there ws big increse in notifictions of TB cses in Indi (see lso Section 4.1.1) from the privte sector. However, while the totl number of TB ptients reported s successfully treted lso incresed in Indi, there ws n increse in the percentge of TB ptients for whom the tretment outcome ws ctegorized s not evluted (17%). As consequence, the overll tretment success rte fell from 86% to 74%, nd the impct is lrge enough to be evident in the ggregted dt for 214 for the world nd the WHO South-Est Asi Region (Fig 4.21). The NTP in Indi hs been tking ctions to improve reporting of tretment outcomes from privte sector providers, including by fcilitting reporting of outcomes vi the ntionl web-bsed reporting system known s Nikshy, nd the im is to chieve complete reporting of outcomes from the privte sector by 217. Of note, when the 214 dt for Indi re restricted to the sme providers/fcilities, the tretment success rte remins comprble to 213, t 87%. When Indi is excluded from globl clcultions, the tretment success rte is 86%. Among the six WHO regions, the highest tretment success rtes in 214 were in the Western Pcific Region (92%) nd the Estern Mediterrnen Region (91%), nd the lowest (t 76%) were in the Region of the Americs (due to high levels of loss to follow up nd missing dt) nd the Europen Region (due to high rtes of tretment filure nd deth, influenced by the high frequency of MDR/RR-TB). Only eight of the 3 high TB burden countries hd reched or exceeded 9% tretment success rte, lthough the vlidity of tretment outcome dt ws not lwys scertined. In severl high TB burden countries, the completeness of outcome reporting ws low. In the Centrl Africn Republic, Congo, Liberi nd Ppu New Guine, loss to follow-up exceeded 15%, wheres in Angol, Congo, Indi nd Lesotho more thn 1% of cses were unevluted. In Brzil (71% success), 21% of cses were either lost to follow-up or their tretment outcome ws missing. Despite the decrese in the overll tretment success :: FIG. 4.2 Tretment outcomes for new nd relpse TB cses in 214, 3 high TB burden countries, WHO regions nd globlly 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 Afric The Americs Estern Mediterrnen Europe South-Est Asi Western Pcific Globl Tretment outcomes re for new cses only Tretment success Filure Died Lost to follow-up Not evluted Percentge of cohort (%) 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 15 August 215). GLOBAL TUBERCULOSIS REPORT 216 :: 77

89 :: FIG Tretment outcomes for new nd relpse TB cses (bsolute numbers), 2 214, 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 2 1 The Americs Filed/Died/Lost to follow-up Cohorts before 212 included new cses only Europe Western Pcific rte, the bsolute number of TB ptients reported to hve been successfully treted hs continued to increse over time, both globlly nd in ll WHO regions (Fig. 4.21) Tretment outcomes for new nd relpse TB ptients coinfected with HIV In the 216 round of globl TB dt collection, 16 countries (which collectively ccounted for 8% of the HIV-positive TB ptients reported by NTPs in 214) reported tretment outcomes for the 214 ptient cohort disggregted by HIV sttus. This included 19 of the 3 high TB/HIV burden countries. Tretment outcomes for these countries, s well s the six WHO regions nd globlly, re shown in Fig Overll, the tretment success rte in 214 ws worse for HIV-positive TB ptients (75%) thn for HIV-negtive TB ptients (83%). There were prticulrly lrge differences in the Region of the Americs, the Estern Mediterrnen nd the Western Pcific regions, where the tretment success rtes for HIV-positive TB ptients were 56%, 53% nd 72% respectively, compred with 77%, 82% nd 93% respectively mong HIV-negtive ptients. Globlly, the proportion of TB ptients who died during tretment ws bout four times higher mong HIV-positive TB ptients (11% versus 3%). In WHO regions the reltive difference ws lowest in the Africn Region (1% versus 5%) nd highest in the Western Pcific Region (15% versus 2%). Resons for the comprtively poor outcomes of HIVpositive 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 nd TB screening mong people living with HIV, erly ART nd provision of TB preventive tretment. WHO recently published revised lgorithm for clinicl mngement of HIV-positive people who re seriously ill nd suspected of hving TB Tretment outcomes for TB ptients with MDR/RR-TB nd XDR-TB A totl of 127 countries nd territories reported tretment outcomes for people strted on MDR-TB tretment in 213. The number of cses reported in nnul cohorts hs stedily incresed over time, reching cses globlly in the 213 cohort, 17% increse over the previous yer (Fig. 4.23). Overll, the proportion of MDR/RR-TB ptients in the 213 cohort who successfully completed tretment (i.e. cured or tretment completed) ws 52%: 17% died, 15% were lost to follow-up, 9% were determined to be tretment filure nd 7% hd no outcome informtion. The tretment success rte ws highest in the WHO Estern 1 World Helth Orgniztion. Consolidted guidelines on the use of ntiretrovirl drugs for treting nd preventing HIV infection. Recommendtions for public helth pproch. 2nd edition. Genev: WHO; 216. ( pdf, ccessed 26 August 216). See Annex :: GLOBAL TUBERCULOSIS REPORT 216

90 :: FIG Tretment outcomes for new nd relpse TB/HIV cses in 214, 3 high TB/HIV burden countries, WHO regions nd globlly :: FIG Tretment outcomes for rifmpicin-resistnt TB cses strted on tretment in 213, 3 high MDR TB burden countries, WHO regions nd globlly Angol Botswn Brzil Cmeroon Centrl Africn Republic Chd Chin Congo DR Congo Ethiopi 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 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 Afric The Americs Estern Mediterrnen Europe South-Est Asi Western Pcific Afric The Americs Estern Mediterrnen Europe South-Est Asi Western Pcific Globl Percentge of cohort (%) Globl Percentge of cohort (%) Tretment success Filure Died Lost to follow-up Not evluted No dt reported Mediterrnen Region (68%), nd lowest in the South-Est Asi Region (49%). In the 213 cohort, tretment filure ws highest in the WHO Europen Region (13%), nd the deth rte ws highest in the Africn nd South-Est Asi regions (21%). Loss to follow-up ws highest in the WHO Region of the Americs (25%). Despite the low levels of tretment success, over 15 people who strted MDR-TB tretment globlly between 27 nd 213 were reported to hve completed their tretment successfully. Among the 3 high MDR-TB burden countries, the Democrtic Republic of Kore, Keny, Mynmr, Nigeri, nd Somli reported >75% tretment success mong the MDR/RR-TB cohorts enrolled in 213. Conversely, tretment success ws <5% in countries with the lrgest cohorts: Indi, the Philippines, the Russin Federtion, South Afric nd Ukrine. This ws primrily due to high deth rtes in Indi, South Afric nd Ukrine; high tretment filure rtes in the Russin Federtion nd Ukrine; nd high rtes of loss to follow up or missing dt in Indi, the Philippines nd South Afric. Dt on tretment outcomes for MDR/RR-TB ptients were not reported by Ppu New Guine nd Thilnd. Among 486 XDR-TB ptients strted on tretment in 213 in 47 countries nd for whom outcomes were reported, 28% completed tretment successfully, 27% died, tretment filed for 21%, nd 23% were lost to follow-up or GLOBAL TUBERCULOSIS REPORT 216 :: 79

91 :: FIG Countries tht hd used shorter MDR TB tretment regimens by the end of 215 No Yes Not pplicble STREAM Tril sites = Ethiopi, Mongoli, South Afric nd Viet Nm. :: FIG Countries tht hd used bedquiline nd/or delmnid for the tretment of M/XDR TB s prt of expnded ccess, compssionte use or under norml progrmmtic conditions by the end of 215 No known use of bedquiline or delmnid Either bedquiline or delmnid used Both bedquiline nd delmnid used No dt Not pplicble Dt shown reflects country reports supplemented with dditionl informtion from phrmceuticl mnufcturers. 8 :: GLOBAL TUBERCULOSIS REPORT 216

92 :: Box 4.6 Active TB drug-sfety monitoring nd mngement DSM is the ctive nd systemtic, clinicl nd lbortory ssessment of ptients on tretment with new nti-tb drugs, novel MDR-TB regimens, or XDR-TB regimens, to detect, mnge nd report suspected or confirmed drug toxicities. The overll objectives of DSM re to reduce risks from drug-relted hrms in ptients on second-line tretment for drug-resistnt TB nd to generte stndrdized dt to inform future policy updtes on the use of such medicines. DSM includes three essentil ctivities to chieve these objectives: Ptients trgeted for DSM should undergo ctive nd systemtic clinicl nd lbortory ssessment during tretment to detect drug toxicity nd dverse events (AEs). Proposed schedules hve been developed for use in ptients on shorter regimens or on new medictions. All AEs detected should be mnged in timely mnner, to deliver the best possible ptient cre. Mngement of AEs is beyond the scope of this document, nd further detils re provided in other implementtion documents. b Stndrdized dt should be systemticlly collected nd reported for ny detected serious dverse event (SAE). These dt will eventully be used to chrcterize the types of SAEs, ssess the sfety of the tretment, nd inform future policy on the use of these medicines. In 215, 51 of the 14 countries tht enrolled ptients on MDR-TB tretment (including 15 of the 3 high MDR-TB burden countries) reported AEs in lest one ptient. 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 216). b World Helth Orgniztion. Compnion hndbook to the WHO guidelines for the progrmmtic mngement of drug-resistnt tuberculosis (WHO/ HTM/TB/214.11). Genev: WHO; 214 ( bitstrem/1665/13918/1/ _eng.pdf, ccessed 15 August 216). their tretment outcome ws not evluted. The Russin Federtion ccounted for nerly 5% of the XDR-TB ptients for whom outcomes were reported in 213. Among six countries with XDR-TB cohorts of more thn 1 individuls, mortlity ws highest (>4%) in Indi nd South Afric. Tretment success rtes in ptients with drug-resistnt TB remin uncceptbly low. The wider use of shorter MDR-TB tretment regimens of 9 12 months (Box 4.3) nd of new TB drugs (bedquiline nd delmnid) for ptients with M/XDR-TB could help to improve this sitution. At lest 23 countries in Afric nd Asi hve introduced shorter regimens s prt of trils or observtionl studies under opertionl reserch conditions (Fig. 4.24). These regimens chieved high tretment success rtes (87 9%) in selected MDR/RR-TB ptients included in pooled met-nlysis undertken to inform the ltest WHO policy updte for the tretment of drug-resistnt TB (Box 4.3). As prt of efforts to improve ccess to tretment nd tretment outcomes for MDR/XDR-TB, t lest 7 countries hd imported or strted using bedquiline nd 39 countries hd used delmnid by the end of 215 (Fig. 4.25). 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, 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 is required (Box 4.6). Further detils on reserch nd development of new drugs nd novel regimens re given in Chpter 8. 1 World Helth Orgniztion. Active TB drug-sfety monitoring nd mngement (DSM). WHO. Avilble from: res-of-work/drug-resistnt-tb/tretment/phrmcovigilnce/en/ GLOBAL TUBERCULOSIS REPORT 216 :: 81

93 Chpter 5 :: TB prevention services :: KEY FACTS AND MESSAGES 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 people living with HIV; prevention of trnsmission of Mycobcterium tuberculosis through infection control; nd vccintion of children with the Bcille-Clmette-Guérin (BCG) vccine. Globlly in 215, there were n estimted 1.2 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. In comprison, only children in this ge group (7.1%) were reported to hve been strted on TB preventive tretment in 215, bsed on dt from 88 countries. A totl of people who were newly enrolled in HIV cre were strted on TB preventive tretment in 215, bsed on dt from 58 countries. This ws lrge increse from negligible levels in 25, when WHO first requested dt. South Afric ccounted for the lrgest shre (45%) of the totl in 215, s in previous yers, followed by Mlwi, Mozmbique nd Keny. Ten countries reported dt for the first time, including Keny. Despite progress in providing TB preventive tretment to people living with HIV, much more remins to be done. Of the 3 high TB/HIV burden countries, 21 did not report ny provision of preventive tretment in 215. In the nine high TB/HIV burden countries tht did report dt, coverge mong people newly enrolled in HIV cre rnged from 2% in Indonesi to 79% in Mlwi. 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 helth-cre 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 215, 9977 helth-cre workers were reported with TB from 67 countries; Chin ccounted for 3% of these cses nd South Afric for 21%. In 16 countries, 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 215, 163 countries reported providing BCG vccintion s stndrd prt of these progrmmes, of which 12 reported coverge of bove 9%. Monitoring nd evlution of TB prevention services is chllenging given the lck of systems for recording nd reporting dt, nd the involvement of multiple service providers. In 216, WHO developed stndrd indictors to monitor nd evlute the provision of TB preventive tretment. Countries re encourged to dopt these indictors nd n electronic surveillnce system tht fcilittes collection nd nlysis of the relevnt dt. 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 implementtion t lrger scle. Innovtive dignostic tests with improved performnce nd predictive vlue re needed to trget individuls who will benefit most from TB preventive tretment. 82 :: GLOBAL TUBERCULOSIS REPORT 216

94 Prevention of new infections of Mycobcterium tuberculosis nd their progression to 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. The trgets of n 8% reduction in TB incidence by 23 nd 9% reduction by 235, compred with 215, require n historiclly unprecedented ccelertion in the rte t which TB incidence flls fter 225 (Chpter 2). This cn only hppen if the probbility of progression from ltent TB infection (LTBI) to ctive TB disese mong the 2 3 billion people lredy infected worldwide is reduced below the current lifetime risk of 5 15%. 1 In some low-burden countries, rectivtion ccounts for bout 8% of new cses of disese. 2,3 Interventions tht could result in much greter reduction include more effective tretments for LTBI nd new vccine cpble of preventing rectivtion of LTBI in dults. There re three mjor ctegories of helth interventions currently vilble for TB prevention: tretment of LTBI through isonizid dily for 6 or 9 months, or isonizid plus rifmpicin dily for 3 4 months, or rifmpicin dily for 3 4 months or isonizid plus rifpentine once week for 3 months with prticulr ttention to children ged under 5 yers who re household contcts of TB cses with bcteriologiclly confirmed pulmonry disese, nd people living with HIV (Section 5.1); prevention of trnsmission of Mycobcterium tuberculosis through infection control (Section 5.2); nd vccintion of children with the Bcille-Clmette-Guérin (BCG) vccine (Section 5.3). The three min sections of this chpter present nd discuss the sttus of progress in provision of these services. Prticulr ttention is given to countries in the lists of 3 high TB burden nd 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 Mycobcterium tuberculosis without cliniclly-mnifested evidence of ctive TB disese. There re two prticulr risk groups for whom specific efforts to dignose nd tret LTBI re recommended by WHO: children ged under 5 yers who re household contcts of pulmonry TB cses, nd people living with HIV. 4 Coverge of contct investigtion 1 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). nd tretment of LTBI mong child contcts nd people living with HIV re in the top-1 list of indictors for monitoring implementtion of the End TB Strtegy, with trget of over 9% coverge by 225 t the ltest (Chpter 2, Tble 2.1). Dt on provision of TB preventive tretment for people living with HIV hve been collected 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 hs now been developed by WHO Globl LTBI Tsk Force, 5 nd the recommended indictors re shown in Tble 5.1. The rest of this section discusses findings from dt gthered from countries nd territories in WHO s 216 round of globl TB dt collection bout TB preventive tretment for the three risk groups Child contcts under 5 yers of ge who re household contcts of TB cses In 215, of the 189 countries tht reported t lest one notified bcteriologiclly confirmed pulmonry TB cse, 88 (47%) reported dt bout the number of contcts ged under 5 yers who were strted on TB preventive tretment (Fig. 5.1). A totl of child household contcts were initited on TB preventive tretment (Tble 5.2), with the lrgest numbers reported by the WHO Africn Region (28% of the globl totl) nd Estern Mediterrnen Region (2% of the globl totl). At country level, Afghnistn reported the lrgest number (1 164) followed by Bngldesh (9833). Only nine of the 3 high TB burden countries reported dt. A few countries in the WHO Europen Region noted tht it ws not possible to report dt for children specificlly becuse preventive tretment is provided to dults s well s children; this my lso pply to some low TB burden countries tht did not report dt. Thus, the dt reported to WHO understte the ctul number of children who were strted on TB preventive tretment. Comprisons of the number of children strted on tretment for LTBI in 215 with ntionl estimtes of the number of children ged under 5 yers who were contcts of bcteriologiclly confirmed pulmonry TB cses nd eligible for TB preventive tretment re lso shown in Tble 5.2. Globlly, the children strted on TB preventive tretment in 215 represented 7.1% (rnge, %) of the 1.2 million (rnge, 1.18 million to 1.26 million) children estimted to be eligible for it. Higher levels of coverge were chieved in the WHO Region of the Americs (best estimte 67%; rnge, 63 71%) followed by the Europen Region (best estimte 42%; rnge, 4 44%). In the high TB or TB/HIV burden countries tht reported dt, coverge rnged from 2.6% in Cmeroon to 41% in Mlwi People living with HIV There hs been considerble increse in the provision of preventive TB tretment in recent yers, especilly in 5 GLOBAL TUBERCULOSIS REPORT 216 :: 83

95 :: TABLE 5.1. Summry of monitoring nd evlution indictors for LTBI progrmmtic mngement recommended by WHO COUNTRY GROUP AT RISK POPULATIONS WITH STRONG RECOMMENDATIONS CORE GLOBAL AND NATIONAL INDICATORS CORE NATIONAL INDICATORS OPTIONAL INDICATORS LOW TB BURDEN High-income nd upper middle-income countries with n estimted TB incidence rte of less thn 1 per 1 popultion HIGH TB BURDEN Resource-limited nd other high nd middleincome countries with n estimted TB incidence rte equl to or more thn 1 per 1 popultion 1) People living with HIV. 2) Adults nd children who re household contcts of pulmonry TB cses. 3) Clinicl indictions: ptients with silicosis; ptients inititing ntitumour necrosis fctor (TNF) tretment; ptients on dilysis; ptients prepring for orgn or hemtologic trnsplnttion. 1) People living with HIV. 2) Children under 5 yers of ge who re household contcts of pulmonry TB cses. 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 1) Proportion of eligible individuls from t risk popultions (ccording to ntionl guidelines) tested for ltent TB infection. 2) 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. 3) 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. 1) Proportion of eligible people living with HIV who completed course of TB preventive therpy. 2) 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. 1) 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, 215 Country response Number vilble from routine surveillnce Number estimted from survey Number not vilble No response Not pplicble 84 :: GLOBAL TUBERCULOSIS REPORT 216

96 :: TABLE 5.2 TB preventive tretment in 215 for people living with HIV nd children under 5 yers of ge who were household contcts of bcteriologiclly confirmed pulmonry TB cse, 16 high TB or TB/HIV burden countries tht reported dt, WHO regions nd globlly NUMBER OF PEOPLE LIVING WITH HIV NEWLY ENROLLED IN CARE (A) b PEOPLE NEWLY ENROLLED IN HIV CARE WHO WERE STARTED ON TB PREVENTIVE TREATMENT IN 215 COVERAGE, % NUMBER (B) b (B A) ESTIMATED NUMBER OF CHILDREN UNDER 5 YEARS OF AGE WHO WERE HOUSEHOLD CONTACTS OF A NOTIFIED BACTERIOLOGICALLY CONFIRMED PULMONARY TB CASE, AND ELIGIBLE FOR TB PREVENTIVE TREATMENT, IN 215 (C) c CHILDREN UNDER 5 YEARS OF AGE WHO WERE STARTED ON TB PREVENTIVE TREATMENT IN 215 NUMBER (D) COVERAGE, % (D C) c Bngldesh 45 (41 49 ) (2 24) Cmbodi (46 55) (13 16) Cmeroon 11 (1 13 ) ( ) Ethiopi (28 34 ) Indonesi (61 73 ) Keny (21 25 ) (5. 6.) Mlwi (44 52) (37 45) Mozmbique (16 19 ) Mynmr (14 17 ) ( ) Nigeri (35 42) (15 18) Philippines (41 49 ) (13 16) Sierr Leone (57 68) South Afric (45 53 ) UR Tnzni 19 (17 21 ) ( ) Viet Nm 16 (14 17 ) (1 12) Zimbbwe (69 83) (28 34) Afric (43 45 ) ( ) Americs (23 25 ) (63 71) Estern Mediterrnen (14 16 ) (11 12) Europe (16 17 ) (4 44) South-Est Asi (47 54 ) ( ) Western Pcific (78 9 ) (12 14) GLOBAL ( ) ( ) indictes dt not vilble. There were 22 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, Democrtic People s Republic of Kore, Democrtic Republic of the Congo, Ghn, Guine-Bissu, Indi, Lesotho, Liberi, Nmibi, Pkistn, Ppu New Guine, Russin Federtion, Swzilnd, Thilnd, Ugnd nd Zmbi. b In some countries due to dt qulity issues, the figures my not exclusively include number of people living with HIV who re newly enrolled in to HIV cre. c Best estimtes re followed by the uncertinty intervl, nd re shown to two significnt figures. :: FIG. 5.2 Provision of TB preventive tretment to people living with HIV, Number of people living with HIV (thousnds) Globl South Afric Rest of world Rest of Afric Up to 214, countries were requested to report dt on the provision of isonizid preventive therpy (IPT). In 215, countries were requested to report dt on the number of people treted for LTBI ccording to the new TB/HIV monitoring nd evlution guide published in 215. GLOBAL TUBERCULOSIS REPORT 216 :: 85

97 :: Box 5.1 Enblers for estblishing effective monitoring nd evlution of tretment for LTBI In April 216, WHO in collbortion with the Republic of Kore s Centers for Disese Control nd Prevention, nd Interntionl Tuberculosis Reserch Center orgnized globl consulttion on the progrmmtic mngement of LTBI. This ws the first such consulttion in the er of the End TB Strtegy, nd brought together prticipnts from both high nd low TB burden countries to discuss nd identify chllenges, opportunities nd best prctices in the progrmmtic mngement of LTBI. Brriers to monitoring nd evlution of the provision of tretment for LTBI tht were identified included the nonnotifible sttus of LTBI in mny countries, the existence of multiple pper-bsed registers for recording of tretment, frgmenttion due to the involvement of multiple service providers nd lck of regultion of the privte sector. Exmples of pproches tht cn fcilitte effective monitoring nd evlution system were shred. These included: incorporting tretment of LTBI in the routine surveillnce system for TB by mking LTBI notifible condition (Jpn); improving dt mngement, including by using n electronic web-bsed register (the Netherlnds) nd linking dt from multiple electronic dtbses (Norwy); nd estblishing better reltionships with the privte sector (Republic of Kore), especilly to improve the reporting of preventive tretment for people in clinicl risk groups. the WHO Africn Region (Fig. 5.2). In 215, totl of 57 countries (representing 61% of the estimted globl burden of HIV-ssocited TB) reported providing preventive TB tretment to people newly enrolled in HIV cre, up from 49 countries in 214. The totl number of people strted on preventive tretment globlly ws , similr to the level of 214 nd up from the very low levels in 25 when WHO first requested dt. Most of this progress hs occurred since 21, following definition of four-symptom lgorithm for screening for TB mong people living with HIV nd ssocited WHO guidnce. 1,2 As in previous yers, South Afric ccounted for the lrgest proportion (45%) of the globl totl in 215 (Fig. 5.2), followed by Mlwi, Mozmbique nd Keny (Tble 5.2). Ten countries reported dt for the first time, including Keny, nd severl other countries in the WHO Africn Region reported higher numbers in 215 compred with 214 (e.g. Ethiopi, Mozmbique, Nigeri nd Zimbbwe). Despite this progress, much more remins to be done. Of the 3 high TB/HIV burden countries, 21 did not report ny provision of preventive tretment in 215, nd in the nine tht did report dt, coverge mong people newly enrolled in HIV cre rnged from 2% in Indonesi to 79% in Mlwi (Tble 5.2). 1 Gethun H, Kittikrisk W, Heilig CM, Corbett EL, Ayles H, Cin KP et l. Development of stndrdized screening rule for tuberculosis in people living with HIV in resource-constrined settings: individul prticipnt dt met-nlysis of observtionl studies. PLoS Med. 211;8(1):e1391 ( pubmed/ , ccessed 3 August 216). 2 World Helth Orgniztion. Guidelines for intensified tuberculosis cse-finding nd isonizid preventive therpy for people living with HIV in resource-constrined settings. Genev: WHO; 215 ( pps.who.int/iris/bitstrem/1665/44472/1/ _eng. pdf, ccessed 31 August 216) Other t-risk popultions Dt on provision of preventive tretment to other t-risk popultions were reported by seven countries: Frnce, Jpn, the Netherlnds, Norwy, Portugl, Republic of Kore nd Slovki (Tble 5.3). Only four countries could report denomintors, nd then only for subset of risk groups. All seven countries reported providing preventive tretment to dult contcts, nd coverge ws more thn 5% in the four countries tht reported denomintors. Dt for clinicl risk groups such s ptients strting nti-tumour necrosis fctor (TNF) therpy nd those prepring for trnsplnttion were reported by Norwy, Portugl nd Slovki. The lck of routinely reported dt, prticulrly for clinicl risk groups, mkes it difficult to monitor coverge levels. Better monitoring mechnisms need to be estblished; exmples of how to do this re provided in Box TB infection control TB infection control is one of the key components of the second pillr of the End TB Strtegy (Chpter 2) nd is lso one of the collbortive TB/HIV ctivities tht flls under pillr one. 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. 3,4 TB infection control should be prt of ntionl infection 3 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): :: GLOBAL TUBERCULOSIS REPORT 216

98 :: TABLE 5.3 Provision of TB preventive therpy to other t-risk popultions in 215,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 TREATMENT AT-RISK POPULATIONS FOR WHICH THERE IS A CONDITIONAL RECOMMENDATION TO PROVIDE PREVENTIVE TREATMENT ADULT CONTACTS OF TB CASES PATIENTS INITIATING ANTI-TNF TREATMENT PATIENTS RECEIVING DIALYSIS PATIENTS PREPAR- ING FOR ORGAN OR HAEMATOLOGICAL TRANSPLANTATION PATIENTS WITH SILICOSIS IMMIGRANTS FROM HIGH TB BURDEN COUNTRIES HEALTH WORKERS PRISONERS HOMELESS PEOPLE ILLICIT DRUG USERS Frnce Jpn Netherlnds Norwy Portugl Republic of Kore Slovki indictes dt not vilble. Dt for Frnce nd Norwy re for 214. prevention nd control policy, nd TB nd HIV progrmmes t ntionl nd subntionl level should provide mngeril direction to implement TB infection control mesures. In helth-cre fcilities nd congregte settings, comprehensive set of infection control mesures comprising dministrtive, environmentl nd personl protection mesures should be implemented. 1 Periodic ssessment of TB infection control in helth-cre fcilities is essentil to ensure tht pproprite mesures re in plce. 2 In the ltest revision of WHO guidnce on monitoring nd evlution of collbortive TB/HIV ctivities, 3 the risk of TB mong helth-cre workers reltive to the generl dult popultion is n indictor recommended to mesure the impct of TB infection control ctivities in helth-cre 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 one. In 215, 9977 TB cses mong helth-cre workers were reported from 67 countries; Chin ccounted for 3% of these cses nd South Afric for 21%. The notifiction rte mong helth-cre workers could be clculted for 46 of the 67 countries; it rnged from zero in Belize, Gmbi, Hiti, Jordn nd Mrshll Islnds to 1565 cses per 1 1 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). 2 World Helth Orgniztion. Checklist for Periodic Evlution of TB Infection Controlin Helth-Cre Fcilities. Genev. WHO; 215 ( for_periodic_evlution_of_tb_infection_control_in_helth_fcilities. pdf, ccessed 16 September 216). 3 World Helth Orgniztion. A guide to monitoring nd evlution for collbortive TB/HIV ctivities: 215 revision. Genev: WHO; 215 ( ccessed 31 August 216). popultion in South Afric. 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 (UN) popultion division (215 revision). The rtios of the TB notifiction rte mong helth-cre workers to the rte in the generl dult popultion re shown in Fig The rtio ws bove 2 in 16 countries, including South Afric. In the other four high TB/HIV burden countries for which the rtio could be clculted, the rtio ws between 1 nd 2 in three countries (Botswn, the Russin Federtion nd Zimbbwe) nd below 1 in one country (Chin). 5.3 TB vccintion There is cler need for vccine tht is more effective thn BCG, especilly to reduce the risk of infection with Mycobcterium tuberculosis nd the risk of progression from infection to ctive TB disese in dults. Although there re 13 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 BCG my be limited to neontes nd infnts in recognized highrisk groups, or to skin-test negtive older children. A summry of ntionl policies on BCG vccintion 4 is 4 Zwerling A, Behr MA, Verm A, Brewer TF, Menzies D, Pi M. The BCG World Atls: dtbse of globl BCG vccintion policies nd prctices. PLoS Medicine. 211;8(3):e1112. GLOBAL TUBERCULOSIS REPORT 216 :: 87

99 :: FIG. 5.3 Notifiction rte rtio of TB mong helthcre workers compred with the generl dult popultion, 215 Notifiction rte rtio No dt Not pplicble :: FIG. 5.4 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 never hd universl BCG vccintion progrmmes. Source: Zwerling A, Behr MA, Verm A, Brewer TF, Menzies D, Pi M. The BCG World Atls: A dtbse of Globl BCG Vccintion Policies nd Prctices. PLoS Med. 211 Mr;8(3):e This is n open-ccess rticle distributed under the terms of the Cretive Commons Attribution License, which permits unrestricted use, distribution, nd reproduction in ny medium. 88 :: GLOBAL TUBERCULOSIS REPORT 216

100 :: FIG. 5.5 Coverge of BCG vccintion, 215 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. shown in Fig Among 18 countries for which dt were collected, 157 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 1 (for 215) re shown in Fig In the 163 countries tht reported dt, 12 reported coverge of bove 9%. Among the 3 high TB burden countries, coverge rnged from 56% in the Centrl Africn Republic to 99% in Bngldesh, Brzil, Cmbodi, Chin, Thilnd nd the United Republic of Tnzni. A further 16 of these countries reported coverge of t lest 9%. Coverge ws below 8% in seven of the high TB burden countries: Angol, Centrl Africn Republic, Keny, Lesotho, Liberi, Nigeri nd Ppu New Guine. 1 timeseries/tscovergebcg.html GLOBAL TUBERCULOSIS REPORT 216 :: 89

101 Chpter 6 :: Universl helth coverge, socil protection nd ddressing socil determinnts: Implictions for TB :: KEY FACTS AND MESSAGES Progress towrds universl helth coverge (UHC) is essentil for ll of the helth-relted Sustinble Development Gols (SDGs), including ending the tuberculosis (TB) epidemic. UHC is lso closely ligned with the gol of ending poverty. Two regulrly monitored UHC finncing indictors revel the helth finncing conditions tht must chnge in mny of the highest TB burden countries to enble UHC nd meet the mbitious milestones on route to end TB. These re totl government spending on helth s proportion of gross domestic product (GDP) nd out-of-pocket (OOP) expenditures s shre of totl helth expenditures. In 214, government expenditures on helth were less thn the WHO benchmrk of t lest 6% in 15 of 191 countries (79%) for which dt were vilble. OOP expenditures represented over 45% of overll helth expenditures in 46 countries in 214, including 11 of the 3 highest TB burden countries. There re opportunities for improving TB service coverge s prt of wider efforts, nd exmples re highlighted in this chpter, including: In some high TB burden settings, emerging UHC helth finncing schemes, including ntionl helth insurnce, could led to mjor reductions in OOP expenditures in low-income popultions. Models need to explicitly include support for TB cre nd public helth functions, nd to ddress dministrtive nd finncing constrints tht my otherwise hinder the impct of these schemes. More nlysis is needed to inform their design nd implementtion but Thilnd s well s countries in the Region of the Americs re good pthfinders. In Asi, building on estblished pproches to privte provider enggement in TB cre could help to ddress the burgeoning privte sector in helth-cre delivery. This includes combintion of provider incentives nd regultion, nd ppliction of innovtive institutionl intermediries nd communictions technologies. Such levers cn help to ssure the qulity of services provided. In the context of humnitrin emergencies nd postemergency system rebuilding, such s in the Estern Mediterrnen nd sub-shrn Afric, drug-supply coordintion nd cross-progrmme use of common lbortory technology re enbling ccess to TB nd MDR-TB cre nd prevention. In Europe, modifiction of helth system incentives is helping to improve ptient-centred cre, including by reducing costly hospitliztion of ptients with drugsusceptible TB nd long stys for ptients with MDR-TB, while expnding investments in outptient cre. Socil protection cn be dvnced through better models of cre nd socil benefits. Mny low- nd middle-income countries hve used interntionl nd community-level funds to finnce socil nd economic support for TB nd MDR-TB ptients, but these support pckges need to be better documented nd evluted. For overll impct nd sustinbility, using ntionl socil protection pltforms is priority. The End TB Strtegy includes 22 trget to eliminte ctstrophic costs for TB-ffected households. WHOrecommended bseline ntionl surveys re underwy to ssess the nture nd severity of TB ptient costs, nd to improve service delivery nd socil protection ccordingly. One country survey ws conducted in 215, eight begn in 216 nd nother ten re currently being plnned for Ending TB nd ending poverty re intertwined gols. Ministries of helth, ffected communities nd prtners cn do more to use vilble evidence of the links in order to dvocte for poverty elimintion nd ction on relted risk fctors (e.g. noncommunicble disese prevention, food security, nd housing). 9 :: GLOBAL TUBERCULOSIS REPORT 216

102 This chpter ims to provide tuberculosis (TB) perspective on wht progress on universl helth coverge (UHC) cn men for TB nd for movement on other elements of the Sustinble Development Gol (SDG) gend; for exmple, ending poverty, dvncing socil protection nd reducing inequlity. 1 It covers six topics: the definition nd dimensions of UHC (Section 6.1); monitoring progress towrds UHC (Section 6.2); opportunities for UHC nd specificlly for those ffected by TB tht re provided by innovtions in finncing nd systems (Section 6.3); hrnessing the benefits of socil protection pltforms (Section 6.4); ssessing totl costs borne by TB ptients nd the relted occurrence of ctstrophic totl costs due to TB (Section 6.5); nd linking with poverty elimintion efforts nd ction on other socil determinnts of TB (Section 6.6). This chpter is in lrge prt descriptive. It ddresses some of the chllenges fced s countries embrk on new UHCrelted policies nd schemes; it lso discusses the helth finncing, socil protection nd socil development opportunities tht TB progrmmes nd ffected communities cn build on in their efforts to end TB. Country experiences nd epidemiologicl, policy nd opertionl reserch inform the discussion. 6.1 Definition of universl helth coverge To chieve ll of the helth-relted SDGs, WHO promotes the need for ccelerted progress towrds SDG Trget 3.8 i.e. UHC by 23 (see lso Box 2.2 in Chpter 2). According to WHO nd the World Bnk, UHC mens ll people receiving the helth services they need, including helth inititives designed to promote better helth, prevent illness, nd to provide tretment, rehbilittion, nd pllitive cre of sufficient qulity to be effective, while t the sme time ensuring tht the use of these services does not expose the user to finncil hrdship. 2 UHC is hugely mbitious im nd so fr no country hs fully chieved it; nevertheless, mny countries hve shown tht drmtic gins re possible in low-, middlend high-income settings. Furthermore, globl helth security depends on commitment to UHC. As noted recently by Dr Mrgret Chn, Director-Generl of WHO, Well-functioning helth systems tht cover entire popultions re now regrded s the first line of defence ginst 1 United Ntions. Trnsforming our world: The 23 Agend for Sustinble Development. New York: UN; 215 ( sustinbledevelopment.un.org/post215/trnsformingourworld/ publiction, ccessed 5 September 216). 2 World Helth Orgniztion/World Bnk. Trcking universl helth coverge: first globl monitoring report. Genev: WHO; 215 ( en/, ccessed 5 September 216). :: FIG. 6.1 Three dimensions to consider when moving towrds universl helth coverge Extend to non-covered Reduce costshring nd fees Current pooled funds Popultion: who is covered? Direct costs: proportion of the costs covered Include other services Services: which services re covered? Source: WHO. The world helth report: helth systems finncing: the pth to universl coverge. Genev: World Helth Orgniztion, 21. the thret from emerging nd re-emerging diseses. 3 Ending the globl TB epidemic nd resolving the multidrug-resistnt TB (MDR-TB) crisis depend on mjor movement towrds UHC before 225. There is no rtionle for discussing universl coverge for interventions ginst one helth chllenge in isoltion from the movement for UHC in generl. The dimensions of UHC efforts re reflected in the UHC cube, which is shown in Fig. 6.1, nd exmples re given of how ech dimension is relevnt for serving those ffected by TB. The first dimension is expnding pooled funding to enble coverge of more of the popultion (including, for exmple, specific groups who re especilly vulnerble to poverty, ill-helth or rights brriers). In TB, this cn men ensuring tht the poorest communities nd mrginlized groups (e.g. migrnts, ethnic minorities) re covered by vilble socil or ntionl helth insurnce schemes nd hve better physicl or legl ccess to services. The second dimension is expnding the services in ny essentil pckge covered by pooled funding. For TB, this my men covering the costs of initil consulttions, X-rys, second-line drugs, treting dverse events, nd mngement of comorbidities nd TB sequele. All these services re essentil for effective TB cre. The third dimension is incresing the shre of individul direct costs of cre covered by pooled funds. Surveys of TB ptient costs suggest tht in mny settings the finncil burden is significnt (on verge equivlent to 5% of nnul income), bout hlf of which is incurred when using non-tb specific services in the public nd/ 3 Chn M. Keynote ddress t high-level side event on universl helth coverge in Afric t TICAD (Tokyo Interntionl Conference for Africn Development). ( universl-helth-fric/en/, ccessed 5 September 216). GLOBAL TUBERCULOSIS REPORT 216 :: 91

103 or privte sector, before TB dignosis is mde nd TB tretment strts. 1 UHC efforts cross ll three dimensions could improve overll primry cre service ccess nd rpidly reduce the cost burden fced by ptients. 6.2 Monitoring progress on universl helth coverge WHO nd the World Bnk hve jointly proposed core indictors for monitoring progress towrds UHC, ddressing service ccess, helth finncing nd finncil protection. 2 For mesuring ccess, effective TB tretment coverge is mong the proposed eight core service-ccess indictors tht cn be regulrly monitored s trcers for overll UHC. Effective TB tretment coverge is defined s notifictions, divided by incidence, multiplied by the tretment success rte. 3 For helth finncing, UHC clls for the bsolute level of funding for helth cre to be sufficient to ensure tht it is possible to provide essentil helth services to the whole popultion. In ddition, the costs of using those services, once vilble, must not be prohibitive (i.e. using them should not result in finncil hrdship). The three helth finncing indictors proposed for nnul monitoring of progress towrds UHC re: Totl government spending on helth s proportion of gross domestic product (GDP) the suggested benchmrk is t lest 6%. 4,5 Government helth spending per cpit in low-income countries the suggested benchmrk in the Millennium Development Gol (MDG) er ws US$ 86 (in 212 prices). 2,4 A new benchmrk for SDG-relted helth interventions for low nd upper middle income countries will soon be recommended by WHO. Out-of-pocket (OOP) expenditures s proportion of totl helth expenditures the suggested benchmrk is t most 15%. 6 The level of OOP pyments provides 1 Tnimur T, Jrmillo E, Weil D, Rviglione M, Lonnroth K. Finncil burden for tuberculosis ptients in low- nd middle-income countries: systemtic review. Eur Respir J. 214;43(6): ( ccessed 5 September 216). 2 World Helth Orgniztion/World Bnk Group. Monitoring progress towrds universl helth coverge t country nd globl levels: frmework, mesures nd trgets (WHO/HIS/HIA/14). Genev: WHO; 214 ( WHO_HIS_HIA_14.1_eng.pdf, ccessed 5 September 216). 3 See reporting in: World Helth Orgniztion/World Bnk Group. Trcking universl helth coverge: First globl monitoring report. Genev: WHO, World Helth Orgniztion. Helth systems finncing: the pth to universl coverge: world helth report 21. Genev: WHO; 21 ( ccessed 5 September 216). 5 This figure is determined by combintion of revenue genertion nd prioritiztion of helth within government expenditures. 6 Xu K, Evns DB, Crrin G, Aguilr-River AM, Musgrove P, Evns T. Protecting households from ctstrophic helth spending. Helth Affirs. 27;26(4): proxy mesure of the degree to which people lck finncil protection. 7 Country reporting ginst these three indictors is vilble in the WHO Globl Helth Expenditure Dtbse. 8 Two other indictors for ssessing finncil protection re proposed for periodic monitoring through popultionbsed surveys: The proportion of households experiencing ctstrophic helth expenditures. This occurs when household OOP expenditures crowd out consumption of other necessry goods nd services. Ctstrophic helth expenditures re defined s helth-cre expenditures tht exceed given frction of the household s expenditure. The frction used by WHO nd the World Bnk is currently 25%. The proportion of people experiencing impoverishing expenditures, defined s the extent to which OOP expenditures push people into poverty, given predefined poverty line. Accepted poverty lines vry. The interntionl poverty line used by the World Bnk uses the consumption indictor of US$ 1.5 or US$ 2. per dy per cpit t purchsing power prity. WHO uses reltive poverty line, bsed on subsistence level of food expenditure. Fig. 6.2, Fig. 6.3 nd Fig. 6.4 provide n indiction of where the 3 high TB burden countries stnd in reltion to three of the core helth finncing indictors described bove. Fig. 6.2 shows the ltest dt (for 214) on government helth expenditures (GHE). 9 GHE were less thn 6% of GDP in most countries (15/191, 79%). In only 41 countries did GHE exceed 6% of GDP. Of these countries, only six re low or lower-middle income Djibouti, Lesotho, Kiribti, Micronesi, Mrshll Islnds nd Swzilnd nd only one (Lesotho) is mong the highest TB burden countries. In 214, government spending on helth per cpit ws fr below the suggested benchmrk of US$ 86 per cpit in ll low-income countries (dt not shown). Most countries spent less thn US$ 2 per cpit. The country tht ws closest to this benchmrk ws Senegl, which spent US$ 26 per cpit. In 214, OOP expenditures were less thn 15% of totl helth spending in 46 of the 19 countries for which dt were vilble, including five of the 3 high TB burden countries: Mozmbique, Nmibi, Ppu New Guine, Thilnd nd South Afric (Fig. 6.3). There were 46 countries where OOP expenditures ccounted for t lest 45% of totl helth expenditures, including 11 high TB burden countries: Bngldesh, Cmbodi, Centrl Africn Republic, Indi, Indonesi, Mynmr, Nigeri, Pkistn, Philippines, Russin Federtion, Sierr Leone. 7 Note: OOP expenditures re defined s direct pyments mde to helth-cre providers by individuls t the time of helth service use; therefore, they exclude prepyment WHO Ntionl helth ccounts dtbse, ccessed July 216 vi 92 :: GLOBAL TUBERCULOSIS REPORT 216

104 :: FIG. 6.2 Government spending on helth, s percentge of gross domestic product (GDP), 214 Percentge of GDP < No dt Not pplicble :: FIG. 6.3 Out-of-pocket expenditures s percentge of totl helth expenditures, 214 Percentge No dt Not pplicble GLOBAL TUBERCULOSIS REPORT 216 :: 93

105 :: FIG. 6.4 Totl helth expenditures by source of finncing in BRICS nd other selected high TB burden countries, 214 Percentge South Afric Brzil Chin Russin Federtion Countries re ordered ccording to the sum of mndtory nd voluntry pre-pyment. Source: Dt extrcted from World Helth Orgnistion s Globl Helth Expenditure Dtbse ( Fig. 6.4 provides the brekdown of totl helth expenditures by source of funding, including OOP expenditures, for BRICS (Brzil, Russin Federtion, Indi, Chin, South Afric) nd other high TB burden countries, reltive to the verge brekdown for countries tht re members of the Orgnistion for Economic Co-opertion nd Development (OECD). 1 It suggests tht most of the high TB burden countries hve fr to go in enbling substntil coverge of lterntives to OOP expenditures. 6.3 Innovtions in domestic helth finncing nd in helth systems towrds UHC To drmticlly reduce OOP expenditures nd to more robustly fund helth systems in generl, mndtory prepyment finncing mechnisms (e.g. txtion, socil or ntionl helth insurnce schemes) need to form the core of domestic helth finncing. 2 An estimte of the dditionl finncing needed in low- nd middle-income countries to move towrds levels of helth coverge in higher income countries is US$ 3 billion between now nd 235, with US$ 21 billion of this sum to be derived from incresed do- 1 Note: mndtory pre-pyment refers to pre-pyments required for individuls either by the government, the employer nd/or the individul themselves. 2 World Helth Orgnistion. The World Helth Report 21. Helth systems finncing: the pth to universl coverge. Genev: World Helth Orgnistion; 21 Indonesi Pkistn Indi Nigeri Mndtory pre-pyment Voluntry pre-pyment Out-of-pocket expenditure Non-profit institutions serving households (e.g. NGOs) Privte expenditure, other OECD verge mestic resources nd US$ 9 million proposed to come from interntionl sources. 3 Box 6.1 provides sense of how some pthfinding low- nd middle-income countries in Asi re moving to develop more robust finncing systems, nd especilly to ddress coverge for poor people. The ntionl helth insurnce experience of Thilnd, s well s experiences in rnge of Ltin Americn countries, 4 provide good pthfinder exmples of how to rech lrge shres of the popultion, including the poor, with helth services free of ctstrophic burden. Beyond popultion-wide finncing schemes, UHC mens reching those ffected by TB, irrespective of where they seek cre, including in the privte sector. This requires rnge of innovtive demnd- nd supply-side pproches, s prt of overll government stewrdship of the helth system s whole. Box 6.2 provides n overview of some of the innovtions being pplied in Asi to hrness the significnt scope of the privte sector while lso enbling better qulity of cre overll. Countries in severl regions hve developed nd pplied mndtory cse notifiction systems to engge with public nd privte institutions, nd with providers not previously collborting ctively with ntionl TB efforts. Chin s well-estblished web-bsed communicble diseses notifiction system tht incorportes TB hs given boost to TB cse notifictions from public hospitls. Similrly, NIKSHAY, Indi s recent web-bsed, cse-bsed TB notifiction system hs led to remrkble increse in cse notifictions from the privte sector. In mny countries of the Americs, high levels of cse notifiction re possible through reltively strong public nd socil security sectors in helth cre. 5 To chieve UHC lso requires enbling ccess for highly vulnerble popultions. Trget 1.5 of the SDGs is by 23, build the resilience of the poor nd those in vulnerble situtions nd reduce their exposure nd vulnerbility to climte-relted extreme events nd other economic, socil nd environmentl shocks nd dissters. 6 In prts of the WHO Estern Mediterrnen Region, humnitrin emergencies brought on by civil unrest nd wr hve led to lrge popultions being internlly displced, nd to refugee crisis. Among the first steps towrds regining bsic helth service coverge, including TB cre, hs been securing dequte drug supplies nd pplying estblished good prctices in screening, testing nd cre in emergencies. WHO nd prtners, including the Globl Fund to Fight AIDS, Tuberculosis nd Mlri (the Globl Fund), the Interntionl 3 Jmison DT, Summers LH, Alleyne G, Arrow KJ, Berkley S, Bingwho A et l. Globl helth 235: world converging within genertion. Lncet. 213;382(998): ( pubmed/ , ccessed 5 September 216) 4 Atun R, Monteiro de Andrde LO, Aleid G. et l. Helth-system reform nd universl helth coverge in Ltin Americ. Lncet (994): Uplekr M, Atre S, Wells W, Weil D, et l. Mndtory TB cse notifiction in high TB-incidence countries: policy nd prctice. Eur Respir J United Ntions. Trnsforming our world: The 23 Agend for Sustinble Development. New York: UN; 215 ( sustinbledevelopment.un.org/post215/trnsformingourworld/ publiction, ccessed 5 September 216). 94 :: GLOBAL TUBERCULOSIS REPORT 216

106 :: Box 6.1 Implictions for TB of evolving helth finncing schemes in selected Asin high TB burden countries Innovtive helth finncing schemes towrds UHC, be they ntionl helth insurnce (NHI) or other models, cn potentilly hve profound nd positive benefits for extending ccess to high qulity helth cre to ll those in need, including those ffected by TB. This box provides some exmples of the schemes nd the min issues in ssuring finncing nd coverge for TB nd other services in selected high TB burden countries in Asi. Indonesi is mking strides towrds UHC under its NHI progrmme or Jminn Kesehtn Nsionl (JKN), which ws lunched in 214. The system is finnced by premiums pid by employers, the employee nd, for those with low income, the ntionl government. Beneficiries cn ccess pckge of helth services through public nd selected privte helth-cre providers, who re pid by cpittion for primry helth-cre services nd by reimbursement bsed on disese clssifiction for hospitl cre. TB services covered include dignosis nd tretment services for drugsusceptible TB. In ddition to the insurnce scheme, there is lso substntil budget-line support, including first-line TB drugs finnced by the centrl government, nd secondline drugs finnced primrily by the Globl Fund. High demnd nd costs, prticulrly in higher- level fcilities, re chllenging sustinbility. Therefore, the government is in the process of reviewing the benefits pckge, including through cost effectiveness nlysis. The NTP is working with JKN, vi Indonesi s Centre for Helth Finncing nd Helth Security, to crete TB service provision guidelines nd monitoring tools for JKN. The government hs nnounced its intention to shift finncing of TB cre nd prevention to the NHI scheme, which is likely to led to chnges in ccess to TB medictions nd services. The mechnisms for finncing public helth functions re lso in flux. A significnt proportion of TB ptients in Indonesi re treted in the privte sector, nd JKN my enble further leverge in promoting notifiction nd qulity cre. By incresing investment in primry cre, JKN my help to defry pre-tb dignostic costs for ptients. The Philippines is committed to chieving UHC vi investment in PhilHelth, the country s NHI progrmme. The scheme is finnced by government revenue nd per cpit premium pyments, for which the government subsidizes the contribution for those identified by locl governments s indigent. Locl government units hve supplementry mechnism, whereby the units ggregte dditionl funds to finnce locl service delivery opertions. TB services (hospitliztion, first-line drugs, nd consulttions) re provided free of chrge by PhilHelth to ptients served by ccredited providers. The progrmme is prticulrly importnt in encourging privte prctitioners nd institutions to provide stndrdized TB cre. A series of opertionl chllenges persist with PhilHelth. For exmple: not ll ptients re educted bout the PhilHelth benefits or the loctions of PhilHelth-ccredited fcilities; not ll providers re in the PhilHelth system due to the complex ccredittion system; reimbursement processes cn impede interest of providers to pursue the ccredittion process; nd currently, MDR-TB is not included in the benefits pckge but n expnsion of the progrmme is being formulted. Under the updted Ntionl Strtegic Pln for the NTP, mesures re proposed to resolve severl of these bottlenecks. b Viet Nm is expnding its socil helth insurnce (SHI) system with the im of chieving universl coverge by 22. The scheme is finnced by combintion of ntionl revenue nd employer employee contributions. The government tx revenue subsidizes the premium for the poor nd for ethnic minorities, with prtil subsidies for the ner-poor nd students. Since My 216, under the SHI, ltent TB infection, TB dignosis nd tretment services re covered by the government, lthough users contribute co-pyment tht rnges from % to 2%. The NTP hs plns to estblish foundtion tht cn cover co-pyment of TB ptients nd the premium for TB ptients who do not yet hve helth insurnce crd. One re of concern is drug supply, which will shift under SHI finncing. Currently, first-line TB drugs hve been finnced nd distributed by the centrl government, nd second-line TB drugs by the Globl Fund. The NTP is now working with counterprts within the Ministry of Helth nd the SHI gency to ensure tht finncing is secure from centrl SHI resources, to mintin full supply of qulity-ssured drugs to TB ptients. c Thilnd hs robust nd progressive NHI scheme in plce. There re three schemes for Thi ntionls: the Universl Coverge Scheme (UCS), the Socil Security Scheme nd the Civil Servnts Medicl Benefit Scheme. These schemes cover 99% of the Thi popultion. In 213, the Ministry of Public Helth initited scheme for migrnts not covered under the socil security scheme nd, by the end of 215, nerly 1.45 million migrnts could purchse subsidized helth insurnce. The UCS currently covers bout 75% of the Thi popultion. It is entirely tx-revenue finnced, nd is dministered by the Ntionl Helth Security Office (NHSO), n independent government gency tht purchses nd reimburses services. The Ministry of Public Helth provides the qulity stndrds, public helth functions nd consolidtion of cse reporting. Finncing for TB services is chnnelled through the TB Fund within the NHSO. UCS provides free first-line nd second-line TB nd MDR-TB tretment, moleculr dignostics for certin groups nd resistnce monitoring. Overll, coverge for TB services ppers to be high, with dditionl UHC efforts under wy to cover previously uncovered popultions, such s migrnts n importnt risk group for TB. The NHSO nd NTP re in the process of ddressing gps nd discrepncies in TB informtion flow by hrmonizing systems. Improved informtion will enble further review of the qulity of TB cre provided. d Continued GLOBAL TUBERCULOSIS REPORT 216 :: 95

107 Box 6.1 continued Chin hs NHI schemes tht re estimted to rech 95% of the popultion. The Bsic Medicl Insurnce scheme is co-finnced by government revenue nd per cpit premium pyments. Under recent helth-cre reforms, Chin is moving towrds mixed source funding mechnism, whereby funds from multiple levels of government, individul beneficiries nd socil ssistnce progrmmes will be pooled to improve finncil sustinbility. At the sme time, reforms hve ltered the delivery model for TB cre. Ptients will no longer ccess cre from TB dispensries, nd stte-owned hospitls will be the primry TB service providers. Bsic TB cre in these hospitls is techniclly free, but complicted reimbursement mechnism combined with benefit pckge limittions my result in high costs for drug-sensitive TB services. e Enbling or expnding finncing for MDR-TB tretment is mong the ongoing chllenges under ll of the evolving schemes bove. f Sources: Hrimurti, Pndu; Pmbudi, Eko; Pigzzini, Ann; Tndon, Ajy The nuts nd bolts of Jmkesms Indonesi s government-finnced helth coverge progrm for the poor nd ner-poor. Universl Helth Coverge (UNICO) studies series; no 8. Wshington D.C.: The Worldbnk. The-nuts-nd-bolts-of-Jmkesms-Indonesis-government-finncedhelth-coverge-progrm-for-the-poor-nd-ner-poor. Mukti, A. G., D. Mustikwti, D. Collins, F. Hfi, B. Setyningsih, nd H. Utmi. Policy Options nd Levers for Finncing TB Services in Indonesi. USAID TB CARE I, 213. b Sources: Chkrborty, Srbni Philippines government sponsored helth coverge progrm for poor households. Universl Helth Coverge (UNICO) studies series; no. 22. Wshington, DC: World Bnk. documents.worldbnk.org/curted/en/ /philippinesgovernment-sponsored-helth-coverge-progrm-for-poor-households. Holohn, M., F. Luelmo, R. Morfe, T. Ryn, nd M. Vonitis. USAID/ Philippines: Externl Evlution of the Tuberculosis Portfolio (26-211). Report No USAID, 212.Smith-Arthur A, Kk N, Mtji R (213) Synthesis report: inclusion of TB in ntionl insurnce progrms. tbcre2.org/sites/tbcre2.org/files/synthesis%2report%2on%2 Country%2%2Assessments%2on%2TB%2Insurnce%2Study%2 TB%2CARE%2II%2Finl.pdf c Sources: Kshi Brbr Crsso, Grce Chee, Alte Cico, Duong Hong Quyen, Phn Cm Tu, Alexei Sitruk. August 214. Options for Integrting Procurement nd Supply Chin Systems for ARVs, Methdone, nd nti-tuberculosis Drugs in Vietnm. Bethesd, MD: Helth Finnce & Governnce Project, Abt Assocites Inc. d Sources: Guinto RLLR Currn UZ, Suphnchimt, R, Pocock, NS. (215). Universl helth coverge in One ASEAN : re migrnts included? Globl Helth Action, 8, 1.342/gh.v v Hnvorvongchi, Piy Thilnd Helth finncing reform in Thilnd : towrd universl coverge under fiscl constrints. UNICO study series ; no. 2. Wshington, DC: World Bnk. worldbnk.org/curted/en/ /thilnd-helthfinncing-reform-in-thilnd-towrd-universl-coverge-under-fisclconstrints. e Sources: Yu H. Universl Helth Insurnce Coverge for 1.3 Billion People: Wht Accounts for Chin s Success? Helth Policy (215): Korolev, Alexnder, Chin s Helthcre: Developing Universl Coverge Pln (Jnury 27, 213). Fr Estern Affirs. No. 1, 212, pp Ministry of Helth (211) Ntionl Tuberculosis Control Progrmme ( ). nd Wei X, Yin J, Zou G et l. Ptient Cre Pthwys under the Model of Integrting Tuberculosis Service with Generl Hospitls in Chin. Trop Med Int Helth Tropicl Medicine & Interntionl Helth (213): Pn Y, Chen S, Chen M, et l. Disprity in reimbursement for tuberculosis cre mong different helth insurnce schemes: evidence from three counties in Centrl Chin. Infectious Diseses of Poverty Infect Dis Poverty 5.1 (216): 1-9. f See lso: TB CARE II (215) Exploring the promise of improving ccess nd delivery of TB services through insurnce-bsed finncing reforms: Meeting report. Report%2415.pdf Orgniztion of Migrtion, the United Ntions High Commission for Refugees nd other orgniztions re supporting TB efforts in countries fcing these emergencies, nd collborting with countries receiving migrnts nd refugees. New technicl ssistnce, evidence genertion, guidnce nd coordintion mechnisms re emerging. 1,2,3 Recently, the Ebol epidemic took n enormous toll in three countries in West Afric Guine, Liberi nd Sierr Leone ll of which were still recovering from conflicts. The economic, socil nd helth repercussions were severe. The TB response ws ffected, long with mny public helth priorities. Now, ll three countries re using the opportunities tht hve come with broder investment in post-ebol helth systems nd focus on public helth functions. Box 6.3 provides some exmples relted to extending TB dignostic cpcity. In middle-income countries, UHC progress nd better disese control often depend on reforming well-estblished helth system institutions, mngement nd finncing mechnisms. Box 6.4 offers n exmple of the rmifictions of helth finncing pproches, specificlly in Centrl nd Estern Europe, for ptient cre nd cost burdens overll. It lso highlights efforts underwy through reserch, policy dilogue nd collbortion to overcome the bottlenecks. 6.4 Hrnessing the benefits vilble with socil protection pltforms As hs been well documented, nd dvocted for in the SDGs nd the End TB Strtegy, socil protection cn contribute to ending poverty nd ending disese epidemics, including those of TB nd HIV. Action for UHC is in itself mjor lever for socil protection. Ecologicl nlysis suggests tht there is n inverse ssocition between government investment in socil protection nd ntionl TB incidence in countries worldwide. 4 There re vrying institutionl definitions of socil protection, but the brod concepts re cler. Socil protection represents system of policies nd progrmmes tht seek to reduce poverty nd support 1 The Globl Fund to Fight AIDS, TB nd Mlri. The chllenging operting environments policy, GF/B35/3. The Globl Fund; World Helth Orgniztion. Tuberculosis control in complex emergencies. WHO Regionl Office for the Estern Mediterrnen; 215 ( EMROPUB_215_EN_1913.pdf, ccessed 5 September 216). 3 World Helth Orgniztion. Interregionl workshop for tuberculosis control nd cre mong refugees nd migrnt popultions (216) My 216. Ctni, Itly. 216( communicble-diseses/tuberculosis/publictions/216/ interregionl-workshop-for-tuberculosis-control-nd-cremong-refugees-nd-migrnt-popultions-216, ccessed 5 September Sirok A, Ponce NA, Lonnroth K. Assocition between spending on socil protection nd tuberculosis burden: globl nlysis. Lncet Infect Dis. 216;16(4): :: GLOBAL TUBERCULOSIS REPORT 216

108 :: Box 6.2 Innovtions in engging privte cre providers in Asi For lrge proportion of people with TB in Asi, the pthwy to cre begins with visit to neighbourhood privte prctitioner. In scling up enggement of ll cre providers through public privte mix (PPM) pproches, working with numerous forml nd informl, wekly orgnized nd poorly regulted privte prctitioners is both demnding nd resource intensive for NTPs (see Tble 4.2 in Chpter 4). Intermediry orgniztions in high TB-incidence countries in Asi hve worked with NTPs to ddress collbortion with privte prctitioners by developing nd implementing innovtive models of enggement. The results re impressive; some hve been published nd some presented in recent meeting of the globl PPM Working Group. In the socil frnchising model in Mynmr, which ws designed, implemented nd scled up with the ssistnce of n interntionl NGO, frnchisee prctitioners use integrted service delivery to contribute 15% of ll TB cses notified in the country while lso chieving high tretment success rtes tht re comprble to those reported by public sector helth centres (see Box 4.2). Socil frnchising for TB cre provision hs been s successful in other settings s it is for reproductive helth nd other public helth progrmmes. Breking wy from the trditionl methods, the socil business models developed nd implemented by nother interntionl NGO in Bngldesh nd Pkistn incorporte ctive screening for TB in privte clinics, privte hospitls nd lbortories, while lso providing ccess to new rpid dignostic tests t subsidized or no cost for TB ptients in privte clinics. TB screening in privte clinics in the megcity of Krchi doubled the cse notifictions from the city in yer; lso, over 2 dditionl TB cses were detected by the project site in Dhk in yer. In further dvncing the :: FIG. B6.2.1 Innovtions in TB public-privte mix (PPM) models Collbortion (Enblers nd incentives) Access to (free) drugs nd dignostics MoH/NTP Stewrdship Intermediry (Public, NGO, Privte) PP PH NGO Community/People with TB Lws nd regultions model, simultneous screening for lung helth nd dibetes in privte clinics ws lter dded s prt of the pckge. c Use of digitl tools hs helped significntly in fcilitting project opertions nd in ensuring dherence to recommended routines by both providers nd ptients in privte clinics. c Privte provider interfce gency models re being implemented by n interntionl NGO in close collbortion with the NTP nd the locl TB progrmmes in three cities in Indi (Mehsn, Mumbi nd Ptn). These models hve produced impressive results with remrkbly lrge yield of TB cses: nerly 2 dditionl TB cses every month in Mumbi lone. The pckge of innovtions tht suits the ecosystems of privte helth cre in the respective cities includes introduction of vouchers for free dignosis nd free drugs for ptients in privte clinics through linkges with privte lbortories nd phrmcies in the neighbourhoods, nd tiered referrls to ccess these services. The projects ensure tht ll the essentil tsks required to ensure qulity TB cre provision re ccomplished through smrt use of digitl tools nd technologies such s cll centre, mobile phones, electronic notifictions nd short text messges. d Another pioneering nd innovtive inititive in Indi hs successfully fostered prtnership between privte lbortories nd mnufcturers to support doption of low-price, high-volume model tht improves ccess to new dignostics nd strengthens linkges between public nd privte sectors. e Beyeler N, York De L Cruz A, Montgu D. The impct of clinicl socil frnchising on helth services in low- nd middle-income countries: systemtic review. PLoS One. 213;8(4):e6669. b Khn AJ, Khowj S, Khn FS, Qzi F, Loti I, Hbib A, et l. Engging the privte sector to increse tuberculosis cse detection: n impct evlution study. Lncet Infect Dis. 212;12(8): c Khn A. Socil enterprise models for lung helth nd dibetes screening nd mngement in three Asin megcities. 214;( ssets/documents/m6/khn%2-%2 Estblishment%2of%2socil%2 business%2model.pdf, ccessed 12 July 216). d Working with frontline privte providers: Digitl tools for ese of opertions Digitl tools for dherence support e innovtions in scling up collbortion nd regultion. Report of eleventh globl meeting on Public-Privte mix for TB cre nd prevention 216 ( int/tb/res-of-work/engging-creproviders/11thgloblppmreport.pdf, ccessed 12 July 216). Clinton Helth Access Inititive. Cse study: ctlyzing the mrket for ccurte tuberculosis testing in Indi s extensive privte sector through IPAQT. Boston: CHAI; 216 ( clintonhelthccess.org/content/ uplods/216/6/cse-study-indi- IPAQT-June-216.pdf, ccessed 5 September 216). MoH: ministry of helth; NTP: ntionl tuberculosis progrmme; NGO: nongovernmentl orgniztion; PH: public hospitl or privte hospitl; PP: privte provider (forml, informl, phrmcy, lbortory) GLOBAL TUBERCULOSIS REPORT 216 :: 97

109 :: Box 6.3 After Ebol: enhncing the cpcity for TB nd MDR-TB dignosis In 215, some TB cses were reported in the three post-ebol West Africn countries: Guine, Liberi nd Sierr Leone. WHO estimtes tht Liberi nd Sierr Leone re mong the 1 countries with the highest TB rtes per cpit worldwide. Reported cses for the three countries represent only 42 6% of the estimted incident TB cses, nd popultion-bsed surveys re needed to improve estimtes. With finncing from the United Sttes Agency for Interntionl Development (USAID) nd from the Globl Fund, WHO is supporting the strengthening of TB cpcity ccompnying other efforts to strengthen helth systems. During the Ebol outbrek, Guine, Liberi nd Sierr Leone ll received support from prtner gencies to introduce GeneXpert instruments for Ebol screening. As these countries trnsition from the outbrek response to routine disese surveillnce, n opportunity hs risen for the integrtion of these instruments into the generl lbortory network, including for testing for TB, rifmpicin-resistnt TB nd HIV virl lod. A review of the current plcement of the mchines will inform the best deployment to serve the multiple needs of the popultions covered. The ssessment is tking into considertion epidemiology, vilbility of other compnion dignostic tools, lbortory personnel nd power supply. In ll three countries, WHO is supporting the dt mngers of the TB progrmmes to mp TB cses notified by prefecture or district, nd to clculte needs for the rpid moleculr dignostic tool bsed on recommended dignostic lgorithms. The Foundtion for Innovtive New Dignostics (FIND), non-profit public privte prtnership tht helps to enble evidence genertion nd roll-out of new dignostic tools, is providing trining using the Globl Lbortory Inititiveendorsed Xpert MTB/RIF trining pckge. Other helth systems pltforms tht emerged in response to the Ebol outbrek cn lso improve timely TB dignosis. For exmple, in 215, the Ministry of Helth nd Socil Welfre of Liberi invited Riders for Helth (RfH), n NGO, to mnge their fleet of 25 new vehicles nd 2 new motorcycles donted during the Ebol outbrek. RfH offers trnsporttion of medicl smples to the nerest lbortory for testing. Plnning is underwy, with NTP nd Globl Fund finncing, to enble trnsfer of sputum smples from nywhere in the country to Xpert MTB/RIF sites nd the centrl TB lbortory. 42% estimted cse detection coverge in Liberi, 55% in Guine nd 6% in Sierr Leone. economic growth. Socil protection cn build resilience to risks nd shocks, dvnce equity in ssets nd ccess to services, nd improve economic nd socil opportunities. 1 The Interntionl Lbour Orgniztion coordintes efforts to promote socil protection floors ; tht is, ntionlly defined sets of bsic socil security gurntees tht should ensure, t minimum tht, over the life cycle, ll in need hve ccess to essentil helth cre nd to bsic income security which together secure effective ccess to goods nd services defined s necessry t the ntionl level. 2 The SDGs include socil protection trget (Trget 1.3), which is to implement ntionlly pproprite socil protection systems nd mesures for ll, including floors, nd by 23 chieve substntil coverge of the poor nd the vulnerble. 3 In TB cre, ptient economic support tody my include (for t lest some ptients) csh trnsfers, food pckges or nutritionl support, toiletries or trnsport vouchers. Also, in fewer cses, it my include ccess to socil benefits, sickness insurnce or disbility grnts, nd explicit protections of rights to work, housing nd helth-cre ccess. Both economic nd nutritionl support cn be importnt for TB ptients. Economic support is often criticl s TB disese is strongly relted to poverty, nd seeking nd stying in TB cre cn be impoverishing. Nutritionl cre is needed to improve nutritionl recovery for those TB ptients who re undernourished before nd/or during TB tretment. 4 Few TB ptient support pckges re well documented nd evluted. Improved design, mngement nd evlution my help, but stnd-lone TB-specific pproches my be hrd to sustin. For greter coverge nd impct, mking more use of developed or nscent ntionl socil protection pltforms is priority. 5 Review of documenttion on csh trnsfer progrmmes by the WHO Globl TB Progrmme suggests tht t lest 13 of the highest TB burden countries hve experience with lrge-scle csh trnsfer schemes beyond TB, 6 lthough mny such schemes still hve finncil nd dministrtive constrints. Tble 6.1 illustrtes the TB-specific nd broder pproches vilble in some high TB burden countries. With documenttion from prtners, WHO included pointers on effective socil protection in Implementing the 1 World Bnk. Mnging risk, promoting growth: Developing systems for socil protection in Afric. The World Bnk s Afric Socil Protection Strtegy, Wshington: World Bnk, June Interntionl Lbour Orgniztion. World socil protection report 214/15: building economic recovery, inclusive development nd socil justice. Genev: ILO; 214 ( reserch/globl-reports/world-socil-security-report/214/ WCMS_24521/lng--en/index.htm, ccessed 6 September 216). 3 United Ntions. Trnsforming our world: The 23 Agend for Sustinble Development. New York: UN; 215. ( sustinbledevelopment.un.org/post215/trnsformingourworld/ publiction, ccessed 5 September 216). 4 World Helth Orgniztion. Nutritionl cre nd support for people with tuberculosis. Genev: WHO, World Helth Orgniztion. Implementing the end TB strtegy: the essentils. Genev: WHO, Brzil, Chin, Ethiopi, Indi, Indonesi, Keny, Mozmbique, Nmibi, Nigeri, Pkistn, South Afric, Tnzni nd Thilnd. 98 :: GLOBAL TUBERCULOSIS REPORT 216

110 :: Box 6.4 Reforming systems to expnd people-centred outptient cre in high MDR-TB burden countries in Europe MDR-TB poses prticulr chllenge in WHO s Europen Region, which hs nine of the world s 3 high MDR-TB burden countries. For both ptient-centered cre nd costeffectiveness, TB cre is best delivered in the community. Nevertheless, mny of these high MDR-TB-burden countries still provide substntil inptient cre for ptients with drug-susceptible nd drug-resistnt TB (see Fig. B6.4.1 nd Fig. B6.4.2). Some historicl systems of institutionl stffing, pyment nd reimbursement creted perverse incentives in mny settings to hospitlize ptients unnecessrily, or for much longer periods thn required. These incentives often persist. Also, for lck of resources (nd insufficient cpcity), outptient nd primry cre services hve been ill-prepred to provide dequte TB nd MDR-TB tretment nd cre. Mjor chllenges to enble greter outptient cre include developing pproprite, country-specific TB cre delivery models; creting sustinble finncing mechnisms for TB cre; ensuring dequte humn resources; nd providing socil protection for TB ptients. With technicl support, mny of these countries re incresing their efforts to reduce hospitliztion rtes by improving ptient-centred outptient services, decresing the number of TB beds nd the unnecessrily long durtion of hospitl stys, rellocting TB budgets ccordingly, nd ressigning stff in hospitls to overll pulmonry nd primry helth cre. In concerted effort to support countries to fce their MDR-TB chllenge nd the necessry reform of systems, the Center for Helth Policies nd Studies (PAS) nd the WHO Regionl Office for Europe (EURO) conceived the Tuberculosis Regionl Estern Europen nd Centrl Asin Project (TB-REP), which is funded by the Globl Fund. The im of TB-REP is to use systems-bsed pproch to improve TB tretment outcomes nd ccelerte progress in ending the epidemic by removing helth system brriers nd scling up helth system reforms. The project complements country TB-specific nd broder helth reform efforts supported by Continued :: FIG. B6.4.1 Hospitliztion of drug-susceptible cses in the WHO Europen region, 215 Montenegro Bosni nd Herzegovin Czech Republic Sloveni Norwy Armeni Slovki Kzkhstn Romni Serbi Albni Switzerlnd Finlnd Uzbekistn Kyrgyzstn Republic of Moldov The Former Yugoslv Republic of Mcedoni Russin Federtion Estoni Tjikistn Countries for which dt re vilble Turkey 5 Sweden 5 Irelnd 49 Georgi 3 Portugl Percentge hospitlized :: FIG. B6.4.2 Hospitliztion of M/XDR-TB cses in the WHO Europen region, 215 Armeni Czech Republic Serbi Russin Federtion Slovki Tjikistn Montenegro Bosni nd Herzegovin The Former Yugoslv Republic of Mcedoni Republic of Moldov Georgi Romni Netherlnds Kzkhstn Kyrgyzstn Sweden Portugl Estoni Switzerlnd Turkey Finlnd Norwy Countries for which dt re vilble Averge length of hospitliztion (dys) GLOBAL TUBERCULOSIS REPORT 216 :: 99

111 Box 6.4 continued USAID, the World Bnk nd the Germn governmentowned development bnk, KfW, mong others. It enbles intercountry ctivities involving 11 estern Europen nd centrl Asin countries b for the coming four yers. Among the ims re minimizing TB ptient hospitliztion rtes nd verge lengths of hospitl sty by shifting resources towrds more people-centred cre, including outptient services, nd supporting other costeffective solutions to locl chllenges. The countries involved in TB-REP will be supported by PAS, s principl recipient for the project, WHO/ EURO nd other prtners, including the TB Europe Colition, the Europen Respirtory Society, the London School of Economics nd Politicl Science, the London School of Hygiene nd Tropicl Medicine, nd the Stop TB Prtnership. Work will include nlytic reviews, documenttion nd dpttion of good prctices, opertionl reserch, development of humn resources for helth, cpcity-building, dvoccy nd civil society enggement. b The 11 countries ddressed in TB-REP re Armeni, Azerbijn, Belrus, Georgi, Kzkhstn, Kyrgyzstn, the Republic of Moldov, Tjikistn, Turkmenistn, Ukrine nd Uzbekistn. End TB Strtegy: the essentils. 1 These pointers include ssessing needs; building collbortion with socil protection counterprts; determining cler terms of eligibility; mking informed decision on interventions nd level of support; enbling sustinble funding; nd improving mngement, monitoring, evlution nd reserch. There is some consensus tht MDR-TB ptients nd low-income or undernourished ptients with drug-susceptible TB should probbly hve higher priority thn other TB ptients for socil protection resources. WHO guidnce on the role of nutritionl cre nd support for TB ptients suggests there is need to more effectively differentite nutritionl need nd economic needs in deciding on support. 2 Updted WHO TB tretment guidelines now in development include review of the evidence to determine which ptient support interventions hve documented impct on tretment outcomes. Their impct on the cost burden fced by ptients will not be covered in this guidnce. In conclusion, socil support for TB ptients must become more efficient nd sustinble. Ntionl TB progrmmes (NTPs), working with helth nd socil sector prtners nd nongovernmentl orgniztions (NGOs), cn enble ptient support to move from project-bsed 1 World Helth Orgniztion. Implementing the End TB Strtegy: the essentils. Genev: WHO, 215 ( publictions/215/end_tb_essentil.pdf?u=1, ccessed 6 September 216). 2 World Helth Orgniztion. Guideline: nutritionl cre nd support for ptients with tuberculosis. Genev: WHO; 214 ( iris/bitstrem/1665/94836/1/ _eng.pdf, ccessed 5 September 216). pproch to progrmmtic one, integrted with lrger pltforms. Good prctices depend on context, but opportunities exist in mny high TB burden countries to extend the rech, depth nd impct of socil protection for those in need nd for TB prevention overll. 6.5 Assessing the totl costs borne by TB ptients nd determining the occurrence of ctstrophic totl costs due to TB To inform policy nd prctices for improved socil protection of TB ptients nd ffected households, nd to rech the 22 trget of eliminting ctstrophic costs for TB TB-ffected households, 3 WHO is supporting countries to design, implement nd nlyse TB ptient cost surveys. In 215, the WHO Globl TB Progrmme worked with tsk force of experts to develop field-testing version of stndrdized methodology for this work, nd produced questionnire nd protocol for country dpttion. The ntionlly representtive ptient surveys hve both primry nd secondry objectives. The primry objectives re: To document costs nd identify the min cost drivers to inform policy. To monitor progress towrds the End TB Strtegy trget tht no (zero per cent) of TB-ffected households fce ctstrophic totl costs due to TB. The secondry objectives re: To enble subgroup nlyses (e.g. for drug-susceptible TB nd MDR-TB seprtely, nd nlyses by socioeconomic sttus, sex, nd loction such s urbn or rurl). To determine the ssocition between costs nd tretment outcome (using routine cohort dt). A key indictor tht cn be derived from survey is the proportion of ptients with ctstrophic totl costs due to TB. This is defined for opertionl purposes s the number of TB ptients (nd their households) who experience ctstrophic totl costs divided by the number of ll TB ptients treted in the NTP network. Ctstrophic totl costs is defined s totl costs (indirect nd direct combined) incurred during illness nd tretment tht exceed given threshold (e.g. 2%) of the household s nnul income. The numertor is the totl direct nd indirect costs incurred from the onset of symptoms to the end of TB tretment for the household, nd the denomintor is nnul household income. This TB-specific indictor of ctstrophic totl costs is distinct from the indictor tht WHO uses to mesure finncil protection. WHO uses the shre of the popultion incurring ctstrophic expenditures, which, s noted bove, refers to OOP expenditures for helth cre (for ll 3 Lonnroth K, Glziou P, Weil D, Floyd K, Uplekr M, Rviglione M. Beyond UHC: monitoring helth nd socil protection coverge in the context of tuberculosis cre nd prevention. PLoS Med. 214;11(9):e11693 ( pubmed/ , ccessed 5 September 216). 1 :: GLOBAL TUBERCULOSIS REPORT 216

112 :: TABLE 6.1 TB ptient socil support in selected high TB or MDR-TB burden countries, nd potentil linkges with broder socil protection pltforms COUNTRY INTERVENTIONS CHALLENGES MEASURES TAKEN TO IMPROVE EFFECTIVENESS SOCIAL PROTECTION PLATFORMS Belrus In-kind food, trnsport nd csh support to MDR-TB ptients Lrge MDR-TB ptient popultion, mny of whom hve other socil service needs (e.g. relted to lcohol nd drug use) Incresed domestic budget for socil support enbles donor support trnsition Linkge with NHI Direct bnk csh trnsfers nd in-kind support Trnsporttion support for prisoner relese liison Lrge scle: NHI, sick leve nd disbility coverge, socil services Brzil Food prcels nd some discrete csh nd trnsport support; trgeted efforts for vulnerble groups Resource constrints inhibit expnsion; slow process to link formlly with cshtrnsfer system NTP hs prioritized the chllenge Documented link of improved TB tretment outcomes with csh trnsfers Further reserch is under wy Institutionl nd prlimentry discussions on linking TB ptients with csh-trnsfer progrmme Lrge scle: Bols Fmili csh trnsfer progrmme for women nd children Linkges with helth services nd eduction Indi Rnge of interventions from food nd vouchers, smll fcility pyments to ptients, socil welfre pyment ccess, prepyment crds, etc. Limited ptient coverge, wide vribility cross sttes nd loclities on TB specific support pckges, nd weknesses in dministrtion; NGOs ply role but not formlly linked Stted concern of government Opertionl reserch studies documenting inputs nd results Shring of stte-specific experiences in TB ptient csh trnsfers, nutrition nd socil service linkges NGO enggement to help ptients ccess benefits Efforts to link online TB register to the ntionl unique identifier system used for other mjor socil progrmmes Lrge scle: Food support, including: Antyody Ann Yojn Food Security Act Finncil support: stte-level nd ntionl-level inititives Disbility nd livelihood schemes Keny Food pckges, trgeting undernourished MDR-TB ptients; food support nd some csh trnsfers; trnsport Finncing limits extension nd level of ptient support NTP priority Assessment of nutritionl sttus of ptient cohorts, nutritionl needs nd district TB performnce review Linkge to ntionl nutrition progrmme nd externl donors for more coverge of MDR-TB ptients Active link with ntionl insurnce subsidy progrmme Vision 23 ntionl development gend Ntionl socil development policy nd helth sector services fund Ntionl insurnce subsidy progrmme Ntionl nutrition progrmme Mynmr Food pckges nd/ or csh trnsfers for TB/MDR-TB ptients from mjor project finncing; dditionl NGO nd community contributions Different sources funding different levels of food support, even within single helth fcilities; finncing limits coverge Supportive donor community NTP-led effort for stndrdiztion of food pckge levels nd csh trnsfers for MDR-TB ptients Socil protection included in new Ntionl TB Strtegic Pln Ntionl socil protection strtegy nd progrmme under development UHC-oriented helth policies including essentil pckge of free services nd service extension Philippines Food nd trnsport support, especilly for MDR-TB ptients, nd piloting of conditionl csh trnsfer Finncing limits coverge nd dministrtive bottlenecks, with vribility in prctice Ptient support dvocted for in new legisltion Donor support for relted opertionl reserch Active system for inclusion of ptients with PhiHelth, nd outrech to conditionl cshtrnsfer progrmme Lrge scle: Bridging Progrm for the Filipino Fmily conditionl csh trnsfer (4Ps) Listhnn register of fmilies living in poverty PhilHelth NHI progrmme South Afric Food pckges, or vouchers, nd trnsport support for MDR- TB ptients, other NGO nd locl re provided benefits; some disbility grnt nd other grnt recipients Widely vrible support elements for TB or MDR-TB ptients in different sttes nd fcilities; vrible ppliction of disbility grnt ccess for hospitlized nd needy mbultory ptients New collbortion cross helth, socil development nd benefits dministrtion gency Reserch nd ptient costing efforts Enhncement of informtion on disbility grnts nd other grnts; strong opportunities for enggement with community orgniztions, nd to expnd TB linkges to rnge of socil development Additionl domestic TB finncing mobilized Lrge scle: Child Support grnt Cre Dependency grnt Disbility grnt Socil Relief of Distress grnt Workmen s Compenstion Fund NHI in process Vrious low-income countries nutrition focus Food pckges, vouchers or csh provided by the WFP, often with finncing from The Globl Fund nd sometimes linked s prt of HIV-trgeted food ssistnce Vribility in defining beneficiries nd in documenttion; finncil constrints nd sustinbility issues Potentil for: improved use of WHO nutrition nd TB cre guidnce; improved ssessment to determine beneficiries; nd incresed monitoring nd evlution, nd enggement with ntionl food or nutrition prtners Ntionl nutrition progrmmes vry in coverge smll scle in mny low-income settings, except where supported by WFP, relief gencies, NGOs The Globl Fund, The Globl Fund to Fight AIDS, Tuberculosis nd Mlri; HIV, humn immunodeficiency virus; MDR, multidrug resistnt; NGO, nongovernmentl orgniztion; NHI, ntionl helth insurnce; NTP, ntionl TB progrmme; TB, tuberculosis; UHC, universl helth coverge; WHO, World Helth Orgniztion; WFP, World Food Progrmme. Sources: Opertionl documents of NTPs, Ministries of Helth nd socil welfre nd development ministries, The Globl Fund, World Food Progrmme. GLOBAL TUBERCULOSIS REPORT 216 :: 11

113 conditions) exceeding given frction of household s totl consumption. The ctstrophic expenditures indictor focuses on the finncil burden tht households fce from the pyments tht they mke for helth services for ny of their members, nd generl household surveys re used to generte the dt on ll helth-cre spending nd to compre OOP expenditures to overll household consumption. The ctstrophic totl costs due to TB indictor, on the other hnd, is bsed on dt from interviews with TB ptients in helth fcilities. It cptures the totl economic burden, including pyments for cre (e.g. dignostic nd tretment services, nd medicines), pyments ssocited with cre seeking (e.g. trvel costs) nd the opportunity costs ssocited with cre seeking (e.g. lost income). For these resons, the TB-specific mesures of ctstrophic totl costs due to TB re not comprble with the popultion-bsed ctstrophic expenditures mesure of finncil protection referred to in Section 6.2. However, the TB-specific estimtes of these costs re relevnt to UHC becuse they offer the potentil to provide useful informtion on the mgnitude nd nture of demnd-side brriers to ccess cre (tke-up nd completion), nd cn mke n importnt contribution to the dignosis of brriers to progress towrds UHC. Fig. 6.5 provides n overview of the sttus of plnning nd conduct of TB ptient cost surveys following WHO recommendtions. Box 6.5 presents summry of findings from survey conducted in Mynmr. 6.6 Ending poverty nd ddressing other socil determinnts of TB As shown in Fig. 6.6, there is strong inverse ssocition between GDP per cpit nd TB incidence. The first gol of the SDGs is ending poverty in ll its forms everywhere nd it includes two trgets for The first (Trget 1.1) is to erdicte extreme poverty for ll people everywhere, currently mesured s people living on less thn US$ 1.25 dy. The second (Trget 1.2) is to reduce t lest by hlf the proportion of men, women nd children of ll ges living in poverty in ll its dimensions, ccording to ntionl definitions. Societies tht hve experienced brod socioeconomic development hve seen substntil reduction in TB incidence nd mortlity rtes. Poverty llevition hs historiclly contributed the most to the reduction in TB rtes in countries tht now hve low TB burden. However, economic growth lone is not gurntee for rpid decline in TB cses nd deths. Unequl welth distribution, with lrge prts of the popultion re left behind, leves fertile ground for sustined TB burden. Not ll economic development is of benefit to the fight ginst TB. Industriliztion with rpid urbniztion increses popultion density nd is often coupled with rpid 1 United Ntions. Trnsforming our world: The 23 Agend for Sustinble Development. New York: UN; 215 ( sustinbledevelopment.un.org/post215/trnsformingourworld/ publiction, ccessed 5 September 216). growth of urbn deprivtion nd overcrowded slums. Drmtic lifestyle chnges in emerging economies for exmple, incresing smoking nd lcohol use, nd chnges in diet nd exercise cn hve negtive impct on TB rtes vi n increse in noncommunicble diseses tht ct s risk fctors for TB. In most societies, the poorest re lso the worst ffected by these risk fctors nd diseses. Underfunded or poorly orgnized helth systems re often not equipped to ensure equitble ccess to high-qulity TB dignosis nd tretment. The poorest nd most vulnerble groups fce severe brriers to ccessing dignosis nd tretment, nd to stying in cre. They lso hve prticulrly high risk of suffering severe finncil nd socil consequences s result of TB, nd my hve the lest ccess to ny socil protection mechnisms. Although poverty is cuse of TB, the disese is lso cuse of poverty; this vicious circle plys out on individul, household nd community level. There is strong evidence of mjor direct socil, medicl nd behviourl risk fctors for TB, mny of which re lso closely linked to underlying poverty. Tble 6.2 provides summry review of the popultion ttributble frction (PAF) for some TB risk fctors with lrge popultion-level impct. The PAF is n estimte of the reltive reduction in TB incidence tht would result from the elimintion of given risk fctor. PAF estimtes cn be used to more effectively dvocte for the reduction of these risk fctors, through public helth interventions nd efforts to ddress their underlying socil determinnts. The tble includes only few of the known TB risk fctors, focusing minly on risk fctors for progression from TB infection to ctive disese. The tble does not include some importnt risk fctors such s contct with people with infectious TB, crowding, poor ventiltion nd silicosis. Moreover, the clcultion of the PAF does not consider the secondry effects of TB trnsmission from people tht fll ill with TB. In ddition, due to lck of detiled globl dt on the distribution of the vrious risk fctors in the popultion, the estimtions ssume the sme prevlence of the risk fctors in ll (dult) popultion segments. More sophisticted estimtions cn be mde when risk fctor distribution dt re vilble, nd when the dynmic effects of indirect prevention of onwrd trnsmission re modelled. Such models re conceptully more pproprite, but they lso introduce more uncertinty into the estimted impct of chnges in risk fctor exposure. Box 6.6 provides n introduction to some ongoing modelling efforts to ssess the effect of mesures to reduce risk fctors on future TB burden in selected countries. In response to socil determinnts of TB, there re number of societl-level ctions tht cn help to drive effective TB prevention beyond the poverty llevition, UHC finncing nd socil protection discussed bove, for which governments re ultimtely responsible. Societl-level ctions include: integrted public helth progrmmes tht help to reduce dibetes, smoking nd hrmful lcohol use; 12 :: GLOBAL TUBERCULOSIS REPORT 216

114 :: FIG. 6.5 Surveys of costs fced by TB ptients nd their households: progress nd plns s of August 216 Completed Strting in 216 Plnned for Source: Globl TB Progrmme survey monitoring up to August 216. :: Box 6.5 Mynmr TB ptient cost survey In Mynmr, from December 215 to Februry 216, the Ministry of Helth worked with ntionl reserch prtner to conduct ntionlly representtive ptient cost survey involving 996 eligible TB ptients in helth fcilities. Mynmr is low-income country with mong the highest TB burdens in the WHO South-Est Asi Region. The survey ws the first to pply the new WHO-recommended protocol for TB ptient cost surveys nd to dpt its instrument. The cross-sectionl survey included questions on the ptient s current tretment nd retrospective questions on the costs incurred by ptients for this illness episode before they were dignosed s hving TB. Current costs were extrpolted for the full tretment durtion to estimte totl costs (both direct nd indirect) for the whole TB episode, s percentge of household income. If totl costs exceeded 2% of nnul household income, the TB-ffected household ws deemed to hve fced ctstrophic totl costs. The survey results suggested tht, in Mynmr, n estimted 65% of TB-ffected households fce ctstrophic costs. On verge, totl TB-relted costs were US$ 1178 per household nd the lrgest proportion of this totl ws ccounted for by foregone income (49%) followed by nutritionl supplement costs (25%), nd post-dignosis medicl costs (14%). Being on MDR-TB tretment nd in lower household welth quintile were both significnt predictors of fcing ctstrophic costs. The high proportion of TB-ffected households experiencing ctstrophic costs bolsters the need for effective, ptientcentred helth cre free of chrge, nd the need for socil protection. The lrge proportion of totl spending ttributble to lost wges nd food or nutritionl supplements suggests tht efforts to reduce income loss (reduced time spent seeking cre through decentrliztion nd more ptientfriendly service orgniztion, s well s employment protection), income support nd/or food support my need to be considered to reduce the burdensome costs fced by ptients nd their fmilies. The NTP is convening consulttion to review the results, nd to further discuss the probble dynmics behind the highest res of spending nd the income losses ssocited with TB nd its tretment. The prticipnts will consider the probble policy nd prctice implictions, nd further opertionl reserch tht might be needed. The results should inform ongoing work on Mynmr s first ntionl socil protection strtegy, nd its ongoing efforts to strengthen helth services. GLOBAL TUBERCULOSIS REPORT 216 :: 13

115 :: FIG. 6.6 Assocition between GDP per cpit nd TB incidence, for 17 countries with vilble dt 1 Rte per 1 popultion per yer (log scle) GDP per cpit (constnt 216 US$), log scle Source: GDP per cpit dt were obtined from the World Bnk dtbse ( :: TABLE 6.2 Popultion ttributble frctions for risk fctors for TB RELATIVE RISK FOR ACTIVE TB DISEASE PREVALENCE (%) b (ADULTS IN 3 HIGH TB BURDEN COUNTRIES) HIV Undernutrition Dibetes POPULATION ATTRIBUTABLE FRACTION (ADULTS IN 3 HIGH TB BURDEN COUNTRIES) Alcohol misuse Smoking Indoor ir pollution Source: Lönnroth K, Cstro K, Chky JM, Chuhn LS, Floyd K, Glziou P, Rviglione M. Tuberculosis control nd elimintion 21 25: cure, cre nd socil chnge. Lncet. 21 My 22;375(9728): doi: 1.116/ S (1) b Estimte of prevlence is bsed on weighted verge (by popultion size) for the 3 high TB burden countries. food security inititives for high-risk popultions nd regions; environmentl protection, especilly in certin industries (e.g. mining); building codes (e.g. for homes, workplces, helth fcilities, prisons, schools nd institutions for elderly) tht re conducive to infection control; good urbn plnning (e.g. with slum upgrding); nd effective nd sfe energy nd cooking devices tht minimize pollution. In moving forwrd to end TB nd on the SDGs in generl, there needs to be close collbortion cross nd beyond government on multiple development priorities. Hence, this globl TB report includes results for some key SDG indictors for the 3 highest TB burden countries (Tble 6.3). As the colour coding in the tble shows, most of the highest TB burden countries hve indictors suggesting lower thn verge sttus reltive to benchmrks. Therefore, there is substntil chllenge hed to rmp up investment nd commitment to the new development gend. 14 :: GLOBAL TUBERCULOSIS REPORT 216

116 :: TABLE 6.3 Sttus of selected SDG indictors in August 216, 3 high TB burden countries COUNTRY SDG 1 INDICATOR PROPORTION LIVING ON LESS THAN US$ 1.25 (PPP) PER DAY SDG 2 INDICATOR PROPORTION OF POPULATION UNDERNOURISHED SDG 1 INDICATOR GINI COEFFICIENT (%) b SDG 11 INDICATOR PROPORTION OF URBAN POPULATIONS LIVING IN SLUMS Angol Bngldesh Brzil Cmbodi Centrl Africn Republic Chin Congo DPR Kore 42 DR Congo Ethiopi Indi Indonesi Keny Lesotho Liberi Mozmbique Mynmr Nmibi Nigeri Pkistn Ppu New Guine Philippines Russin Federtion 27 Sierr Leone South Afric Thilnd UR Tnzni Viet Nm Zmbi Zimbbwe High-burden country verge Globl verge Indictes vlues tht were not vilble. PPP, purchsing power prity. Dt come from the United Ntions Sttistics Division SDG indictor dtbse. Individul dt points re coloured pink if they re worse thn the globl verge nd green if better thn the globl verge. b The Gini coefficient is mesure of sttisticl dispersion intended to represent the income distribution of country s popultion nd is the most commonly used mesure of inequlity. Generlly, the coefficient rnges from % to 1%; vlue of % expresses complete equlity between everyone in the popultion, nd vlue of 1% expresses mximum inequlity in the popultion i.e. one person hs ll the income. GLOBAL TUBERCULOSIS REPORT 216 :: 15

117 :: Box 6.6 Modelling the effect of risk fctor reduction on future trend of TB incidence To quntify the popultion-level impct of risk fctor on the burden of TB, previous studies hve reported the popultion ttributble frction (PAF) for one specific risk fctor. The PAF incorportes informtion on the prevlence of risk fctor exposure nd the strength of ssocition (often mesured s reltive risks) between the risk fctor nd TB disese. Reltively strightforwrd to clculte, PAF cn be interpreted s the proportion of TB burden tht would be prevented if the risk fctor exposure were removed, with other things the sme. Despite its populrity, the PAF pproch hs two limittions. First, it ssumes tht the probbility of disese is independent mong individuls, which is clerly not the cse for TB. In other words, the pproch does not ccount for the impct of risk fctor on disese trnsmission nd therefore often underestimtes the overll popultion-level impct. Second, the PAF pproch is timeless nd cnnot be used to project the impct of risk fctor reduction on the future trend of TB epidemiology. A few studies hve pplied dynmic modelling of TB trnsmission to investigte the impct of risk fctors on TB. Dynmic models incorporte the nturl history of TB (susceptible or ltent infection, ctive disese or recovered) nd the effect (reltive risk) of risk fctors on the nturl history of TB (e.g. incresing the rte of rectivtion or incresing the cse ftlity rte upon hving disese). This type of model ccounts for the trnsmissible nture of TB disese nd cn be used for the purpose of future projections, lthough cution is needed when interpreting the results from such complex models. To illustrte, two exmples of such dynmic modelling re provided below. In dynmic modelling study conducted in Chin, Lin et l. projected the potentil impct of reducing tobcco smoking nd indoor ir pollution from solid fuels on the trend of TB incidence. The study found tht ggressive interventions on smoking nd indoor ir pollution could ccelerte the decline of TB incidence (Fig. B6.6.1). Pn et l. b investigted the impct of dibetes prevention on TB morbidity nd mortlity in 13 high burden countries without generlized HIV epidemic (Afghnistn, Bngldesh, Brzil, Cmbodi, Chin, Indi, Indonesi, Mynmr, Pkistn, Philippines, Russin Federtion, Thilnd nd Viet Nm). These countries cover over 6% :: FIG. B6.6.1 Projected incidence of TB in Guizhou Province, Chin under different scenrios for reduction in smoking prevlence nd exposure to solid-fuel use Annul incidence (per 1 ) E Yer Smoking nd solid-fuel use scenrios: Both unchnged Smoking: moderte Solid fuel: hlf current Smoking: ggressive Solid fuel: urbn rurl Both to zero Not voidble of ll incident TB cses globlly. The study indicted tht, in the worst cse scenrio in which dibetes prevlence increses gretly over the next two decdes, the TB incidence would increse (reversing the current slow rte of decline in TB incidence). On the other hnd, simply stopping the rise in the prevlence of dibetes would ccelerte the decline of TB, preventing 6. million TB cses nd 1.1 million TB deths in the 13 countries over 2 yers. Aggressive interventions tht reduce dibetes incidence would hve n even lrger impct on TB, voiding 7.8 million cses nd 1.5 million deths. See Fig. B.6.6.2, A/B/C/D. Lin HH, Murry M, Cohen T, Colijn C, Ezzti M. Effects of smoking nd solid-fuel use on COPD, lung cncer, nd tuberculosis in Chin: time-bsed, multiple risk fctor, modelling study. Lncet. 28;372(9648): b Pn S-C, Ku C-C, Ko D, Ezzti M, Fng C-T, Lin H-H. Effect of dibetes on tuberculosis control in 13 countries with high tuberculosis: modelling study. Lncet Dibetes Endocrinol. 215;3(5): F 16 :: GLOBAL TUBERCULOSIS REPORT 216

118 :: Box 3.2 Updtes to estimtes of TB disese burden in this report nd nticipted updtes :: FIG. B6.6.2 Projected TB incidence/mortlity/prevlence (B/C/D) under different scenrios of dibetes control (A) in 13 high TB burden countries, Dibetes prevlence (%) A Lrge rise Continue current trend Stop rise Aggressive intervention To bckground level Tuberculosis incidence (per 1 ) B C D 25 Tuberculosis mortlity (per 1 people) Tuberculosis prevlence (per 1 ) Yer Yer Source: Pn S-C, Ku C-C, Ko D, Ezzti M, Fng C-T, Lin H-H. Effect of dibetes on tuberculosis control in 13 countries with high tuberculosis: modelling study. Lncet Dibetes Endocrinol. 215;3(5): GLOBAL TUBERCULOSIS REPORT 216 :: 17

119 Chpter 7 :: TB finncing :: KEY FACTS AND MESSAGES The Stop TB Prtnership s Globl Pln to End TB, 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 will increse from US$ 8.3 billion in 216 to US$ 12.3 billion in 22. Most of this funding is for drugsusceptible tuberculosis (TB) (e.g. US$ 6.4 billion in 216), but the mount for multidrug-resistnt TB (MDR-TB) doubles from US$ 1.7 billion in 216 to US$ 3.6 billion by 22; the reminder is for TB/HIV interventions. Over the period , further US$ 6 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 126 countries with 97% of the world s notified TB cses, US$ 6.6 billion ws vilble for TB prevention, dignosis nd tretment in low- nd middle-income countries in 216. This is n increse from previous yers, but is still bout US$ 2 billion less thn 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 US$ 6.6 billion vilble in 216, 84% ws from domestic sources. However, this ggregte figure is strongly influenced by the BRICS countries (Brzil, the Russin Federtion, Indi, Chin nd South Afric), which collectively ccount for bout 5% of the world s TB cses, nd rely mostly or exclusively (the exception is Indi) on domestic funding. In other countries with high TB burden, interntionl donor funding domintes, ccounting for 75% of reported funding in the group of 25 high TB burden countries outside BRICS, 87% of funding in low-income countries nd 6% of funding in lower middle-income countries. The single lrgest source of interntionl donor funding is the Globl Fund to Fight AIDS, Tuberculosis nd Mlri. Interntionl donor funding for TB flls fr short of donor contributions for HIV nd mlri. The ltest dt from the Orgnistion for Economic Co-opertion nd Development (OECD) creditor reporting system show totls of US$ 5.4 billion for HIV/AIDS, US$ 1.7 billion for mlri nd US$.7 billion for TB in 214. To provide some context for these mounts, the ltest estimtes (for 213) of the burden of disese in terms of disbility-djusted life yers (DALYs) lost due to illness nd deth re 69 million for HIV/AIDS, 5 million for mlri nd 65 million for TB. The cost per ptient treted is usully in the rnge of US$ 1 1 for drug-susceptible TB nd US$ 2 2 for MDR-TB. Helth finncing dt from ntionl helth ccounts provide insights into the current sttus of progress towrds universl helth coverge, s discussed in Chpter 6. The Globl Pln to End TB, Genev: Stop TB Prtnership; 215 ( ccessed 28 July 216). 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 peer-reviewed publictions. 1 This chpter hs four min sections. It strts with summry of the most up-to-dte estimtes of finncil resources required for full response to the TB epidemic (Section 7.1). It then presents nd discusses trends in funding for TB prevention, dignosis nd tret- 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 ( pubmed/ , ccessed 28 July 216). ment by ctegory of expenditure nd source of funding for the period , globlly nd for mjor country groupings (Section 7.2). The third prt of the chpter nlyses funding gps reported by ntionl TB progrmmes (NTPs) to WHO, with brekdowns by ctegory of expenditure nd country group (Section 7.3). The finl section provides the ltest estimtes (for 215) of the unit costs of tretment for drug-susceptible TB nd multidrug-resistnt TB (MDR-TB) (Section 7.4). As highlighted in the finncing chpter of the Globl tuberculosis report 215, 2 nlysis of helth finncing dt 2 World Helth Orgniztion. Globl tuberculosis report 215. Genev: WHO; 215 ( bitstrem/1665/19112/1/ _eng.pdf, ccessed 27 July 216). 18 :: GLOBAL TUBERCULOSIS REPORT 216

120 cn provide 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 milestone of zero set for this indictor for 22 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 covered in Chpter 6. Further country-specific dt on TB finncing cn be found in finnce profiles tht re vilble online Estimtes of funding required for full response to the globl TB epidemic, The ltest estimtes of the funding required for full response to the globl TB epidemic, to chieve the End TB Strtegy milestones for 22, hve been set out in the Stop TB Prtnership s Globl Pln to End TB, Worldwide, the mount for implementtion of TB prevention, dignostic nd tretment interventions rises from lmost US$ 9.5 billion in 216 to US$ 14 billion in 22 (Fig 7.1). Most of this totl (75%) is for dignosis nd tretment of drug-susceptible TB, which grows from US$ 7.4 billion in 216 (US$ 6.4 billion in low- nd middle-income countries) to US$ 9.7 billion in 22. However, the mount for drugresistnt TB doubles from US$ 1.8 billion in 216 to US$ 3.6 billion in Reltively smll mounts re needed for TB/HIV interventions, minly becuse the figure does not include the funding needed for ntiretrovirl therpy for HIV-positive TB ptients. 4 An dditionl US$ 9 billion is needed for TB reserch nd development over the 5-yer period (dt not shown; this topic is discussed further in Chpter 8). Of the totl of US$ 58 billion over 5 yers (excluding reserch nd development), US$ 52 billion ws estimted to be required in low- nd middle-income countries (growing from US$ 8.3 billion in 216 to US$ 12.3 billion in 22). Within this group of countries, estimtes of the funding tht could be mobilized from domestic nd interntionl donor sources were restricted to countries eligible to p The Globl Pln to End TB, Genev: Stop TB Prtnership; 215 ( ccessed 28 July 216). 3 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). 4 Funding needs for ART for HIV-positive TB ptients re prt of HIV resource needs estimtes, nd re not included in the Globl Pln to End TB, to void double counting. For detils on resource needs estimtes for HIV/AIDS, see Stover J, Bollinger L, Izzol JA, Loures L, DeLy P, Ghys PD et l. Wht is required to end the AIDS epidemic s public helth thret by 23? The cost nd impct of the fst-trck pproch. PLoS One. 216;11(5):e ( gov/pubmed/ , ccessed 28 July 216). :: FIG. 7.1 Estimtes of funding required globlly for drugsusceptible TB, MDR-TB nd TB/HIV in the Globl Pln to End TB (constnt 215 US$ billions) US$ billions Drug-susceptible TB MDR-TB TB/HIV Source: Dt from Stop TB Prtnership Globl Pln to End TB ply to the Globl Fund to Fight AIDS, Tuberculosis nd Mlri (the Globl Fund). 5 For eligible countries, the funding required over 5 yers mounts to US$ 29 billion; it ws estimted tht bout US$ 16 billion of this mount could be mobilized from domestic sources nd tht the reminder (n verge of US$ 2.6 billion per yer) would need to come from interntionl donors. The Globl Pln to End TB did not ttempt to ssess the broder investments required to increse the overll coverge nd qulity of helth-cre services, nd 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, reflected in Pillr 2 of the End TB Strtegy nd discussed in Chpter 6. 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. 7.2 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 over the period in 126 countries (Tble 7.1). These countries ccounted for 97% of the globl number of TB cses reported in 215, nd included 126 low- nd middle-income countries. The methods used to collect, review nd nlyse finncil dt re summrized in Box 7.1. In these 126 countries, funding for TB prevention, dignosis nd tretment reched US$ 6.6 billion in 216, up from US$ 6 billion in 215 nd lmost double the US$ 3.5 billion tht ws vilble in 26 (ll figures re in constnt vlues for 216, see Fig. 7.2). Of the totl of US$ 6.6 bil- 5 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. GLOBAL TUBERCULOSIS REPORT 216 :: 19

121 :: TABLE countries included in nlyses of TB finncing, by income group nd WHO region, 216,b Africn LOW-INCOME (3/31 COUNTRIES REPRESENTING 13% OF NOTIFIED CASES GLOBALLY IN 215) Benin, Burkin Fso, Burundi, Centrl Africn Republic, Chd, DR Congo, Eritre, Ethiopi, Gmbi, Guine, Guine-Bissu, Liberi, Mdgscr, Mlwi, Mli, Mozmbique, Niger, Rwnd, Senegl, Sierr Leone, South Sudn, Togo, Ugnd, UR Tnzni, Zimbbwe LOWER-MIDDLE-INCOME (48/52 COUNTRIES REPRESENTING 58% OF NOTIFIED CASES GLOBALLY IN 215) Cbo Verde, Cmeroon, Congo, Côte d Ivoire, Ghn, Keny, Lesotho, Muritni, Nigeri, So Tomé nd Principe, Swzilnd, Zmbi Americs Hiti Bolivi, El Slvdor, Guteml, Hondurs, Nicrgu Estern Mediterrnen Europen South-Est Asi Western Pcific Afghnistn, Somli Democrtic People s Republic of Kore, Nepl Djibouti, Morocco, Pkistn, Sudn, Syri, Tunisi, Yemen Armeni, Kyrgyzstn, Republic of Moldov, Tjikistn, Ukrine, Uzbekistn Bngldesh, Bhutn, Indi, Indonesi, Mynmr, Sri Lnk, Timor-Leste Cmbodi, Kiribti, Lo People s Democrtic Republic, Mongoli, Ppu New Guine, Philippines, Smo, Solomon Islnds, Tong, Vnutu, Viet Nm Excluded Comoros Egypt, Kosovo, Micronesi (Federl Sttes of), West Bnk nd Gz Strip UPPER-MIDDLE-INCOME (48/55 COUNTRIES REPRESENTING 26% OF NOTIFIED CASES GLOBALLY IN 215) Angol, Botswn, Gbon, Muritius, Nmibi, South Afric Belize, Brzil, Colombi, Cub, Dominicn Republic, Ecudor, Grend, Guyn, Jmic, Mexico, Pnm, Prguy, Peru, Sint Luci, Sint Vincent nd the Grendines, Surinme, Venezuel (Bolivin Republic of) Irn (Islmic Republic of), Irq, Jordn, Lebnon Azerbijn, Belrus, Bosni nd Herzegovin, Bulgri, Georgi, Kzkhstn, Montenegro, Romni, Russin Federtion, Serbi, The Former Yugoslv Republic of Mcedoni, Turkey BRICS (48% OF NOTIFIED CASES GLOBALLY IN 215) South Afric Brzil Russin Federtion 25 HIGH-BURDEN COUNTRIES EXCLUDING BRICS (37% OF NOTIFIED CASES GLOBALLY IN 215) Angol, Centrl Africn Republic, Congo, DR Congo, Ethiopi, Keny, Lesotho, Liberi, Mozmbique, Nmibi, Nigeri, Sierr Leone, UR Tnzni, Zmbi, Zimbbwe Pkistn Mldives, Thilnd Indi Bngldesh, Indonesi, Mynmr, Thilnd Americn Smo, Chin, Fiji, Mlysi, Mrshll Islnds, Plu, Tuvlu Albni, Algeri, Cost Ric, Dominic, Equtoril Guine, Liby, Turkmenistn Anlyses focus on low nd middle-income countries. b Additionl countries included in trend nlyses of TB finncing compred with those included in previous globl reports re shown in bold. Chin Cmbodi, Democrtic People s Republic of Kore, Ppu New Guine, Philippines, Viet Nm 11 :: GLOBAL TUBERCULOSIS REPORT 216

122 lion, most (US$ 4.4 billion, 67%) is for the dignosis nd tretment of drug-susceptible TB. However, tht mount still flls considerbly short of the US$ 6.4 billion estimted to be needed for low- nd middle-income countries in the Globl Pln (Section 7.1). Funding for MDR-TB ws US$ 1.7 billion in 216, nd this mount hs been comprtively stble since 214, following mrked increse in (Fig. 7.2). Trends in funding for MDR-TB hve been driven by the BRICS (Brzil, Russin Federtion, Indi, Chin nd South Afric) group of countries (Fig. 7.3), with just over one third of reported funding for MDR-TB ccounted for by the Russin Federtion in 216 (Tble 7.2, Fig. 7.2). Given the lrge gps in detection tht remin for MDR-TB, nd the gps between the numbers of cses detected nd strted on tretment :: FIG. 7.2 Funding for TB prevention, dignosis nd tretment by intervention re, (constnt 216 US$ billions) US$ billions Other TB/HIV Totl Drug-susceptible TB MDR-TB :: FIG. 7.3 Funding for drug-susceptible TB nd MDR-TB, , by country group (constnt 216 US$ millions) BRICS 25 other HBCs Other countries US$ millions Drug-susceptible TB MDR-TB (Chpter 4), much more funding is required for MDR-TB globlly nd in most of the high MDR-TB burden countries. Bsed on the estimtes in the Globl Pln (Section 7.1), funding for MDR-TB needs to double between 216 nd 22. A detiled brekdown of the funding estimted to be required for drug-susceptible TB, MDR-TB nd collbortive TB/HIV ctivities in 216, bsed on NTPs ssessments of their needs, is shown for the 3 high TB burden countries (TB HBCs) in Tble Overll, domestic funding for the TB-specific budgets of NTPs ccounts for the lrgest single shre of funding, followed by funding for inptient nd outptient cre (Fig. 7.4). Since most (91%) of the funding estimted to be used for inptient nd outptient cre is ccounted for by middle-income countries, it cn be ssumed tht virtully ll of this funding is from domestic sources (interntionl donor funding for inptient nd outptient cre is only likely to occur in low-income countries, vi generl budget support to the helth sector). Bsed on this ssumption, bout 84% of the estimted funding of US$ 6.6 billion in 216 is from domestic sources. :: FIG. 7.4 Funding for TB prevention, dignosis nd tretment by funding source, (constnt 216 US$ billions) US$ billions Inptient nd outptient cre Totl Domestic Globl Fund Other % of funding for inptient nd outptient cre is ccounted for by middle nd high-income countries; such countries do not typiclly receive interntionl donor funding for inptient nd outptient cre services. Dt is n estimte bsed on country-reported utiliztion. 1 Chpter 2 explins how the updted list of TB HBCs to be used by WHO in ws defined. GLOBAL TUBERCULOSIS REPORT 216 :: 111

123 :: Box 7.1 Methods use 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 hve been described in detil elsewhere;,b this box provides summry. Ech yer, WHO requests ll 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 216 round of globl TB dt collection, the fiscl yers were 216 nd 215. Consistency in ctegories of expenditure used to report 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 drug-susceptible TB used in the 216 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. 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, ll high-income countries were requested to report funding requirements nd expenditures in totl, without ny brekdown by ctegory of expenditure or source of funding. All countries (irrespective of income level) were sked to report on the use of inptient nd outptient cre required for tretment of people with drug-susceptible 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 dt (preferble), or on the expected use 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). 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 nd funding proposls (known s concept notes) submitted to the Globl Fund d (Tble B7.1.1); comprehensive budgets for ntionl strtegic plns re now n essentil requirement for funding pplictions to the Globl Fund. 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- nd second-line drugs, nd to identify whether reported budgets include funding for buffer stocks. In 216, dditionl efforts to improve the qulity of finncil dt reported to WHO included presenttions nd discussions with NTP stff during workshops on the development of ntionl strtegic plns or TB modelling. In review nd vlidtion of dt, prticulr ttention hs lwys been given to HBCs. A summry of dt vlidtion methods used for the 3 TB HBCs is shown in Tble B Usully, TB funding reported by NTPs does not include the finncil costs ssocited with the inptient nd outptient cre required during tretment. Since mny detiled costing studies in wide rnge of countries show tht these costs ccount for lrge shre of the cost of treting someone with TB, WHO nlyses of TB finncing hve lwys included estimtes of the funding used for both inptient nd outptient cre. WHO estimtes the funding used for inptient nd outptient cre of 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, e nd then by the reported number of TB ptients notified or projected to be notified. This is done seprtely for drug-susceptible TB nd MDR-TB. 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 ccounts (SHA). f In 216, SHA dt were vilble for 27 countries (including the six HBCs shown in Tble B7.1.1), g nd were used in preference to estimtes bsed on reported use 112 :: GLOBAL TUBERCULOSIS REPORT 216

124 :: Box 3.2 Updtes to estimtes of TB disese burden in this report nd nticipted updtes nd unit costs estimtes from WHO- CHOICE. In few cses, there were lrge discrepncies (e.g. Cmbodi, the Philippines nd the United Republic of Tnzni). Further discussions with country focl points for ntionl helth ccount dt re needed in order to better understnd the resons for these discrepncies. Expnded implementtion of SHA nd ssocited vlidtion ginst existing disese-specific trcking systems my lso 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 likely to be 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. Exmples for TB include Indonesi, Nigeri nd South Afric. :: TABLE B7.1.1 Methods used to review nd vlidte finncing dt reported by NTPs, 3 high TB burden countries COUNTRY UNIT COST DATA AVAILABLE FROM INDEPENDENT ECONOMIC EVALUATION TRIANGULATION OF WHO TB DATA WITH OTHER SOURCES NATIONAL HEALTH ACCOUNT DATA, FOR COMPARISON OF INPATIENT AND OUTPATIENT CARE EXPENDITURES FOR DRUG- SUSCEPTIBLE AND MDR-TB COSTED NATIONAL STRATEGIC PLAN SUBMITTED AS PART OF A FUNDING APPLICATION TO THE GLOBAL FUND Angol no no no Bngldesh yes no yes Brzil yes no no Cmbodi yes yes, 212 yes Centrl Africn Republic no no no Chin yes no no Congo no no no DPR Kore no no no DR Congo no yes, 214 yes Ethiopi yes no yes Indi yes no yes Indonesi yes no yes Keny yes no no Lesotho no no no Liberi no no no 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). Mozmbique Mynmr Nmibi Nigeri no no no yes no no yes, 212 no yes yes no no b Floyd K, Fitzptrick C, Pntoj A, Rviglione M. Domestic nd donor finncing for tuberculosis cre nd control in low-income nd middleincome countries: n nlysis of trends, 22 11, nd requirements to meet 215 trgets. Lncet Glob Helth. 213;1(2):e ( pubmed/ , ccessed 28 July 216). c Lurence YV, Griffiths UK, Vssll A. Costs to helth services nd the ptient of treting tuberculosis: systemtic literture review. Phrmcoeconomics. 215;33(9): ( pubmed/ , ccessed 29 July 216). d Globl Fund Dt nd the Open Dt Protocol ccessed My 216 nd country finncil gp nlysis mterils pproved for funding in the first rounds of New Funding Model. Pkistn Ppu New Guine Philippines Russin Federtion Sierr Leone South Afric UR Tnzni Thilnd Viet Nm Zmbi Zimbbwe yes no yes yes yes yes yes yes yes yes yes no no yes, 212 no yes, 213 no yes, 212 no no no no yes no yes no no no yes yes yes yes yes e 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 29 July 216). f OECD/Eurostt/WHO. A system of helth ccounts. OECD Publishing; 211 ( ccessed 29 July 216). g Helth ccounts. Genev: World Helth Orgniztion ( int/helth-ccounts/en/, ccessed 29 July 216). GLOBAL TUBERCULOSIS REPORT 216 :: 113

125 :: TABLE 7.2 Reported NTP budget by intervention re nd estimted cost of inptient nd outptient cre for drug-susceptible (DS-TB) nd MDR-TB, 3 high TB burden countries, 216 (current US$ millions) NATIONAL STRATEGIC PLAN BUDGET RESOURCES REQUIRED FOR INPATIENT AND OUTPATIENT CARE TOTAL DS-TB MDR-TB TB/HIV DS-TB MDR-TB RESOURCES REQUIRED FOR TB CARE 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 b Sierr Leone South Afric Thilnd UR Tnzni Viet Nm Zmbi Zimbbwe high TB burden countries Blnk cells indicte dt not reported. indictes vlues tht cnnot be clculted. No mount is shown for Chin nd the Russin Federtion becuse the NTP budgets reported by those countries include ll budgets for inptient nd outptient cre. b In the Russin Federtion, the stff nd infrstructure reported for TB cre nd control were llocted to DS-TB (54%) nd MDR-TB (46%) by WHO bsed on the proportion of beddys used by DS-TB nd MDR-TB ptients. 114 :: GLOBAL TUBERCULOSIS REPORT 216

126 :: FIG. 7.5 Funding for NTP budgets from domestic sources nd interntionl donors, , 9 country groups (constnt 216 US$ billions). BRICS b. 25 HBCs excluding BRICS c. Rest of world US$ billions d. Low-income countries e. Lower-middle-income countries f. Upper-middle-income countries 3 US$ billions g. Afric h. Asi b i. Other regions c.6 3 US$ billions Domestic Interntionl donors d Globl Fund only Rest of the world includes 96 countries tht re not in the list of 3 high TB burden countries. b Asi includes the WHO regions of South-Est Asi nd the Western Pcific. c Other regions consist of three WHO regions: the Estern Mediterrnen Region, the Europen Region, nd the Region of the Americs. d This includes the Globl Fund. Interntionl donor funding for the TB-specific budgets of NTPs hs generlly incresed yer-on-yer since 26, nd reched US$ 1. billion in 216. The exception ws , when mounts of donor funding reported by NTPs dropped by US$ 15 million (US$.9 billion to US$.75 billion). This chnge ws not s mrked s the fll indicted by the creditor reporting system (CRS) of the Orgnistion for Economic Co-opertion nd Development (OECD) (see Box 7.2). Some possible resons for this sitution re tht the OECD dt include trnsfers to entities other thn NTPs, nd tht the lists of countries included do not fully overlp. Globl ggregtes for countries reporting finncing dt to WHO concel substntil vrition mong countries in the shre of funding from domestic nd interntionl sources (Fig. 7.5, Tble 7.3). Domestic funding domintes (representing 91 96% of the funding vilble to NTPs in 216) in three country groups (tht re not mutully exclusive): BRICS, upper middle-income countries, nd regions outside Afric nd Asi. In other country groups, interntionl donors (especilly the Globl Fund) re the most importnt source of funding nd re responsible for most of the growth in TB funding in the pst decde, especilly in the 25 TB HBCs outside BRICS (listed in Tble 7.1) 1 nd the 1 See Chpter 2 for further explntion of the HBC lists being used by WHO in GLOBAL TUBERCULOSIS REPORT 216 :: 115

127 :: Box 7.2 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 over the period 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 to the United Kingdom, is not cptured in the CRS. Also, government contributions to multilterl orgniztions re not ttributed to the government of origin but only to the multilterl orgniztion. b Fig. B7.2.1 shows trends in interntionl donor funding between 24 nd 214, for four mjor ctegories. The totl from ll sources in 214 ws US$.7 billion, up from US$.1 billion in 24. In 214, 57% of interntionl TB donor funding ws from the Globl Fund (US $.4 billion) nd the next lrgest contributor ws the US government (32%; US $ 247 million). Given tht bout one third of the contributions to the Globl Fund re from the US government, bout hlf of interntionl donor funding globlly ::FIG. B7.2.1 Interntionl donor funding for TB prevention, dignosis nd tretment by region, US$ millions Other multilterls Globl Fund United Sttes Other countries originted from the US government in 214. c The remining funding cme from other countries (9%) nd multilterl orgniztions (2%), mong which the lrgest donors were the governments of the United Kingdom (5%) nd Jpn (2%). Throughout the period , the Globl Fund ws consistently the lrgest provider of interntionl donor funding, but there ws striking drop of 44% from pek of US$.8 billion in 213 to US$.44 billion in 214. This 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 over the period , reching pek of US$ 247 million in 214. Asi nd Afric received the vst mjority of interntionl donor funding (Fig. B7.2.2), nd the decline in funding from the Globl Fund ws evident in in four geogrphicl subregions. These reductions were prtly mitigted by incresed funding from the US government in Asi, Afric nd Europe (but not the Americs). A comprison of interntionl donor funding for HIV/ AIDS (coded s sexully trnsmitted disese [STD] control within the OECD reporting system), mlri nd TB is shown in Fig. B In 214, non-oecd countries received US$ 5.4 billion for HIV/AIDS, US$ 1.7 billion for mlri nd US$.7 billion for TB. To provide some context for these mounts, the ltest estimtes (for 213) of the burden of disese in terms of disbility djusted life yers (DALYs) lost due to illness nd deth re 69 million for HIV/AIDS, 5 million for mlri nd 65 million for TB. d The decline in interntionl donor funding observed for TB between 213 nd 214 ws lso evident for HIV/AIDS, but not for mlri. The first- nd second-rnking donors for TB nd mlri re the Globl Fund nd the US government, wheres the order is reversed for HIV/AIDS (62% directly from the US government nd 29% from the Globl Fund). As opposed to commitments, which my not mterilize. b An importnt exmple is funding from the Globl Fund to non-oecd countries, which is ttributed to the Globl Fund nd not to the governments or other entities tht contribute to the Globl Fund. c It should be noted tht contributions from the United Sttes government cptured in the OECD dtbse re lower thn officil lloctions. In 214, the officil lloction for TB ws US$ 243 million nd n dditionl US$ 154 million ws llocted for TB/HIV vi the President s Emergency Pln for AIDS Relief (PEPFAR). d ghdx.helthdt.org/globl-burden-disese-study-213-gbd-213-dtdownlods :: GLOBAL TUBERCULOSIS REPORT 216

128 :: Box 7.2 Interntionl donor funding for TB prevention, dignosis :: FIG. B7.2.2 Interntionl donor funding for TB prevention, dignosis nd tretment by region, Afric Americ 4 US$ millions 2 1 US$ millions Asi 5 Europe 4 4 US$ millions 3 2 US$ millions Globl Fund United Sttes Other countries Other multilterls :: FIG. B7.2.3 Interntionl donor funding for TB, HIV nd mlri by source, (constnt 214 US$ millions) 4 STD control including HIV/AIDS TB Mlri US$ millions United Sttes Globl Fund Other countries Other multilterls GLOBAL TUBERCULOSIS REPORT 216 :: 117

129 :: TABLE 7.3 Reported NTP budget, vilble funding for NTP budget from domestic nd interntionl donor sources, funding gp nd shre of NTP budget provided by domestic nd interntionl donor funding, 3 high TB burden countries, 216 (current US$ millions) TOTAL NATIONAL STRATEGIC PLAN BUDGET 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 FUNDING GAP Bngldesh Brzil Cmbodi Centrl Africn Republic Chin Congo DPR Kore DR Congo Ethiopi Indi Indonesi b 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 Blnk cells indicte dt not reported. indictes vlues tht cnnot be clculted. Funding gp reflects the nticipted gp for the yer t the time country reported dt in the 216 round of globl TB dt collection. b For Indonesi, vilble funding from domestic sources dt re not shown becuse the Government of Indonesi is currently reviewing contributions from domestic sources. 118 :: GLOBAL TUBERCULOSIS REPORT 216

130 :: FIG. 7.6 Reported funding gps for TB prevention, dignosis nd tretment, by income group nd WHO region, (constnt 216 US$ millions) 7 Totl gp in 216 = US$.8 billion 6 Totl gp in 216 = US$.8 billion 6 5 US$ millions US$ millions Lower-middle-income countries Low-income countries Upper-middle-income countries Africn region Region of the Americs Estern Mediterrnen region Europen region South-Est Asi region Western Pcific region group of low-income nd lower middle-income countries (Fig. 7.5). Interntionl donors ccount for 75% of the totl funding in 216 in the group of 25 TB HBCs outside BRICS, 87% of funding in low-income countries nd 6% of funding in lower middle-income countries. At the individul country level, interntionl donors remin bsolutely criticl to funding for NTPs in most of the 3 TB HBCs (Tble 7.3). As noted bove, funding reported by NTPs does not cpture ll interntionl donor funding for TB. Donor funding is lso provided to entities other thn NTPs, including interntionl nd ntionl governmentl nd nongovernmentl orgniztions. A more comprehensive nlysis of interntionl donor funding for TB, including comprisons with HIV nd mlri, is provided in Box 7.2, bsed on donor reports to the OECD. 1 Amounts for TB re much lower thn donor contributions for HIV nd mlri. 7.3 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. 7.6). 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 216 they mounted to totl of US$.8 billion. This is less thn hlf of the gp of US$ 1.7 billion tht exists between the US$ 8.3 billion estimted to be needed in low- nd middleincome countries in 216 ccording to the Globl Pln (Section 7.1) nd the US$ 6.6 billion vilble in 216 (Section 7.2). The difference cn be explined by the fct tht, in 1 Out-of-pocket expenditures re lso not included in NTP reports. These re discussed in more detil in Chpter 6. mny countries, ntionl strtegic plns for TB re less mbitious thn the trgets set in the Globl Pln (Section 7.1). Lower middle-income countries ccount for the lrgest reported funding gps (lmost US$.5 billion in 216). Geogrphiclly, lmost hlf of the totl reported funding gp is ccounted for by countries in the WHO Africn Region, with the lrgest gps reported by Ethiopi nd Nigeri (Tble 7.3). Funding gps were reltively smll in upper middle-income countries in 216 (Fig. 7.6), nd hve fllen in recent yers. This trend is mostly explined by lrge reductions in the funding gps reported by Chin, Kzkhstn nd the Russin Federtion, which reported funding gps in but negligible or zero gps therefter. Funding gps reported by low-income countries hve fllen since 212, reflecting trnsition of some countries out of the low-income country group nd into the group of middleincome countries. Of the US$.8 billion funding gp reported by NTPs in 216, US$.63 billion is for drug-susceptible TB nd US$.14 billion is for MDR-TB. Reltive to totl funding needs, the funding gp is lrger for drug-susceptible TB thn for MDR-TB. Domestic funding ccounts for lrger shre of the funding for MDR-TB thn for drug-susceptible TB: this is not surprising given tht most of the high MDR- TB burden countries re middle- or high-income countries. 7.4 Unit costs of tretment for drugsusceptible nd multidrug-resistnt TB, 215 The cost per ptient treted in 215 for drug-susceptible nd MDR-TB ws estimted for 117 countries nd 82 countries, respectively. 2 All 3 countries in the lists of TB nd 2 Anlysis for drug-susceptible TB ws limited to countries tht notified t lest 1 TB cses in 215. For MDR-TB, estimtes were restricted to countries tht reported t lest 1 ptients on second-line tretment for MDR-TB. GLOBAL TUBERCULOSIS REPORT 216 :: 119

131 :: FIG. 7.7 Estimted cost per ptient treted for drug-susceptible TB in 117 countries, 215 Cost per ptient treted (216 US$, log scle) WHO region TB cselod (notified TB cses) Centrl Africn Republic Liberi Mozmbique Angol Zmbi DR Congo Zimbbwe Thilnd Ethiopi Indonesi Mynmr Ppu New Guine DPR Kore Bngldesh Lesotho Indi Sierr Leone Cmbodi Keny UR Tnzni Pkistn Congo Viet Nm Nigeri Nmibi Philippines Russin Federtion South Afric Afric Chin The Americs Estern Mediterrnen Brzil Europe South-Est Asi Western Pcific GDP per cpit (216 US$, log scle) Limited to countries with t lest 1 notified ptients in 215. :: FIG. 7.8 Estimted cost per ptient treted for MDR-TB in 82 countries, 215 Cost per ptient treted (215 US$, log scle) MDR-TB cselod (notified cses) 2 Somli Ethiopi DR Congo Mozmbique DPR Kore Tjikistn Bngldesh Mynmr Kyrgyzstn Zimbbwe Ppu New Guine Pkistn Nigeri Keny Republic of Moldov Indi Angol Uzbekistn Viet Nm Ukrine Indonesi Thilnd Philippines Belrus South Afric Peru Azerbijn WHO region Afric The Americs Estern Mediterrnen Russin Federtion Chin Europe Kzkhstn South-Est Asi Western Pcific GDP per cpit (215 US$, log scle) Limited to countries with t lest 2 ptients on second-line tretment in :: GLOBAL TUBERCULOSIS REPORT 216

132 :: Box 7.3 Methods used to estimte the cost per ptient treted for drug-susceptible 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 where no expenditure dt could be reported, informtion bout the totl funding vilble ws used s proxy for expenditures. Also, for few countries, WHO-CHOICE estimtes were replced with estimtes of unit costs obtined directly from recent studies or discussions with experts. 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 7.1, ntionl NTP expenditures 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 (with the exception of collbortive TB/ HIV ctivities) were ssumed to be for drug-susceptible TB. For lmost ll 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). Multiplying quntities of visits nd bed dys by their price estimtes yields the totl estimted cost of inptient nd outptient services. For 27 countries (including six HBCs, see Box 7.1), TB inptient nd outptient expenditures vilble from ntionl helth ccounts b were used insted of the estimted cost from this ingredients-bsed pproch. Unit costs were then clculted s the sum of 215 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 29 July 216). Helth ccounts. Genev: World Helth Orgniztion ( int/helth-ccounts/en/, ccessed 29 July 216). MDR-TB HBCs were included in this nlysis. Unit cost estimtes re shown in Fig. 7.7 nd Fig. 7.8, nd nlyticl methods re summrized in Box Drug-susceptible TB The cost per ptient treted for drug-susceptible TB ws generlly in the rnge US$ 1 US$ 1 (Fig. 7.7). In generl, bout 8% of this cost ws ccounted for by reported NTP expenditures, with the reminder being inptient nd outptient cre. There is positive reltionship between the cost per ptient treted nd gross domestic product (GDP) per cpit, s well s the size of the ptient cselod (indicting economies of scle, e.g. in Chin nd Indi). In most (28/3) of the TB HBCs included in the nlysis, the cost per ptient treted for drug-susceptible TB ws less thn GDP per cpit; the exceptions were Liberi nd Sierr Leone. The cost per ptient treted ws typiclly higher in countries in the WHO Europen Region nd the WHO Region of the Americs. In countries of the former Soviet Union, the higher cost is prtly explined by reltively lengthy hospitliztions, with dmissions lsting up to n verge of 75 dys nd ccounting for bout 4 6% of the totl cost per ptient. However, there re some striking exmples of reductions in relince on hospitliztion. For exmple, the Russin Federtion reported hospitliztion of bout 65% of TB ptients with drug-susceptible TB in 216, compred with 93% in 214, nd in Georgi the figures were 3% nd 83%, respectively Multidrug-resistnt TB For MDR-TB, the cost per ptient treted rnges from bout US$ 2 2 in most countries (Fig. 7.8). As with drug-susceptible TB, the cost per ptient treted is relted to GDP per cpit. Following new WHO recommendtions tht shortened regimens of 9 12 months cn be used for ptients (other thn pregnnt women) with rifmpicin-resistnt or MDR pulmonry TB who do not hve resistnce to second-line drugs, 1 t cost of bout US$ 1 per person for the drug regimen, there is scope for the unit cost of second-line tretment for MDR-TB to fll in the coming yers. 1 For further detils bout the new recommendtions, see Chpter 4. GLOBAL TUBERCULOSIS REPORT 216 :: 121

133 Chpter 8 :: TB reserch nd development :: KEY FACTS AND MESSAGES Intensified reserch nd innovtion is the third pillr of the End TB Strtegy. WHO hs developed Globl Action Frmework for TB Reserch, to foster high-qulity reserch to end the TB epidemic t both country nd globl levels. In 216, four dignostic tests were reviewed nd recommended by WHO: the loop-medited isotherml mplifiction test for TB (known s TB-LAMP), two line probe ssys (LPAs) for the detection of resistnce to the first-line nti-tb drugs isonizid nd rifmpicin, nd n LPA for the detection of resistnce to second-line nti-tb drugs. A next-genertion crtridge clled Xpert Ultr, which my replce the Xpert MTB/RIF crtridge nd could potentilly replce conventionl culture s the primry dignostic tool for TB, will be ssessed in 217. The Xpert Ultr crtridge is designed to be used in existing GeneXpert instruments. A new dignostic pltform clled the GeneXpert Omni is lso in development. This is intended for point-of-cre testing for TB nd rifmpicin-resistnt TB using Xpert Ultr crtridges. Assessment of this new pltform s n lterntive to the GeneXpert instrument is expected in 217. Development of new drugs nd regimens for the tretment of TB continues, with both dvnces nd setbcks in A new compound (Q23) entered Phse I tril, but the development of AZD5847 by Astr-Zenec ws officilly ended (due to lck of demonstrted nti-tb ctivity) nd the development of TBA-354 ws discontinued (due to signs of toxicity in the Phse I tril). There re nine nti-tb drugs in dvnced phses of clinicl development for the tretment of drug-susceptible, multidrug-resistnt TB or ltent TB infection (LTBI), of which six re new nd three re lredy pproved or repurposed. The six new compounds re bedquiline, delmnid, PBTZ169, pretomnid, Q23 nd sutezolid. The three pproved or repurposed drugs undergoing further testing re rifmpicin, rifpentine nd linezolid. There re 13 vccine cndidtes in clinicl trils: eight in Phse II or Phse III trils, nd five in Phse I trils. They include cndidtes for prevention of TB infection nd cndidtes for prevention of TB disese in people with LTBI. Intensified reserch nd innovtion is one of the three pillrs of the WHO End TB Strtegy. 1 Its two min components re discovery, development nd rpid uptke of new tools, interventions nd strtegies nd reserch to optimize implementtion nd impct, nd promote innovtions (Chpter 2). The strtegy sets trgets for reductions in TB incidence nd TB mortlity by 23 nd 235. Reching these trgets will require mjor technologicl brekthrough by 225, so tht the rte t which TB incidence flls cn be drmticlly ccelerted compred with historic levels between 225 nd 235 (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 dur- 1 World Helth Orgniztion. WHO End TB Strtegy: globl strtegy nd trgets for tuberculosis prevention, cre nd control fter 215. Genev: WHO; 215 ( en/, ccessed 8 August 216). 2 The Globl Pln to End TB, Genev: Stop TB Prtnership; 215 ( ccessed 28 July 216). ing the period , compred with funding levels during the decde tht never exceeded US$.7 billion per yer. 3 This chpter provides n overview of progress in the development of new TB dignostics, drugs nd vccines s of August 216, bsed on recent publictions nd communictions with nd contributions from the secretrits of the relevnt working groups of the Stop TB Prtnership, nd vrious stkeholders. The Globl Action Frmework for TB Reserch (GAF), 4 which hs been developed by WHO to foster high-qulity TB reserch cross the spectrum, is profiled in Box Report on Tuberculosis Reserch Funding Trends, : A Decde of Dt. New York: Tretment Action Group; 215 ( 4 World Helth Orgniztion. A Globl Action Frmework for TB reserch in support of the third pillr of WHO s End TB Strtegy. Genev: WHO; 215 ( globl-frmework-reserch/en/, ccessed 8 August 216). 122 :: GLOBAL TUBERCULOSIS REPORT 216

134 :: Box 8.1 WHO s Globl Action Frmework for TB Reserch WHO hs developed Globl Action Frmework (GAF) to foster high-qulity TB reserch cross the spectrum (from bsic science to implementtion reserch), with the overll gol of ending the globl TB epidemic. The GAF hs two mjor dimensions: promoting reserch t country level nd promoting reserch t globl level, s summrized below. Promoting reserch t country level At country level, WHO encourges the estblishment of ntionl TB reserch network of stkeholders (individuls nd orgniztions) tht will drive reserch nd innovtion bsed on shred desire to ddress the ntionl TB epidemic. It is expected tht the network will provide systemtic pproch to ddressing issues in TB prevention, dignosis nd tretment reserch. The pproch should strt with situtionl nlysis of the TB epidemic, nd of the performnce of the ntionl TB control progrmme nd wider helth system, nd mpping of reserch cpcity. This should be followed by the development of ntionl TB reserch gend to ddress identified gps, the outcomes of which should inform TB cre policy nd prctice. To support the development of such plns for reserch, WHO s Globl TB Progrmme hs developed toolkit to ssist high nd medium TB burden countries with ech of these steps. Erly dopters of this pproch include Brzil, Ethiopi, the Russin Federtion, South Afric nd Viet Nm. Promoting reserch t globl level WHO is promoting TB reserch by shring innovtions, orgnizing vriety of knowledge-shring pltforms, nd fcilitting the development of regionl nd globl networks for reserch nd cpcity-building. This pproch involves prtnering with countries, orgniztions nd institutions. WHO is lso encourging interntionl collbortion between technologiclly dvnced countries nd those with limited resources, nd is providing technicl support to regionl nd globl networks of TB reserchers. 8.1 New dignostics for TB An overview of the dignostics pipeline The dignostic technology lndscpe, which consists mostly of moleculr tests, continues to look promising. An overview of the dignostic pipeline for rpid moleculr tests in August 216 is shown in Fig The list of technologies is not necessrily complete, but does reflect technologies tht hve been documented in recent report published by the Tretment Action Group. 1 Technologies under development include tests to detect TB, drug resistnce or TB nd drug resistnce combined. At lest three new commercil technologies Epistem Genedrive, Epistem, United Kingdom; EsyNAT, Ustr Biotechnologies, Chin; nd Molbio TrueNAT, Molbio, Indi re intended for use t the microscopy level. However, vilble performnce dt for these tests re limited nd highly vrible, nd to dte no multicentre evlution or demonstrtion studies in different epidemiologicl settings hve been conducted. Such studies re essentil to generte the dt required by WHO to ssess nd produce recommendtions on their use, but funding nd cpcity to undertke the studies re limited. Severl mnufcturers hve lso indicted tht they re developing centrlized testing pltforms suitble for high lbortory throughput. However, these pltforms re not yet redy for field evlution studies, nd to be useful lrge investment in smple trnsporttion systems would be required. Cepheid is developing new pltform clled GeneXpert Omni, which is intended for point-of-cre (POC) testing for TB nd rifmpicin-resistnt TB using Xpert MTB/RIF crtridges or the next-genertion Xpert Ultr crtridges. The device is expected to be smller, lighter nd less expensive thn other currently vilble pltforms for POC nucleic cid detection. The pltform is expected to come with built-in 4-hour bttery nd n uxiliry bttery tht provides n dditionl 12 hours of run time. Delys in the development of the GeneXpert Omni men tht the instruments re not likely to be vilble before the second hlf of 217. The new pltform will be ssessed for equivlence to the current GeneXpert pltform before its lunch. The GeneXpert Omni is expected to be n lterntive to nd complement the existing multi-module instruments. Mjor gps tht remin in the dignostic pipeline include tests for the dignosis of TB in children, rpid drug susceptibility tests for drugs tht my be prt of new tretment regimens, tests tht ccurtely predict progression from ltent TB infection (LTBI) to ctive TB disese, nd lterntives to TB microscopy nd culture for tretment monitoring. In ddition, experience with GeneXpert hs mde it cler tht ny new technology will need to be rolled out with n entire set of interventions, including comprehensive trining, qulity ssurnce, implementtion plns, dt connectivity, nd service nd mintennce support. 1 Frick M, Lessem E, McKenn L. Pipeline report: Tuberculosis (TB) edition. London/New York: HIV i-bse/tretment Action Group; 216 ( Pipeline%2TB%2Edition_.pdf, ccessed 8 August 216). GLOBAL TUBERCULOSIS REPORT 216 :: 123

135 :: FIG. 8.1 An overview of progress in the development of moleculr TB dignostics, August 216 TECHNOLOGIES IN DEVELOPMENT FOR USE IN REFERENCE LEVEL LABORATORIES m2 RelTime MTB System, Abbott, USA TruArry MDR-TB, Akonni, USA INFINITI System MDR-TB BioFilm Chip Microrry, AutoGenomics, USA BD ProbeTec ET Direct TB ssy, BD, USA TB drug resistnce rry, Cpitl Bio, Chin AMTD test, Hologic Genprobe, USA Cobs TqMn MTB test, Roche, Switzerlnd Anyplex, Seegene, Kore Mgicplex MTB, Seegene, Kore TRC Rpid M.TB, Tosoh Bioscience, Jpn MeltPro, Zeesn Biotech, Chin TECHNOLOGIES IN DEVELOPMENT FOR USE IN INTERMEDIATE LEVEL LABORATORIES FluoroType MTB/FluoroType MTB RNA, Hin Lifesciences, Germny icubte System, icubte, USA AdvnSure, LG Life sciences, Kore veremtb, Veredus Lbortories, Singpore SPEED-OLIGO, Vircell, Spin MolecuTech REBA, YD Dignostics, Kore LATE-PCR, Brndeis University, USA GeneXpert XDR crtridge, Cepheid, USA Xpert Ultr, Cepheid, USA Enigm ML, Enigm Dignostics, UK TECHNOLOGIES IN DEVELOPMENT FOR USE IN PERIPHERAL LEVEL LABORATORIES Genedrive MTB/RIF ID, Epistem, UK HYDRA, Insilix Inc, USA Truelb/Truent MTB, Molbio/bigtec Dignostics, Indi EsyNAT TB Dignostic kit, Ustr Biotechnologies, Chin GenePOC test, GenePOC, Cnd Xpert Omni, Cepheid, USA This is not n exhustive list of technologies in development. Those listed re the ones documented in publictions by UNITAID nd TAG. UNITAID Tuberculosis Dignostic Technology nd Mrket Lndscpe, 3rd edition. Genev: World Helth Orgniztion. Frick M., Lessem E., McKenn L., 216 pipeline report. Tuberculosis (TB) Edition. Dignostics, tretment, prevention nd vccines in development, HIV i-bse/tretment Action Group. London/New York TB dignostic tests reviewed by WHO in 216 WHO reviewed three dignostic technologies in 216: the loop-medited isotherml mplifiction test for TB (referred to s TB-LAMP); line probe ssys (LPAs) to test for resistnce to first-line nti-tb drugs; nd LPAs to test for resistnce to second-line nti-tb drugs. These technologies re discussed below. Loop-medited isotherml mplifiction test for TB TB-LAMP developed by Eiken, Jpn is mnul test tht tkes less thn 1 hour. Results cn be red with the nked eye under ultrviolet light, nd the TB-LAMP instrument cn be used t the peripherl helth centre level, which is where sputum smer microscopy is often performed. The level of trining of stff required to perform the test is lso similr to tht needed for microscopy. TB-LAMP performs better thn sputum smer microscopy, detecting t lest 4% more ptients with pulmonry TB; this is n increse comprble to other rpid tests tht hve been recommended by WHO in recent yers. The test does not detect drug resistnce nd is therefore only suitble for testing of ptients t low risk of multidrug-resistnt TB (MDR-TB). Following review of the ltest evidence, WHO recommends tht TB-LAMP cn be used s replcement for microscopy for the dignosis of pulmonry TB in dults with signs nd symptoms of TB. It cn lso be considered s follow-on test to microscopy in dults with signs nd symptoms of pulmonry TB, especilly when further testing of sputum smer-negtive specimens is necessry. Line probe ssys to test for resistnce to first-line nti-tb drugs Two LPAs for the detection of resistnce to the first-line drugs isonizid nd rifmpicin hve been developed, one by the Nipro Corportion, Jpn nd the other by Hin Lifesciences, Germny. These LPAs cn provide results on drug resistnce within dys, compred with up to 4 weeks for phenotypic culture-bsed testing. Following review of the ltest evidence, WHO recommends tht both these LPAs cn be considered for use s n initil test to detect resistnce to rifmpicin nd isonizid in smer-positive specimens. They cn lso be used to test cultured isoltes of Mycobcterium tuberculosis. Direct testing of sputum smer-negtive specimens is not recommended. Further detils re vilble online. 1 Line probe ssy to test for resistnce to second-line nti-tb drugs An LPA for the detection of resistnce to second-line nti- TB drugs (fluoroquinolones nd injectbles) hs been developed by Hin Lifesciences, Germny. Following review of the ltest evidence, WHO recommends tht this LPA cn be considered s n initil test for resistnce to second-line nti-tb drugs, given its bility to provide rpid results, especilly when used for the direct testing of sputum specimens from ptients with confirmed multidrug-resistnt TB (MDR-TB) or rifmpicin-resistnt TB. The speed of testing 1 The use of moleculr line probe ssys for the detection of resistnce to isonizid nd rifmpicin. Policy Guidnce. Genev: World Helth Orgniztion; 216 (WHO/HTM/TB ). Avilble t :: GLOBAL TUBERCULOSIS REPORT 216

136 is criticl to llow for the time-sensitive step of triging ptients between the stndrdized short regimen for MDR- TB (which is recommended for use only in ptients who do not hve second-line drug resistnce). If the LPA result is negtive, WHO recommends tht phenotypic culturebsed testing my be necessry, especilly in settings with high pretest probbility for resistnce to fluoroquinolones or second-line injectble drugs, or both. Further detils re vilble online Technologies scheduled for evlution in 217 Xpert Ultr A new version of the Xpert MTB/RIF ssy, clled Xpert Ultr, is in development by Cepheid. The current ssy hs been modified with the im of improving its sensitivity for the detection of TB nd its specificity in the detection of resistnce to rifmpicin; it cn be used in the Omni pltform (described bove). In erly 217, WHO will initite two-step evlution process of Xpert Ultr bsed on dt from evlutions by the Foundtion for Innovtive New Dignostics (FIND). The first step is rpid noninferiority (i.e. equivlence) study tht will compre the new Xpert Ultr ssy with the current Xpert MTB/RIF ssy. If noninferiority is demonstrted, the Xpert Ultr ssy will be recommended s replcement for the current Xpert MTB/RIF ssy. Lter in 217, the second evlution step will involve multicountry studies. Updted criticl concentrtions for culture-bsed drug susceptibility testing Phenotypic methods to detect resistnce to nti-tb drugs re bsed on ssessment of the bility of the M. tuberculosis complex (MTBC) to grow in culture medi contining criticl concentrtions (CC) of specific nti-tb gents (which indictes resistnce) or, conversely, its inbility to grow in tht medi (which indictes susceptibility). Susceptibility is used s proxy for successful tretment outcome, nd resistnce s proxy for tretment filure. New drugs for the tretment of MDR-TB hve been recommended by WHO (Section 8.2), nd other drugs re being repurposed (notbly linezolid nd clofzmine) in the shortened MDR-TB regimens. Methods for testing for susceptibility to these drugs re therefore needed. Other nti-tb gents for exmple, the fluoroquinolones, second-line injectble gents, thiomides, cycloserine nd pyrzinmide re becoming incresingly importnt in the tretment of drug-resistnt TB; hence, there is need for the CCs of these nti-tb gents to be re-evluted s well. WHO hs initited systemtic pproch to ggregting nd nlysing dt (published nd unpublished) to ssess the ssocition of CC or miniml inhibitory concen- trtion with epidemiologicl cut-offs nd ptient outcomes. Through this pproch, WHO expects to be ble to revise current CCs nd vlidte new CCs, especilly for the new nd repurposed drugs. Role of moleculr sequencing s reference stndrd for drug susceptibility testing Drug resistnce in MTBC is, possibly exclusively, due to muttions ffecting the bcteril genome. Rpid moleculr dignostic tests hve been developed for the simultneous detection nd identifiction of MTBC, nd for the most common muttions cusing resistnce to specific drugs. However, for some nti-tb drugs, the ssocition between the observed phenotypic resistnce, mechnisms of resistnce nd the genetic bsis of the phenotype re still poorly understood. Mny new tools for sequencing nd nlysing the genome of MTBC hve become widely ccessible for the moleculr detection of the muttions ssocited with drug resistnce, but uncertinties remin bout the correltion between specific single nucleotide polymorphisms (SNPs) nd their expressed phenotypic resistnce (s mesured by both solid nd liquid culture methods). In 217, WHO will evlute the ccurcy of genotypic drug susceptibility testing (DST) compred with the current phenotypic gold stndrds. WHO will lso ssess whether genotypic DST cn replce phenotypic DST, t lest for certin key drugs such s pyrzinmide nd rifmpicin Tests tht predict progression from ltent to ctive TB Identifying nd effectively treting people with LTBI who hve no signs nd symptoms of TB disese will be key to chieving the 23 nd 235 trgets of the End TB Strtegy (Chpter 2). On verge, 5 15% of those infected will develop ctive TB during their lifetime, typiclly within the first 2 5 yers fter the initil infection. Current tests for LTBI re the interferon gmm relese ssys (IGRAs) nd the tuberculin skin test (TST). These tests re immunity bsed, nd hve limited bility to predict disese or to identify which individuls with TB infection re likely to progress to ctive TB disese. They lso hve limited sensitivity in people with HIV infection, nd cnnot differentite between recent nd remote infection, or whether person hs been reinfected if re-exposed. Current IGRA ssys primrily detect CD4 T-cell response. However, new genertion ssy, the QuntiF- ERON-TB Plus (QFT-Plus, Qigen, Hilden, Germny), hs been developed to stimulte gmm interferon production by both CD4 nd CD8 T-cells. First results indicte tht the CD8 T-cell response my be ble to identify people t greter risk of progression to ctive TB. 2 1 World Helth Orgniztion. The use of moleculr line probe ssys for the detection of resistnce to second-line nti-tuberculosis drugs (WHO/HTM/TB/216.7). Genev: WHO; 216 ( int/tb/res-of-work/lbortory/policy_sttements/en/, ccessed 8 August 216). 2 Brcellini L, Borroni E, Brown J, Brunetti E, Cmpisi D, Cstellotti PF et l. First evlution of QuntiFERON-TB Gold Plus performnce in contct screening. Eur Respir J. 216:ERJ GLOBAL TUBERCULOSIS REPORT 216 :: 125

137 8.1.5 Dignostic connectivity The roll out of rpid dignostic tools for TB ptients llows for fster nd more ccurte testing. However, these benefits cn be jeoprdized if bottlenecks occur in the hndling of smples nd results. Stremlining the flow of dt between testing, storge nd sending of results is criticl sequence of steps tht must ccompny the roll out of new tests. For dignostic systems to mke mesurble impct on ptient cre, they should be ble to communicte through stndrdized digitl interfce, using technologies tht re fesible regrdless of the income level of the country or setting. 1 Dignostics connectivity solutions re now being monitored by WHO s core indictor for lbortory strengthening under the End TB Strtegy. 8.2 New drugs nd drug regimens Development of new drugs nd regimens for the tretment of TB continues, with both dvnces nd setbcks in A new compound (Q23) entered Phse I tril, but the development of AZD5847 by Astr-Zenec ws officilly ended (due to lck of demonstrted nti-tb ctivity) nd the development of TBA-354 ws discontinued (due to signs of toxicity in the Phse I tril). 2 The sttus of the pipeline for new nti-tb drugs in August 216 is shown in Fig There re currently nine new or repurposed drugs in Phse I, II or III trils for the tretment of drug-susceptible TB, MDR-TB or LTBI. Of these, six re new compounds (bedquiline, delmnid, PBTZ169, pretomnid, Q23 nd sutezolid.) nd three re drugs tht hve lredy been pproved or hve been repurposed nd re undergoing further testing (linezolid, rifmpicin nd rifpentine). These drugs re discussed below New compounds in development Bedquiline After pprovl by the US Food nd Drug Administrtion in December 212 nd WHO s interim policy guidnce on its use in June 213, 3 bedquiline hs been introduced in severl countries for the tretment of severe forms of MDR- 1 World Helth Orgniztion. Digitl helth for the End TB Strtegy: n gend for ction (WHO/HTM/TB/215.21). Genev: WHO; 215 ( helth_endtbstrtegy.pdf, ccessed 8 August 216). 2 TBA-354, belonging to the nitroimidzole clss, ws the first cndidte to enter Phse 1 TB trils over the pst 6 yers. However, in Phse 1 dose-esclting tril the drug ws found to be ssocited with mild signs of neurotoxicity (repetitive uncontrolled eye movements nd overctive reflexes, from which ll ffected study prticipnts recovered). The TB Allince nnounced the discontinution of its development in Mrch tbllince.org/news/phse-1-clinicl-tril-tb-drug-cndidte-tb- 354-discontinued 3 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 216). TB (Chpter 4). 4,5 The sfety nd efficcy of bedquiline s prt of short MDR-TB regimens of 6 nd 9 months durtion, compred with the current stndrd of cre recommended by WHO, is now being investigted in the second stge of the Phse III STREAM tril tht strted recruitment in Mrch 216. The first results re expected towrds the end of 22. Delmnid A conditionl mrketing uthoriztion for delmnid ws grnted by the Europen Medicines Agency in April 214. This ws for the tretment of pulmonry MDR-TB in dult ptients when n effective tretment regimen cnnot otherwise be composed for resons of resistnce or tolerbility. Interim guidnce on the use of delmnid ws issued by WHO in October The follow-up stge of Phse III tril of the sfety nd efficcy of delmnid s n ddition to n optimized bckground regimen (OBR) for the tretment of MDR-TB in dults ws recently completed. It is nticipted tht results will be published in 218. The use of delmnid in ddition to OBR for tretment of MDR-TB in children is being investigted in Phse I nd II trils. Prtil results were presented in PBTZ169 A new series of piperzine-contining benzothizinones (PBTZ) hve shown highly potent ctivity ginst drugsusceptible nd drug-resistnt TB. 8 PBTZ169 is comptible with ll TB drugs nd ppers to hve synergies with bedquiline nd clofzimine. A Phse I tril of PBTZ169 ws completed in the Russin Federtion in July 216, nd second Phse I tril will be undertken in Switzerlnd in 217. A Phse II tril is expected to strt towrds the end of 216 in the Russin Federtion. 4 Guglielmetti L, Le Du D, Jchym M, Henry B, Mrtin D, Cumes E et l. Compssionte use of bedquiline for the tretment of multidrugresistnt nd extensively drug-resistnt tuberculosis: interim nlysis of French cohort. Clin Infect Dis. 215;6(2): ( ncbi.nlm.nih.gov/pubmed/ , ccessed 8 August 216). 5 Ndjek N, Conrdie F, Schnippel K, Hughes J, Bntubni N, Ferreir H et l. Tretment of drug-resistnt tuberculosis with bedquiline in high HIV prevlence setting: n interim cohort nlysis. Int J Tuberc Lung Dis. 215;19(8): ( pubmed/ , ccessed 8 August 216). 6 World Helth Orgniztion. The use of delmnid in the tretment of multidrug-resistnt tuberculosis: interim policy guidnce (WHO/ HTM/TB/214.23). Genev: WHO; 214. ( bitstrem/1665/137334/1/who_htm_tb_214.23_eng.pdf, ccessed 8 August 216). 7 Hfkin J, Fris M, Hesseling A, Grci-Prts AJ, et l. Phrmcokinetics nd sfety of delmnid in peditric MDR-TB ptients: ges 6 17 yers. Interscience Conference on Antimicrobil Agents nd Chemotherpy (ICAAC). Sn Diego, Cliforni. 215; nd Hfkin J, Fris M, De Leon A, et l. Long-term sfety, tolerbility nd phrmcokinetics of delmnid in peditric MDR-TB ptients, ges yers. 46th Union World Conference on Lung Helth. Cpe Town, South Afric Mkrov V, Lechrtier B, Zhng M et l. Towrds new combintion therpy for tuberculosis with next genertion benzothizinones. EMBO Mol Med. 214 Mr;6(3): :: GLOBAL TUBERCULOSIS REPORT 216

138 :: FIG. 8.2 The globl development pipeline for new nti-tb drugs, August 216 Discovery Preclinicl development Clinicl development Led optimiztion Erly stge development Good Lbortory Prctice toxicity Phse I Phse II Phse III Cyclopeptides Dirylquinolines DprE Inhibitors InhA Inhibitor, Ures Mcrolides, Azindoles Mycobcteril Gyrse Inhibitors Pyrzinmide Anlogs Ruthenium(II)Complexes Spectinmides Trnslocse-1 Inhibitors, Clp, Mmp13, Oxzolidinones, Pyrimidines DprE1, Aryl Sulfonmides, PKS13, Squrmides TBI-166 CPZEN-45* SQ69* 1599* BTZ-43* TBA-7371* GSK-7* Q23* PBTZ169* Sutezolid (PNU- 148) Linezolid EBA c High Dose Rifmpicin for Drug-susceptible TB Bedquiline (TMC27) Pretomnid (PA-824) Pyrzinmide Regimen Levofloxcin with OBR b for MDR-TB Rifpentine Moxifloxcin for Drug-susceptible TB Delmnid (OPC-67683) with OBR b for MDR-TB Pretomnid- Moxifloxcin- Pyrzinmide Regimen (STAND) Bedquiline Pretomnid Linezolid NiX-TB Regimen Bedquiline STREAM MDR-TB Tril Stge 2 with orl OBR b (9 mo) or OBR b with injectbles (6 mo) Bedquiline Linezolid with OBR for MDR-TB (NExT Tril) Chemicl clsses: fluoroquinolone, rifmycin, oxzolidinone, nitroimidzole, dirylquinoline, benzothizinone, imidzopyridine mide. * New chemicl clss Detils for projects listed cn be found t nd ongoing projects without led compound series identified cn be viewed t b OBR = Optimized Bckground Regimen c EBA = Erly Bctericidl Activity Source: Working Group on New TB Drugs, Pretomnid Pretomnid is nitroimidzole developed by the Globl Allince for TB drug development (TB Allince). It is currently being tested s prt of three potentil combintion regimens for the tretment of both drug-susceptible nd drug-resistnt TB (further detils in Section 8.2.2). Q23 Q23 is new compound of the imidzopyridine clss developed by Qurient. It blocks the growth of TB bcilli by trgeting the respirtory cytochrome bc1 complex, inhibiting the synthesis nd homeostsis of denosine triphosphte (ATP). 1 Different levels of single dose re being tested in Phse I tril. Sutelozid Sutezolid (PNU-148) is n oxzolidinone nd n nlogue of linezolid. Results from study of erly bctericidl ctivity presented in 212 showed tht this compound led to significnt reduction in counts of colony-forming units compred with the bseline level following 14 dys of tretment. In August 216, however, there ws no further informtion vilble to WHO bout its subsequent development. 1 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): Approved or repurposed drugs Rifpentine Investigtion of the potentil effectiveness of rifpentine in the tretment of drug-susceptible TB hs continued, bsed on the encourging results from TB Tril Consortium (TBTC) Studies 29 nd 29X. TBTC Study 31/A5349 is investigting the possibility of shortening tretment of drug-susceptible pulmonry TB to 4 months by using rifpentine, with or without moxifloxcin. Recruitment strted in Jnury 216. Rifmpicin A recent 2-month study testing the sfety of high doses of rifmpicin together with stndrd tretment for drugsusceptible TB showed no significnt increse in dverse events t doses of 1 mg/kg, 15 mg/kg nd 2 mg/kg New regimens for the tretment of drugsusceptible or drug-resistnt TB Besides individul compounds, new combintions of drugs re being tested in severl Phse II or Phse III trils. The TB Allince is investigting the efficcy, sfety nd tolerbility of pretomnid in combintion with moxifloxcin nd pyrzinmide (PMZ). Following the encour- 2 Jindni A, Borguly G, de Ptino IW, Gonzles T, de Fernndes RA, Shresth B et l. A rndomised Phse II tril to evlute the toxicity of high-dose rifmpicin to tret pulmonry tuberculosis. Int. J. Tuberc. Lung Dis. 216;2(6): GLOBAL TUBERCULOSIS REPORT 216 :: 127

139 ging results of the 2-month NC-2 Phse IIb tril, 1 the STAND tril ws lunched in Februry 215. This is Phse III tril of the sfety nd efficcy of P(1 mg)mz for 4 months, P(2 mg)mz for 4 months nd P(2 mg) MZ for 6 months in ptients with drug-susceptible TB; nd of P(2 mg)mz for 6 months in ptients with drugresistnt TB. In lte 215, enrolment ws temporrily suspended due to three deths relted to high liver toxicity. Subsequently, the TB Allince hs been working with regultory uthorities nd the tril s dt sfety nd monitoring committee to determine whether to restrt enrolment, nd if so, when to do so. A Phse IIb tril (NC-5) to test ll-orl combintion regimens strted in October 214. The regimens being tested re bedquiline (t two different doses), pretomnid nd pyrzinmide for ptients with drug-susceptible TB, nd the sme drugs in combintion with moxifloxcin for ptients with MDR-TB. Enrolment ws completed towrds the end of 215, nd results re expected in lte 216. The NiX-TB tril is being implemented by the TB Allince in South Afric. It is investigting the sfety nd efficcy of 6-month combintion of bedquiline, pretomnid nd linezolid in ptients with extensively drug-resistnt TB (XDR-TB). The primry end-point is the incidence of bcteriologic filure (relpse or clinicl filure) 6 months fter completion of tretment, with long-term follow-up for 24 months fter the end of tretment. Alongside this tril, the efficcy of esclting doses of linezolid in ptients with drug-susceptible TB over period of 2 weeks is lso being investigted. Results will inform djustments to the dosing of linezolid in the NiX-TB tril s well s other regimens tht include linezolid. The endtb nd TB-PRACTECAL trils re scheduled to strt round the end of 216. The former is Phse III tril funded by UNITAID, nd implemented by Prtners in Helth nd Médecins Sns Frontières (MSF). It will compre severl regimens for tretment of MDR-TB or XDR- TB with the current WHO stndrd of cre. The regimens being tested contin bedquiline or delmnid (or both), moxifloxcin or levofloxcin, nd pyrzinmide plus linezolid or clofzimine (or both), in vrious combintions. The TB-PRACTECAL tril is Phse II/III dptive 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. The tril is funded by MSF nd will be conducted in Belrus, Uzbekistn, nd potentilly in countries in southern Afric. The NeXT study is n open lbel tril of 6 9 month injection-free regimen contining bedquiline, ethionmide or high-dose isonizid, linezolid, levofloxcin, nd pyrzinmide, compred with the WHO-recommended 1 Dwson R, Dicon AH, Everitt D, vn Niekerk C, Donld PR, Burger DA et l. Efficiency nd sfety of the combintion of moxifloxcin, pretomnid (PA-824), nd pyrzinmide during the first 8 weeks of ntituberculosis tretment: Phse 2b, open-lbel, prtly rndomised tril in ptients with drug-susceptible or drug-resistnt pulmonry tuberculosis. Lncet. 215;385(9979): month shorter regimen for MDR-TB tretment. Recruitment strted in South Afric in Tretment of ltent TB infection Severl studies evluting shorter regimens for LTBI re being implemented, prticulrly for prevention of LTBI in people living with HIV. ACTG A5279 is evluting the sfety nd effectiveness of ultr-short-course rifpentine or isonizid (or both) for the prevention of ctive TB in HIV-positive people with LTBI. Rifpentine (t dosge bsed on weight) in combintion with 3 mg of isonizid for 1 month is being compred with 3 mg of isonizid for 9 months. Results re expected in the lst qurter of 217. The Weekly High dose Isonizid nd rifpentine (P) Periodic Prophylxis for TB tril, known s WHIP3 TB, is due to strt by the end of 216. It will evlute 3-month regimen of high dose rifpentine plus isonizid for people living with HIV, dministered either s single round or given nnully. It will be implemented in South Afric, Mozmbique nd Ethiopi, in two prts. Prt A will compre single round of weekly high dose rifpentine plus isonizid for three months (3HP) to six months of dily isonizid (6H); Prt B will compre periodic 3HP (p3hp) to single round of 3HP. Two trils to investigte drugs or regimens for the prevention of TB in contcts of MDR-TB ptients re being implemented or re plnned. The V-QUIN MDR study is ssessing 6 months of dily levofloxcin for household contcts of ptients with MDR-TB. It is being conducted in Viet Nm nd recruitment strted in Mrch 216. The TB- CHAMP study is multicentre tril to evlute the efficcy of levofloxcin in children ged 5 yers who re household contcts of MDR-TB cses. It is due to strt in South Afric in October New vccines to prevent TB Both the slow decline in TB incidence globlly nd the persistent thret of MDR-TB highlight the criticl need for new TB vccines tht re more effective thn the Bcille- Clmette-Guérin (BCG) vccine in preventing TB. The sttus of the pipeline for new vccines in August 216 is shown in Fig The pipeline includes recombinnt BCGs, whole-cell derived vccines, recombinnt virl-vectored pltforms, protein nd djuvnt combintions, nd mycobcteril extrcts. These vccines im either to prevent infection (pre-exposure) or to prevent primry progression to disese or rectivtion of LTBI (post-exposure). Further detils re provided below Phse II nd Phse III clinicl trils There re currently eight vccines in Phse II or Phse III trils. M72/AS1E M72/AS1E is mde by GlxoSmithKline (GSK) nd is recombinnt fusion protein of the M. tuberculosis ntigens 128 :: GLOBAL TUBERCULOSIS REPORT 216

140 :: FIG. 8.3 The development pipeline for new TB vccines, August 215 Phse I Phse II Phse IIb Phse III MTBVAC Biofbri, TBVI, Zrgos DAR-91 Drtmouth VPM 12 SII, Mx Plnck, VPM, TBVI Vcce Anhui Zhifei Longcom Ad5 Ag85A McMster, CnSino RUTI Archivel Frm, S.L M72 + AS1E GSK, Aers ChAdOx1.85A / MVA85A Oxford, Birminghm H1/H56: IC31 SSI, Vlnev, Aers MVA85A / MVA85A (ID, Aerosol) Oxford TB / FLU-4L RIBSP H4: IC31 Snofi Psteur, SSI, Aers ID93 + GLA-SE IDRI, Wellcome Trust, Aers Virl Vector Protein/Adjuvnt Mycobcteril Whole Cell or Extrct Source: Aers, Working Group on New TB Vccines, A nd 39 A with the AS1E djuvnt. A lrge rndomized plcebo-controlled Phse IIb tril, conducted by GSK nd Aers, is enrolling pulmonry TB-negtive, IGRA-positive, HIV-negtive dults in Keny, South Afric nd Zmbi. The primry end-point is the protective efficcy of two doses of M72/AS1E ginst pulmonry TB disese. Secondry end-points include sfety nd immunogenicity. H4:IC31 nd H56:IC31 The H4:IC31 nd H56:IC31vccines re protein subunits with djuvnts, initilly developed by the Sttens Serum Institute (SSI) in Copenhgen, Denmrk. H4:IC31 is being developed s booster vccine to BCG with Snofi Psteur. The vccine cndidte contins fusion protein of Ag85B nd TB1.4, formulted with the IC31 djuvnt. It is being tested in South Afric in Phse II pre-proof of concept TB prevention study mong IGRAnegtive, HIV-negtive dolescents t high risk of cquiring M. tuberculosis infection; n intensive immunogenicity study is lso being done in the sme popultion. H4:IC31 is lso being evluted in Phse I/II tril in infnts. H56:IC31 is n djuvnted subunit vccine tht combines three M. tuberculosis ntigens (Ag85B, ESAT-6 nd Rv266c) with Vlnev s IC31 djuvnt, developed by SSI nd Aers. A Phse I study to evlute its sfety nd immunogenicity in HIV-negtive dults with nd without LTBI nd with no history or evidence of TB disese hs been completed. Two Phse I trils hve been completed to determine the sfety nd immunogenicity profile of H56:IC31 in HIV-negtive, BCG-vccinted dults with nd without LTBI, nd in ptients who hve recently been treted for pulmonry TB disese. These Phse I trils demonstrted n cceptble sfety profile nd found the vccine to be immunogenic t ll doses studied. A Phse II tril including H4:IC31, H56:IC31 nd BCG in 84 dolescents is now under wy. VPM 12 VPM 12 is live recombinnt vccine tht ws originlly developed t the Mx Plnck Institute of Infection Biology, Germny, with further development by Vkzine Projekt Mngement, the Tuberculosis Vccine Inititive nd the Serum Institute of Indi. 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. A Phse III tril for prevention of TB disese in dults is plnned in Indi. RUTI RUTI is non-live nd polyntigenic vccine bsed on frgmented nd detoxified M. tuberculosis bcteri. It is being developed by Archivel Frm s n immunotherpeutic vccine, in conjunction with short intensive ntibiotic therpy. A Phse II tril in South Afric ws completed recently, nd other clinicl trils re in the plnning stges. DAR-91 booster The DAR-91 booster vccine is whole-cell, hetinctivted, non-tuberculous mycobcteril vccine, developed by Drtmouth nd Aers. It ws shown to be effective in Phse III tril in the United Republic of Tnzni mong people who were HIV-positive. A Phse I booster tril in the United Sttes of Americ mong BCG-primed dults with nd without HIV infection found tht it ws sfe nd well tolerted. With funding from GHIT-Jpn, 2-yer Phse II tril mong dolescents ws initited in April 216 in the United Republic of Tnzni. GLOBAL TUBERCULOSIS REPORT 216 :: 129

141 ID93 + GLA-SE The ID93 + GLA-SE vccine comprises three M. tuberculosis immune-dominnt ntigens (Rv268, Rv3619 nd Rv362), one M. tuberculosis ltency-ssocited ntigen (Rv1813), nd the djuvnt GLA-SE. It ws developed by the Infectious Disese Reserch Institute in collbortion with Aers. A Phse I tril in BCG-vccinted, QuntiFERON- TB-Gold negtive nd positive helthy dults hs been completed in South Afric. ID93 ntigen (2 mg or 1 mg) in combintion with GLA-SE djuvnt (2 mg or 5 mg), given s three doses, ws found to hve n cceptble sfety profile in BCG-vccinted helth dults (both QuntiFERON negtive nd QuntiFERON positive). Overll, significntly higher CD4+ responses were seen in ll three intervention rms when compred with plcebo. A Phse II tril in South Afric, with the support of the Wellcome Trust, is evluting sfety nd immunogenicity in HIV-nive TB ptients tht hve recently completed tretment for pulmonry TB disese. Vcce The Vcce vccine is specified lyste developed by the phrmceuticl compny Anhui Zhifei Longcom Biologic Phrmcy Co., Ltd. It 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. In collbortion with the Gungxi Center for Disese Control nd Prevention in Chin, Phse III tril is being implemented to ssess its efficcy nd sfety in preventing TB disese in people with LTBI. It is the lrgest TB vccine tril undertken in the pst decde, including 1 people ged yers with TST >15 mm. The tril ws scheduled to be completed by mid Phse I trils There re five vccines in Phse I trils. MTBVAC MTBVA is live M. tuberculosis strin ttenuted vi deletions of the phop nd fdd26 genes. It ws developed by the University of Zrgoz, Institut Psteur nd Biofbri, with the support of the TB Vccine Inititive (TBVI). The primry trget popultion is neontes (BCG replcement vccine), with secondry trget being dolescents nd dults (booster vccine). In September 215, MTBVAC moved into Phse Ib tril in infnts. Ad5 Ag85A Ad5 Ag85A is n denovirus serotype 5 vector expressing Ag85A, which hs been developed by McMster University with support from CnSino. It hs been evluted for sfety nd immunogenicity in 24 helthy humn volunteers (both BCG-nive nd previously BCG-immunized) in Cnd. Overll, it ws found to be sfe, well tolerted nd immunogenic in both tril groups, stimulting polyfunctionl T-cell responses. More potent immunogenicity ws observed in the previously BCG-vccinted volunteers. A sfety nd immunogenicity study of the erosol dministrtion of this vccine ws recently completed. TB/FLU-4 L TB/FLU-4 L is recombinnt influenz vectored vccine cndidte tht hs been developed by the Reserch Institute for Biologicl Sfety Problems nd the Reserch Institute on Influenz in the Russin Federtion. The influenz virus strin A/Puerto Rico/8/34 (H1N1) ws used s prent strin for construction of n ttenuted replictiondeficient vector expressing M. tuberculosis ntigens Ag85A nd ESAT-6. It ws designed s mucosl boost vccine for infnts, dolescents nd dults. A Phse I tril in BCGvccinted QuntiFERON-TB-Gold negtive helthy dult volunteers using intrnsl dministrtion ws recently completed, nd Phse II tril is plnned. ChAdOx1.85 A ChAdOx1.85 A is simin denovirus expressing ntigen 85 A, which ws developed t the University of Oxford to boost BCG induced protection. It is being evluted in Phse I tril in BCG-vccinted dults, both lone nd s prt of prime-boost strtegy with MVA85A. MVA85A (Aerosol) MVA85A (Aerosol) is n erosolized vccine MVA85A cndidte tht ws developed t the University of Oxford. Its sfety nd immunogenicity hs been tested in 24 BCGvccinted dults in the United Kingdom in Phse I tril. The tril demonstrted tht erosol vccintion with MVA85A ppers to be sfe nd fesible compred with intrderml MVA85A, nd produces stronger CD4+ T-cell response thn intrderml MVA85A. Further studies ssessing the erosol route re under wy in people with LTBI. 13 :: GLOBAL TUBERCULOSIS REPORT 216

142 Annex 1 Access to the WHO globl TB dtbse ::

143

144 A.1 Dtbse contents The 216 globl TB report is bsed on dt collected nnully from countries nd territories, including 194 Member Sttes. These dt re stored in the globl TB dtbse. In 216, 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 control; 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 lowincidence countries (defined s countries with n incidence rte of <2 cses per 1 popultion or <1 cses in totl). Countries reported dt using dedicted website ( which ws opened for reporting in erly April 216. Countries in the Europen Union submitted notifiction nd tretment outcomes dt 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 isonizid preventive therpy (IPT) to people living with HIV 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 15 August 216. The number of countries nd territories tht hd reported dt by 15 August 216 is shown in Tble A1.1. :: TABLE A1.1 Reporting of dt in the 216 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 Globl Countries tht did not report by the dedline were mostly low-incidence countries in Western Europe. A.2 Accessing TB dt using the WHO Globl TB Progrmme website You cn find most of the dt held in the globl TB dtbse by going to This web pge gives you 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 ondemnd 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 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. 1 GLOBAL TUBERCULOSIS REPORT 216 :: 133

145 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 (Figure A1.1). :: FIG. A1.1 Interctive pge to view MDR-TB indictors by region or country nd yer Dignosis, notifiction nd tretment of rifmpicin-resistnt TB (MDR/RR-TB) Notifiction nd enrolment on tretment Tretment outcomes for MDR/RR-TB Number of cses 3 2 yer yer % of cohort Notified MDR/RR-TB Strted on MDR-TB tretment Estimted MDR-TB mong notified pulmonry TB cses (with low nd high bounds) Tretment success Filure Lost to follow-up Not evluted Died Notified TB cses % new TB cses with drug susceptibility testing (DST) results % previously treted TB cses with DST results Notified MDR/RR-TB cses Ptients strted on MDR-TB tretment MDR/RR-TB cses in tretment outcome cohort Estimted MDR-TB mong notified pulmonry TB cses (best) 33 Estimted MDR-TB mong notified pulmonry TB cses (low bound) 16 Estimted MDR-TB mong notified pulmonry TB cses (high bound) 49 Outcomes for MDR-TB tretment re reported two yers fter the end of the yer of enrolment. Ptients my not necessrily hve been treted using interntionlly-recommended regimens or norms. % TB cses with 1st line DST exceeding 1% re shown s 1%; this my hppen if TB notifiction is incomplete especilly in systems where reporting of TB nd DST re not linked. Generted on 216-Aug-3 Source: 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. Key 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 (Figure A1.2). 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 216

146 :: FIG. A1.2 A dt tble in the GHO Dt Repository GLOBAL TUBERCULOSIS REPORT 216 :: 135

147

148 Annex 2 Country profiles :: FOR 3 HIGH-BURDEN COUNTRIES :: 2 high TB burden countries bsed on bsolute number of incident cses 1 high TB burden countries bsed on severity of disese burden (incidence per cpit)

149

150 Angol popultion 215 :: 25 million Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 11 (6.6 17) 45 (27 67) Mortlity (HIV+TB only) 7.2 (1.6 17) 29 (6.5 67) Incidence (includes HIV+TB) 93 (6 132) 37 (24 529) Incidence (HIV+TB only) 28 (17 41) 111 (68 165) Incidence (MDR/RR-TB) b 4.1 ( ) 16 (1.4 31) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 5.7 ( ) 34 (16 51) 4 (19 6) Mles 4.4 ( ) 49 (34 64) 53 (36 7) Totl 1 (6.6 14) 83 (63 12) 93 (6 132) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) TB cse notifictions, 215 Totl cses notified 61 6 Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 23% % pulmonry 93% % bcteriologiclly confirmed mong pulmonry 51% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (45 1) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.1.37) TB/HIV cre in new nd relpse TB ptients, 215 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy Drug-resistnt TB cre, 215 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 2 7 mong notified pulmonry TB cses (43 5 ) Estimted % of TB cses with MDR/RR-TB 2.8% (.1 6.7) 21% (2.2 39) % notified tested for rifmpicin resistnce 227 MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 227, XDR-TB: Ptients strted on tretment d MDR/RR-TB: 227, XDR-TB: Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence Incidence (HIV + TB only) Femles Mles Tretment success rte nd cohort size 1 Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses, ll types, registered in 214 MDR/RR-TB cses strted on second-line tretment in % 116 XDR-TB cses strted on second-line tretment in 213 TB preventive tretment, 215 % 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 TB finncing, 216 Ntionl TB budget (US$ millions) 22 Funding source 39% domestic, % interntionl, 61% unfunded 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 215 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from GLOBAL TUBERCULOSIS REPORT 216 :: 139

151 Bngldesh popultion 215 :: 161 million Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 73 (43 11) 45 (27 68) Mortlity (HIV+TB only).23 (.19.29).14 (.12.18) Incidence (includes HIV+TB) 362 ( ) 225 ( ) Incidence (HIV+TB only).63 (.39.94).39 (.24.59) Incidence (MDR/RR-TB) b 9.7 (5.4 14) 6 ( ) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 2 (9.9 31) 131 (62 2) 151 (72 231) Mles 17 (9.8 24) 194 ( ) 211 ( ) Totl 37 (23 51) 325 (247 43) 362 ( ) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus <1% % pulmonry 79% % bcteriologiclly confirmed mong pulmonry 72% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (4 88) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.11.37) TB/HIV cre in new nd relpse TB ptients, 215 Number (%) Ptients with known HIV-sttus who re HIV-positive c 92 16% on ntiretrovirl therpy 82 89% Drug-resistnt TB cre, 215 New cses Previously treted cses Totl number d Estimted MDR/RR-TB cses 5 1 mong notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 1.6% ( ) 29% (24 34) % notified tested for rifmpicin resistnce 5% 63% MDR/RR-TB cses tested for resistnce to second-line drugs 25 Lbortory-confirmed cses MDR/RR-TB: 954, XDR-TB: Ptients strted on tretment e MDR/RR-TB: 88, XDR-TB: Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence (HIV + TB only) Femles Mles Incidence Tretment success rte nd cohort size 1 Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses, ll types, registered in % 45 MDR/RR-TB cses strted on second-line tretment in % 686 XDR-TB cses strted on second-line tretment in 213 % 3 TB preventive tretment, 215 % 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 22% (2 24) TB finncing, 216 Ntionl TB budget (US$ millions) 52 Funding source 12% domestic, 87% interntionl, 1% unfunded 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. Estimtes of TB incidence nd mortlity will be reviewed once finl results from the 215/216 ntionl TB prevlence survey re vilble. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. Totl budget (US$ millions) c 17 HIV-positive cses were identified from 56 dignosed TB ptients considered t high risk for HIV co-infection nd 75 were known to be HIV-positive before being dignosed with TB. d Includes cses with unknown previous TB tretment history. e Includes ptients dignosed before 215 nd ptients who were not lbortory-confirmed Funded domesticlly Funded interntionlly Unfunded 14 :: GLOBAL TUBERCULOSIS REPORT 216 Dt for ll yers cn be downloded from

152 Brzil popultion 215 :: 28 million Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 5.5 ( ) 2.7 ( ) Mortlity (HIV+TB only) 2.2 ( ) 1.1 ( ) Incidence (includes HIV+TB) 84 (72 97) 41 (35 47) Incidence (HIV+TB only) 13 (11 15) 6.3 ( ) Incidence (MDR/RR-TB) b 2.3 ( ) 1.1 ( ) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 3.8 ( ) 24 (14 33) 28 (17 38) Mles 4.3 (3 5.6) 52 (41 64) 57 (44 69) Totl 8.1 (6.2 1) 76 (69 83) 84 (72 97) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 23% % with known HIV sttus 82% % pulmonry 87% % bcteriologiclly confirmed mong pulmonry 73% 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), (.7.11) TB/HIV cre in new nd relpse TB ptients, 215 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 215 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 1 9 mong notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 1.5% ( ) 8% (5.9 1) % notified tested for rifmpicin resistnce 26% 35% MDR/RR-TB cses tested for resistnce to second-line drugs 237 Lbortory-confirmed cses MDR/RR-TB: 1 197, XDR-TB: 14 Ptients strted on tretment d MDR/RR-TB: 619, XDR-TB: 29 Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence (HIV + TB only) Femles Mles Incidence Tretment success rte nd cohort size 1 Success Cohort New nd relpse 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 % 759 XDR-TB cses strted on second-line tretment in % 17 TB preventive tretment, 215 % 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 TB finncing, 216 Ntionl TB budget (US$ millions) 6 Funding source 77% domestic, <1% interntionl, 22% unfunded 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 215 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from GLOBAL TUBERCULOSIS REPORT 216 :: 141

153 Chin popultion 215 :: million Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 35 (34 37) 2.6 ( ) Mortlity (HIV+TB only) 2.6 ( ).19 (.9.33) Incidence (includes HIV+TB) 918 ( ) 67 (57 77) Incidence (HIV+TB only) 15 (12 19) 1.1 ( ) Incidence (MDR/RR-TB) b 7 (55 84) 5.1 (4 6.1) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 37 (23 52) 258 ( ) 296 ( ) Mles 38 (26 49) 585 ( ) 622 (485 76) Totl 75 (58 92) 843 ( ) 918 ( ) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 47% % pulmonry 96% % 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), (.4.5) TB/HIV cre in new nd relpse TB ptients, 215 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 215 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 57 mong notified pulmonry TB cses (48 67 ) Estimted % of TB cses with MDR/RR-TB 6.6% ( ) 3% (25 34) % notified tested for rifmpicin resistnce 8% % MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 9 662, XDR-TB: 357 Ptients strted on tretment d MDR/RR-TB: 5 691, XDR-TB: 122 Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence (HIV + TB only) Femles Mles Incidence 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, ll types, registered in % MDR/RR-TB cses strted on second-line tretment in % XDR-TB cses strted on second-line tretment in % 159 TB preventive tretment, 215 % 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 TB finncing, 216 Ntionl TB budget (US$ millions) 372 Funding source 97% domestic, 2% interntionl, 1% unfunded Tretment success rte (%) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB 4 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 215 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded 142 :: GLOBAL TUBERCULOSIS REPORT 216 Dt for ll yers cn be downloded from

154 Democrtic People s Republic of Kore popultion 215 :: 25 million Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 15 (1 22) 61 (4 87) Mortlity (HIV+TB only).37 (.16.65).15 (.7.26) Incidence (includes HIV+TB) 141 (19 178) 561 (432 76) Incidence (HIV+TB only).45 (.32.6) 1.8 ( ) Incidence (MDR/RR-TB) b 6 ( ) 24 (14 34) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 4.9 (2 7.8) 49 (3 69) 54 (32 76) Mles 6 ( ) 81 (61 11) 87 (65 19) Totl 11 (7.4 14) 13 ( ) 141 (19 178) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus % % pulmonry 82% % bcteriologiclly confirmed mong pulmonry 5% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), 215 8% (64 1) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.7.17) TB/HIV cre in new nd relpse TB ptients, 215 Ptients with known HIV-sttus who re HIV-positive on ntiretrovirl therpy Drug-resistnt TB cre, 215 Number (%) New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 4 6 mong notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 2.2% ( ) 16% (8.4 24) % notified tested for rifmpicin resistnce % 2% 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: 125, XDR-TB: Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence (HIV + TB only) Femles Mles Incidence Tretment success rte nd cohort size 1 Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses, ll types, registered in 214 MDR/RR-TB cses strted on second-line tretment in % 17 XDR-TB cses strted on second-line tretment in 213 TB preventive tretment, 215 % 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 TB finncing, 216 Ntionl TB budget (US$ millions) 3 Funding source 19% domestic, 27% interntionl, 54% unfunded 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 215 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from GLOBAL TUBERCULOSIS REPORT 216 :: 143

155 Democrtic Republic of the Congo popultion 215 :: 77 million Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 51 (3 77) 66 (39 99) Mortlity (HIV+TB only) 16 (13 2) 21 (17 26) Incidence (includes HIV+TB) 25 ( ) 324 (21 463) Incidence (HIV+TB only) 39 (23 57) 5 (3 74) Incidence (MDR/RR-TB) b 1 (4.6 15) 13 (6 19) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 18 (8.8 27) 91 (43 139) 19 (52 165) Mles 15 (9 21) 126 (86 167) 142 (95 188) Totl 33 (21 45) 217 ( ) 25 ( ) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 1% % with known HIV sttus 5% % pulmonry 82% % bcteriologiclly confirmed mong pulmonry 83% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (33 74) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.16.46) TB/HIV cre in new nd relpse TB ptients, 215 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 215 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 4 mong notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 3.2% (1.4 5) 14% (6.9 21) % notified tested for rifmpicin resistnce 2% 76% 9 28 MDR/RR-TB cses tested for resistnce to second-line drugs 6 Lbortory-confirmed cses MDR/RR-TB: 499, XDR-TB: 4 Ptients strted on tretment d MDR/RR-TB: 413, XDR-TB: Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence (HIV + TB only) Femles Mles Incidence Tretment success rte nd cohort size 1 Success Cohort New cses registered in % Previously treted cses registered in % 1 99 HIV-positive TB cses, ll types, registered in 214 MDR/RR-TB cses strted on second-line tretment in % 268 XDR-TB cses strted on second-line tretment in 213 TB preventive tretment, 215 % 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 TB finncing, 216 Ntionl TB budget (US$ millions) 6 Funding source 3% domestic, 6% interntionl, 37% unfunded Tretment success rte (%) New cses Previously treted cses 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 215 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded 144 :: GLOBAL TUBERCULOSIS REPORT 216 Dt for ll yers cn be downloded from

156 Ethiopi Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 25 (15 38) 26 (15 38) Mortlity (HIV+TB only) 3.9 ( ) 4 ( ) Incidence (includes HIV+TB) 191 ( ) 192 (142 25) Incidence (HIV+TB only) 16 (1 23) 16 (1 23) Incidence (MDR/RR-TB) b 6.2 ( ) 6.2 (3.5 9) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 7.3 (2.2 12) 77 (5 15) 85 (52 117) Mles 11 (6.9 15) 95 (7 12) 16 (77 136) Totl 18 (12 24) 173 (143 23) 191 ( ) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) popultion 215 :: 99 million TB cse notifictions, 215 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 6% % with known HIV sttus 77% % pulmonry 7% % bcteriologiclly confirmed mong pulmonry 54% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (55 96) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.9.25) TB/HIV cre in new nd relpse TB ptients, 215 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 215 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 3 3 mong notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 2.7% (1.5 4) 14% (5.6 23) % notified tested for rifmpicin resistnce 9% 75% MDR/RR-TB cses tested for resistnce to second-line drugs 113 Lbortory-confirmed cses MDR/RR-TB: 597, XDR-TB: 2 Ptients strted on tretment d MDR/RR-TB: 597, XDR-TB: 2 Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence (HIV + TB only) Femles Mles Incidence Tretment success rte nd cohort size 1 Success Cohort New cses registered in % Previously treted cses registered in 214 HIV-positive TB cses, ll types, registered in 214 MDR/RR-TB cses strted on second-line tretment in % 397 XDR-TB cses strted on second-line tretment in 213 TB preventive tretment, 215 % of HIV-positive people (newly enrolled in cre) on preventive tretment 47% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment TB finncing, 216 Ntionl TB budget (US$ millions) 81 Funding source 11% domestic, 51% interntionl, 38% unfunded Tretment success rte (%) New cses Previously treted cses 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 215 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from GLOBAL TUBERCULOSIS REPORT 216 :: 145

157 Indi popultion 215 :: million Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 48 (38 59) 36 (29 45) Mortlity (HIV+TB only) 37 (21 57) 2.8 ( ) Incidence (includes HIV+TB) 2 84 ( ) 217 ( ) Incidence (HIV+TB only) 113 (58 186) 8.6 (4.4 14) Incidence (MDR/RR-TB) b 13 (88 18) 9.9 (6.7 14) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 136 (78 193) 86 ( ) 995 ( ) Mles 119 (78 161) 1 73 ( ) 1 85 ( ) Totl 255 ( ) 2 59 ( ) 2 84 ( ) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 67% % pulmonry 82% % bcteriologiclly confirmed mong pulmonry 64% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (36 11) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.11.36) TB/HIV cre in new nd relpse TB ptients, 215 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 215 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 79 mong notified pulmonry TB cses (72 87 ) Estimted % of TB cses with MDR/RR-TB 2.5% ( ) 16% (14 18) % notified tested for rifmpicin resistnce 6% 6% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: , XDR-TB: 3 48 Ptients strted on tretment d MDR/RR-TB: , XDR-TB: 2 13 Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence (HIV + TB only) Femles Mles Incidence Tretment success rte nd cohort size 1 Success Cohort New nd relpse 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 % 248 TB preventive tretment, 215 % 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 TB finncing, 216 Ntionl TB budget (US$ millions) 28 Funding source 38% domestic, 62% interntionl, % unfunded 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. Estimtes of TB incidence nd mortlity re interim in nture, pending results from the ntionl TB prevlence survey plnned for 217/218. 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 215 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded 146 :: GLOBAL TUBERCULOSIS REPORT 216 Dt for ll yers cn be downloded from

158 Indonesi popultion 215 :: 258 million Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 1 (67 15) 4 (26 57) Mortlity (HIV+TB only) 26 (2 34) 1 (7.6 13) Incidence (includes HIV+TB) 1 2 ( ) 395 ( ) Incidence (HIV+TB only) 78 (48 116) 3 (18 45) Incidence (MDR/RR-TB) b 32 (19 45) 12 (7.4 17) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 36 (16 57) 384 ( ) 42 (21 63) Mles 39 (23 54) 559 ( ) 597 (415 78) Totl 75 (49 1) 942 ( ) 1 2 ( ) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 11% % pulmonry 93% % bcteriologiclly confirmed mong pulmonry 64% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (23 5) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.8.21) TB/HIV cre in new nd relpse TB ptients, 215 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 215 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 1 mong notified pulmonry TB cses (8 12 ) Estimted % of TB cses with MDR/RR-TB 2.8% ( ) 16% (1 2) % notified tested for rifmpicin resistnce <1% 8% MDR/RR-TB cses tested for resistnce to second-line drugs 895 Lbortory-confirmed cses MDR/RR-TB: 2 135, XDR-TB: 28 Ptients strted on tretment d MDR/RR-TB: 1 519, XDR-TB: 22 Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence (HIV + TB only) Femles Mles Incidence Tretment success rte nd cohort size 1 Success Cohort New nd relpse 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 % 89 XDR-TB cses strted on second-line tretment in 213 4% 1 TB preventive tretment, 215 % 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 TB finncing, 216 e 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 215 nd ptients who were not lbortory-confirmed. e Finnce dt re not shown becuse the government of Indonesi is currently reviewing contributions from domestic sources. Dt for ll yers cn be downloded from GLOBAL TUBERCULOSIS REPORT 216 :: 147

159 Keny popultion 215 :: 46 million Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 9 (6.1 12) 2 (13 27) Mortlity (HIV+TB only) 7.2 (.71 21) 16 (1.5 45) Incidence (includes HIV+TB) 17 (87 129) 233 ( ) Incidence (HIV+TB only) 36 (29 43) 78 (63 94) Incidence (MDR/RR-TB) b 2 ( ) 4.3 ( ) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 6.1 ( ) 35 (22 48) 41 (26 57) Mles 6.8 (4.6 9) 59 (45 73) 66 (5 82) Totl 13 (9.6 16) 94 (82 16) 17 (87 129) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 1% % with known HIV sttus 97% % pulmonry 82% % bcteriologiclly confirmed mong pulmonry 59% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (63 93) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.7.28) TB/HIV cre in new nd relpse TB ptients, 215 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 215 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 1 4 mong notified pulmonry TB cses (98 1 7) Estimted % of TB cses with MDR/RR-TB 1.3% ( ) 9.4% (8.7 1) % notified tested for rifmpicin resistnce 8% 29% MDR/RR-TB cses tested for resistnce to second-line drugs 22 Lbortory-confirmed cses MDR/RR-TB: 368, XDR-TB: 1 Ptients strted on tretment d MDR/RR-TB: 368, XDR-TB: Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence (HIV + TB only) Femles Mles Incidence Tretment success rte nd cohort size 1 Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % 227 HIV-positive TB cses, ll types, registered in % 3 17 MDR/RR-TB cses strted on second-line tretment in % 266 XDR-TB cses strted on second-line tretment in 213 % 1 TB preventive tretment, 215 % of HIV-positive people (newly enrolled in cre) on preventive tretment 33% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 5.5% (5 6) TB finncing, 216 Ntionl TB budget (US$ millions) 59 Funding source 2% domestic, 8% interntionl, % unfunded 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 215 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded 148 :: GLOBAL TUBERCULOSIS REPORT 216 Dt for ll yers cn be downloded from

160 Mozmbique popultion 215 :: 28 million Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 21 (12 32) 74 (43 115) Mortlity (HIV+TB only) 34 (21 5) 12 (73 178) Incidence (includes HIV+TB) 154 (1 22) 551 ( ) Incidence (HIV+TB only) 79 (5 115) 284 ( ) Incidence (MDR/RR-TB) b 7.3 (4.1 1) 26 (15 36) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 7.4 (3 12) 56 (27 86) 64 (3 98) Mles 7.4 (4.2 11) 83 (57 18) 9 (62 119) Totl 15 (9.2 2) 139 (16 172) 154 (1 22) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 7% % with known HIV sttus 99% % pulmonry 89% % bcteriologiclly confirmed mong pulmonry 5% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (27 59) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.21.6) TB/HIV cre in new nd relpse TB ptients, 215 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 215 New cses Previously treted cses Totl number Estimted MDR/RR-TB cses 2 8 mong notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 3.7% (2.4 5) 2% (1.9 37) % notified tested for rifmpicin resistnce 17% 31% MDR/RR-TB cses tested for resistnce to second-line drugs 195 Lbortory-confirmed cses MDR/RR-TB: 646, XDR-TB: 29 Ptients strted on tretment d MDR/RR-TB: 646, XDR-TB: 16 Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence Incidence (HIV + TB only) Femles Mles Tretment success rte nd cohort size 1 Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses, ll types, registered in 214 MDR/RR-TB cses strted on second-line tretment in % 313 XDR-TB cses strted on second-line tretment in 213 TB preventive tretment, 215 % of HIV-positive people (newly enrolled in cre) on preventive tretment 45% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment TB finncing, 216 Ntionl TB budget (US$ millions) 24 Funding source 4% domestic, 72% interntionl, 24% unfunded 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 215 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from GLOBAL TUBERCULOSIS REPORT 216 :: 149

161 Mynmr popultion 215 :: 54 million Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 27 (16 4) 49 (3 74) Mortlity (HIV+TB only) 4.8 ( ) 9 (6.4 12) Incidence (includes HIV+TB) 197 ( ) 365 ( ) Incidence (HIV+TB only) 17 (11 25) 32 (21 47) Incidence (MDR/RR-TB) b 14 (8.9 18) 26 (17 33) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 6 ( ) 66 (35 97) 72 (38 16) Mles 7.7 (4.8 11) 117 (87 147) 125 (92 158) Totl 14 (9.4 18) 183 ( ) 197 ( ) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) TB cse notifictions, 215 Totl cses notified 14 7 Totl new nd relpse % tested with rpid dignostics t time of dignosis 22% % with known HIV sttus 65% % pulmonry 88% % bcteriologiclly confirmed mong pulmonry 39% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), 215 7% (54 96) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.1.26) TB/HIV cre in new nd relpse TB ptients, 215 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 215 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 9 mong notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 5.1% (3.2 7) 27% (15 39) % notified tested for rifmpicin resistnce 7% 46% MDR/RR-TB cses tested for resistnce to second-line drugs 43 Lbortory-confirmed cses MDR/RR-TB: 2 793, XDR-TB: 11 Ptients strted on tretment d MDR/RR-TB: 2 27, XDR-TB: 7 Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence (HIV + TB only) Femles Mles Incidence Tretment success rte nd cohort size 1 Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses, ll types, registered in 214 7% MDR/RR-TB cses strted on second-line tretment in % 667 XDR-TB cses strted on second-line tretment in 213 TB preventive tretment, 215 % of HIV-positive people (newly enrolled in cre) on preventive tretment 1% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 3.6% ( ) TB finncing, 216 Ntionl TB budget (US$ millions) 69 Funding source 21% domestic, 52% interntionl, 28% unfunded 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 215 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded 15 :: GLOBAL TUBERCULOSIS REPORT 216 Dt for ll yers cn be downloded from

162 Nigeri popultion 215 :: 182 million Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 18 (96 29) 99 (53 16) Mortlity (HIV+TB only) 57 (43 74) 31 (24 4) Incidence (includes HIV+TB) 586 (345 89) 322 ( ) Incidence (HIV+TB only) 1 (56 155) 55 (31 85) Incidence (MDR/RR-TB) b 29 (15 43) 16 (8.2 24) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 33 (14 52) 198 (67 328) 231 (82 38) Mles 34 (2 47) 322 (21 434) 355 ( ) Totl 67 (43 91) 519 ( ) 586 (345 89) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 58% % with known HIV sttus 1% % pulmonry 94% % bcteriologiclly confirmed mong pulmonry 68% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (9.8 25) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.22.77) TB/HIV cre in new nd relpse TB ptients, 215 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 215 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 4 7 mong notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 4.3% ( ) 25% (19 31) % notified tested for rifmpicin resistnce 4% 64% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 1 241, XDR-TB: 1 Ptients strted on tretment d MDR/RR-TB: 656, XDR-TB: 1 Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence (HIV + TB only) Incidence Femles Mles Tretment success rte nd cohort size 1 Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % 4 89 HIV-positive TB cses, ll types, registered in % MDR/RR-TB cses strted on second-line tretment in % 339 XDR-TB cses strted on second-line tretment in 213 % 2 TB preventive tretment, 215 % 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 16% (15 18) TB finncing, 216 Ntionl TB budget (US$ millions) 257 Funding source 12% domestic, 33% interntionl, 55% unfunded 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 215 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from GLOBAL TUBERCULOSIS REPORT 216 :: 151

163 Pkistn popultion 215 :: 189 million Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 44 (9.3 11) 23 (4.9 56) Mortlity (HIV+TB only) 1.6 ( ).83 (.6 1.1) Incidence (includes HIV+TB) 51 (33 729) 27 ( ) Incidence (HIV+TB only) 8.8 (5.4 13) 4.6 ( ) Incidence (MDR/RR-TB) b 26 (16 36) 14 (8.5 19) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 25 (12 37) 231 (141 32) 255 ( ) Mles 21 (13 29) 234 (163 35) 255 ( ) Totl 46 (3 61) 465 ( ) 51 (33 729) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 4% % pulmonry 81% % bcteriologiclly confirmed mong pulmonry 51% 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), (.2.23) TB/HIV cre in new nd relpse TB ptients, 215 Number (%) Ptients with known HIV-sttus who re HIV-positive 59 <1% on ntiretrovirl therpy 59 1% Drug-resistnt TB cre, 215 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 14 mong notified pulmonry TB cses (11 16 ) Estimted % of TB cses with MDR/RR-TB 4.2% ( ) 16% (15 17) % notified tested for rifmpicin resistnce 1% 84% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 3 59, XDR-TB: 99 Ptients strted on tretment d MDR/RR-TB: 2 553, XDR-TB: 68 Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence (HIV + TB only) Femles Mles Incidence Tretment success rte nd cohort size 1 Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % 8 5 HIV-positive TB cses, ll types, registered in 214 MDR/RR-TB cses strted on second-line tretment in % XDR-TB cses strted on second-line tretment in 213 3% 64 TB preventive tretment, 215 % 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 TB finncing, 216 Ntionl TB budget (US$ millions) 62 Funding source <1% domestic, 65% interntionl, 35% unfunded 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 215 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded 152 :: GLOBAL TUBERCULOSIS REPORT 216 Dt for ll yers cn be downloded from

164 Philippines popultion 215 :: 11 million Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 14 (8.8 19) 13 (8.7 19) Mortlity (HIV+TB only).44 (.24.7).44 (.24.7) Incidence (includes HIV+TB) 324 ( ) 322 (277 37) Incidence (HIV+TB only) 4.3 ( ) 4.3 ( ) Incidence (MDR/RR-TB) b 17 (14 2) 17 (14 2) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 14 (6.4 22) 1 (64 135) 114 (71 156) Mles 17 (11 23) 194 ( ) 211 ( ) Totl 31 (22 4) 294 ( ) 324 ( ) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 2% % with known HIV sttus 13% % pulmonry 97% % bcteriologiclly confirmed mong pulmonry 36% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (74 99) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.3.6) TB/HIV cre in new nd relpse TB ptients, 215 Number (%) Ptients with known HIV-sttus who re HIV-positive 255 <1% on ntiretrovirl therpy 178 7% Drug-resistnt TB cre, 215 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 15 mong notified pulmonry TB cses (12 18 ) Estimted % of TB cses with MDR/RR-TB 2.6% ( ) 29% (21 38) % notified tested for rifmpicin resistnce 1% 45% MDR/RR-TB cses tested for resistnce to second-line drugs 414 Lbortory-confirmed cses MDR/RR-TB: 3 788, XDR-TB: 2 Ptients strted on tretment d MDR/RR-TB: 4 142, XDR-TB: 12 Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence (HIV + TB only) Femles Mles Incidence Tretment success rte nd cohort size 1 Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % 6 62 HIV-positive TB cses, ll types, registered in % 174 MDR/RR-TB cses strted on second-line tretment in % XDR-TB cses strted on second-line tretment in 213 5% 6 TB preventive tretment, 215 % of HIV-positive people (newly enrolled in cre) on preventive tretment 43% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 14% (13 16) TB finncing, 216 Ntionl TB budget (US$ millions) 14 Funding source 21% domestic, 41% interntionl, 38% unfunded Tretment success rte (%) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB 15 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 215 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from GLOBAL TUBERCULOSIS REPORT 216 :: 153

165 Russin Federtion popultion 215 :: 143 million Estimtes of TB burden, b 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 15 (15 16) 11 (1 11) Mortlity (HIV+TB only) 1.5 (<.1 7.4) 1 ( 5.2) Incidence (includes HIV+TB) 115 (98 132) 8 (69 92) Incidence (HIV+TB only) 11 (9.3 13) 7.9 ( ) Incidence (MDR/RR-TB) c 6 (49 71) 42 (34 49) Estimted TB incidence by ge nd sex (thousnds), b yers > 14 yers Totl Femles 4.6 ( ) 31 (19 44) 36 (21 5) Mles 4.4 (3 5.8) 74 (58 9) 79 (61 96) Totl 9 (6.8 11) 16 (96 115) 115 (98 132) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus d % pulmonry 93% % bcteriologiclly confirmed mong pulmonry 49% 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), (.11.19) TB/HIV cre in new nd relpse TB ptients, 215 Ptients with known HIV-sttus who re HIV-positive 6 47 on ntiretrovirl therpy Drug-resistnt TB cre, 215 Number (%) New cses Previously treted cses Totl number e Estimted MDR/RR-TB cses 42 mong notified pulmonry TB cses (35 48 ) Estimted % of TB cses with MDR/RR-TB 22% (14 25) 53% (4 59) % notified tested for rifmpicin resistnce 38% 31% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: , XDR-TB: Ptients strted on tretment f MDR/RR-TB: , XDR-TB: 1 25 Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence (HIV + TB only) Femles Mles Incidence Tretment success rte nd cohort size 1 Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % 5 79 HIV-positive TB cses, ll types, registered in 214 MDR/RR-TB cses strted on second-line tretment in % XDR-TB cses strted on second-line tretment in % TB preventive tretment, 215 % 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 TB finncing, g 216 Ntionl TB budget (US$ millions) Funding source 1% domestic, % interntionl, % unfunded 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. 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 The reported number of TB ptients with known HIV sttus is for new TB ptients in the civilin sector only. It ws not possible to clculte the percentge of ll TB ptients with known HIV sttus. e Includes cses with unknown previous TB tretment history. Totl budget (US$ millions) f Includes ptients dignosed before 215 nd ptients who were not lbortory-confirmed. g The decline in finncing between 215 nd 216 in terms of US dollrs reflects chnge in the US Dollr Rouble exchnge rte. However, the domestic price regultion system ensures tht the level nd qulity of TB cre is mintined Funded domesticlly Funded interntionlly Unfunded 154 :: GLOBAL TUBERCULOSIS REPORT 216 Dt for ll yers cn be downloded from

166 South Afric popultion 215 :: 54 million Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 25 (21 29) 46 (39 53) Mortlity (HIV+TB only) 73 (27 14) 133 (5 256) Incidence (includes HIV+TB) 454 ( ) 834 ( ) Incidence (HIV+TB only) 258 (165 37) 473 (33 68) Incidence (MDR/RR-TB) b 2 (13 27) 37 (24 5) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 16 (6.9 25) 175 (91 26) 191 (98 285) Mles 17 (9.8 23) 246 (173 32) 263 ( ) Totl 33 (21 44) 422 ( ) 454 ( ) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 64% % with known HIV sttus 97% % pulmonry 9% % bcteriologiclly confirmed mong pulmonry 6% 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), (.1.42) TB/HIV cre in new nd relpse TB ptients, 215 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 215 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 1 mong notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 3.5% ( ) 7.1% ( ) % notified tested for rifmpicin resistnce 65% 71% MDR/RR-TB cses tested for resistnce to second-line drugs 7 42 Lbortory-confirmed cses MDR/RR-TB: , XDR-TB: 1 24 Ptients strted on tretment d MDR/RR-TB: , XDR-TB: 73 Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence (HIV + TB only) Femles Mles Incidence Tretment success rte nd cohort size 1 Success Cohort New nd relpse 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 % 611 TB preventive tretment, 215 % 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 TB finncing, 216 Ntionl TB budget (US$ millions) 425 Funding source 87% domestic, 8% interntionl, 5% unfunded 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 215 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from GLOBAL TUBERCULOSIS REPORT 216 :: 155

167 Thilnd popultion 215 :: 68 million Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 8.4 (6.9 1) 12 (1 15) Mortlity (HIV+TB only) 5.4 ( ) 8 (4.9 12) Incidence (includes HIV+TB) 117 (69 176) 172 (12 259) Incidence (HIV+TB only) 15 (8 25) 22 (12 37) Incidence (MDR/RR-TB) b 4.5 ( ) 6.6 ( ) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 3.9 ( ) 32 (5.2 58) 36 (7.3 64) Mles 2.7 ( ) 78 (53 13) 81 (55 17) Totl 6.6 (4.1 9) 11 (82 138) 117 (69 176) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 98% % pulmonry 84% % bcteriologiclly confirmed mong pulmonry 64% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (35 89) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.7.21) TB/HIV cre in new nd relpse TB ptients, 215 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 215 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 2 5 mong notified pulmonry TB cses (2 3 ) Estimted % of TB cses with MDR/RR-TB 2.2% ( ) 24% (18 3) % notified tested for rifmpicin resistnce 1% 3% 7 97 MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 466, XDR-TB: 5 Ptients strted on tretment d MDR/RR-TB: 56, XDR-TB: 5 Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence (HIV + TB only) Incidence Femles Mles Tretment success rte nd cohort size 1 Success Cohort New nd relpse cses registered in 214 8% 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 213 XDR-TB cses strted on second-line tretment in 213 TB preventive tretment, 215 % 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 TB finncing, 216 Ntionl TB budget (US$ millions) 31 Funding source 36% domestic, 1% interntionl, 54% unfunded 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 215 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded 156 :: GLOBAL TUBERCULOSIS REPORT 216 Dt for ll yers cn be downloded from

168 United Republic of Tnzni popultion 215 :: 53 million Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 3 (13 53) 56 (25 99) Mortlity (HIV+TB only) 25 (16 35) 47 (31 66) Incidence (includes HIV+TB) 164 (78 281) 36 ( ) Incidence (HIV+TB only) 57 (27 1) 17 (5 186) Incidence (MDR/RR-TB) b 2.6 ( ) 4.9 (1 8.8) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 8.4 (2.9 14) 56 (9.2 12) 64 (12 116) Mles 9.5 (5.4 14) 9 (52 129) 1 (57 142) Totl 18 (11 25) 146 (91 21) 164 (78 281) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 93% % pulmonry 79% % bcteriologiclly confirmed mong pulmonry 53% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (22 78) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.17.76) TB/HIV cre in new nd relpse TB ptients, 215 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 215 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 73 mong notified pulmonry TB cses (32 1 1) Estimted % of TB cses with MDR/RR-TB 1.3% ( ) 4.7% (.37 9) % notified tested for rifmpicin resistnce <1% 3% 692 MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 178, XDR-TB: Ptients strted on tretment d MDR/RR-TB: 123, XDR-TB: Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence (HIV + TB only) Femles Mles Incidence Tretment success rte nd cohort size 1 Success Cohort New nd relpse cses registered in 214 9% 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 % 92 XDR-TB cses strted on second-line tretment in 213 TB preventive tretment, 215 % 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 6.9% ( ) TB finncing, 216 Ntionl TB budget (US$ millions) 4 Funding source 5% domestic, 4% interntionl, 55% unfunded 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. The min direct mesurement of TB disese burden is the 212 ntionl TB prevlence survey. Lbortory chllenges during the survey ment tht the prevlence of bcteriologiclly confirmed pulmonry TB could only be estimted with considerble uncertinty. This explins why estimtes of TB incidence nd mortlity, which re informed by the prevlence survey, lso hve wide uncertinty intervls. A review of estimtes of TB disese burden nd how to improve their precision will be undertken in erly 217. 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 215 nd ptients who were not lbortory-confirmed. e Funding sources for 215 were not reported. Totl budget (US$ millions) e 216 Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from GLOBAL TUBERCULOSIS REPORT 216 :: 157

169 Viet Nm popultion 215 :: 93 million Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 16 (11 22) 17 (12 23) Mortlity (HIV+TB only) 1.1 (.2 2.7) 1.1 ( ) Incidence (includes HIV+TB) 128 (13 155) 137 (11 166) Incidence (HIV+TB only) 5.5 ( ) 5.9 ( ) Incidence (MDR/RR-TB) b 7.3 ( ) 7.8 (5.6 1) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 5.5 ( ) 28 (1 46) 34 (13 54) Mles 5.8 (3.6 8) 88 (67 19) 94 (71 117) Totl 11 (7.7 15) 116 (11 131) 128 (13 155) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) TB cse notifictions, 215 Totl cses notified Totl new nd relpse 1 78 % tested with rpid dignostics t time of dignosis 11% % with known HIV sttus 79% % pulmonry 82% % bcteriologiclly confirmed mong pulmonry 69% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (65 98) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.9.19) TB/HIV cre in new nd relpse TB ptients, 215 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 215 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 5 2 mong notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 4.1% ( ) 25% (24 26) % notified tested for rifmpicin resistnce 8% 1% MDR/RR-TB cses tested for resistnce to second-line drugs 15 Lbortory-confirmed cses MDR/RR-TB: 2 62, XDR-TB: 28 Ptients strted on tretment d MDR/RR-TB: 2 131, XDR-TB: 3 Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence (HIV + TB only) Femles Mles Incidence Tretment success rte nd cohort size 1 Success Cohort New nd relpse 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 % 959 XDR-TB cses strted on second-line tretment in 213 TB preventive tretment, 215 % 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 TB finncing, % (1 12) Ntionl TB budget (US$ millions) 71 Funding source 9% domestic, 22% interntionl, 69% unfunded 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 215 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded 158 :: GLOBAL TUBERCULOSIS REPORT 216 Dt for ll yers cn be downloded from

170

171 Cmbodi popultion 215 :: 16 million Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 8.6 (6.1 12) 55 (39 74) Mortlity (HIV+TB only).44 (.19.79) 2.8 (1.2 5) Incidence (includes HIV+TB) 59 (38 85) 38 ( ) Incidence (HIV+TB only) 1.4 ( ) 9.2 (5.9 13) Incidence (MDR/RR-TB) b 1.3 ( ) 8.3 (3.8 13) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 2.6 (.9 4.4) 26 (15 36) 28 (16 41) Mles 3.5 ( ) 27 (19 36) 31 (21 41) Totl 6.1 (4 8.2) 53 (4 66) 59 (38 85) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 84% % pulmonry 63% % bcteriologiclly confirmed mong pulmonry 48% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (42 92) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.9.26) TB/HIV cre in new nd relpse TB ptients, 215 Number (%) Ptients with known HIV-sttus who re HIV-positive 74 3% on ntiretrovirl therpy 68 92% Drug-resistnt TB cre, 215 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 57 mong notified pulmonry TB cses (29 84) Estimted % of TB cses with MDR/RR-TB 1.8% ( ) 11% (1.4 2) % notified tested for rifmpicin resistnce <1% 8% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 77, XDR-TB: Ptients strted on tretment d MDR/RR-TB: 75, XDR-TB: Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence (HIV + TB only) Femles Mles Incidence Tretment success rte nd cohort size 1 Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in 214 HIV-positive TB cses, ll types, registered in 214 MDR/RR-TB cses strted on second-line tretment in % 121 XDR-TB cses strted on second-line tretment in 213 TB preventive tretment, 215 % of HIV-positive people (newly enrolled in cre) on preventive tretment 25% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 14% (13 16) TB finncing, 216 Ntionl TB budget (US$ millions) 29 Funding source 8% domestic, 37% interntionl, 55% unfunded 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 215 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded 16 :: GLOBAL TUBERCULOSIS REPORT 216 Dt for ll yers cn be downloded from

172 Centrl Africn Republic popultion 215 :: 4.9 million Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 2.2 ( ) 45 (26 7) Mortlity (HIV+TB only) 2.7 (1 5.3) 55 (2 17) Incidence (includes HIV+TB) 19 (12 27) 391 ( ) Incidence (HIV+TB only) 8.6 (5.3 13) 176 (17 262) Incidence (MDR/RR-TB) b.21 (.45) 4.3 ( 9.2) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 1.3 ( ) 7.2 (3.6 11) 8.4 (4.2 13) Mles 1 ( ) 9.7 (6.6 13) 11 (7.2 14) Totl 2.3 ( ) 17 (13 21) 19 (12 27) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 1% % with known HIV sttus 48% % pulmonry 82% % bcteriologiclly confirmed mong pulmonry 61% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (38 84) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.13.48) TB/HIV cre in new nd relpse TB ptients, 215 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy Drug-resistnt TB cre, 215 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 14 mong notified pulmonry TB cses (23 25) Estimted % of TB cses with MDR/RR-TB.4% ( 1.6) 14% (6.9 21) % notified tested for rifmpicin resistnce <1% 14% 15 MDR/RR-TB cses tested for resistnce to second-line drugs 38 Lbortory-confirmed cses MDR/RR-TB: 62, XDR-TB: 2 Ptients strted on tretment d MDR/RR-TB: 38, XDR-TB: Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence (HIV + TB only) Femles Mles Incidence Tretment success rte nd cohort size 1 Success Cohort New cses registered in 214 7% 9 29 Previously treted cses registered in % 476 HIV-positive TB cses, ll types, registered in % 2 56 MDR/RR-TB cses strted on second-line tretment in % 16 XDR-TB cses strted on second-line tretment in 213 TB preventive tretment, 215 % 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 TB finncing, 216 Ntionl TB budget (US$ millions) 1.8 Funding source 15% domestic, 55% interntionl, 31% unfunded Tretment success rte (%) New cses Previously treted cses 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 215 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from GLOBAL TUBERCULOSIS REPORT 216 :: 161

173 Congo popultion 215 :: 4.6 million Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 2.3 ( ) 49 (29 75) Mortlity (HIV+TB only) 2.4 (2 2.9) 53 (44 63) Incidence (includes HIV+TB) 18 (11 25) 379 ( ) Incidence (HIV+TB only) 6.4 ( ) 138 (84 25) Incidence (MDR/RR-TB) b.67 (.29 1) 15 (6.3 22) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 1 (.5 1.5) 6.9 (3.6 1) 7.9 (4.1 12) Mles.92 ( ) 8.7 (6 11) 9.6 (6.5 13) Totl 1.9 ( ) 16 (12 19) 18 (11 25) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 3% % with known HIV sttus 13% % pulmonry 75% % bcteriologiclly confirmed mong pulmonry 51% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (4 88) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.17.44) TB/HIV cre in new nd relpse TB ptients, 215 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 215 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 3 mong notified pulmonry TB cses (16 43) Estimted % of TB cses with MDR/RR-TB 3.2% (1.4 5) 14% (6.9 21) % notified tested for rifmpicin resistnce MDR/RR-TB cses tested for resistnce to second-line drugs 5 Lbortory-confirmed cses MDR/RR-TB: 41, XDR-TB: Ptients strted on tretment d MDR/RR-TB: 13, XDR-TB: Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence (HIV + TB only) Femles Mles Incidence Tretment success rte nd cohort size 1 Success Cohort New nd relpse cses registered in % 4 18 Previously treted cses, excluding relpse, registered in % 182 HIV-positive TB cses, ll types, registered in 214 MDR/RR-TB cses strted on second-line tretment in 213 XDR-TB cses strted on second-line tretment in 213 TB preventive tretment, 215 % 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 TB finncing, 216 Ntionl TB budget (US$ millions) 3.8 Funding source 12% domestic, 68% interntionl, 2% unfunded 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 215 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded 162 :: GLOBAL TUBERCULOSIS REPORT 216 Dt for ll yers cn be downloded from

174 Lesotho popultion 215 :: 2.1 million Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 1.2 ( ) 55 (29 89) Mortlity (HIV+TB only) 4.8 (3 7) 223 ( ) Incidence (includes HIV+TB) 17 (11 24) 788 ( ) Incidence (HIV+TB only) 12 (7.7 18) 566 (359 82) Incidence (MDR/RR-TB) b 1.1 ( ) 52 (36 7) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles.54 (.18.9) 5.9 ( ) 6.5 (2.9 1) Mles.63 (.36.9) 9.7 (6.8 13) 1 (7.2 14) Totl 1.2 ( ) 16 (12 19) 17 (11 24) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 96% % pulmonry 86% % bcteriologiclly confirmed mong pulmonry 49% 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), (.21.61) TB/HIV cre in new nd relpse TB ptients, 215 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 215 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 43 mong notified pulmonry TB cses (35 51) Estimted % of TB cses with MDR/RR-TB 4.8% ( ) 14% (9.3 18) % notified tested for rifmpicin resistnce 21% 57% MDR/RR-TB cses tested for resistnce to second-line drugs 8 Lbortory-confirmed cses MDR/RR-TB: 332, XDR-TB: Ptients strted on tretment d MDR/RR-TB: 217, XDR-TB: 5 Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence (HIV + TB only) Femles Mles Incidence Tretment success rte nd cohort size 1 Success Cohort New nd relpse cses registered in 214 7% 9 Previously treted cses, excluding relpse, registered in % 936 HIV-positive TB cses, ll types, registered in % MDR/RR-TB cses strted on second-line tretment in % 163 XDR-TB cses strted on second-line tretment in % 3 TB preventive tretment, 215 % 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 TB finncing, 216 Ntionl TB budget (US$ millions) 6.4 Funding source 12% domestic, 19% interntionl, 69% unfunded 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 215 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from GLOBAL TUBERCULOSIS REPORT 216 :: 163

175 Liberi popultion 215 :: 4.5 million Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 3.2 ( ) 7 (41 17) Mortlity (HIV+TB only).84 (.7 1) 19 (16 22) Incidence (includes HIV+TB) 14 (9 2) 38 (199 44) Incidence (HIV+TB only) 1.8 ( ) 4 (25 58) Incidence (MDR/RR-TB) b.43 (.99) 9.5 ( 22) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 1.1 ( ) 3.8 ( ) 4.9 ( ) Mles.91 ( ) 8.1 (5.5 11) 9 (6 12) Totl 2 ( ) 12 (8.8 15) 14 (9 2) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 73% % pulmonry 78% % bcteriologiclly confirmed mong pulmonry 61% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (29 65) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.17.5) TB/HIV cre in new nd relpse TB ptients, 215 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 215 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 14 mong notified pulmonry TB cses ( 32) Estimted % of TB cses with MDR/RR-TB 2.8% (.1 6.7) 21% (2.2 39) % notified tested for rifmpicin resistnce <1% % 15 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: 15, XDR-TB: Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence Incidence (HIV + TB only) Femles Mles Tretment success rte nd cohort size 1 Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % 37 HIV-positive TB cses, ll types, registered in 214 MDR/RR-TB cses strted on second-line tretment in 213 XDR-TB cses strted on second-line tretment in 213 TB preventive tretment, 215 % 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 TB finncing, 216 Ntionl TB budget (US$ millions) 1.3 Funding source % domestic, 1% interntionl, % unfunded 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 215 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded 164 :: GLOBAL TUBERCULOSIS REPORT 216 Dt for ll yers cn be downloded from

176 Nmibi popultion 215 :: 2.5 million Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB).78 ( ) 32 (21 45) Mortlity (HIV+TB only).88 ( ) 36 ( ) Incidence (includes HIV+TB) 12 (9.3 15) 489 ( ) Incidence (HIV+TB only) 4.9 ( ) 199 ( ) Incidence (MDR/RR-TB) b 1.1 ( ) 45 (34 53) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles.57 (.27.87) 4.4 (2.8 6) 5 (3 6.9) Mles.63 (.39.86) 6.4 (4.8 8) 7.1 ( ) Totl 1.2 ( ) 11 (9.2 12) 12 (9.3 15) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 98% % pulmonry 83% % bcteriologiclly confirmed mong pulmonry 76% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), 215 8% (64 1) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.5.3) TB/HIV cre in new nd relpse TB ptients, 215 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 215 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 54 mong notified pulmonry TB cses (47 61) Estimted % of TB cses with MDR/RR-TB 5% ( ) 12% (9.3 14) % notified tested for rifmpicin resistnce 32 MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 32, XDR-TB: 3 Ptients strted on tretment d MDR/RR-TB: 38, XDR-TB: 2 Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence (HIV + TB only) Femles Mles Incidence Tretment success rte nd cohort size 1 Success Cohort New cses registered in % Previously treted cses registered in % 2 68 HIV-positive TB cses, ll types, registered in 214 8% MDR/RR-TB cses strted on second-line tretment in % 184 XDR-TB cses strted on second-line tretment in 213 % 6 TB preventive tretment, 215 % 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 TB finncing, 216 Ntionl TB budget (US$ millions) 38 Funding source 51% domestic, 26% interntionl, 23% unfunded Tretment success rte (%) New cses Previously treted cses 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 215 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from GLOBAL TUBERCULOSIS REPORT 216 :: 165

177 Ppu New Guine Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 3.1 ( ) 4 (24 61) Mortlity (HIV+TB only).67 (.4 1) 8.8 (5.2 13) Incidence (includes HIV+TB) 33 (27 4) 432 ( ) Incidence (HIV+TB only) 4.9 (3 7.3) 64 (39 96) Incidence (MDR/RR-TB) b 1.9 ( ) 25 (16 33) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 2 ( ) 14 (11 18) 16 (12 21) Mles 1.6 ( ) 15 (12 19) 17 (13 21) Totl 3.6 ( ) 29 (26 33) 33 (27 4) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) popultion 215 :: 7.6 million TB cse notifictions, 215 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 36% % pulmonry 54% % bcteriologiclly confirmed mong pulmonry 31% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), 215 8% (66 98) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.7.17) TB/HIV cre in new nd relpse TB ptients, 215 Number (%) Ptients with known HIV-sttus who re HIV-positive 758 8% on ntiretrovirl therpy % Drug-resistnt TB cre, 215 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 1 1 mong notified pulmonry TB cses (8 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 147 Lbortory-confirmed cses MDR/RR-TB: 254, XDR-TB: 11 Ptients strted on tretment d MDR/RR-TB: 225, XDR-TB: 11 Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence (HIV + TB only) Femles Mles Incidence Tretment success rte nd cohort size 1 Success Cohort New cses registered in 214 7% 4 77 Previously treted cses registered in % 728 HIV-positive TB cses, ll types, registered in 214 MDR/RR-TB cses strted on second-line tretment in 213 XDR-TB cses strted on second-line tretment in 213 TB preventive tretment, 215 % 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 TB finncing, 216 Ntionl TB budget (US$ millions) 11 Funding source domestic, 1% interntionl, % unfunded Tretment success rte (%) New cses Previously treted cses 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 215 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded 166 :: GLOBAL TUBERCULOSIS REPORT 216 Dt for ll yers cn be downloded from

178 Sierr Leone popultion 215 :: 6.5 million Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 3.3 ( ) 51 (3 76) Mortlity (HIV+TB only).82 (.4 1.4) 13 (6.2 21) Incidence (includes HIV+TB) 2 (13 28) 37 ( ) Incidence (HIV+TB only) 2.6 ( ) 41 (26 59) Incidence (MDR/RR-TB) b.7 ( 1.5) 11 ( 23) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 1.2 ( ) 6.3 (2.4 1) 7.5 (2.9 12) Mles 1.3 (.8 1.9) 11 (7.5 14) 12 (8.3 16) Totl 2.5 ( ) 17 (13 22) 2 (13 28) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 97% % pulmonry 95% % bcteriologiclly confirmed mong pulmonry 69% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), 215 6% (42 93) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.12.36) TB/HIV cre in new nd relpse TB ptients, 215 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 215 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 42 mong notified pulmonry TB cses ( 86) Estimted % of TB cses with MDR/RR-TB 2.8% (.1 6.7) 21% (2.2 39) % 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:, XDR-TB: Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence Incidence (HIV + TB only) Femles Mles Tretment success rte nd cohort size 1 Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % 227 HIV-positive TB cses, ll types, registered in 214 MDR/RR-TB cses strted on second-line tretment in 213 XDR-TB cses strted on second-line tretment in 213 TB preventive tretment, 215 % of HIV-positive people (newly enrolled in cre) on preventive tretment 7% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment TB finncing, 216 Ntionl TB budget (US$ millions) 1 Funding source % domestic, 1% interntionl, % unfunded 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 215 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from GLOBAL TUBERCULOSIS REPORT 216 :: 167

179 Zmbi popultion 215 :: 16 million Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 5 ( ) 31 (18 47) Mortlity (HIV+TB only) 12 (6.9 2) 77 (42 121) Incidence (includes HIV+TB) 63 (41 91) 391 ( ) Incidence (HIV+TB only) 38 (24 55) 235 ( ) Incidence (MDR/RR-TB) b 2.3 ( ) 14 (8.6 2) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 2.8 ( ) 21 (8.8 33) 24 (9.9 38) Mles 3.2 ( ) 36 (25 47) 39 (27 52) Totl 6 ( ) 57 (44 71) 63 (41 91) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 1% % with known HIV sttus 95% % pulmonry 79% % bcteriologiclly confirmed mong pulmonry 49% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (41 9) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.16.48) TB/HIV cre in new nd relpse TB ptients, 215 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 215 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 1 5 mong notified pulmonry TB cses (99 2 1) Estimted % of TB cses with MDR/RR-TB 1.1% ( ) 18% (11 26) % notified tested for rifmpicin resistnce <1% 9% 695 MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 196, XDR-TB: Ptients strted on tretment d MDR/RR-TB: 99, XDR-TB: Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence (HIV + TB only) Femles Mles Incidence Tretment success rte nd cohort size 1 Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in 214 8% HIV-positive TB cses, ll types, registered in 214 MDR/RR-TB cses strted on second-line tretment in % 58 XDR-TB cses strted on second-line tretment in 213 TB preventive tretment, 215 % of HIV-positive people (newly enrolled in cre) on preventive tretment 66% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment TB finncing, 216 Ntionl TB budget (US$ millions) 11 Funding source 9% domestic, 51% interntionl, 4% unfunded 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 215 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded 168 :: GLOBAL TUBERCULOSIS REPORT 216 Dt for ll yers cn be downloded from

180 Zimbbwe popultion 215 :: 16 million Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 1.7 ( ) 11 (6.3 16) Mortlity (HIV+TB only) 6.3 (2.2 13) 4 (14 81) Incidence (includes HIV+TB) 38 (28 49) 242 ( ) Incidence (HIV+TB only) 26 (17 37) 167 (17 24) Incidence (MDR/RR-TB) b 1.8 (1 2.5) 12 (6.4 16) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 2.4 ( ) 14 (8.3 19) 16 (9.4 23) Mles 2.6 ( ) 19 (14 24) 22 (15 28) Totl 5 ( ) 33 (27 39) 38 (28 49) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 96% % pulmonry 87% % bcteriologiclly confirmed mong pulmonry 54% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (55 97) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.9.4) TB/HIV cre in new nd relpse TB ptients, 215 Number (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 215 New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 1 1 mong notified pulmonry TB cses (69 1 6) Estimted % of TB cses with MDR/RR-TB 3.2% (1.4 5) 14% (6.9 21) % notified tested for rifmpicin resistnce MDR/RR-TB cses tested for resistnce to second-line drugs 95 Lbortory-confirmed cses MDR/RR-TB: 468, XDR-TB: 4 Ptients strted on tretment d MDR/RR-TB: 433, XDR-TB: 5 Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, Notified (new nd relpse) Incidence (HIV + TB only) Femles Mles Incidence Tretment success rte nd cohort size 1 Success Cohort New cses registered in % Previously treted cses registered in % HIV-positive TB cses, ll types, registered in % MDR/RR-TB cses strted on second-line tretment in % 351 XDR-TB cses strted on second-line tretment in 213 TB preventive tretment, 215 % of HIV-positive people (newly enrolled in cre) on preventive tretment 31% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 31% (28 34) TB finncing 216 Ntionl TB budget (US$ millions) 28 Funding source domestic, 54% interntionl, 46% unfunded 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 215 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from GLOBAL TUBERCULOSIS REPORT 216 :: 169

181

182 Annex 3 Regionl profiles :: FOR 6 WHO REGIONS

183

184 WHO Africn Region WHO MEMBER STATES 47 Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 45 (35 56) 45 (35 57) Mortlity (HIV+TB only) 3 (23 36) 3 (24 37) Incidence (includes HIV+TB) 2 72 ( ) 275 ( ) Incidence (HIV+TB only) 834 (71 969) 84 (72 98) Incidence (MDR/RR-TB) b 11 (88 12) 11 (8.9 13) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 142 ( ) 96 ( ) 1 1 ( ) Mles 145 ( ) 1 48 ( ) 1 62 ( ) Totl 287 (256 32) 2 44 ( ) 2 72 ( ) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % with known HIV sttus 81% % pulmonry 84% % bcteriologiclly confirmed mong pulmonry 64% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (42 55) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.22.34) TB/HIV cre in new nd relpse TB ptients, 215 Number Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 215 (%) f New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 42 mong notified pulmonry TB cses (38 47 ) Estimted % of TB cses with MDR/RR-TB 3% ( ) 15% (7.5 22) % notified tested for rifmpicin resistnce 21% 51% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: , XDR-TB: 1 1 Ptients strted on tretment d MDR/RR-TB: , XDR-TB: 795 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 % 63 TB preventive tretment, 215 % of HIV-positive people (newly enrolled in cre) on preventive tretment 39% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 5.6% ( ) TB finncing (low- nd middle-income countries), g,h 216 Ntionl TB budget (US$ millions) 1 41 Funding source 39% domestic, 32% interntionl, 29% 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 215 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. Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, 215 Tretment success rte (%) Totl budget (US$ millions constnt 216) popultion 215 :: 989 million Notified (new nd relpse) Incidence (HIV + TB only) Femles Mles Incidence New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from GLOBAL TUBERCULOSIS REPORT 216 :: 173

185 WHO/PAHO Region of the Americs popultion 215 :: 991 million WHO MEMBER STATES 35 OTHER COUNTRIES AND TERRITORIES 11 Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 19 (17 2) 1.9 (1.8 2) Mortlity (HIV+TB only) 6 (4 8).59 (.42.79) Incidence (includes HIV+TB) 268 (25 287) 27 (25 29) Incidence (HIV+TB only) 32 (29 35) 3.2 ( ) Incidence (MDR/RR-TB) b 11 (1 12) 1.1 (1 1.2) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 13 (11 15) 88 (76 1) 11 (87 115) Mles 13 (11 15) 155 ( ) 168 ( ) Totl 26 (23 28) 243 ( ) 268 (25 287) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % with known HIV sttus 82% % pulmonry 85% % bcteriologiclly confirmed mong pulmonry 77% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (76 87) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.8.1) 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, 215 Number Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 215 (%) f New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 7 7 mong notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 2.9% ( ) 12% (7.3 17) % notified tested for rifmpicin resistnce 29% 45% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 4 489, XDR-TB: 122 Ptients strted on tretment d MDR/RR-TB: 3 374, XDR-TB: 13 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 % 2 92 XDR-TB cses strted on second-line tretment in % 9 Notified cses by ge group nd sex, 215 Tretment success rte (%) Femles Mles TB preventive tretment, 215 % 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 67% (63 71) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing (low- nd middle-income countries), g,h 216 Ntionl TB budget (US$ millions) 496 Funding source 37% domestic, 42% interntionl, 21% 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 215 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 constnt 216) Funded domesticlly Funded interntionlly Unfunded 174 :: GLOBAL TUBERCULOSIS REPORT 216 Dt for ll yers cn be downloded from

186 WHO Estern Mediterrnen Region WHO MEMBER STATES 21 OTHER COUNTRIES AND TERRITORIES 1 Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 8 (38 14) 12 (5.8 21) Mortlity (HIV+TB only) 3 (3 4).46 (.38.54) Incidence (includes HIV+TB) 749 ( ) 116 (86 149) Incidence (HIV+TB only) 13 (9.5 17) 2 ( ) Incidence (MDR/RR-TB) b 39 (3 5) 6 ( ) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 39 (27 52) 321 ( ) 36 (264 47) Mles 36 (28 45) 354 (285 43) 39 ( ) Totl 75 (59 92) 675 (57 788) 749 ( ) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % with known HIV sttus 17% % pulmonry 77% % bcteriologiclly confirmed mong pulmonry 56% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (49 84) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.5.2) Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) Incidence (Rte per 1 popultion per yer) popultion 215 :: 648 million Notified (new nd relpse) Incidence Incidence (HIV + TB only) TB/HIV cre in new nd relpse TB ptients, 215 Number Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 215 (%) f New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 19 mong notified pulmonry TB cses (16 22 ) Estimted % of TB cses with MDR/RR-TB 4.1% (3 5.1) 17% (12 23) % notified tested for rifmpicin resistnce 2.% 65% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 4 81, XDR-TB: 117 Ptients strted on tretment d MDR/RR-TB: 3 367, XDR-TB: 71 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 % 44 MDR/RR-TB cses strted on second-line tretment in % 1 95 XDR-TB cses strted on second-line tretment in 213 3% 67 Notified cses by ge group nd sex, 215 Tretment success rte (%) Femles Mles TB preventive tretment, 215 % of HIV-positive people (newly enrolled in cre) on preventive tretment 4% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 12% (11 12) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing (low- nd middle-income countries), g,h 216 Ntionl TB budget (US$ millions) 173 Funding source 3% domestic, 49% interntionl, 2% 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 215 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 constnt 216) Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from GLOBAL TUBERCULOSIS REPORT 216 :: 175

187 WHO Europen Region WHO MEMBER STATES 53 OTHER COUNTRIES AND TERRITORIES 1 Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 32 (31 33) 3.5 ( ) Mortlity (HIV+TB only) 5 (2 1).54 ( ) Incidence (includes HIV+TB) 323 ( ) 36 (33 38) Incidence (HIV+TB only) 27 (23 31) 3 ( ) Incidence (MDR/RR-TB)b 12 (11 14) 14 (12 15) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 12 (1 14) 99 (84 116) 111 (94 13) Mles 13 (11 14) 199 ( ) 212 ( ) Totl 25 (22 27) 299 ( ) 323 ( ) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % with known HIV sttus 72% % pulmonry 86% % bcteriologiclly confirmed mong pulmonry 61% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (72 84) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.1.13) TB/HIV cre in new nd relpse TB ptients, 215 Number Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 215 (%) f New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 74 mong notified pulmonry TB cses (68 81 ) Estimted % of TB cses with MDR/RR-TB 16% (11 2) 48% (42 53) % notified tested for rifmpicin resistnce 44% 49% 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: 3 92 Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, popultion 215 :: 91 million Notified (new nd relpse) Incidence (HIV + TB only) Femles Mles Incidence 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 % Tretment success rte (%) TB preventive tretment, 215 % of HIV-positive people (newly enrolled in cre) on preventive tretment 36% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 42% (4 44) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing (low- nd middle-income countries), g,h 216 Ntionl TB budget (US$ millions) Funding source 91% domestic, 6.8% interntionl, 2.3% 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 215 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 constnt 216) Funded domesticlly Funded interntionlly Unfunded 176 :: GLOBAL TUBERCULOSIS REPORT 216 Dt for ll yers cn be downloded from

188 WHO South-Est Asi Region WHO MEMBER STATES 11 Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 71 (6 83) 37 (31 43) Mortlity (HIV+TB only) 74 (56 95) 3.9 ( ) Incidence (includes HIV+TB) 4 74 ( ) 246 ( ) Incidence (HIV+TB only) 227 (159 37) 12 (8.2 16) Incidence (MDR/RR-TB) b 2 (15 25) 1 (7.9 13) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 211 ( ) 1 54 ( ) 1 75 ( ) Mles 195 ( ) 2 79 ( ) 2 99 ( ) Totl 46 (33 489) 4 33 ( ) 4 74 ( ) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % with known HIV sttus 52% % pulmonry 83% % bcteriologiclly confirmed mong pulmonry 63% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (39 79) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.12.25) TB/HIV cre in new nd relpse TB ptients, 215 Number Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 215 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 215 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 11 mong notified pulmonry TB cses (1 12 ) Estimted % of TB cses with MDR/RR-TB 2.6% (2.3 3) 17% (15 19) % notified tested for rifmpicin resistnce 5.1% 57% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: , XDR-TB: 3 99 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 % 261 TB preventive tretment, 215 % of HIV-positive people (newly enrolled in cre) on preventive tretment 8.9% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 2.3% ( ) TB finncing (low- nd middle-income countries), g,h 216 Ntionl TB budget (US$ millions) 578 Funding source 29% domestic, 54% interntionl, 17% 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, 215 Tretment success rte (%) Totl budget (US$ millions constnt 216) popultion 215 :: million Notified (new nd relpse) Incidence (HIV + TB only) Femles Mles Incidence New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from GLOBAL TUBERCULOSIS REPORT 216 :: 177

189 WHO Western Pcific Region WHO MEMBER STATES 27 OTHER COUNTRIES AND TERRITORIES 9 Estimtes of TB burden, 215 Number (thousnds) Rte (per 1 popultion) Mortlity (excludes HIV+TB) 89 (81 98) 4.8 ( ) Mortlity (HIV+TB only) 6 (4 8).31 (.2.44) Incidence (includes HIV+TB) 1 59 ( ) 86 (78 94) Incidence (HIV+TB only) 34 (29 4) 1.8 ( ) Incidence (MDR/RR-TB) b 1 (88 12) 5.5 ( ) Estimted TB incidence by ge nd sex (thousnds), yers > 14 yers Totl Femles 67 (51 84) 471 ( ) 537 (419 67) Mles 72 (59 86) 979 ( ) 1 5 (98 1 2) Totl 138 ( ) 1 45 ( ) 1 59 ( ) TB cse notifictions, 215 Totl cses notified Totl new nd relpse % with known HIV sttus 43% % pulmonry 92% % bcteriologiclly confirmed mong pulmonry 38% Universl helth coverge nd socil protection TB tretment coverge (notified/estimted incidence), % (77 93) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.5.7) TB/HIV cre in new nd relpse TB ptients, 215 Number Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % Drug-resistnt TB cre, 215 (%) f New cses Previously treted cses Totl number c Estimted MDR/RR-TB cses 83 mong notified pulmonry TB cses (73 93 ) Estimted % of TB cses with MDR/RR-TB 5.1% (3 7.2) 26% (23 3) % notified tested for rifmpicin resistnce 8.8% 36% MDR/RR-TB cses tested for resistnce to second-line drugs 1 61 Lbortory-confirmed cses MDR/RR-TB: 18 22, XDR-TB: 45 Ptients strted on tretment d MDR/RR-TB: , XDR-TB: 196 Mortlity (excludes HIV+TB) (Rte per 1 popultion per yer) Incidence (Rte per 1 popultion per yer) Notified cses by ge group nd sex, 215 popultion 215 :: million Notified (new nd relpse) Incidence (HIV + TB only) Femles Mles Incidence Tretment success rte nd cohort size Success Cohort New nd relpse e cses registered in % Previously treted cses, excluding relpse, registered in 214 8% HIV-positive TB cses, ll types, registered in % 5 7 MDR/RR-TB cses strted on second-line tretment in % XDR-TB cses strted on second-line tretment in % 282 Tretment success rte (%) TB preventive tretment, 215 % 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 13% (12 14) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB TB finncing (low- nd middle-income countries), g,h 216 Ntionl TB budget (US$ millions) 684 Funding source 71% domestic, 13% interntionl, 16% 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 215 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 constnt 216) Funded domesticlly Funded interntionlly Unfunded 178 :: GLOBAL TUBERCULOSIS REPORT 216 Dt for ll yers cn be downloded from

190 Annex 4 TB burden estimtes, notifictions nd tretment outcomes :: FOR INDIVIDUAL COUNTRIES AND TERRITORIES, WHO REGIONS AND THE WORLD

191

192 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 Estimted numbers re shown rounded to two significnt figures. Estimted rtes re shown rounded to three significnt figures unless the vlue is under 1, in which cse rtes re shown rounded to two significnt figures. Dt source Dt shown in this file were tken from the WHO globl TB dtbse on 21 September 216. Dt shown in the min prt of the report were tken from the dtbse on 15 August 216. 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 Bngldesh Estimtes of TB incidence nd mortlity will be reviewed once finl results from the 215/216 ntionl TB prevlence survey re vilble. 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 re interim in nture, pending results from the ntionl TB prevlence survey plnned for 217/218. Russin Federtion UN Popultion Division estimtes re lower thn the popultion registered by the Federl Stte Sttistics Service of the Russin Federtion. The reported number of TB ptients with known HIV sttus (Tble A4.4) is for new TB ptients in the civilin sector only. It ws not possible to clculte the percentge of ll TB ptients with known HIV sttus. 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. GLOBAL TUBERCULOSIS REPORT 216 :: 181

193 :: TABLE A4.1 TB incidence estimtes, 215 Incidence (including HIV) Incidence (HIV-positive) Incidence (MDR/RR-TB) Popultion (millions) Number (thousnds) Rte Number (thousnds) Rte Number (thousnds) Rte Afghnistn (4 88) 189 (122 27).46 (.28.68) 1.4 ( ) 3( ) 9.2(5.5 13) Albni 3.55 (.46.63) 19 (16 22).1 (<.1 <.1).27 (.21.34).15 (<.1.27).52 (.1.93) Algeri 4 3 (23 37) 75 (58 94).2 (.14.27).51 (.36.68).47 (.14.8) 1.2 (.35 2.) Americn Smo < 1 ( <.1) 8.3 ( ) ( ) <.1 (<.1 <.1) <.1 (<.1 <.1).43 (.25.63) Andorr < 1 ( <.1) 6.5 ( ) ( ) ( ) Angol (6 132) 37 (24 529) 28 (17 41) 111 (68 165) 4.1 ( ) 16 (1.4 31) Anguill < 1 ( ) 21 (14 31) ( ) ( ) Antigu nd Brbud < 1.1 (<.1 <.1) 7.5 ( ) ( ) 2.1 ( ) <.1 (<.1 <.1).17 (.11.24) Argentin (9.5 13) 25 (22 29).79 (.61.99) 1.8 ( ).53 (.37.69) 1.2( ) Armeni ( ) 41 (36 46).11 (.1.13) 3.7 ( ).27 (.2.34) 8.9 (6.6 11) Arub < 1.1 (<.1 <.1) 12 (11 14) <.1 (<.1 <.1).29 (.18.39) Austrli ( ) 6( ).3(<.1 <.1).12(.1.14).62 (.39.85).26 (.16.35) Austri 9.65 (.56.75) 7.6 ( ).2 (<.1 <.1).19 (.14.23).2 (<.1.32).23 (<.1.37) Azerbijn ( ) 69 (57 83).11 (<.1.16) 1.1 ( ) 2.5 (2. 3.) 26 (21 31) Bhms < 1.7 (<.1 <.1) 18 (16 21).2 (<.1 <.1) 5.7 ( ) <.1 (<.1.18) 2.4 ( ) Bhrin 1.25 (.21.28) 18 (15 21).1 (<.1 <.1).84 (.71.99) <.1 ( <.1).33 (.71) Bngldesh ( ) 225 ( ).63 (.39.94).39 (.24.59) 9.7 (5.4 14) 6( ) Brbdos < 1 ( ) ( ) Belrus ( ) 55 (41 71).3 (.2.44) 3.2 ( ) 3.5 ( ) 37 (29 44) Belgium ( ) 9.4 (8.1 11).8 (<.1.1).74 (.61.88).23 (<.1.38).2 (<.1.34) Belize < 1.9 (<.1.1) 25 (21 29).2 (<.1 <.1) 5.8 (5. 6.8).1 (<.1.12) 2.8 ( ) Benin ( ) 6 (39 86) 1 ( ) 9.2 (5.9 13).1 (<.1.2).92 (<.1 1.8) Bermud < 1 ( ) ( ) Bhutn < ( ) 155 (12 196).11 (<.1.14) 14 (9.8 18).52 (.43.62) 6.7 (5.5 8.) Bolivi (Plurintionl Stte of) (8.1 18) 117 (76 167).55 (.35.79) 5.1 ( ).5 (.25.74) 4.7 ( ) Bonire, Sint Eusttius nd Sb < 1 ( ) 1(.9 1.2) ( ) ( ) Bosni nd Herzegovin ( ) 37 (29 47) ( <.1).1 (<.1.15).1 (<.1.19).26 (<.1.5) Botswn 2 8 (5.2 11) 356 (23 58) 4.8 ( ) 213 (136 36).47 (.3.63) 21 (13 28) Brzil (72 97) 41 (35 47) 13 (11 15) 6.3 ( ) 2.3 ( ) 1.1 ( ) British Virgin Islnds < 1 ( ) ( ) Brunei Drusslm < 1.24 (.21.28) 58 (49 66) ( ).15 (.13.18) ( ) ( ) Bulgri ( ) 24 (22 26) ( ) <.1 (<.1 <.1).1 (.75.13) 1.4 (1. 1.8) Burkin Fso (6.1 13) 52 (34 74).89 ( ) 4.9 ( ).4 (.18.77) 2.2 (<.1 4.3) Burundi (8.8 19) 122 (79 174) 1.9 ( ) 17 (11 24).5 (.21.8) 4.5 ( ) Cbo Verde < 1.72 (.47 1.) 139 (9 198).8 (<.1.12) 16 (1 23).27 (.55) 5.2 ( 11) Cmbodi (38 85) 38 ( ) 1.4 ( ) 9.2 (5.9 13) 1.3 ( ) 8.3 (3.8 13) Cmeroon (32 71) 212 (137 33) 18 (11 26) 76 (48 11) 1.9 (.87 3.) 8.1 (3.7 13) Cnd ( ) 5.1 ( ).15 (.12.17).4 (.33.48).31 (.16.45) <.1 (<.1.13) Cymn Islnds < 1.1 (<.1 <.1) 13 (12 15) ( ) ( ) Centrl Africn Republic 5 19 (12 27) 391 ( ) 8.6 (5.3 13) 176 (17 262).21 (.45) 4.3 ( 9.2) Chd (14 3) 152 (98 217) 6.4 ( ) 45 (28 68).89 ( ) 6.3 (.22 12) Chile 18 3 ( ) 16 (14 19).15 (.11.19).82 (.63 1.).61 (.4.82).34 (.22.46) Chin ( ) 67 (57 77) 15 (12 19) 1.1 ( ) 7 (55 84) 5.1(4. 6.1) Chin, Hong Kong SAR (4.4 6.) 71 (61 82).3 (<.1 <.1).46 (.39.54).77 (.51.1) 1.1 (.7 1.4) Chin, Mco SAR < 1.43 (.37.49) 72 (62 83) ( ).36 (.31.42).16 (<.1.25) 2.7 ( ) Colombi (11 19) 31 (24 39) 2.1 ( ) 4.4 ( ).56 (.38.73) 1.2 ( ) Comoros < 1.27 (.18.39) 35 (22 49).1 (<.1 <.1) 1.1 (.7 1.6) <.1 (.2) 1.2 ( 2.5) Congo 5 18 (11 25) 379 ( ) 6.4 ( ) 138 (84 25).67 (.29 1.) 15 (6.3 22) Cook Islnds < 1 ( ) 7.8 (5. 11) ( ) <.1 ( <.1) ( ) ( ) Cost Ric 5.53 (.41.67) 11 (8.5 14).4 (<.1 <.1).86 ( ).12 (<.1.22).25 (<.1.46) Côte d'ivoire (23 52) 159 (13 227) 8.5 (5.5 12) 38 (24 54) 1.4 ( ) 6.2 (2.5 1) Croti 4.56 (.48.64) 13 (11 15).1 ( <.1).15 (.12.19) ( ) ( ) Cub 11.8 (.69.92) 7 (6. 8.1).7 (<.1 <.1).65 (.55.75).25 (.11.4).22 (<.1.35) Curço < 1.1 ( <.1) 3.7 ( ) ( ) 1.9 ( ) ( ) ( ) Cyprus 1.7 (<.1 <.1) 6.2 ( ) ( ).12 (<.1.15) ( ) ( ) Czechi (.47.63) 5.2 (4.4 6.).1 ( <.1) <.1 (<.1 <.1).15 (<.1.26).14 (<.1.25) Democrtic People's Republic of Kore (19 178) 561 (432 76).45 (.32.6) 1.8 ( ) 6( ) 24(14 34) Democrtic Republic of the Congo ( ) 324 (21 463) 39 (23 57) 5 (3 74) 1 (4.6 15) 13 (6. 19) Denmrk 6.34 (.29.39) 6 ( ).1 (<.1 <.1).19 (.14.23) <.1 ( <.1) <.1 ( <.1) Djibouti < ( ) 378 ( ).2 (.15.25) 22 (17 28).18 (.89.27) 2 (1 3) Dominic < 1.1 (<.1 <.1) 11 (9.5 13) ( ) <.1 (<.1 <.1) ( ) ( ) Dominicn Republic ( ) 6 (44 78) 1.6 (1. 2.3) 15 (9.5 21).28 (.16.39) 2.7 ( ) Ecudor (5.5 12) 52 (34 75) 1 ( ) 6.2 (4. 9.).75 (.45 1.) 4.6 ( ) Egypt (12 15) 15 (13 16).5 (<.1 <.1) <.1 (<.1 <.1) 2.2 ( ) 2.4 (2. 2.8) El Slvdor ( ) 43 (4 47).21 (.19.23) 3.5 ( ).4 (.14.67).65 ( ) Equtoril Guine < ( ) 172 (15 194).73 (.62.84) 86 (74 99).66 (<.1.12) 7.8 (1. 14) Rtes re per 1 popultion. 182 :: GLOBAL TUBERCULOSIS REPORT 216 Dt for ll yers cn be downloded from

194 :: TABLE A4.1 TB incidence estimtes, 215 Incidence (including HIV) Incidence (HIV-positive) Incidence (MDR/RR-TB) Popultion (millions) Number (thousnds) Rte Number (thousnds) Rte Number (thousnds) Rte Eritre ( ) 65 (3 113).18 (<.1.32) 3.5 ( ).14 (.29) 2.7 ( 5.5) Estoni 1.24 (.2.27) 18 (15 21).2 (<.1 <.1) 1.8 ( ).71 (.5.92) 5.4 (3.8 7.) Ethiopi ( ) 192 (142 25) 16 (1 23) 16 (1 23) 6.2 ( ) 6.2 (3.5 9.) Fiji < 1.45 (.35.57) 51 (39 64).1 (<.1 <.1).93 ( ) ( ) ( ) Finlnd 6.31 (.26.35) 5.6 ( ).1 ( <.1).1 (<.1.13).17 (<.1.28).31 (.11.51) Frnce (4.7 6.) 8.2 ( ).41 (.32.5).63 (.49.78).88 (.63.11).14 (<.1.17) French Polynesi < 1.5 (<.1 <.1) 19 (16 22) <.1 (<.1 <.1) 1.7 (.39 3.) Gbon 2 8 (5.9 1) 465 (344 64).25 (.15.37) 14 (8.8 21).4 (.23.56) 23 (13 32) Gmbi ( ) 174 ( ).6 (.39.86) 3 (19 43).12(.25) 6( 13) Georgi 4 4 ( ) 99 (8 12).26 (.16.38) 6.4 ( ).98( ) 25(2 28) Germny ( ) 8.1 ( ).2 (.15.25).24 (.19.3).23 (.11.34).29 (.14.42) Ghn (21 75) 16 (77 273) 9.9 (4.6 17) 36 (17 62) 1.5 ( 3.4) 5.5 ( 12) Greece (.42.56) 4.5 ( ).2 (<.1 <.1).18 (.14.22).11 (.28).1 (.26) Greenlnd < 1.9 (<.1.11) 164 ( ) <.1 (<.1 <.1) 5.5 ( ) Grend < 1.1 ( <.1) 5.4 ( ) ( ) 2.2 ( ) <.1 (<.1 <.1).16 (<.1.25) Gum < 1.9 (<.1.1) 51 (44 59) ( ) <.1 (<.1 <.1) ( ) ( ) Guteml ( ) 25 (2 32).27 (.21.34) 1.7 ( ).23 (.15.31) 1.4 ( ) Guine (14 32) 177 ( ) 5.4 ( ) 43 (27 63).78 ( 1.7) 6.2 ( 13) Guine-Bissu ( ) 373 ( ) 1.8 ( ) 97(6 142).21(.49) 11( 27) Guyn < 1.71 (.55.9) 93 (72 117).17 (.13.22) 22 (17 28).43 (.29.58) 5.6 ( ) Hiti (17 25) 194 ( ) 3.4 ( ) 32 (21 46).79 ( ) 7.4 (4.2 1) Hondurs ( ) 43 (36 51).36 (.23.52) 4.5 ( ).11 (.58.17) 1.4 ( ) Hungry 1.92 ( ) 9.3 (8. 11).1 (<.1 <.1).12 (<.1.15).37 (.23.52).38 (.23.53) Icelnd < 1.1 (<.1 <.1) 2.4 ( ) ( ) ( ) ( ) ( ) Indi ( ) 217 ( ) 113 (58 186) 8.6 (4.4 14) 13 (88 18) 9.9 (6.7 14) Indonesi ( ) 395 ( ) 78 (48 116) 3 (18 45) 32 (19 45) 12 (7.4 17) Irn (Islmic Republic of) (9.8 16) 16 (12 2).35 (.25.46).44 (.31.58).25 (.15.35).32 (.19.44) Irq (14 18) 43 (38 49).2 (<.1 <.1) <.1 (<.1 <.1) 1.2 ( ) 3.3 ( ) Irelnd 5.34 (.29.39) 7.2 ( ).1 (<.1 <.1).31 (.24.39) <.1 (.11) <.1 (.23) Isrel 8.32 (.28.37) 4 ( ).2 (<.1 <.1).23 (.2.27).32 (.17.48).4 (.21.6) Itly (3. 4.) 5.8 (5. 6.7).21 (.16.26).35 (.27.44).12 (.74.16).2 (.12.27) Jmic 3.13 (.1.16) 4.6 ( ).3 (<.1 <.1) 1.1 ( ) <.1 ( <.1) <.1 (.24) Jpn (18 24) 17 (14 19).9 (<.1.11) <.1 (<.1 <.1).27 (.18.36).21 (.14.28) Jordn 8.53 (.41.67) 7 ( ) ( ) <.1 ( <.1).39 (.12.67).51 (.16.88) Kzkhstn (14 17) 89 (8 99).5 (.32.72) 2.8 ( ) 8.8 (7.1 1) 5 (4 57) Keny (87 129) 233 ( ) 36 (29 43) 78 (63 94) 2( ) 4.3 ( ) Kiribti < 1.62 (.48.78) 551 ( ) ( ) 2.3 (1.7 3.).41 (.25.56) 36 (22 5) Kuwit 4.86 (.74.99) 22 (19 25) ( ) <.1 (<.1 <.1).14 (<.1.24).36 (.13.62) Kyrgyzstn (7.1 1) 144 (12 17).26 (.17.37) 4.4 ( ) 5( ) 84(69 99) Lo People's Democrtic Republic 7 12 (8. 18) 182 (118 26).59 (.36.88) 8.7 (5.3 13).76 ( ) 11 (5.7 16) Ltvi 2.8 (.69.92) 41 (35 47).21 (.17.24) 1 (8.8 12).99 (.75.12) 5 ( ) Lebnon 6.75 (.65.87) 13 (11 15).1 (<.1 <.1).15 (.12.19).28 (<.1.49).48 (.12.84) Lesotho 2 17 (11 24) 788 ( ) 12 (7.7 18) 566 (359 82) 1.1 ( ) 52 (36 7) Liberi 5 14 (9. 2) 38 (199 44) 1.8 ( ) 4 (25 58).43 (.99) 9.5 ( 22) Liby ( ) 4 (26 57).5 (<.1 <.1).87 ( ).12 (.69.16) 1.9 ( ) Lithuni ( ) 56 (48 64).6 (<.1 <.1) 2 ( ).36 (.3.41) 13 (1 14) Luxembourg < 1.3 (<.1 <.1) 6.1 (5.2 7.) ( ).51 (.4.65) ( ) ( ) Mdgscr (37 82) 236 ( ) 3.6 ( ) 15 (9.1 22).46 (.12.81) 1.9 (.5 3.3) Mlwi (18 53) 193 (14 31) 18 (9.4 29) 14 (55 168).44 (.12.75) 2.6 (.7 4.4) Mlysi 3 27 (23 31) 89 (77 13) 1.5 ( ) 4.8 ( ).53 (.41.64) 1.7 ( ) Mldives < 1.19 (.15.24) 53 (41 66) ( ) <.1 (<.1 <.1) <.1 (<.1 <.1) 1.6 (1.2 2.) Mli 18 1 (6.5 14) 57 (37 81) 1.4 (.85 2.) 7.7 (4.8 11).61 ( ) 3.5 (.8 6.3) Mlt < 1.4 (<.1 <.1) 8.8 (7.5 1).1 (<.1 <.1) 1.6 ( ) ( ) ( ) Mrshll Islnds < 1.18 (.15.22) 344 ( ) ( ).67 (.5.86) ( ) ( ) Muritni ( ) 17 (69 152).44 (.27.66) 11 (6.6 16).15 (.32) 3.7 ( 7.9) Muritius 1.28 (.18.39) 22 (14 31).3 (<.1 <.1) 2.7 ( ) <.1 (.12).39 (.94) Mexico (22 32) 21 (17 25) 3 ( ) 2.3 ( ).91 ( ).72 (.59.87) Micronesi (Federted Sttes of) < 1.13 (.1.16) 124 (96 157) <.1 (<.1.11) 7.8 (4.6 11) Monco < 1 ( ) ( ) Mongoli 3 13 (6.5 21) 428 (22 73).1 (<.1 <.1).34 (.26.44).63 (.37.89) 21 (13 3) Montenegro < 1.13 (<.1.19) 21 (13 3) ( ).17 (.11.25) <.1 ( <.1).5 ( 1.2) Montserrt < 1 ( ) ( ) Morocco (34 4) 17 (98 117).79 (.63.96) 2.3 ( ).58 (.32.84) 1.7 ( ) Mozmbique (1 22) 551 ( ) 79 (5 115) 284 ( ) 7.3 (4.1 1) 26 (15 36) Mynmr ( ) 365 ( ) 17 (11 25) 32 (21 47) 14 (8.9 18) 26 (17 33) Nmibi 2 12 (9.3 15) 489 ( ) 4.9 ( ) 199 ( ) 1.1 ( ) 45 (34 53) Rtes re per 1 popultion. Dt for ll yers cn be downloded from GLOBAL TUBERCULOSIS REPORT 216 :: 183

195 :: TABLE A4.1 TB incidence estimtes, 215 Incidence (including HIV) Incidence (HIV-positive) Incidence (MDR/RR-TB) Popultion (millions) Number (thousnds) Rte Number (thousnds) Rte Number (thousnds) Rte Nuru < 1.1 (<.1 <.1) 113 (97 13) <.1 (<.1 <.1) 16 (13 18) Nepl (39 5) 156 ( ) 1.9 ( ) 6.7 ( ) 1.5 ( ) 5.3 ( ) Netherlnds ( ) 5.8 (5. 6.7).7 (<.1 <.1).42 (.35.5).23 (.1.36).14 (<.1.21) New Cledoni < 1.6 (<.1 <.1) 24 (21 28) ( ) ( ) New Zelnd 5.34 (.29.39) 7.4 ( ) ( ) <.1 (<.1 <.1).1 (<.1.19).22 (<.1.42) Nicrgu ( ) 51 (39 64).15 (.12.2) 2.5 ( ).78 (.34.12) 1.3 (.56 2.) Niger 2 19 (12 27) 95 (62 136) 1 ( ) 5.2 ( ).71 ( 1.5) 3.6 ( 7.5) Nigeri (345 89) 322 ( ) 1 (56 155) 55 (31 85) 29 (15 43) 16 (8.2 24) Niue < 1 ( ) 8.1 (5.2 12) ( ) ( ) Northern Mrin Islnds < 1.3 (<.1 <.1) 58 (5 67) ( ) <.1 (<.1 <.1) <.1 ( <.1) 3.6 ( 9.3) Norwy 5.33 (.28.38) 6.3 ( ).1 (<.1 <.1).15 (.12.19).1 (<.1.19).19 (<.1.36) Omn 4.38 (.32.43) 8.4 ( ) ( ) <.1 (<.1.1).15 (<.1.24).33 (.13.53) Pkistn (33 729) 27 ( ) 8.8 (5.4 13) 4.6 ( ) 26 (16 36) 14 (8.5 19) Plu < 1.2 (<.1 <.1) 76 (65 87) ( ) <.1 (<.1 <.1) ( ) ( ) Pnm 4 2 ( ) 5 (38 63).23 (.17.29) 5.7 ( ).89(.55.12) 2.3( ) Ppu New Guine 8 33 (27 4) 432 ( ) 4.9 (3. 7.3) 64(39 96) 1.9( ) 25(16 33) Prguy ( ) 41 (35 47).24 (.2.28) 3.6 (3. 4.2).87 (.44.13) 1.3 (.66 2.) Peru (29 47) 119 (92 15) 2.3 ( ) 7.2 ( ) 3.2 ( ) 1 (8.6 12) Philippines ( ) 322 (277 37) 4.3 ( ) 4.3 ( ) 17 (14 2) 17 (14 2) Polnd ( ) 19 (16 21).14 (.11.18).37 (.28.46).7 (.49.91).18 (.13.24) Portugl ( ) 23 (2 27).35 (.29.41) 3.4 ( ).33 (.19.47).32 (.18.45) Puerto Rico 4.6 (<.1 <.1) 1.6 ( ).1 (<.1 <.1).28 (.24.32) ( ) ( ) Qtr 2.76 (.65.87) 34 (29 39) ( ) <.1 (<.1 <.1).1 (.24).45 ( 1.1) Republic of Kore 5 4 (37 43) 8 (74 85).48 (.38.58).95 ( ) 2.9 ( ) 5.8 ( ) Republic of Moldov (4. 8.8) 152 (98 217).55 (.35.79) 13 (8.5 19) 3.9 ( ) 96 (71 118) Romni 2 16 (14 19) 84 (72 97).42 (.35.5) 2.2 ( ).94 ( ) 4.8 ( ) Russin Federtion (98 132) 8 (69 92) 11 (9.3 13) 7.9 ( ) 6 (49 71) 42 (34 49) Rwnd ( ) 56 (48 65) 1.8 ( ) 15 (9.8 22).16 (.1.21) 1.4 ( ) Sint Kitts nd Nevis < 1 ( ) 5.1 ( ) ( ).7 (.54.87) <.1 (<.1 <.1).31 (.16.45) Sint Luci < 1.2 (<.1 <.1) 8.8 (7.6 1) ( ) 1.4 (.89 2.) ( ) ( ) Sint Vincent nd the Grendines < 1.1 (<.1 <.1) 7.4 ( ) ( ) 1.1 (.9 1.2) <.1 (<.1 <.1).22 (.1.34) Smo < 1.2 (<.1 <.1) 11 (9.7 13) ( ) ( ) Sn Mrino < 1 ( ) 2.5 ( ) ( ) ( ) So Tome nd Principe < 1.18 (.18.19) 97 (94 1).3 (<.1 <.1) 15 (9.7 21).36 (.26.46) 19 (14 24) Sudi Arbi ( ) 12 (1 14).14 (.11.16).43 (.36.51).15 (.12.18).48 (.38.57) Senegl (14 3) 139 (9 198) 1.4 ( ) 9.5 (6.1 14).41 (.25.57) 2.7 ( ) Serbi ( ) 21 (19 24).3 (<.1 <.1).33 (.26.41).28 (.13.43).32 (.15.49) Seychelles < 1.1 (<.1 <.1) 9.5 (8.2 11) ( ) <.1 (<.1 <.1) ( ) ( ) Sierr Leone 6 2 (13 28) 37 ( ) 2.6 ( ) 41 (26 59).7 ( 1.5) 11 ( 23) Singpore ( ) 44 (38 51).5 (<.1 <.1).81 (.69.94).34 (.18.5).61 (.32.89) Sint Mrten (Dutch prt) < 1 ( ) 5.9 ( ) <.1 (<.1 <.1).14 (<.1.19) Slovki 5.35 (.3.41) 6.5 ( ) ( ) <.1 ( <.1) <.1 (<.1 <.1) <.1 (<.1 <.1) Sloveni 2.15 (.13.17) 7.2 ( ) ( ) <.1 ( <.1) ( ) ( ) Solomon Islnds < 1.52 (.4.65) 89 (69 112).32 (.19.45) 5.5 ( ) Somli 11 3 (19 42) 274 ( ).53 (.33.77) 4.9 ( ) 3.1 ( ) 29 (17 41) South Afric ( ) 834 ( ) 258 (165 37) 473 (33 68) 2 (13 27) 37 (24 5) South Sudn (12 26) 146 (95 29) 2.1 (1.3 3.) 17 (11 24).76 ( ) 6.2 (3. 9.7) Spin ( ) 12 (1 14).4 (.34.48).87 (.73 1.).42 (.16.69) <.1 (<.1.15) Sri Lnk (9.7 18) 65 (47 86).4 (<.1 <.1).21 (.13.3).89 (.19).43 (.92) Sudn 4 35 (21 53) 88 (52 133) 1.6 ( ) 4 ( ) 1.6 (.89 3.) 4 ( ) Surinme < 1.18 (.14.23) 33 (26 42).5 (<.1 <.1) 1 (7.8 13).24 (.11.37) 4.4 (2. 6.8) Swzilnd (4.7 1) 565 (366 87) 5.2 ( ) 48 ( ).89( ) 69(36 11) Sweden 1.9 (.77 1.) 9.2 (7.9 11).3 (<.1 <.1).27 (.21.34).45 (.26.64).46 (.27.65) Switzerlnd 8.61 (.52.7) 7.4 ( ).3 (<.1 <.1).39 (.3.5).29 (.13.45).35 (.16.54) Syrin Arb Republic ( ) 2 (15 25).34 (.21.47) 1.8 ( ) Tjikistn ( ) 87 (67 19).2 (.15.25) 2.4 (1.8 3.) 1.9( ) 22(18 26) Thilnd (69 176) 172 (12 259) 15 (8. 25) 22 (12 37) 4.5 ( ) 6.6 ( ) The Former Yugoslv Republic of Mcedoni Rtes re per 1 popultion (.26.28) 13 (12 14) ( ) <.1 (<.1 <.1) <.1 (<.1.16).44 (.12.77) Timor-Leste ( ) 498 ( ).9 (<.1.13) 7.3 (4.5 11).22 (.15.29) 19 (13 24) Togo ( ) 52 (37 69).82 ( ) 11 (7.2 16).13 (.28) 1.8 ( 3.8) Tokelu < 1 ( ) ( ) Tong < 1.2 (<.1 <.1) 15 (13 17) ( ) <.1 (<.1 <.1) <.1 (<.1 <.1).79 ( ) Trinidd nd Tobgo 1.23 (.19.26) 17 (14 19).4 (<.1 <.1) 2.9 ( ).1 (<.1.12).74 (.59.88) Tunisi ( ) 37 (29 47).3 (<.1 <.1).26 (.18.34).25 (<.1.43).22 (<.1.38) Turkey (12 17) 18 (16 21).1 (<.1.11).12 (.1.15).71 (.6.83).9 ( ) Turkmenistn ( ) 7 (54 88).85 (.67 1.) 16 (12 19) 184 :: GLOBAL TUBERCULOSIS REPORT 216 Dt for ll yers cn be downloded from

196 :: TABLE A4.1 TB incidence estimtes, 215 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 ( ) 6.7 ( ) ( ) 6.7 (5.5 8.) <.1 (<.1 <.1).15 (<.1.21) Tuvlu < 1.2 (<.1 <.1) 232 ( ) ( ).23 (.18.29) <.1 (<.1 <.1) 12 (6.9 17) Ugnd (47 119) 22 (12 34) 26 (16 37) 66 (42 94) 1.9 (1. 2.8) 4.9 ( ) Ukrine (26 58) 91 (59 13) 9 (5.7 13) 2 (13 29) 22 (17 27) 49 (38 6) United Arb Emirtes 9.14 (<.1.21) 1.6 (1. 2.2).1( <.1) <.1(<.1 <.1) <.1(<.1 <.1) <.1(<.1 <.1) United Kingdom of Gret Britin nd Northern Irelnd (6. 7.2) 1 (9.2 11).31 (.25.38).48 (.38.59).11 (.72.15).17 (.11.23) United Republic of Tnzni (78 281) 36 ( ) 57 (27 1) 17 (5 186) 2.6 ( ) 4.9 (1. 8.8) United Sttes of Americ (8.9 12) 3.2 ( ).58 (.49.67).18 (.15.21).18 (.14.23) <.1 (<.1 <.1) Uruguy 3 1 ( ) 3 (26 35).16 (.14.19) 4.7 (4. 5.5) <.1 (<.1.14).21 (<.1.41) US Virgin Islnds < 1.1 (<.1 <.1) 7.7 ( ) ( ) ( ) Uzbekistn 3 24 (17 31) 79 (57 15) 1.2 ( ) 3.9 ( ) 1 (7.6 12) 33 (25 4) Vnutu < 1.17 (.14.2) 63 (52 74) ( ) ( ) Venezuel (Bolivrin Republic of) (6.9 11) 29 (22 36).96 ( ) 3.1 ( ).34 (.19.49) 1.1 ( ) Viet Nm (13 155) 137 (11 166) 5.5 ( ) 5.9 ( ) 7.3 ( ) 7.8 (5.6 1) Wllis nd Futun Islnds < 1 ( ) ( ) West Bnk nd Gz Strip 5.5 (<.1 <.1) 1.1 ( ) ( ) ( ) <.1(<.1 <.1) <.1(<.1 <.1) Yemen (11 15) 48 (42 54).15 (.11.18).55 (.42.68).34 (.16.52) 1.3 (.6 1.9) Zmbi (41 91) 391 ( ) 38 (24 55) 235 ( ) 2.3 ( ) 14 (8.6 2) Zimbbwe (28 49) 242 ( ) 26 (17 37) 167 (17 24) 1.8 (1. 2.5) 12 (6.4 16) WHO regions Africn Region ( ) 275 ( ) 834 (71 969) 84 (72 98) 11 (88 12) 11 (8.9 13) Region of the Americs (25 287) 27 (25 29) 32 (29 35) 3.2 ( ) 11 (1 12) 1.1 (1. 1.2) Estern Mediterrnen Region ( ) 116 (86 149) 13 (9.5 17) 2( ) 39(3 5) 6( ) Europen Region ( ) 36 (33 38) 27 (23 31) 3( ) 12 (11 14) 14 (12 15) South-Est Asi Region ( ) 246 ( ) 227 (159 37) 12 (8.2 16) 2 (15 25) 1 (7.9 13) Western Pcific Region ( ) 86 (78 94) 34 (29 4) 1.8 ( ) 1 (88 12) 5.5 ( ) Globl ( ) 142 ( ) 1 17 ( ) 16 (14 18) 58 (52 64) 7.9 ( ) Rtes re per 1 popultion. Dt for ll yers cn be downloded from GLOBAL TUBERCULOSIS REPORT 216 :: 185

197 :: TABLE A4.2 Estimtes of TB mortlity, 215. Deths from TB mong HIV-positive people re officilly clssified s deths cused by HIV/AIDS in the Interntionl Clssifiction of Diseses. Popultion (millions) Number (thousnds) Rte Number (thousnds) Rte Number (thousnds) Afghnistn (7.1 18) 37 (22 55).17 (.14.21).53 (.44.63) 12 (7.3 18) 37 (22 56) Albni 3.1 (<.1.15).35 (.22.51) <.1 (<.1 <.1) <.1 (.17).12 (<.1.17).4 (.25.59) Algeri ( ) 8.2 (5.3 12).35 (<.1.13) <.1 (.32) 3.3 ( ) 8.2 (5.4 12) Americn Smo < 1 <.1 (<.1 <.1).68 (.42 1.) ( ) ( <.1) <.1(<.1 <.1).68(.42 1.) Andorr < 1 <.1 (<.1 <.1).54 (.33.79) <.1 (<.1 <.1).54 (.33.79) Angol (6.6 17) 45 (27 67) 7.2 (1.6 17) 29 (6.5 67) 18 (1 29) 73 (41 115) Anguill < 1 Antigu nd Brbud < 1 <.1 (<.1 <.1) 1.3 ( ) <.1 ( <.1).28 ( 1.4) <.1 (<.1 <.1) 1.6 (.9 2.5) Argentin 43.7 (.67.73) 1.6 ( ).1 (<.1.52).24 ( 1.2).81 ( ) 1.9 ( ) Armeni 3.92 (.77.11) 3 ( ).14 (<.1.74).46 ( 2.4).11 (.67.15) 3.5 ( ) Arub < 1 <.1 (<.1 <.1) 1( ) <.1 (<.1 <.1) 1 ( ) Austrli (.44.44).18 (.18.19) <.1 (.19) <.1 ( <.1).48 (.38.59).2 (.16.25) Austri 9.78 (.77.79).91 (.9.92) <.1 (.1) <.1(.12).8(.74.86).94(.87 1.) Azerbijn 1.38 (.35.42).39 (.36.43).2 (<.1.55).21 (<.1.56).58 (.34.89).6 (.35.91) Bhms < 1 <.1 (<.1 <.1).49 (.49.49) <.1 (<.1 <.1).93 ( ) <.1 (<.1 <.1) 1.4 ( ) Bhrin 1 <.1 (<.1 <.1).44 (.38.5) <.1 ( <.1).11 (.56) <.1 (<.1.12).55 (.28.9) Bngldesh (43 11) 45 (27 68).23 (.19.29).14 (.12.18) 73 (44 11) 45 (27 68) Brbdos < 1 <.1 (<.1 <.1).33 (.33.34) <.1 (<.1 <.1).33 (.33.34) Belrus 9.45 (.42.49) 4.8 ( ).72 (.21.15).76 ( ).53 (.46.6) 5.5 ( ) Belgium (.52.55).47 (.46.49).11 (<.1.55).1 (.49).65 (.38.98).57 (.34.87) Belize < 1 <.1 (<.1 <.1) 2.4 ( ) <.1 (<.1.1).85 (<.1 2.9).12 (<.1.18) 3.3 ( ) Benin 11 1 ( ) 9.5 (5.7 14).29 (.11.56) 2.7 (1. 5.2) 1.3 ( ) 12 (7.9 17) Bermud < 1 Bhutn < 1.12 (.79.17) 16 (1 22).24 (.18.3) 3.1 ( ).14 (.1.2) 19 (13 25) Bolivi (Plurintionl Stte of) (.22.5) 3.2 (2. 4.6).17 (.1.26) 1.6 ( ).51 (.37.69) 4.8 ( ) Bonire, Sint Eusttius nd Sb < 1 <.1 (<.1 <.1) <.1 (<.1.13) <.1 (<.1 <.1) <.1 (<.1.13) Bosni nd Herzegovin 4.12 (.1.13) 3 ( ) <.1 (<.1 <.1) <.1 ( <.1).12 (.1.13) 3.1 ( ) Botswn 2.59 (.35.9) 26 (15 4) 1.4 ( ) 63 (3 11) 2 ( ) 9 (53 136) Brzil ( ) 2.7 ( ) 2.2 ( ) 1.1 ( ) 7.7 (6.5 9.) 3.7 ( ) British Virgin Islnds < 1 Brunei Drusslm < 1.23 (.21.25) 5.3 ( ).23 (.21.25) 5.3 ( ) Bulgri 7.9 (.88.92) 1.3 ( ) <.1 ( <.1) ( <.1).9 (.88.93) 1.3 ( ) Burkin Fso ( ) 9 (5.4 14).27 (.12.48) 1.5 ( ) 1.9 ( ) 11 (6.7 15) Burundi (1.6 4.) 24 (14 36).66 ( ) 5.9 (2.9 1) 3.3 ( ) 3 (19 43) Cbo Verde < 1.27 (.26.29) 5.3 ( ).37 (.24.51) 7 ( ).64 (.51.79) 12 (9.8 15) Cmbodi (6.1 12) 55 (39 74).44 (.19.79) 2.8 (1.2 5.) 9.1 (6.5 12) 58 (42 77) Cmeroon (4.1 1) 3 (18 45) 6.2 ( ) 27 (15 42) 13 (9. 18) 56 (39 77) Cnd (.1.11).29 (.29.3).19 (<.1.96) <.1 (.27).12 (.78.18).35 (.22.51) Cymn Islnds < 1 Centrl Africn Republic ( ) 45 (26 7) 2.7 (1. 5.3) 55 (2 17) 4.9 ( ) 11 (58 156) Chd ( ) 23 (13 35) 2.5 (2. 3.) 18 (14 21) 5.7 ( ) 4 (3 52) Chile (.46.47) 2.6 ( ).2 (<.1.97).11 (.54).49 (.43.54) 2.7 (2.4 3.) Chin (34 37) 2.6 ( ) 2.6 ( ).19 (<.1.33) 38 (36 4) 2.8 ( ) Chin, Hong Kong SAR 7.18 (.18.18) 2.5 ( ) <.1 (<.1 <.1) <.1 (<.1.11).19 (.18.19) 2.6 ( ) Chin, Mco SAR < 1.35 (.22.51) 5.9 ( ) <.1 (<.1 <.1) <.1 (<.1.15).35 (.22.51) 6 ( ) Colombi 48 1 (.99 1.) 2.1 ( ).42 (.13.88).87 ( ) 1.4( ) 3( ) Comoros < 1.61 (.36.92) 7.8 (4.6 12) <.1 (<.1 <.1).38 (.16.68).64 (.39.95) 8.1 (4.9 12) Congo ( ) 49 (29 75) 2.4 (2. 2.9) 53 (44 63) 4.7 ( ) 12 (79 129) Cook Islnds < 1 <.1 (<.1 <.1) 1.4 ( ) ( ) ( ) <.1(<.1 <.1) 1.4( ) Cost Ric 5.49 (.46.52) 1 ( ) <.1 (<.1.25).15 (<.1.52).56 (.44.71) 1.2 ( ) Côte d'ivoire 23 5 (3. 7.5) 22 (13 33) 2.5 ( ) 11 (4.9 2) 7.5 (4.9 11) 33 (22 46) Croti 4.33 (.33.33).78 (.78.78) <.1 ( <.1) <.1(.1).34(.32.36).8(.75.86) Cub (.46.48).41 (.41.42).1 (<.1.45) <.1 (.39).57 (.35.84).5 (.31.74) Curço < 1 <.1 (<.1 <.1).15 (<.1.22) <.1 ( <.1).25 ( 1.2) <.1 (<.1 <.1).4 (<.1 1.3) Cyprus 1 <.1 (<.1 <.1).1 (<.1.11) <.1 ( <.1) <.1 ( <.1) <.1 (<.1 <.1).11 (<.1.16) Czechi (.39.39).37 (.37.37) <.1 ( <.1) <.1 ( <.1).4 (.38.42).38 (.36.4) Democrtic People's Republic of Kore Mortlity (HIV-negtive people) Mortlity (HIV-positive people) Mortlity (HIV-negtive nd HIV-positive people) b (1 22) 61 (4 87).37 (.16.65).15 (<.1.26) 16 (1 22) 62 (4 88) Democrtic Republic of the Congo (3 77) 66 (39 99) 16 (13 2) 21 (17 26) 67 (45 93) 87 (59 12) Denmrk 6.2 (.19.21).35 (.33.37) <.1 ( <.1) <.1 (.12).21 (.18.25).38 (.31.45) Djibouti < 1.35 (.23.49) 39 (26 56).35 (<.1.11) 4 (.26 13).38 (.25.54) 43 (28 61) Dominic < 1 <.1 (<.1 <.1) 4.7 ( ) ( ) ( ) <.1(<.1 <.1) 4.7( ) Dominicn Republic (.27.77) 4.6 ( ).38 (.12.78) 3.6( ).87(.5 1.3) 8.2(4.8 13) Rte Rtes re per 1 popultion. b All clcultions re mde before numbers re rounded. 186 :: GLOBAL TUBERCULOSIS REPORT 216 Dt for ll yers cn be downloded from

198 :: TABLE A4.2 Estimtes of TB mortlity, 215. 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 (.41.59) 3.1 ( ).3 (.13.54) 1.9 ( ).8 (.59 1.) 4.9 ( ) Egypt (.2.24).24 (.21.26).18 (.12.25) <.1 (<.1 <.1).24 (.21.26).26 (.23.28) El Slvdor 6.12 (.85.15) 1.9 ( ).24 (<.1.12).39 ( 1.9).14 (.78.22) 2.3 ( ) Equtoril Guine < 1.63 (.4.92) 7.5 (4.8 11).12 (.32.27) 14 (3.8 32).18 (.83.33) 22 (9.8 39) Eritre 5.6 ( ) 12 (5.3 2).53 (.18.11) 1 (.34 2.).66 ( ) 13 (6.2 21) Estoni 1.25 (.25.25) 1.9 ( ) <.1 (<.1.15).25 ( 1.2).28 (.21.37) 2.2 ( ) Ethiopi (15 38) 26 (15 38) 3.9 ( ) 4 ( ) 29 (19 42) 3 (19 43) Fiji < 1.64 (.63.65) 7.1 (7. 7.3) <.1 (<.1 <.1).17 (<.1.54).65 (.62.68) 7.3 (7. 7.6) Finlnd 6.37 (.37.37).68 (.67.68) <.1 (<.1 <.1) <.1 ( <.1).38 (.36.4).69 (.66.72) Frnce (.49.55).8 (.76.85).56 (<.1.27) <.1 (.41).57 (.43.73).89 ( ) French Polynesi < 1 <.1 (<.1 <.1) 1.5 ( ) <.1 (<.1 <.1) 1.5 ( ) Gbon ( ) 65 (39 97).54 (<.1.15) 3.2 ( ) 1.2 ( ) 68 (42 11) Gmbi 2.4 (.24.59) 2 (12 3).15 (.8.24) 7.5 (4. 12).54 (.37.76) 27 (18 38) Georgi 4.16 (.13.19) 3.9 ( ).55 (.31.85) 1.4 ( ).21 (.17.26) 5.3 ( ) Germny (.31.32).39 (.39.4).26 (<.1.13) <.1 (.16).34 (.28.42).43 (.34.52) Ghn 27 1 (4.6 18) 37 (17 65) 5.1 ( ) 19 (15 22) 15 (9.2 23) 56 (34 83) Greece (.86.98).84 (.79.89) <.1 (.13) <.1 (.12).94 (.86.1).86 (.78.95) Greenlnd < 1 <.1 (<.1.11) 13 (8.4 2) <.1 (<.1.11) 13 (8.4 2) Grend < 1 <.1 (<.1 <.1).97 (.96.98) <.1 ( <.1).29 ( 1.4) <.1 (<.1 <.1) 1.3 (.6 2.1) Gum < 1 <.1 (<.1.11) 4.2 ( ) <.1 (<.1 <.1) <.1 (<.1 <.1) <.1 (<.1.11) 4.2 ( ) Guteml (.3.35) 2 ( ).5 (<.1.14).31 (<.1.85).37 (.3.45) 2.3 ( ) Guine ( ) 28 (17 43) 1.9 ( ) 15 (1 22) 5.5 ( ) 44 (3 59) Guine-Bissu ( ) 85 (49 129).95 ( ) 51 (43 61) 2.5 ( ) 136 (98 18) Guyn < 1.11 (.93.12) 14 (12 15).33 (<.1.74) 4.4 ( ).14 (.11.18) 18 (14 23) Hiti 11 2 (1.2 3.) 18 (11 28).66 ( ) 6.2 (1.1 15) 2.6 (1.6 4.) 25 (15 37) Hondurs 8.85 (.85.86) 1.1 (1. 1.1).67 (.27.13).83 ( ).15 (.11.21) 1.9 ( ) Hungry 1.76 (.76.76).77 (.77.77) <.1 ( <.1) <.1 ( <.1).78 (.74.82).79 (.75.83) Icelnd < 1 <.1 (<.1 <.1) 2.1 ( ) ( <.1) ( ) <.1 (<.1 <.1) 2.1 ( ) Indi (38 59) 36 (29 45) 37 (21 57) 2.8 ( ) 51 (41 63) 39 (32 48) Indonesi (67 15) 4 (26 57) 26 (2 34) 1 (7.6 13) 13 (92 17) 5 (36 67) Irn (Islmic Republic of) ( ) 1.7 ( ).71 (.29.13) <.1 (<.1.16) 1.4 (.96 2.) 1.8 ( ) Irq ( ) 2.4 (<.1 8.9) <.1 (<.1 <.1) <.1 (<.1 <.1).86 ( ) 2.4 (<.1 8.9) Irelnd 5.17 (.17.17).36 (.36.36) <.1 (<.1 <.1) <.1 (<.1 <.1).19 (.18.2).41 (.39.44) Isrel 8.16 (.15.16).19 (.19.2) <.1 (.12) <.1(.15).18(.12.26).22(.15.32) Itly 6.33 (.32.33).55 (.54.55).28 (<.1.14) <.1 (.23).35 (.28.43).59 (.47.73) Jmic 3 <.1 (<.1 <.1).24 (.24.24) <.1 (<.1.14).21 (<.1.49).13 (<.1.2).45 (.25.71) Jpn (3. 3.3) 2.5 ( ).12 (<.1.59) <.1 ( <.1) 3.2 (3. 3.3) 2.5 ( ) Jordn 8.27 (.26.27).35 (.35.36) <.1 (<.1 <.1) ( ).27(.26.27).35(.35.36) Kzkhstn ( ) 7.8 ( ).69 (<.1.22).39 (<.1 1.2) 1.4 ( ) 8.2 (6.6 1) Keny 46 9 (6.1 12) 2 (13 27) 7.2 (.71 21) 16 (1.5 45) 16 (7.1 29) 35 (15 63) Kiribti < 1.3 (.21.4) 27 (19 36) <.1 (<.1 <.1).47 (.18.9).3 (.22.41) 27 (19 36) Kuwit 4 <.1 (<.1 <.1).14 (.14.14) <.1 ( <.1) <.1 ( <.1) <.1 (<.1 <.1).15 (.13.17) Kyrgyzstn 6.68 (.67.7) 12 (11 12).44 (<.1.14).74 (<.1 2.4).73 (.66.81) 12 (11 14) Lo People's Democrtic Republic (2. 5.1) 49 (29 75).25 (.14.39) 3.6 (2. 5.7) 3.6 ( ) 53 (32 78) Ltvi 2.63 (.62.63) 3.2 ( ).27 (<.1.14) 1.4 ( 6.9).9 (.32.18) 4.6 ( ) Lebnon 6.61 (.38.9) 1 ( ) <.1 (<.1 <.1) <.1 ( <.1).63 (.39.91) 1.1 ( ) Lesotho ( ) 55 (29 89) 4.8 (3. 7.) 223 ( ) 5.9 (4. 8.3) 279 ( ) Liberi ( ) 7 (41 17).84 (.7 1.) 19 (16 22) 4( ) 89 (59 125) Liby 6.68 (.4 1.) 11 (6.3 16).22 (.12.35).35 (.19.56).7 ( ) 11 (6.7 17) Lithuni 3.23 (.23.23) 7.9 (7.8 8.) <.1 (<.1.39).27 ( 1.3).24 (.21.26) 8.2 ( ) Luxembourg < 1 <.1 (<.1 <.1).16 (.16.16) <.1 ( <.1) <.1 (.34) <.1 (<.1 <.1).23 (<.1.45) Mdgscr (7.1 18) 49 (29 75) 1.5 ( ) 6.3 ( ) 13 (8.5 2) 56 (35 81) Mlwi ( ) 13 (7.7 21) 6.6 (3.5 11) 38 (2 62) 8.9 (5.5 13) 52 (32 76) Mlysi ( ) 7.9 (4.5 12).23 (.59.52).77 ( ) 2.6 (1.6 4.) 8.7 (5.1 13) Mldives < 1.2 (.16.23) 5.4 ( ) <.1 (<.1 <.1) <.1 (<.1 <.1).2 (.16.23) 5.4 ( ) Mli ( ) 9.4 (5.6 14).44 (.28.64) 2.5 ( ) 2.1 ( ) 12 (7.9 17) Mlt < 1 <.1 (<.1 <.1).24 (.24.24) <.1 (<.1 <.1).24 (<.1.77) <.1 (<.1 <.1).48 (.17.95) Mrshll Islnds < 1.23 (.16.32) 44 (3 6) <.1 ( <.1).13 (<.1.41).23 (.16.32) 44 (3 6) Muritni 4.84 (.5 1.3) 21 (12 31).14 (.54.27) 3.5 ( ).98 ( ) 24 (15 35) Muritius 1.19 (.19.19) 1.5 ( ).13 (<.1.21) 1( ).32(.26.39) 2.5(2. 3.1) Mexico ( ) 2.1 (2. 2.1).51 (.3 1.7).4 (<.1 1.3) 3.1 ( ) 2.5 ( ) Micronesi (Federted Sttes of) < 1.14 (<.1.2) 14 (8.9 19).14 (<.1.2) 14 (8.9 19) Rte Rtes re per 1 popultion. b All clcultions re mde before numbers re rounded. Dt for ll yers cn be downloded from GLOBAL TUBERCULOSIS REPORT 216 :: 187

199 :: TABLE A4.2 Estimtes of TB mortlity, 215. 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 3.64 (.42.91) 22 (14 31) <.1 (<.1 <.1) <.1 (<.1.17).64 (.42.92) 22 (14 31) Montenegro < 1 <.1 (<.1 <.1).41 (.38.44) <.1 (<.1 <.1) <.1 (<.1.1) <.1 (<.1 <.1).46 (.4.52) Montserrt < 1 <.1 (<.1 <.1) 21 (2 22) <.1 (<.1 <.1) 21 (2 22) Morocco (.43 13) 9.4 (.13 37).14 (.44.3).42 (.13.88) 3.4 (.62 13) 9.8 (.18 38) Mozmbique (12 32) 74 (43 115) 34 (21 5) 12 (73 178) 54 (38 74) 194( ) Mynmr (16 4) 49 (3 74) 4.8 ( ) 9 (6.4 12) 31 (21 45) 58 (38 83) Nmibi 2.78 ( ) 32 (21 45).88 ( ) 36 ( ) 1.7 ( ) 68 (22 138) Nuru < 1 <.1 (<.1 <.1) 9.2 (5.7 14) <.1 (<.1 <.1) 9.2 (5.7 14) Nepl ( ) 2 (14 26).5 (.39.62) 1.7 ( ) 6.1 (4.4 8.) 21(15 28) Netherlnds (.33.35).2 (.2.21) <.1 (<.1.47) <.1 (.28).44 (.22.73).26 (.13.43) New Cledoni < 1 <.1 (<.1 <.1) 2( ) <.1 (<.1 <.1) 2 ( ) New Zelnd 5.1 (.1.1).22 (.22.22) <.1 ( <.1) ( <.1).1 (<.1.11).23 (.22.24) Nicrgu 6.15 (.12.19) 2.5 ( ).28 (<.1.86).46 (<.1 1.4).18 (.13.24) 3 (2.1 4.) Niger ( ) 19 (11 29).37 (.25.51) 1.9 ( ) 4.2 ( ) 21 (13 31) Nigeri (96 29) 99 (53 16) 57 (43 74) 31 (24 4) 24 (15 35) 13(82 19) Niue < 1 <.1 (<.1 <.1) 3.5 (2. 5.4) <.1 (<.1 <.1) 3.5 (2. 5.4) Northern Mrin Islnds < 1 <.1 (<.1 <.1) 4.8 (3. 7.) ( <.1) <.1 (<.1 <.1) <.1 (<.1 <.1) 4.8 (3. 7.) Norwy 5.11 (.11.11).21 (.2.22) <.1 ( <.1) <.1(.1).12(<.1.15).23(.18.29) Omn 4.24 (.15.34).52 (.33.76) <.1 ( <.1) <.1( <.1).24(.15.35).54(.34.77) Pkistn (9.3 11) 23 (4.9 56) 1.6 ( ).83 (.6 1.1) 46 (1 11) 24 (5.5 57) Plu < 1 <.1 (<.1 <.1) 6.2 ( ) ( ) <.1 (<.1 <.1) <.1 (<.1 <.1) 6.2 ( ) Pnm 4.24 (.22.25) 6.1 ( ).39 (<.1.14) 1 (<.1 3.5).28 (.21.36) 7 ( ) Ppu New Guine ( ) 4 (24 61).67 (.4 1.) 8.8 (5.2 13) 3.7 ( ) 49 (32 7) Prguy 7.26 (.22.31) 4 ( ).35 (<.1.11).53 (<.1 1.7).3 (.23.38) 4.5 ( ) Peru 31 2 ( ) 6.2 ( ).49 (.34.67) 1.6 ( ) 2.5 (2. 2.9) 7.8 ( ) Philippines (8.8 19) 13 (8.7 19).44 (.24.7).44 (.24.7) 14 (9.2 2) 14 (9.1 2) Polnd (.52.57) 1.4 ( ).19 (<.1.93) <.1 (.24).56 (.51.62) 1.5 ( ) Portugl 1.21 (.21.22) 2.1 (2. 2.1).46 (<.1.23).45 ( 2.2).26 (.15.4) 2.5 ( ) Puerto Rico 4 <.1 (<.1.1).27 (.27.27) <.1 (<.1 <.1) <.1 (.13).11 (<.1.14).31 (.25.38) Qtr 2 <.1 (<.1.11).32 (.19.49) <.1 ( <.1) ( <.1) <.1 (<.1.11).32 (.19.49) Republic of Kore ( ) 5.1 ( ).46 (.33) <.1 (.65) 2.6 ( ) 5.2 ( ) Republic of Moldov 4.31 (.3.33) 7.7 ( ).18 (.11.27) 4.5 ( ).49 (.42.58) 12 (1 14) Romni ( ) 5.5 ( ).63 (<.1.2).32 (<.1 1.) 1.1 (1. 1.2) 5.8 ( ) Russin Federtion (15 16) 11 (1 11) 1.5 (<.1 7.4) 1 ( 5.2) 17 (13 21) 12 (8.9 15) Rwnd (.26.67) 3.8 ( ).28 (.1.97) 2.4 (<.1 8.3).72 ( ) 6.2 (2.4 12) Sint Kitts nd Nevis < 1 <.1 (<.1 <.1) 2.5 ( ) <.1 ( <.1) <.1 (.46) <.1 (<.1 <.1) 2.6 ( ) Sint Luci < 1 <.1 (<.1 <.1).74 (.67.82) <.1 (<.1 <.1).22 (<.1.5) <.1 (<.1 <.1).97 ( ) Sint Vincent nd the Grendines < 1 <.1 (<.1 <.1) 1.5 ( ) <.1 ( <.1).14 (.69) <.1 (<.1 <.1) 1.6 (1.3 2.) Smo < 1 <.1 (<.1 <.1).93 ( ) <.1 (<.1 <.1).93 ( ) Sn Mrino < 1 So Tome nd Principe < 1 <.1 (<.1.13) 3.6 ( ) <.1 (.15) 1.3 ( 8.) <.1 (<.1.22) 5 (1.1 12) Sudi Arbi ( ) 2.1 ( ).18 (<.1.9) <.1 (.28).68 ( ) 2.2 ( ) Senegl ( ) 23 (14 34).41 (.16.77) 2.7 (1. 5.1) 3.8 ( ) 25 (16 37) Serbi 9.11 (.99.12) 1.2 ( ) <.1 (<.1 <.1) <.1 (<.1 <.1).11 (.1.12) 1.3 ( ) Seychelles < 1 ( ) ( ) ( ) ( ) Sierr Leone ( ) 51 (3 76).82 (.4 1.4) 13 (6.2 21) 4.1 ( ) 63 (41 9) Singpore 6.7 (.58.83) 1.2 (1. 1.5) <.1 (<.1.3).11 (.53).76 (.57.98) 1.4 (1. 1.7) Sint Mrten (Dutch prt) < 1 <.1 (<.1 <.1).49 (.3.72) <.1 (<.1 <.1).49 (.3.72) Slovki 5.32 (.31.32).59 (.58.59) <.1 (<.1 <.1) ( ).32(.32.32).59(.58.59) Sloveni 2.16 (.15.16).75 (.75.76) <.1 (<.1 <.1) ( ).16(.15.16).75(.75.76) Solomon Islnds < 1.57 (.37.81) 9.8 (6.4 14).57 (.37.81) 9.8 (6.4 14) Somli 11 7 (4.1 11) 65 (38 98).21 (.15.28) 2 ( ) 7.2 (4.3 11) 67 (4 1) South Afric (21 29) 46 (39 53) 73 (27 14) 133 (5 256) 97 (49 16) 179 (9 297) South Sudn (2. 5.2) 28 (17 42).76 (.5 1.1) 6.1 ( ) 4.2 ( ) 34 (22 48) Spin (.26.27).57 (.57.58).54 (<.1.27).12 (.58).32 (.19.48).69 (.41 1.) Sri Lnk ( ) 5.6 ( ).11 (<.1.2) <.1 (<.1 <.1) 1.2 ( ) 5.7 (4.5 7.) Sudn (3.8 12) 18 (9.5 3).64 (.52.76) 1.6 ( ) 8 (4.4 13) 2 (11 31) Surinme < 1.14 (.14.15) 2.6 ( ).11 (<.1.24) 2( ).25(.16.37) 4.6( ) Swzilnd 1.4 (.23.61) 31 (18 48) 1.5 ( ) 12 (41 242) 1.9 ( ) 151 (66 271) Sweden 1.27 (.27.28).28 (.28.28) <.1 (.17) <.1 (.18).31 (.22.41).32 (.23.42) Switzerlnd 8.16 (.16.17).2 (.19.2) <.1 (<.1.22) <.1 (.26).21 (.11.34).25 (.13.41) Rte Rtes re per 1 popultion. b All clcultions re mde before numbers re rounded. 188 :: GLOBAL TUBERCULOSIS REPORT 216 Dt for ll yers cn be downloded from

200 :: TABLE A4.2 Estimtes of TB mortlity, 215. 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 (.19.22).11 (.1.12).21 (.19.22).11 (.1.12) Tjikistn 8.22 (.15.31) 2.6 ( ).34 (<.1.13).41 (<.1 1.5).25 (.16.37) 3 ( ) Thilnd (6.9 1) 12 (1 15) 5.4 ( ) 8 (4.9 12) 14 (11 17) 2 (16 25) The Former Yugoslv Republic of Mcedoni 2 <.1 (<.1 <.1).41 (.37.44) <.1 (<.1 <.1) ( <.1) <.1(<.1 <.1).41(.38.45) Timor-Leste ( ) 1 (6 151) <.1 (.19).32 ( 1.6) 1.2 ( ) 1 (6 151) Togo 7.46 (.28.7) 6.4 ( ).2 (.47.47) 2.8 ( ).67 (.4 1.) 9.1 (5.5 14) Tokelu < 1 Tong < 1 <.1 (<.1 <.1) 1.2 ( ) ( ) ( ) <.1(<.1 <.1) 1.2( ) Trinidd nd Tobgo 1.21 (.19.23) 1.5 ( ) <.1 (<.1.14).46 (.12 1.).27 (.21.34) 2 ( ) Tunisi (.49.57) 2.1 (.44 5.) <.1 (<.1.13) <.1 (<.1.12).24 (.53.57) 2.2 ( ) Turkey (.63.85).94 (.8 1.1).15 (<.1.44) <.1 ( <.1).75 (.64.87).96 ( ) Turkmenistn 5.46 (.42.49) 8.5 ( ).46 (.42.49) 8.5 ( ) Turks nd Cicos Islnds < 1 <.1 (<.1 <.1) 1(.2 2.6) <.1(<.1 <.1) 1(.2 2.6) Tuvlu < 1 <.1 (<.1 <.1) 19 (12 28) ( <.1) <.1(<.1 <.1) <.1(<.1 <.1) 19 (12 28) Ugnd ( ) 14 (8.5 21) 6.4 (1.7 14) 16 (4.3 36) 12 (6.1 2) 3 (16 5) Ukrine 45 5 ( ) 11 (11 11) 2.1 ( ) 4.7 ( ) 7.1 ( ) 16 (13 19) United Arb Emirtes 9.43 (.34.52).47 (.38.56) <.1 (<.1 <.1) <.1 (<.1 <.1).45 (.36.54).49 (.4.59) United Kingdom of Gret Britin nd Northern Irelnd 65.3 (.29.3).46 (.46.46).38 (<.1.21) <.1 (.32).34 (.23.46).52 (.36.71) United Republic of Tnzni 53 3 (13 53) 56 (25 99) 25 (16 35) 47 (31 66) 55 (35 79) 13 (65 148) United Sttes of Americ (.58.59).18 (.18.18).77 (<.1.38) <.1 (.12).66 (.47.89).21 (.15.28) Uruguy 3.69 (.65.73) 2 ( ).26 (<.1.6).75 ( ).95 (.69.13) 2.8 (2. 3.6) US Virgin Islnds < 1 Uzbekistn (2.3 3.) 8.8 (7.6 1).32 (.19.5) 1.1 ( ) 2.9 ( ) 9.8 (8.6 11) Vnutu < 1.17 (.11.24) 6.4 (4.2 9.).17 (.11.24) 6.4 (4.2 9.) Venezuel (Bolivrin Republic of) (.72.73) 2.3 ( ).18 (.25.48).58 (<.1 1.5).9 ( ) 2.9 ( ) Viet Nm (11 22) 17 (12 23) 1.1 (.2 2.7) 1.1 ( ) 17 (12 23) 18 (13 25) Wllis nd Futun Islnds < 1 West Bnk nd Gz Strip 5 <.1 (<.1 <.1) <.1 (<.1 <.1) <.1 (<.1 <.1) ( ) <.1(<.1 <.1) <.1(<.1 <.1) Yemen ( ) 5.9 (4. 8.).5 (.38.65).19 (.14.24) 1.6 ( ) 6( ) Zmbi 16 5 ( ) 31 (18 47) 12 (6.9 2) 77 (42 121) 17 (11 25) 18 (7 153) Zimbbwe ( ) 11 (6.3 16) 6.3 (2.2 13) 4 (14 81) 8(3.6 14) 51 (23 91) WHO regions Africn Region (35 56) 45 (35 57) 3 (23 36) 3 (24 37) 74(63 87) 75(63 88) Region of the Americs (17 2) 1.9 (1.8 2.) 5.9 ( ).59 (.42.79) 24 (22 27) 2.5 ( ) Estern Mediterrnen Region (38 14) 12 (5.8 21) 3( ).46(.38.54) 83(4 14) 13(6.2 22) Europen Region (31 33) 3.5 ( ) 4.9 (1.5 1).54 ( ) 37 (33 41) 4.1 ( ) South-Est Asi Region (6 83) 37 (31 43) 74 (56 95) 3.9 ( ) 79 (67 91) 41 (35 47) Western Pcific Region (81 98) 4.8 ( ) 5.7 ( ).31 (.2.44) 95 (87 1) 5.1 ( ) Globl ( ) 19 (17 21) 39 (32 46) 5.3 ( ) 1 8 (1 6 2 ) 24 (22 27) Rte Rtes re per 1 popultion. b All clcultions re mde before numbers re rounded. Dt for ll yers cn be downloded from GLOBAL TUBERCULOSIS REPORT 216 :: 189

201 :: 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 ( 23) Americn Smo Andorr 215 Surveillnce Ntionl ( 84) 215 Surveillnce Ntionl ( ) Angol Anguill Antigu nd Brbud Argentin 25 Survey Ntionl 2.3 ( ) 25 Survey Ntionl 18 (11 25) Armeni 27 Survey Ntionl 11 (8. 14) 27 Survey Ntionl 47 (41 53) Arub Austrli 215 Surveillnce Ntionl 3.6 ( ) 215 Surveillnce Ntionl 24 (9.4 45) Austri 215 Surveillnce Ntionl 2.3 ( ) 215 Surveillnce Ntionl 17 (2.1 48) Azerbijn 213 Survey Ntionl 13 (1 16) 213 Survey Ntionl 29 (23 35) Bhms 212 Surveillnce Ntionl 11 (2.4 29) 215 Surveillnce Ntionl 5 (1.3 99) Bhrin 212 Surveillnce Ntionl 1.9 ( ) 212 Surveillnce Ntionl 1 (2.5 1) Bngldesh 211 Survey Ntionl 1.6 ( ) 211 Survey Ntionl 29 (24 34) Brbdos 214 Surveillnce Ntionl ( 71) 214 Surveillnce Ntionl ( ) Belrus 215 Surveillnce Ntionl 37 (35 39) 215 Surveillnce Ntionl 69 (66 72) 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) 214 Surveillnce Ntionl 8.1 (4.6 13) Bermud 212 Surveillnce Ntionl ( 84) 212 Surveillnce Ntionl ( ) Bhutn 215 Surveillnce Ntionl 38 (19 59) Bolivi (Plurintionl Stte of) 215 Surveillnce Ntionl 12 (9.5 16) Bonire, Sint Eusttius nd Sb 211 Surveillnce Ntionl 1 (2.5 1) Bosni nd Herzegovin 215 Surveillnce Ntionl.51 ( ) 213 Surveillnce Ntionl 1.6 (<.1 8.5) 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 (5.9 1) British Virgin Islnds Brunei Drusslm 215 Surveillnce Ntionl ( 2.3) 215 Surveillnce Ntionl ( 37) Bulgri 212 Surveillnce Ntionl 3.3 (2.1 5.) 212 Surveillnce Ntionl 25 (18 33) Burkin Fso Burundi Cbo Verde Cmbodi 27 Survey Ntionl 1.8 ( ) 27 Survey Ntionl 11 (1.4 2) Cmeroon Cnd 214 Surveillnce Ntionl 1.4 ( ) 214 Surveillnce Ntionl 1.8 (<.1 9.6) Cymn Islnds 213 Surveillnce Ntionl ( 71) 213 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 27 Survey Ntionl 6.6 ( ) 27 Survey Ntionl 3 (25 34) 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 215 Surveillnce Ntionl ( 98) 215 Surveillnce Ntionl ( ) Cost Ric 26 Survey Ntionl 1.9 ( 3.9) 212 Surveillnce Ntionl 9.1 (1.1 29) Côte d'ivoire 26 Survey Ntionl 3.1 (1. 5.3) Croti 215 Surveillnce Ntionl ( 1.4) 215 Surveillnce Ntionl ( 16) Cub 212 Surveillnce Ntionl 2.2 ( ) 214 Surveillnce Ntionl 4.2 (.51 14) Curço 214 Surveillnce Ntionl ( 6) 214 Surveillnce Ntionl ( ) Cyprus 215 Surveillnce Ntionl ( 1) 215 Surveillnce Ntionl ( ) Czechi 214 Surveillnce Ntionl 1.7 (.56 4.) 214 Surveillnce Ntionl 13 (1.7 4) Democrtic People's Republic of Kore 214 Survey Sub-ntionl 2.2 ( ) 214 Survey Sub-ntionl 16 (8.4 24) Democrtic Republic of the Congo Denmrk 214 Surveillnce Ntionl.51 (<.1 2.8) 214 Surveillnce Ntionl ( 19) 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. 19 :: GLOBAL TUBERCULOSIS REPORT 216 Dt for ll yers cn be downloded from

202 :: 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 34 (21 46) Dominic 213 Surveillnce Ntionl ( 98) 213 Surveillnce Ntionl ( ) Dominicn Republic Ecudor 22 Survey Ntionl 7.3 ( ) 212 Surveillnce Ntionl 28 (25 31) Egypt 211 Survey Ntionl 14 (12 16) 215 Surveillnce Ntionl 23 (2 27) El Slvdor 21 Survey Ntionl 1.1 ( ) 214 Surveillnce Ntionl 4.1 ( ) Equtoril Guine Eritre Estoni 215 Surveillnce Ntionl 16 (1 23) 215 Surveillnce Ntionl 54 (37 71) Ethiopi 25 Survey Ntionl 2.7 (1.5 4.) 25 Survey Ntionl 14 (5.6 23) Fiji 26 Surveillnce Ntionl ( 8.2) 26 Surveillnce Ntionl ( 98) Finlnd 215 Surveillnce Ntionl 5.1 ( ) 215 Surveillnce Ntionl ( 6) 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 215 Surveillnce Ntionl 12 (11 14) 215 Surveillnce Ntionl 33 (29 37) Germny 215 Surveillnce Ntionl 2.2 ( ) 215 Surveillnce Ntionl 23 (16 3) Ghn 215 Surveillnce Ntionl 7.2 (5.7 9.) Greece 21 Surveillnce Ntionl 1.5 (<.1 8.) 21 Surveillnce Ntionl 9.1 (.23 41) Greenlnd Grend Gum 212 Surveillnce Ntionl ( 11) 212 Surveillnce Ntionl ( ) Guteml 22 Survey Ntionl 4.2 ( ) 22 Survey Ntionl 29 (21 37) Guine Guine-Bissu Guyn Hiti Hondurs 24 Survey Ntionl 2.2 ( ) 24 Survey Ntionl 21 (1 31) Hungry 21 Surveillnce Ntionl 2.9 ( ) 21 Surveillnce Ntionl 8.1 (3.3 16) Icelnd 215 Surveillnce Ntionl ( 71) 215 Surveillnce Ntionl ( ) 21, Indi 24, 26, Multiple surveys 2.5 ( ) 26, 29 Multiple surveys 16 (14 18) 29 Indonesi 24, 26, 21 Multiple surveys 2.8 ( ) 26, 21 Multiple surveys 16 (1 2) Irn (Islmic Republic of) 214 Survey Ntionl 1.3 (.6 2.) 214 Survey Ntionl 12 (6.1 19) Irq 213 Survey Ntionl 6.1 ( ) 213 Survey Ntionl 24 (16 32) Irelnd 215 Surveillnce Ntionl 1.1 (<.1 5.8) 215 Surveillnce Ntionl ( 31) Isrel 215 Surveillnce Ntionl 8.8 (4.8 15) 215 Surveillnce Ntionl 33 (4.3 78) 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 25 (24 26) 215 Surveillnce Ntionl 43 (42 45) Keny 214 Survey Ntionl 1.3 ( ) 214 Surveillnce Ntionl 9.4 (8.7 1) Kiribti Kuwit 215 Surveillnce Ntionl 1.7 ( ) 215 Surveillnce Ntionl ( ) Kyrgyzstn 211 Survey Ntionl 32 (28 36) 213 Surveillnce Ntionl 56 (53 59) Lo People's Democrtic Republic Ltvi 215 Surveillnce Ntionl 7.9 (5.6 11) 215 Surveillnce Ntionl 3 (21 41) 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 (9.3 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 ( 14) Mlwi 211 Survey Ntionl.75 ( 1.6) 211 Survey Ntionl 6.4 ( ) 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 yers cn be downloded from GLOBAL TUBERCULOSIS REPORT 216 :: 191

203 :: 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 Mlysi 214 Surveillnce Ntionl 1.5 ( ) 214 Surveillnce Ntionl 3.1 ( ) Mldives 215 Surveillnce Ntionl ( 52) Mli Mlt 215 Surveillnce Ntionl ( 25) 215 Surveillnce Ntionl ( ) Mrshll Islnds 214 Surveillnce Ntionl ( 4.4) 215 Surveillnce Ntionl ( 41) Muritni Muritius 215 Surveillnce Ntionl 1.7 (.2 5.9) 215 Surveillnce Ntionl ( 71) Mexico 29 Survey Ntionl 2.6 ( ) 29 Survey Ntionl 11 (9.2 13) Micronesi (Federted Sttes of) Monco Mongoli 27 Survey Ntionl 2.2 ( ) 213 Surveillnce Ntionl 33 (29 38) Montenegro 215 Surveillnce Ntionl 1.9 (<.1 1) 215 Surveillnce Ntionl ( 6) Montserrt Morocco 214 Survey Ntionl 1 (.3 1.7) 214 Survey Ntionl 8.7 (4.8 13) Mozmbique 27 Survey Ntionl 3.7 (2.4 5.) 27 Survey Ntionl 2 (1.9 37) Mynmr 213 Survey Ntionl 5.1 (3.2 7.) 213 Survey Ntionl 27 (15 39) Nmibi 215 Survey Ntionl 5 ( ) 215 Survey Ntionl 12 (9.3 14) Nuru Nepl 211 Survey Ntionl 2.2 ( ) 211 Survey Ntionl 15 (9.2 22) Netherlnds 215 Surveillnce Ntionl 1.6 (.6 3.5) 215 Surveillnce Ntionl 18 (5.2 4) New Cledoni 214 Surveillnce Ntionl ( 28) 214 Surveillnce Ntionl ( 84) 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 214 Surveillnce Ntionl 5.3 (.13 26) 214 Surveillnce Ntionl ( 98) Norwy 215 Surveillnce Ntionl 2.6 (.86 6.) 215 Surveillnce Ntionl 4.8 (.12 24) Omn 214 Surveillnce Ntionl 3.5 ( ) 215 Surveillnce Ntionl ( 37) Pkistn 213 Survey Ntionl 4.2 ( ) 215 Surveillnce Ntionl 16 (15 17) Plu 213 Surveillnce Ntionl ( 41) 213 Surveillnce Ntionl ( ) Pnm 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 (4. 25) Peru 215 Surveillnce Ntionl 5.9 ( ) 215 Surveillnce Ntionl 21 (19 22) Philippines 212 Survey Ntionl 2.6 ( ) 212 Survey Ntionl 29 (21 38) Polnd 215 Surveillnce Ntionl.66 (.42.98) 215 Surveillnce Ntionl 3.7 ( ) Portugl 212 Surveillnce Ntionl.98 ( ) 212 Surveillnce Ntionl 6.9 (2.8 14) Puerto Rico 214 Surveillnce Ntionl ( 9.3) 215 Surveillnce Ntionl ( 98) Qtr 214 Surveillnce Ntionl 1.3 ( ) Republic of Kore 24 Survey Ntionl 3.7 (3. 4.5) 24 Survey Ntionl 17 (12 22) Republic of Moldov 215 Surveillnce Ntionl 32 (29 34) 215 Surveillnce Ntionl 69 (66 72) Romni 215 Survey Ntionl 3 ( ) 215 Survey Ntionl 12 (9.3 15) Russin Federtion 213 Oblsts 22 (14 25) 213 Oblsts 53 (4 59) Rwnd 215 Survey Ntionl 1.5 ( ) 215 Survey Ntionl 11 (3.3 18) Sint Kitts nd Nevis Sint Luci 213 Surveillnce Ntionl ( 52) 213 Surveillnce Ntionl ( ) Sint Vincent nd the Grendines 214 Surveillnce Ntionl ( 98) Smo 213 Surveillnce Ntionl ( 28) 213 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 (16 25) Senegl 214 Survey Ntionl.9 ( ) 214 Survey Ntionl 19 (12 25) Serbi 213 Surveillnce Ntionl 1.1 ( ) 213 Surveillnce Ntionl 4.7 (1.3 11) Seychelles 215 Surveillnce Ntionl ( 46) 215 Surveillnce Ntionl ( ) Sierr Leone Singpore 215 Surveillnce Ntionl 1 ( ) 215 Surveillnce Ntionl.99 (<.1 5.4) Sint Mrten (Dutch prt) Slovki 212 Surveillnce Ntionl ( 2.6) 212 Surveillnce Ntionl 3.7 (<.1 19) 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. 192 :: GLOBAL TUBERCULOSIS REPORT 216 Dt for ll yers cn be downloded from

204 :: 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 Sloveni 215 Surveillnce Ntionl ( 4.1) 215 Surveillnce Ntionl ( 41) Solomon Islnds 213 Surveillnce Ntionl ( 41) Somli 211 Survey Ntionl 8.7 (5.9 11) 211 Survey Ntionl 47 (29 65) South Afric 214 Survey Ntionl 3.5 ( ) 214 Survey Ntionl 7.1 ( ) South Sudn Spin 21, 25 Multiple surveys.44 ( ) 21, 25 Multiple surveys 7.1 (3.3 13) Sri Lnk 26 Survey Ntionl.54 ( 1.3) 213 Surveillnce Ntionl 1.7 ( ) Sudn Surinme 215 Surveillnce Ntionl 9.9 (4.1 19) 215 Surveillnce Ntionl 25 (.63 81) Swzilnd 29 Survey Ntionl 8 (3.1 13) 29 Survey Ntionl 36 (31 42) Sweden 215 Surveillnce Ntionl 4 ( ) 215 Surveillnce Ntionl 18 (3.8 43) Switzerlnd 215 Surveillnce Ntionl 3.2 ( ) 215 Surveillnce Ntionl 26 (9.1 51) Syrin Arb Republic 23 Survey Ntionl 8 (4.9 11) 215 Surveillnce Ntionl 18 (11 27) Tjikistn 214 Surveillnce Ntionl 14 (12 15) 214 Surveillnce Ntionl 77 (73 8) Thilnd 212 Survey Ntionl 2.2 ( ) 212 Survey Ntionl 24 (18 3) The Former Yugoslv Republic of Mcedoni Timor-Leste 215 Surveillnce Ntionl 2.4 (.65 6.) 215 Surveillnce Ntionl 6.7 (.17 32) Togo 213 Surveillnce Ntionl 12 (7. 19) Tokelu Tong Trinidd nd Tobgo Tunisi 215 Surveillnce Ntionl.54 (.2 1.2) 215 Surveillnce Ntionl 17 (7.2 32) Turkey 215 Surveillnce Ntionl 3.6 ( ) 215 Surveillnce Ntionl 21 (17 24) Turkmenistn 213 Survey Ntionl 14 (11 17) 213 Survey Ntionl 38 (31 46) Turks nd Cicos Islnds Tuvlu Ugnd 211 Survey Ntionl 1.6 ( ) 211 Survey Ntionl 12 (5.9 18) Ukrine 214 Survey Ntionl 25 (21 28) 214 Survey Ntionl 58 (53 64) 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 ( ) 27 Survey Ntionl 4.7 (.37 9.) United Sttes of Americ 215 Surveillnce Ntionl 1.5 ( ) 215 Surveillnce Ntionl 5.5 ( ) Uruguy 215 Surveillnce Ntionl.55 ( ) 215 Surveillnce Ntionl ( 17) US Virgin Islnds Uzbekistn 211 Survey Ntionl 24 (18 3) 211 Survey Ntionl 63 (54 71) Vnutu 26 Surveillnce Ntionl ( 12) Venezuel (Bolivrin Republic of) Viet Nm 212 Survey Ntionl 4.1 ( ) 215 Surveillnce Ntionl 25 (24 26) Wllis nd Futun Islnds West Bnk nd Gz Strip Yemen 211 Survey Ntionl 2.3 ( ) 211 Survey Ntionl 18 (11 25) Zmbi 28 Survey Ntionl 1.1 ( ) 28 Survey Ntionl 18 (11 26) Zimbbwe 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 yers cn be downloded from GLOBAL TUBERCULOSIS REPORT 216 :: 193

205 :: TABLE A4.4 TB cse notifictions, 215 Totl cses notified Notified % tested with rpid dignostics t time of dignosis % with known HIV sttus % pulmonry % bcteriologiclly confirmed mong pulmonry Afghnistn Albni Algeri Americn Smo Andorr Angol Anguill Antigu nd Brbud 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 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 New nd relpse cses Cyprus Czechi Democrtic People's Republic of Kore Democrtic Republic of the Congo Denmrk Includes cses for which the tretment history is unknown. 194 :: GLOBAL TUBERCULOSIS REPORT 216 Dt for ll yers cn be downloded from

206 :: TABLE A4.4 TB cse notifictions, 215 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 Frnce French Polynesi Gbon Gmbi Georgi Germny Ghn Greece Greenlnd Grend Gum Guteml Guine Guine-Bissu Guyn Hiti 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 Mli Includes cses for which the tretment history is unknown. Dt for ll yers cn be downloded from GLOBAL TUBERCULOSIS REPORT 216 :: 195

207 :: TABLE A4.4 TB cse notifictions, 215 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 Mynmr Nmibi Nuru Nepl Netherlnds New Cledoni New Zelnd Nicrgu Niger Nigeri Niue Northern Mrin Islnds 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 Sint Luci Sint Vincent nd the Grendines 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. 196 :: GLOBAL TUBERCULOSIS REPORT 216 Dt for ll yers cn be downloded from

208 :: TABLE A4.4 TB cse notifictions, 215 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 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 Includes cses for which the tretment history is unknown. Dt for ll yers cn be downloded from GLOBAL TUBERCULOSIS REPORT 216 :: 197

209 :: TABLE A4.5 Tretment outcomes by TB cse type, 214 nd tretment outcomes for MDR/RR-TB nd XDR-TB cses, 213 New nd relpse, 214 cohort Previously treted, excluding relpse, 214 cohort HIV-positive TB, 214 cohort MDR/RR-TB, 213 cohort XDR-TB, 213 cohort Cohort (Number) Success (%) Afghnistn Albni Algeri* Americn Smo Andorr 6 83 Angol Anguill* 1 1 Antigu nd Brbud Argentin Armeni Arub Austrli Austri Azerbijn* Bhms Bhrin Bngldesh Brbdos 5 1 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 Centrl Africn Republic* Chd* Chile Chin Chin, Hong Kong SAR Chin, Mco SAR Colombi Comoros Congo Cook Islnds* 3 Cost Ric Côte d'ivoire Croti Cub Curço Cohort (Number) Success (%) Cohort (Number) Success (%) Cohort (Number) Cyprus Success (%) Czechi Cohort (Number) Democrtic People's Republic of Kore Democrtic Republic of the Congo* Success (%) Relpses included in the previously treted cohort. 198 :: GLOBAL TUBERCULOSIS REPORT 216 Dt for ll yers cn be downloded from

210 :: TABLE A4.5 Tretment outcomes by TB cse type, 214 nd tretment outcomes for MDR/RR-TB nd XDR-TB cses, 213 New nd relpse, 214 cohort Previously treted, excluding relpse, 214 cohort HIV-positive TB, 214 cohort MDR/RR-TB, 213 cohort XDR-TB, 213 cohort Cohort (Number) Success (%) Cohort (Number) Success (%) Cohort (Number) Success (%) Cohort (Number) Success (%) Cohort (Number) Success (%) Denmrk Djibouti Dominic Dominicn Republic Ecudor Egypt El Slvdor Equtoril Guine Eritre Estoni Ethiopi* Fiji Finlnd Frnce French Polynesi Gbon Gmbi* Georgi Germny Ghn Greece Greenlnd Grend Gum Guteml Guine Guine-Bissu Guyn Hiti Hondurs Hungry Icelnd 9 89 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. Dt for ll yers cn be downloded from GLOBAL TUBERCULOSIS REPORT 216 :: 199

211 :: TABLE A4.5 Tretment outcomes by TB cse type, 214 nd tretment outcomes for MDR/RR-TB nd XDR-TB cses, 213 New nd relpse, 214 cohort Previously treted, excluding relpse, 214 cohort HIV-positive TB, 214 cohort MDR/RR-TB, 213 cohort XDR-TB, 213 cohort Cohort (Number) Success (%) Cohort (Number) Success (%) Cohort (Number) Success (%) Cohort (Number) Success (%) Cohort (Number) Mldives Mli Mlt 1 1 Mrshll Islnds Muritni Muritius Success (%) Mexico Micronesi (Federted Sttes of) Monco 3 1 Mongoli Montenegro Montserrt Morocco Mozmbique Mynmr Nmibi* Nuru Nepl Netherlnds New Cledoni 3 2 New Zelnd Nicrgu Niger Nigeri Niue* Northern Mrin Islnds 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 Sint Luci Sint Vincent nd the Grendines Smo Sn Mrino So Tome nd Principe Sudi Arbi Senegl Serbi Seychelles Sierr Leone Singpore Sint Mrten (Dutch prt)* 7 1 Slovki Relpses included in the previously treted cohort. 2 :: GLOBAL TUBERCULOSIS REPORT 216 Dt for ll yers cn be downloded from

212 :: TABLE A4.5 Tretment outcomes by TB cse type, 214 nd tretment outcomes for MDR/RR-TB nd XDR-TB cses, 213 New nd relpse, 214 cohort Previously treted, excluding relpse, 214 cohort HIV-positive TB, 214 cohort MDR/RR-TB, 213 cohort XDR-TB, 213 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 13 1 Trinidd nd Tobgo Tunisi Turkey Turkmenistn Turks nd Cicos Islnds 1 1 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* 2 1 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. Dt for ll yers cn be downloded from GLOBAL TUBERCULOSIS REPORT 216 :: 21

213

214 ISBN Ending TB by 23