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1 globl TUBERCULOSIS REPORT 218

2 GLOBAL TUBERCULOSIS REPORT 218

3 Globl Tuberculosis Report 218 ISBN World Helth Orgniztion 218 Some rights reserved. This work is vilble under the Cretive Commons Attribution-NonCommercil-ShreAlike 3. IGO licence (CC BY- NC-SA 3. IGO; Under the terms of this licence, you my copy, redistribute nd dpt the work for non-commercil purposes, provided the work is ppropritely cited, s indicted below. In ny use of this work, there should be no suggestion tht WHO endorses ny specific orgniztion, products or services. The use of the WHO logo is not permitted. If you dpt the work, then you must license your work under the sme or equivlent Cretive Commons licence. If you crete trnsltion of this work, you should dd the following disclimer long with the suggested cittion: This trnsltion ws not creted by the World Helth Orgniztion (WHO). WHO is not responsible for the content or ccurcy of this trnsltion. The originl English edition shll be the binding nd uthentic edition. Any medition relting to disputes rising under the licence shll be conducted in ccordnce with the medition rules of the World Intellectul Property Orgniztion. Suggested cittion. Globl tuberculosis report 218. Genev: World Helth Orgniztion; 218. Licence: CC BY-NC-SA 3. IGO. Ctloguing-in-Publiction (CIP) dt. CIP dt re vilble t Sles, rights nd licensing. To purchse WHO publictions, see To submit requests for commercil use nd queries on rights nd licensing, see Third-prty mterils. If you wish to reuse mteril from this work tht is ttributed to third prty, such s tbles, figures or imges, it is your responsibility to determine whether permission is needed for tht reuse nd to obtin permission from the copyright holder. The risk of clims resulting from infringement of ny third-prty-owned component in the work rests solely with the user. Generl disclimers. The designtions employed nd the presenttion of the mteril in this publiction do not imply the expression of ny opinion whtsoever on the prt of WHO concerning the legl sttus of ny country, territory, city or re or of its uthorities, or concerning the delimittion of its frontiers or boundries. Dotted nd dshed lines on mps represent pproximte border lines for which there my not yet be full greement. The mention of specific compnies or of certin mnufcturers products does not imply tht they re endorsed or recommended by WHO in preference to others of similr nture tht re not mentioned. Errors nd omissions excepted, the nmes of proprietry products re distinguished by initil cpitl letters. All resonble precutions hve been tken by WHO to verify the informtion contined in this publiction. However, the published mteril is being distributed without wrrnty of ny kind, either expressed or implied. The responsibility for the interprettion nd use of the mteril lies with the reder. In no event shll WHO be lible for dmges rising from its use. Designed by minimum grphics Cover designed by Irwin Lw Printed in Frnce WHO/CDS/TB/218.2

4 Contents Abbrevitions iv Acknowledgements v Executive Summry 1 Chpter 1. Introduction 7 Chpter 2. Globl commitments to end TB nd multisectorl ccountbility 9 Chpter 3. TB disese burden 27 Chpter 4. Dignosis nd tretment: TB, HIV-ssocited TB nd drug-resistnt TB 67 Chpter 5. TB prevention services 13 Chpter 6. Finncing for TB prevention, dignosis nd tretment 113 Chpter 7. Universl helth coverge, socil protection nd socil determinnts 131 Chpter 8. TB reserch nd development 149 Annexes 1. The WHO globl TB dtbse Country profiles for 3 high TB burden countries Regionl nd globl profiles TB burden estimtes, notifictions nd tretment outcomes 243 iii

5 Abbrevitions DSM AIDS AMR ART BCG BPMZ BRICS CAD CFR CHOICE CHW CI CRS CV CXR DALY DST EBA EDCTP EECA FIND GDG GDP GHCC ctive TB drug-sfety monitoring nd mngement cquired immunodeficiency syndrome ntimicrobil resistnce ntiretrovirl therpy bcille Clmette-Guérin bedquiline, pretomnid, moxifloxcin nd pyrzinmide Brzil, Russin Federtion, Indi, Chin nd South Afric computer-ided detection cse ftlity rtio CHOosing Interventions tht re Cost-Effective (WHO) community helth worker confidence intervl creditor reporting system community volunteer chest X-ry disbility-djusted life-yer drug susceptibility testing erly bctericidl ctivity Europen nd Developing Countries Clinicl Tril Prtnership Estern Europe nd Centrl Asi Foundtion for Innovtive New Dignostics Guideline Development Group gross domestic product Globl Helth Cost Consortium Globl Fund The Globl Fund to Fight AIDS, Tuberculosis nd Mlri GPW Generl Progrmme of Work (WHO) GRADE Grding of Recommendtions Assessment, Development nd Evlution HBC high-burden country HDC Helth Dt Collbortive HIV humn immunodeficiency virus HLM high-level meeting ICD-1 Interntionl clssifiction of diseses (1th edition) IER Deprtment of Informtion, Evidence nd Reserch (WHO) IGRA interferon gmm relese ssy IHME Institute of Helth Metrics nd Evlution ILO Interntionl Lbour Orgniztion LAM liporbinomnnn LEAP Livelihood Empowerment Aginst Poverty LF-LAM lterl flow liporbinomnnn ssy LPA line probe ssy LTBI ltent TB infection MAMS-TB multi-rm, multi-stge TB MBLA moleculr bcteril lod ssy MDG Millennium Development Gol MDR multidrug-resistnt MDR/RR-TB multidrug-resistnt TB or rifmpicin-resistnt TB MDR-TB multidrug-resistnt TB M:F mle to femle (rtio) MIC miniml inhibitory concentrtion mrna messenger RNA NACO Ntionl AIDS Control Orgniztion NCD noncommunicble disese NFC ner-field communiction NGO nongovernmentl orgniztion NHI ntionl helth insurnce NHIF Ntionl Helth Insurnce Fund NHIS Ntionl Helth Insurnce Scheme NIAID Ntionl Institute of Allergy nd Infectious Diseses NIH Ntionl Institutes of Helth NTLD Ntionl Tuberculosis, Leprosy nd Lung Disese Progrmme NTP ntionl TB progrmme OECD Orgnistion for Economic Co-opertion nd Development PnACEA Pn-Africn Consortium for the Evlution of Antituberculosis Antibiotics PCR polymerse chin rection PEPFAR President s Emergency Pln for AIDS Relief PLHIV people living with HIV PMDT progrmmtic mngement of drug-resistnt TB P:N prevlence to notifiction (rtio) PPM public public nd public privte mix ReSeqTB Reltionl Sequencing TB Knowledgebse RNA ribonucleic cid RNTCP Revised Ntionl TB Control Progrmme RR rifmpicin-resistnt RR-TB rifmpicin-resistnt TB RT-qPCR reverse trnscriptse quntittive PCR SDG Sustinble Development Gol SHA System of Helth Accounts SRL suprntionl reference lbortory SSI Sttens Serum Institut TB tuberculosis TB Allince Globl Allince for TB Drug Development TBTC TB Tril Consortium TNF tumour necrosis fctor UCSR Unit Cost Study Repository UHC universl helth coverge UN United Ntions UNAIDS Joint United Ntions Progrmme on HIV/AIDS US United Sttes USA United Sttes of Americ USAID US Agency for Interntionl Development VR vitl registrtion WHO World Helth Orgniztion WRD WHO-recommended rpid dignostic XDR-TB extensively drug-resistnt TB iv

6 Acknowledgements This globl TB report ws produced by core tem of 17 people: Lur Anderson, Annbel Bddeley, Hnnh Monic Dis, Ktherine Floyd, Inés Grci Ben, Nebit Gebreselssie, Christopher Gilpin, Philippe Glziou, Irwin Lw, Nobuyuki Nishikiori, Molebogeng Rngk, Andrew Sirok, Chrlmbos Sismnidis, Ln Syed, Hzim Timimi, Yinyin Xi nd Mtteo Zignol. The tem ws led by Ktherine Floyd. Overll guidnce ws provided by the Director of the Globl TB Progrmme, Terez Ksev. 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 Lur Anderson, Annbel Bddeley, Ann Den, Hnnh Monic Dis, Dennis Flzon, Inés Grcí Ben, Giulino Grgioni, Mede Gegi, Ernesto Jrmillo, Thoms Joseph, Alexei Korobitsyn, Tomáš Mts, Molebogeng Rngk, Kefs Smson, Andrew Sirok, Ln Syed, Hzim Timimi, Olg Toss Auget 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, Csb Ködmön nd Hnn Merk from ECDC for providing vlidted dt files, nd Andrei Ddu nd Giorgi Kuchukhidze from the WHO Regionl Office for Europe for their substntil contribution to follow-up nd vlidtion of dt for ll Europen countries. UNAIDS mnged the process of dt collection from ntionl AIDS progrmmes nd provided ccess to their TB/HIV dtset. Review nd vlidtion of TB/HIV dt ws undertken in collbortion with UNAIDS stff. Mny people contributed to the nlyses, preprtion of figures nd tbles, nd writing required for the min chpters of the report. Chpter 1 (Introduction) nd Chpter 2 (Globl commitments to end TB nd multisectorl ccountbility) were prepred by Ktherine Floyd. She lso wrote the Executive Summry, with inputs from Hnnh Monic Dis, Terez Ksev, Din Weil nd Krin Weyer. Chpter 3 (TB disese burden) ws prepred by Ktherine Floyd, Philippe Glziou, Irwin Lw nd Mtteo Zignol, with contributions from Peter Dodd nd Olg Toss Auget. Chpter 4 (Dignosis nd tretment: TB, HIV-ssocited TB nd drug-resistnt TB) ws prepred by Hzim Timimi, Yinyin Xi nd Mtteo Zignol, with contributions from Lur Anderson, Annbel Bddeley, Hnnh Monic Dis, Dennis Flzon, Ktherine Floyd, Ernesto Jrmillo, Thoms Joseph, Irwin Lw, Chrlmbos Sismnidis nd Ln Syed. For the box on the ntionl inventory study in Indonesi, which mesured the level of underreporting of detected TB cses in the country nd is the lrgest study of its kind to dte globlly, specil thnks re due to the study tem for llowing WHO to feture the results nd lessons lerned in this report. The study tem comprised the Ntionl TB Progrmme (Asik Sury, Sitti Gnef, Sulistyo, Syrifh Khdijh), the Ntionl Institute of Helth Reserch nd Development (Agus Suprpto, Feri Ahmdi, Din Bisr Lolong, Oster Surini Simrmt, Felly Philipus Senewe, Kristin Tobing), the Ntionl TB Expert Committee (Muhmmd N Frid, Pndu Riono) nd the WHO country office (Muhmmd Akhtr, Benymin Sihombing, Regin Christin, Nelsy Sihn, Jonthn Mrbun, Setiwn Jti Lksono). Thnks re lso due to Deepk Blsubrmnin for providing dt relted to TB cse finding mong people living with HIV in Indi. Chpter 5 (TB prevention services) ws prepred by Annbel Bddeley nd Molebogeng Rnkk, with contributions from Ktherine Floyd, Philippe Glziou, Hzim Timimi nd Yinyin Xi. Chpter 6 (Finncing for TB prevention, dignosis nd tretment) ws prepred by Inés Grci Ben nd Andrew Sirok, with support from Ktherine Floyd. Thnks re lso due to Gbriel Gomez (London School of Hygiene nd Tropicl Medicine) for the box on the globl helth costing consortium. The writing of Chpter 7 (Universl helth coverge, socil protection nd socil determinnts) ws led by Nobuyuki Nishikiori, with contributions from Amy Collins, Ktherine Floyd, Inés Grci Ben, Debor Pedrzzoli, Andrew Sirok nd Din Weil; figures nd tbles were prepred by Inés Grci Ben, Andrew Sirok nd Amy Collins. Chpter 8 (TB reserch nd development) ws prepred by Dennis Flzon, Nebit Gebreselssie nd Christopher Gilpin, with support from Ktherine Floyd, Krin Weyer nd Mtteo Zignol. Irwin Lw coordinted the finliztion of figures nd tbles for ll chpters nd subsequent review of proofs, v

7 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 Jessic Ho for her review of Chpter 3; Avinsh Knchr nd Stvinder Singh for their reviews of Chpter 4 nd Chpter 5; Joe Kutzin for his review of Chpter 7; nd Jonthn Dniels, Ann Ginsberg, Brbr Lughon, Din Rozendl, Mel Spigelmn, Zid Tnvir, Irin Usherenko nd Jennifer Woolley for their reviews of Chpter 8. Annex 1, which provides n overview of the globl TB dtbse, ws written by Hzim Timimi. The country profiles tht pper in Annex 2, the regionl profiles tht pper in Annex 3 nd the detiled tbles showing dt for key indictors for ll countries in the ltest yer for which informtion is vilble (Annex 4) were lso prepred by Hzim Timimi. The preprtion of the online technicl ppendix tht explins the methods used to estimte the burden of disese cused by TB ws led by Philippe Glziou, with contributions from Peter Dodd, Molebogeng Rngk, Chrlmbos Sismnidis nd Mtteo Zignol. We thnk Vlérie Robert in the Globl TB Progrmme s monitoring nd evlution unit for impeccble dministrtive support, Nichols Gn, Simone Gigli nd Nicols Jimenez for excellent informtion technology support, Doris M Ft from the WHO Mortlity nd Burden of Disese tem for providing dt extrcted from the WHO Mortlity Dtbse tht were used to estimte TB mortlity mong HIV-negtive people, nd Julin Dher nd Mry Mhy (UNAIDS) for providing epidemiologicl dt tht were used to estimte HIV-ssocited TB incidence nd mortlity. The entire report ws edited by Hilry Cdmn, who we thnk for her excellent work. We lso thnk Sue Hobbs for her outstnding work on the design nd lyout of this report. Her contribution, s lwys, ws very highly pprecited. 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). Production of the report ws lso supported by the governments of Jpn, the Republic of Kore nd the Russin Federtion. We cknowledge with grtitude their support. In ddition to the core report tem nd those mentioned bove, the report benefited from inputs from mny stff working in WHO regionl nd country offices nd hundreds of people working for ntionl TB progrmmes or within ntionl surveillnce systems who contributed to the reporting of dt nd to the review of report mteril prior to publiction. These people re listed below, orgnized by WHO region. We thnk them ll for their invluble contribution nd collbortion, without which this report could not hve been produced. Among the WHO stff not lredy mentioned bove, we thnk in prticulr Edith Alrcon, Mohmed Abdul Aziz, Smih Bghddi, Msoud Dr, Michel Gsn, Jen Irgen, Rfel López Olrte, Prth Prtim Mndl, Csimir Mnzengo Mingiedi, Ernesto Montoro, André Ndongosieme, Wilfred Nkhom, Klpesh Rhevr nd Mukt Shrm for their contribution to dt collection nd vlidtion, nd review nd clernce of report mteril by countries in dvnce of publiction. WHO stff in Regionl nd Country Offices WHO Africn Region Boubcr Abdel Aziz, Abdoulye Mrim Bïss, Esther Aceng-Dokotum, Hrur Admu, Inácio Alvreng, Smuel Herms Andrinriso, Jvier Armburu Gurd, Augusto d Cruz Cludin, Ayodele Awe, Nyé Bh, Mrie Ctherine Broun, Bbou Bzie, Sirimn Cmr, Lstone Chitembo, Dvi Kokou Mwule, Ev De Crvlho, Ndell Dikhte, Noel Djemdji, Sithembile Dlmini-Nqeketo, Ismel Hssen Endris, Louis Gnd, Michel Gsn, Boingotlo Gsennelwe, Crolin Crdoso d Silv Gomes, Kss Hilu, Ptrick Hzngwe, Télesphore Hounsou, Jen Irgen, Bhvin Jni, Moses Jeuronlon, Michel Jose, Kss Ketem, Khelifi Houri, Hillry Kipruto, Julinne Koenig, Aristide Désiré Komngoy Nzonzo, Steve Kubeng Bnz, Angel Ktherine Lo Seone, Shrmil Lreef-Jh, Simbrshe Mby, Csimir Mnzengo, Leonrd Mbemb, Richrd Mbumb Ngimbi, Nkteko Mkhondo, Joseph Mogg, Jules Mugbo Semhore, Christine Musnhu, Ahmd NssuriI, Andre Ndongosieme, Mkhokheli Ngweny, Denise Nkezimn, Wilfred Nkhom, Nicols Nkiere, Abel Nkolo, Ghisline Nkone Asseko, Ishmel Nysulu, Smuel Ogiri, Dniel Olusoti, Amos Omoniyi, Hermnn Ongouo, Philip Onyebujoh, Chijioke Oskwe, Felici Owusu-Antwi, Philip Ptrobs, Richrd Oleko Rehn, Neem Gideon Simkoko, Susn Zimb-Tembo, Addislem Yilm Tefer, Dest Tiruneh, Trore Tieble, Hubert Wng, Addislem Yilm, Assefsh Zehie. WHO Region of the Americs Zohr Abkouk, Edith Alrcon, Pedro Avedillo, Eldonn Boisson, Dvid Chvrri, Betriz Cohenc, Mrcos Espinl, Ingrid Grci, Hrry Geffrrd, Mssimo Ghidinelli, Frnklin Hernndez, Reynold Hewitt, Sndr Jones, Frncisco Leon Brvo, Rfel Lopez Olrte, Junit Mlmberg, Wilmer Mrquino, Alin Perez, Alb Lidi Sánchez, Mrí Jesús Sánchez, Jorge Victori, Mrcelo Vil. vi

8 WHO Estern Mediterrnen Region Mohmed Abdel Aziz, Mohmmd Aloudl, Smih Bghddi, Mi Eltigny Mohmmed, Hni Husseiny, Sindni Ireneus Sebit, Soumi Triki. WHO Europen Region Nikit Afnsyev, Alexey Bobrik, Cssndr Butu, Andrei Ddu, Msoud Dr, Soudeh Eshni, Jmshid Gdoev, Stel Gheorghit, Gyne Ghuksyn, Ogty Gozlov, Vitcheslv Grnkov, Syoht Hsnov, Nino Mmulshvili, Artn Mesi, Myrt Sriyev, Jvhir Suleymnov, Mustf Bhdir Suckli, Szbolcs Szigeti, Mrtin vn den Boom, Gzmend Zhuri; nd three temporry dvisors Giorgi Kuchukhidze, Arksi Hovhnnesyn nd Inn Motrich. WHO South-Est Asi Region Muhmmd Akhtr, Vineet Bhti, Mri Regin Christin, Mnjul Dnnsuriy, Gopinth Deyer, Lopzng Dorji, Hwng Jo Mun, Nvrtnsingm Jnkn, Setiwn Jti Lksono, Subhsh Lkhe, Prth Prtim Mndl, Sundri Mse, Ikushi Onozki, Shushil Dev Pnt, Mlik Prmr, Kirnkumr Rde, Rnjni Rmchndrn, Md Kmr Rezwn, Dipnjn Sujit Roy, Mukt Shrm, Sber Sultn, Ddng Supriydi. WHO Western Pcific Region Shll Ahmdov, Chen Zhongdn, Serongke Deng, Lepiti Hnsell, Anupm Hzrik, Tuhid Islm, Nrntuy Jdmb, Fukushi Morishit, Klpeshsinh Rhevr, Richrd Rehn, Jcques Sebert, Thipphsone Vixysouk, Qung Hieu Vu, Lungten Wngchuk, Rjendr-Prsd Ydv, Subhsh Ydv. Ntionl respondents who contributed to reporting nd verifiction of dt WHO Africn Region Abderrmne Abdelrhim Brk, Mrie Bngour Adm, Sofine Alihlss, Arlindo Tomás do Amrl, Rosmunde Amuteny, Séverin Angonou, Anne Ahemed Tidjne, Godwin Ohis Yosi Asye, Asso Neino Mourtl Mohmed, Wilfried Bekou, Frnk Ade Bonsu, Bllé Boubkr, Jorge Noel Brreto, Serge Bisut Fuez, Aw Boubcr, Miguel Cmr, Ernest Cholopry, Adjim Combry, Ftou Tiépé Coulibly, John Deng, Adm Dillo, Abdoulye Dillo, Ambrosio Disdidi, Themb Dlmini, Sicelo Dlmini, Antoine Etoundi Evoun, Alfred Etwom, Jun Eyene Acuresil, Ykhokh Fll, Lynd Fory, Hervé Gilds Gndo, Evriste Gsn, Belineh Girm, Amnuel Hdgu, Georges Hermn, Nzir Ismil, Adm Jllow, Jorge Jone, Mureen Kmene, Kne Elhdj Mlick, Clr Chol Kspo, Michel Ksw Kyomo, Jmes Ktt, Kenyerere Henry Shdreck, Sidney Kololo, Désiré Aristide Komngoy Nzonzo, Bkry Konte, Ptrick Konwuloh, Jcquemin Koukou Koukou, Felix Kwmi Afutu, Adebol Lwnson, Gertrude Ly Ofli, Tye Lett Jnf, Ptrick Lungu, Llng Bridget Mm, Jocelyn Mhoumbou, Dvid Mmetj, Ivn Mnhiç, Adeline Mnirmbon, Tseliso Isc Mrt, Snele Msuku, Fri Mvhung, Vincent Mbss, Bongiwe Mhlng, Ptrick Migmbi, Louine Morel, Mpung Jmes Upile, Frnk Mugbe, Betrice Mutyob, Lindiwe Mvusi, Ghislin Ndm Mckounz, Fulgence Ndyikengurukiye, Euphrsie Ndihokubwyo, Jcques Ndion-Ngndzien, Norbert Ndjek, Ngufck Njimoh Dubliss, Emmnuel Nkiligi, Hiwet Nugusse, Frnck Hrdin Okemb Okombi, Eunice Omes, Simeon Onyemechi, Oumr Abdelhdi, Pyegr Arbeh, Emile Rkotondrmnn, Hrinjk Mmirison Rndrinrivo, Gobone Rnkgone- Pono, Aduli Gomes Rodrigues, Rujeedw Mohmmed Fezul, Smey Agbenyegn, Chrles Sndy, Kebb D Snneh, Mrie Srr Diouf, Singo-Tokofï Assétin, Nichols Sizib, Bonifcio Sous, Mnguing Stredice, Albertin Thoms, Keit Mrime Tieb Trore, Thusoyone Titi Tsholofelo. WHO Region of the Americs José Arón Agüero Zumbdo, Srit Aguirre, Ahmed Shluddin, Edwin Aizpuru, Xochil Alemán de Cruz, Aish Andrewin, Denise Arkki-Snchez, Dwin Archibld, Chris Archibld, Crmen Arry Girond, Fernndo Arriet Pessolno, Artiles Mill Norm Letici, Crlos Alberto Mrcos Ayl Lun, Ptrici Brtholomy, Mri Bermudez, Tmr Bobb, Shwn Chrles, Krolyn Chong, Eric Commiesie, Mriel Contrer, Yren Cruz, Ofeli Cuevs, Dn Dcost Gomez, Ndi Escobr Slins, Espñ Cedeño Mercedes, Fernndez Hugo, Cecili Figuero Benites, Michelle Frncois, Julio Gry Rmos, Ronld Georges, Izzy Gerstenbluth, Yskr Hlbi, Mri Henry, Olg Joglr, Din Khn, Mrie LFreniere, Hzel Lws, Cludi Llern Polo, Lun López Fátim Letici, Eugène Mduro, Andre Yvette Mldondo Svedr, Mrvin Mnznero, Belkys Mrcelino, M. de Lourdes Mrtínez Olivres, Timothy McLughlin- Munroe, Angélic Medin, Mejí Cbllero Andre Azucen, Mónic Mez Cárdens, Leilwti Mohmmed, Jeetendr Mohnlll, Frncis Morey, Willy Morose, Luis Fernnd Moyno Ariz, Ntiello Mrcel, Jcquelyn Newbold, Alice Neymour, Cheryl Peek-Bll, Toms Portillo Esquivel, Robert Prtt, Mnohr Singh Rjmnickm, Rmirez Norm Lucreci, Andres Rincon, Juli Ros Mri Rios Vidl, Feros Roche, Myrin Román, Kti Romero, Arelisbel Ruiz, Wilmer Slzr, Smyo Peláez Mritz, Angel Snchez, Krl Mrí Sánchez Mendoz, Rhond Seley-Thoms, vii

9 Nicol Skyers, Dnilo Solno, Ntli Sos, Stijberg Deborh, Surez Alvrez Lourdes, Michelle Trotmn, Clrisse Tsng, Meliss Vldez, Iynn Wellington, Smuel Willims, Jennifer Wilson, Oritt Zchrih. WHO Estern Mediterrnen Region Trig Abdll Abdllrhim, Mohmmd Slm Abouzeid, Ahmdi Shhnz, Nmtullh Ahmdzd, Mh Alwi, Rji Al-Azzeh, Al Hmdn Khlood, Abdulbri Alhmmdi, Abdulltif Al Khl, Mohmed Redh Al Lwti, Nd Almrzouqi, Ibrhim AlMshykh, Ebrhim Alromihi, Lyth Al-Slihi, Kifh Alshqeldi, Khls Althuhli, Ftm Alyquobi, Wgdy Amin, Smir Amin, Yssine Aqchmr, Bhnsy Smir, Mohmed Belkhl, Kenz Bennni, Jonne Dghfl, Ahmed Dmiereih, Soud Elhssni, Mohmed Furjni, Aml Gll, Dhikryet Gmr, Assi Hissm, Ahmed Hkwy, Hw Hssn Guessod, Slm Hudi, Shfqt Hussin, Leeq Ahmd Khwj, Abdullh Ltif, Nsir Mhmood, Esm Mhyoub, Nsehi Mhshid, Yssir Piro, Slm Sd, Mohmmd Khlid Seddiq, Mohmmed Sghir, Mohemmed Tben, Him Ycoub. WHO Europen Region Mlik Adenov, Slihdjn Alimov, Ekkehrdt Altpeter, Srh Anderson, Elen Arbuzov, Zz Avlini, Bernhrd Benk, Velimir Bereš, Snježn Brčklo, Rikke Bruun de Neergrd, Aysoltn Chryyev, Dniel Chemtob, Mmuk Chinchruli, Domnic Ion Chiotn, Nico Ciorn, Thierry Mrtin Comolet, Andrei Corlotenu, Vleriu Crudu, Rdmil Curcic, Edit Vlerij Dvidviciene, Jennifer Dvidson, Hyk Dvtyn, Gerrd de Vries, Irène Demuth, Rquel Durte, Mlden Duronjić, Lnfrnco Fttorini, Viktor Gsimov, Mjlind Gjocj, Biljn Grbvčević, Genndy Gurevich, Jen-Pul Guthmnn, Wlter Hs, Armen Hyrpetyn, Peter Helbling, Biljn Ilievsk Poposk, Srh Jckson, Gulnor Jlilov, Jerker Jonsson, Erhn Kbskl, Abdullt Kdyrov, Dzmitry Klimuk, Lriss Korinchuk, Mri Korzeniewsk-Koseł, Xhevt Kurhsni, Yn Levin, Nino Lomtdze, Stevn Lučić, Ekterin Mliukov, Donik Mem, Violet Mihilovic Vucinic, Dce Mihlovsk, Vldimir Milnov, Alen Nikolenk, Jon O Donnell, Anlit Pce- Ascik, Clr Plm Jordn, Nrgiz Prpiev, Nit Peruml, Victori Petric, Sbine Pfeiffer, Ros Cno Portero, Asliddin Rjbzod, Kteryn Ribchenko, Gbriele Rinldi, Jérôme Robert, Elen Scchini, Gerrd Scheiden, Anit Segliņ, Firuz Shripov, Erik Slump, Adrin Socci, Hnn Soini, Ivn Solovic, Sergey Sterlikov, Mj Stosic, Sevinj Tghiyev, Yn Terleev, Dniel Tiefengrber, Shhnoz Usmonov, Tonk Vrlev, Irin Vsilyev, Piret Viiklepp, Vlentin Vilc, Pierre Weicherding, Stefn Wesołowski, Aysegul Yildirim, Mj Zkosk, Hsn Žutić. WHO South-Est Asi Region Knthi Ariyrtne, Si Thu Aung, Rtn Bhttri, Tong Chol Choe, Devesh Gupt, Fthth Hssn, Md. Shmiul Islm, Sirinph Jittimnee, Suksont Jittimnee, Kmolwt Phlin, Ahmdul Hsn Khn, Constntino Lopes, Pronb Kumr Modk, Nirup Pllewtte, Niken Wstu Plupi, Rjendr Prsd Pnt, Jmyng Pem, Gmini Rtnyke, Chewng Rinzin, Kuldeep Singh Schdev, Nzis Arefin Ski, Sulistyo, Phurp Tenzin, Jnk Thilkrtne, Zw Tun, Dhmmik Vidngm, Sulisty Widgd, Yun Yong Hw. WHO Western Pcific Region Zirwtul Adilh Aziz, Pul Ai, Mohmed Nim bin Abdul Kdir, Urnchimeg Borgil, Srh Brown, Ris Bukbuk, Chikuen Chn, Nou Chnly, Cynthi Chee, Phonenly Chittmny, Chou Kuok Hei, Alice Cuenc, Enkhmndkh Dnjd, Jne Dowbobo, Du Xin, Ekiek Myleen Jck, Jenny Eveni, Fni Sen, Ludovic Floury, Louise Fonu, Siple Fuimono, Ann Mrie Celin Grfin, Donn Me Geocnig-Gviol, Gird Mrine, Anie Hryni Hj Abdul Rhmn, Lurence Holding, Noel Itogo, Mrgret Kl, Seiy Kto, Phonesvnh Kommnivnh, Khin Mr Kyi Win, Chi-chiu Leung, Christine Lifuk, Liz Lopez, Ngoc-Phuong Luu, Alice Mnlo, Mo Tn Eng, Chim Mbkwem, Andre McNeill, Mei Jin, Kuniki Miyke, Serfi Mo, Grizeld Mokoi, Nguyen Binh Ho, Nguyen Viet Nhung, Connie Olikong, Prk Wonseo, Sosi Penitni, Kte Pennington, Jen-Pul Pescheux, Mrcelin Rbulimn, Asmh Rzli, Berek Reiher, Mohd Rotpi Abdullh, Bernrd Rouchon, Fetui Selu, Lmek Sle, Shin Insik, Tieng Sivnn, Shunji Tkkur, Brbr Tli, Edwin Tngro, Kyw Thu, Mrou Tiktke, Kzuhiro Uchimur, Frnk Kellis Underwood, Lixi Wng, Zhng Hui. viii

10

11 The United Ntions flg outside the Secretrit building of the United Ntions, New York City, United Sttes of Americ Mike Segr / Reuters

12 Executive Summry Context On 26 September 218, the United Ntions (UN) will hold its first high-level meeting on tuberculosis (TB), t its hedqurters in New York. The title of the meeting United to End TB: An Urgent Globl Response to Globl Epidemic highlights the need for immedite ction to ccelerte progress towrds the gol of ending the TB epidemic by 23. All Member Sttes of WHO nd the UN hve committed to this gol, initilly through their unnimous endorsement of WHO s End TB Strtegy t the World Helth Assembly in My 214 nd then their doption of the UN Sustinble Development Gols (SDGs) in September 215. Specific trgets for 23 set in the End TB Strtegy re 9% reduction in the bsolute number of TB deths nd n 8% reduction in TB incidence (new cses per popultion per yer), compred with levels in The UN high-level meeting follows the first WHO globl ministeril conference on ending TB in the SDG er, which ws held in November 217 in the Russin Federtion. The conference brought together over prticipnts, including ministers of helth nd other leders from 12 countries, nd over 8 prtners, including civil society. Tht conference resulted in the Moscow Declrtion to End TB. At the World Helth Assembly in My 218, ll WHO Member Sttes committed to ccelerte their ctions to end TB, building on the Moscow Declrtion. In the months leding up to the UN high-level meeting, mjor country blocs hve issued communiqués on the need for ction on TB, including drug-resistnt TB in the wider context of ntimicrobil resistnce (AMR). Exmples include the G2, the G7, the BRICS group (Brzil, the Russin Federtion, Indi, Chin nd South Afric) nd the Asi-Pcific Economic Coopertion (APEC). New commitments were mde by ministers from countries in the WHO South-Est Asi Region t the Delhi End TB Summit in Mrch 218 nd by Africn leders t meeting of the Africn Union in July 218. This report WHO hs published globl TB report every yer since This 218 edition is published in the led up to the UN high-level meeting on TB. It provides comprehensive nd up-to-dte ssessment of the TB epidemic, nd of progress in the response to the epidemic, t globl, regionl nd country levels. The report is bsed primrily on dt reported nnully to WHO by countries, nd dtbses mintined by other UN gencies nd the World Bnk. Ltest sttus of the TB epidemic Worldwide, TB is one of the top 1 cuses of deth nd the leding cuse from single infectious gent (bove HIV/AIDS). Millions of people continue to fll sick with TB ech yer. In 217, TB cused n estimted 1.3 million deths (rnge, million) 2 mong HIV-negtive people nd there were n dditionl 3 deths from TB (rnge, ) mong HIV-positive people. 3 Globlly, the best estimte is tht 1. million people (rnge, million) developed TB disese in 217: 5.8 million men, 3.2 million women nd 1. million children. There were cses in ll countries nd ge groups, but overll 9% were dults (ged 15 yers), 9% were people living with HIV (72% in Afric) nd two thirds were in eight countries: Indi (27%), Chin (9%), Indonesi (8%), the Philippines (6%), Pkistn (5%), Nigeri (4%), Bngldesh (4%) nd South Afric (3%). These nd 22 other countries in WHO s list of 3 high TB burden countries ccounted for 87% of the world s cses. 4 Only 6% of globl cses were in the WHO Europen Region (3%) nd WHO Region of the Americs (3%). The severity of ntionl epidemics vries widely mong countries. In 217, there were fewer thn 1 new cses per popultion in most high-income countries, 1 4 in most of the 3 high TB burden countries, nd bove in few countries including Mozmbique, the Philippines nd South Afric. Drug-resistnt TB continues to be public helth crisis. The best estimte is tht, worldwide in 217, 558 people (rnge, ) developed TB tht ws resistnt to rifmpicin (RR-TB), the most effective firstline drug, nd of these, 82% hd multidrug-resistnt TB (MDR-TB). 5 Three countries ccounted for lmost hlf of the world s cses of MDR/RR-TB: Indi (24%), Chin (13%) nd the Russin Federtion (1%). Globlly, 3.5% of new TB cses nd 18% of previously 1

13 treted cses hd MDR/RR-TB. The highest proportions (>% in previously treted cses) re in countries of the former Soviet Union. Among cses of MDR-TB in 217, 8.5% (95% confidence intervl, %) were estimted to hve extensively drug-resistnt TB (XDR-TB). 6 About 1.7 billion people, 23% of the world s popultion, re estimted to hve ltent TB infection, nd re thus t risk of developing ctive TB disese during their lifetime. Progress in reducing TB cses nd deths The disese burden cused by TB is flling globlly, in ll WHO regions, nd in most countries, but not fst enough to rech the first (22) milestones of the End TB Strtegy. By 22, the TB incidence rte (new cses per popultion per yer) needs to be flling t 4 5% per yer, nd the proportion of people with TB who die from the disese (the cse ftlity rtio, CFR) needs to fll to 1%. In 217, the proportion of people with TB who died from the disese ws 16%, down from 23% in 2. Worldwide, the TB incidence rte is flling t bout 2% per yer. 7 The fstest regionl declines from 213 to 217 were in the WHO Europen Region (5% per yer) nd the WHO Africn Region (4% per yer). In the sme 5 yers, prticulrly impressive reductions (4 8% per yer) occurred in southern Afric (e.g. Eswtini, Lesotho, Nmibi, South Afric, Zmbi nd Zimbbwe), following pek in the HIV epidemic nd the expnsion of TB nd HIV prevention nd cre; nd in the Russin Federtion (5% per yer), following intensified efforts to reduce the burden of TB nd scrutiny of progress from the highest politicl levels. Globlly, the bsolute number of TB deths mong HIV-negtive people hs fllen by best estimte of 29% since 2, from 1.8 million in 2 to 1.3 million in 217, nd by 5% since 215 (the bseline yer of the End TB Strtegy). The number of TB deths mong HIV-positive people hs fllen by 44% since 2, from 534 in 2 to 3 in 217, nd by 2% since 215. The TB mortlity rte (i.e. TB deths mong HIVnegtive people per popultion per yer) is flling t bout 3% per yer, nd the overll reduction in the period ws 42%. Of the WHO regions, the fstest declines in the 5 yers were in the WHO Europen Region (11% per yer) nd the WHO South-Est Asi Region (4% per yer). High TB burden countries with rtes of decline exceeding 6% per yer in the 5 yers include the Russin Federtion (13% per yer), Ethiopi (12% per yer), Sierr Leone (1% per yer), Keny (8% per yer) nd Viet Nm (8% per yer). TB dignosis nd tretment Dignosis nd successful tretment of people with TB verts millions of deths ech yer (n estimted 54 million over the period 2 217), but there re still lrge nd persistent gps in detection nd tretment. Worldwide in 217, 6.4 million new cses of TB were officilly notified to ntionl uthorities nd then reported to WHO. This number hs been incresing since 213, following 4 yers (29 212) in which million new cses were reported nnully, minly due to incresed reporting of detected cses by the privte sector in Indi nd, in 217, n upturn in notifictions in Indonesi. The 6.4 million cses reported represented 64% of the estimted 1. million new cses tht occurred in 217. Ten countries ccounted for 8% of the 3.6 million globl gp, the top three being Indi (26%), Indonesi (11%) nd Nigeri (9%). 8 Gps between the estimted number of new cses nd the number ctully reported re due to mixture of underreporting of detected cses, nd underdignosis (either becuse people do not ccess helth cre, or becuse they re not dignosed when they do). Underestimtion or overestimtion of the totl number of new cses is lso possible. An informtive exmple is Indonesi; in 217, ntionl study found tht lthough bout 8% of new cses were detected, 41% of these cses were not reported. Actions to correct underreporting re being put in plce. There were reported cses of TB mong people living with HIV in 217 (51% of the estimted 92 new cses in the sme yer), of whom 84% were on ntiretrovirl therpy. Most of the gps in detection nd tretment were in the WHO Africn Region, where the burden of HIV-ssocited TB is highest. To support countries to close gps in TB detection nd tretment, in 218 WHO, in collbortion with the Stop TB Prtnership nd the Globl Fund to Fight AIDS, Tuberculosis nd Mlri, lunched n inititive clled Find. Tret. All. 9 The inititive includes trget of detecting nd treting 4 million people with TB in the period The ltest tretment outcome dt for new cses show globl tretment success rte of 82% in 216. This is reduction from 86% in 213 nd 83% in 215; in countries where notifictions hve incresed, reporting of tretment outcomes hs not kept pce. Drug-resistnt TB: dignosis nd tretment Urgent ction is required to improve the coverge nd qulity of dignosis, tretment nd cre for people with drug-resistnt TB. Globlly, cses of MDR/RR-TB were detected nd notified in 217 ( smll increse from

14 in 216). Of these, totl of people (87%) were enrolled on tretment with second-line regimen, up from in 216 but still only 25% of the estimted 558 people who developed MDR/RR-TB in 217. Chin nd Indi lone ccounted for 4% of the globl gp; these nd eight other countries 1 ccounted for 75%. Tretment success remins low, t 55% globlly. Exmples of high burden countries in which better tretment success rtes re being chieved include Bngldesh, Ethiopi, Kzkhstn, Mynmr nd Viet Nm (ll of which hve rtes bove 7%). 11 Closing gps in detection nd tretment requires much higher coverge of drug susceptibility testing mong people dignosed with TB, reducing underdignosis of TB, models of cre tht mke it esier to ccess nd continue tretment, new dignostics, nd new medicines nd tretment regimens with higher efficcy nd better sfety. In July 218, the ltest evidence on tretment of drug-resistnt TB ws reviewed by n independent pnel of experts convened by WHO. A rpid communiction on key chnges to recommendtions for the tretment of drug-resistnt TB hs been issued by WHO, to be followed by the relese of updted nd consolidted WHO policy guidelines lter in the yer. TB prevention services The min helth-cre interventions to prevent new infections of Mycobcterium tuberculosis nd their progression to TB disese re tretment of ltent TB infection nd vccintion of children with the bcille Clmette-Guérin (BCG) vccine. TB preventive tretment for ltent TB infection is expnding, but most of those for whom it is strongly recommended re not yet ccessing cre, wheres coverge of BCG vccintion is high. WHO hs strongly recommended tretment for ltent TB infection in two priority groups: people living with HIV, nd children ged under 5 yers who re household contcts of someone who hs bcteriologiclly confirmed pulmonry TB. The number of people living with HIV reported to hve been strted on preventive tretment ws in 217. Of the 15 high TB/HIV burden countries tht reported dt, coverge rnged from 1% in Eswtini to 53% in South Afric. The number for children ged under 5 yers reched in 217 threefold increse from 215 but still only round 23% of the 1.3 million estimted to be eligible. In countries with high incidence of TB, WHO guidnce issued in 218 includes new recommendtion to consider testing nd tretment for people ged 5 yers or more who re household contcts of bcteriologiclly confirmed pulmonry TB cses. This substntilly increses the potentil number of people eligible for tretment. WHO estimtes tht t lest 3 million people will be eligible for TB preventive tretment between 218 nd 222. BCG vccintion should be provided s prt of ntionl childhood immuniztion progrmmes ccording to country s TB epidemiology. In 217, 158 countries reported providing BCG vccintion, of which 12 reported coverge of t lest 9%. Finncing for TB prevention, dignosis nd tretment Funding for the provision of TB prevention, dignostic nd tretment services hs more thn doubled since 26 but continues to fll short of wht is needed. In 119 low- nd middle-income countries tht reported dt (nd ccounted for 97% of reported TB cses globlly), funding reched US$ 6.9 billion in 218. The mount vilble ech yer hs been in the rnge US$ 6 7 billion since 214, fter incresing from US$ 3.3 billion in 26. The Stop TB Prtnership s Globl Pln to End TB estimted tht US$ 1.4 billion is required in these countries in 218, leving gp of US$ 3.5 billion. Without n increse in funding, the nnul gp will widen to US$ 5.4 billion in 22 nd to t lest US$ 6.1 billion in As in previous yers, most of the funding (86%) vilble in 218 is from domestic sources. However, this globl ggregte figure is strongly influenced by BRICS, in which 96% (rnge 91 %) of funding is from domestic sources. In Indi, domestic funding more thn tripled between 216 nd 218. Interntionl donor funding (US$.9 billion in 218, slight decrese from 217) ccounts for 39% of funding in the 25 high TB burden countries outside BRICS nd for 57% of funding in low-income countries. Universl helth coverge, socil protection nd socil determinnts The End TB Strtegy milestones for 22 nd 225 cn only be chieved if TB dignosis, tretment nd prevention services re provided within the context of progress towrds universl helth coverge (UHC), nd if there is multisectorl ction to ddress the socil nd economic fctors tht drive TB epidemics. TB incidence needs to be flling t 1% per yer by 225, nd the proportion of people with TB who die from the disese needs to fll to 6.5% by 225. Such levels hve only been chieved in the context of UHC, combined with socil nd economic development tht reduces known risk fctors for TB infection nd disese. UHC mens tht everyone irrespective of their living stndrds receives the helth services they need, nd tht using helth services does not cuse finncil hrdship. SDG Trget 3.8 is to chieve UHC by 23. 3

15 A 217 WHO/World Bnk report on UHC found tht t lest hlf of the world s popultion lcks ccess to essentil helth services nd lmost 1% experience ctstrophic expenditures on helth. All of the 3 high TB burden countries need to increse service coverge nd reduce levels of ctstrophic expenditures to rech UHC, consistent with findings from surveys of costs fced by TB ptients nd their households. WHO projections published in 217 suggest tht most middle-income countries could mobilize the funding needed to chieve UHC by 23 from domestic resources, while this is unlikely in low-income countries. This report fetures TB-SDG monitoring frmework tht focuses ttention on 14 indictors (from seven SDGs) tht re ssocited with TB incidence. Monitoring of these indictors cn be used to identify key influences on the TB epidemic t ntionl level nd inform the multisectorl ctions required to end it. Mny new cses of TB re ttributble to undernourishment, HIV infection, smoking, dibetes nd lcohol use (five of the indictors fetured in the TB-SDG frmework). A recent modelling study shows tht eliminting extreme poverty nd providing socil protection (both trgets under SDG 1, nd two other indictors in the TB-SDG frmework) could substntilly reduce TB incidence. commitments nd ctions needed to end TB t globl, regionl nd ntionl levels. These re only possible with incresed nd sustined funding, including from domestic sources (especilly in middle-income countries), interntionl donors nd public privte prtnerships. For countries where the burden of TB is lredy low, the focus should be on ctions needed to eliminte TB, pying prticulr ttention to vulnerble groups with the highest risk of infection nd disese. Conclusion TB is n old disese tht ws once deth sentence. Effective drug tretments first becme vilble in the 194s, nd in combintion with socil nd economic development they llowed countries in western Europe, North Americ nd some other prts of the world to reduce their burden of TB disese to very low levels. 13 For most countries, however, the end of TB s n epidemic nd mjor public helth problem remins n spirtion rther thn relity. The UN high-level meeting on TB on 26 September 218, with ttendnce of heds of stte nd other eminent people, provides pltform to step up the commitments nd ctions needed to end the globl TB epidemic, by the SDG dedline of 23. TB reserch nd development The SDG nd End TB Strtegy trgets set for 23 cnnot be met without intensified reserch nd development. Technologicl brekthroughs re needed by 225, so tht the nnul decline in the globl TB incidence rte cn be ccelerted to n verge of 17% per yer. Priorities include vccine to lower the risk of infection, vccine or new drug tretment to cut the risk of TB disese in the 1.7 billion people lredy ltently infected, rpid dignostics for use t the point of cre nd simpler, shorter drug regimens for treting TB disese. The development pipelines re progressing, but slowly. Few dignostic technologies emerged in 217. There re 2 drugs, severl tretment regimens nd 12 vccine cndidtes in clinicl trils. Annul reports by Tretment Action Group published since 26 show tht funding for TB reserch nd development hs incresed in recent yers, peking t US$ 724 million in 216. However, this is only 36% of the estimted requirement of US$ 2 billion per yer. Actions needed to ccelerte progress Accelerting progress towrds ending TB requires closing gps in TB dignosis, tretment nd prevention within the context of progress towrds UHC, multisectorl efforts to ddress the socil nd economic determinnts nd consequences of TB, intensified TB reserch nd development, nd strengthened ccountbility using frmework to trck nd review progress towrds 1 The first milestones, for 22, re 35% reduction in TB deths nd 2% reduction in TB incidence, compred with 215. The SDG trget of ending the TB epidemic is prt of SDG Trget 3.3, under the SDG helth gol (SDG 3). 2 Here nd throughout the report, rnge refers to the 95% uncertinty intervl. 3 When n HIV-positive person dies from TB disese, the underlying cuse is coded s HIV in the Interntionl clssifiction of diseses system. 4 The other 22 countries re Angol, Brzil, Cmbodi, Centrl Africn Republic, Congo, the Democrtic People s Republic of Kore, the Democrtic Republic of the Congo, Ethiopi, Keny, Lesotho, Liberi, Mozmbique, Mynmr, Nmibi, Ppu New Guine, the Russin Federtion, Sierr Leone, Thilnd, the United Republic of Tnzni, Viet Nm, Zmbi nd Zimbbwe. 5 Defined s resistnce to rifmpicin nd isonizid. 6 Defined s MDR-TB plus resistnce to t lest one drug in the following two clsses of medicines used in tretment of MDR-TB: fluoroquinolones nd second-line injectble gents. 7 The bsolute number hs been round 1 million per yer since 2, nd hs fllen slowly since The other seven countries re shown in Fig in the min report The other eight countries re shown in Fig in the min report. 11 The countries listed re those treting t lest MDR/RR-TB ptients nnully. 12 This figure is bsed on recent extension of Globl Pln projections, which indicte tht t lest US$ 13 billion will be required nnully by Around 1 or fewer new TB cses per popultion per yer nd less thn one TB deth per popultion per yer. 4

16 UNITED TO END TUBERCULOSIS: AN URGENT GLOBAL RESPONSE TO A GLOBAL EPIDEMIC 5

17 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. A reltively smll proportion (5 1%) of the estimted 1.7 billion people infected with M. tuberculosis will develop TB disese during their lifetime. However, the probbility of developing TB disese is much higher mong people infected with HIV; it is lso higher mong people ffected by risk fctors such s undernutrition, dibetes, smoking nd lcohol consumption. Overll, bout 9% of cses occur mong dults, with more cses mong men thn women. The mle:femle rtio mong dults is pproximtely 2:1. Dignostic tests for TB disese include: Rpid moleculr tests The only rpid test for dignosis of TB currently recommended by WHO is the Xpert MTB/RIF ssy (Cepheid, USA). It cn provide results within 2 hours, nd ws initilly recommended (in 21) for dignosis of pulmonry TB in dults. Since 213, it hs lso been recommended for use in children nd to dignose specific forms of extrpulmonry TB. The test hs much better ccurcy thn sputum smer microscopy. Sputum smer microscopy Developed more thn yers go, this technique requires the exmintion of sputum smples using microscope to determine the presence of bcteri. Culture-bsed methods These form the current reference stndrd; they require more developed lbortory cpcity nd cn tke up to 12 weeks to provide results. Globlly, use of rpid moleculr tests is incresing, nd mny countries re phsing out the use of smer microscopy for dignostic purposes (lthough microscopy nd culture remin necessry for tretment monitoring). There re lso tests for TB tht is resistnt to firstline nd second-line nti-tb drugs. They include Xpert MTB/RIF, which simultneously tests for TB nd resistnce to rifmpicin (the most effective first-line nti-tb drug); rpid line probe ssys (LPAs) tht test for resistnce to rifmpicin nd isonizid (referred to s first line LPAs); rpid LPA tht tests for resistnce to fluoroquinolones nd injectble nti-tb drugs (referred to s second-line LPA); nd sequencing technologies. First-line LPAs were first recommended by WHO in 28; the second-line LPA ws first recommended in My 216. Culture-bsed methods currently remin the reference stndrd for drug susceptibility testing. Without tretment, the mortlity rte from TB is high. Studies of the nturl history of TB disese in the bsence of tretment with nti-tb drugs (conducted before drug tretments becme vilble) found tht bout 7% of individuls with sputum smer-positive pulmonry TB died within 1 yers of being dignosed, s did bout 2% of people with culture-positive (but smer-negtive) pulmonry TB. Effective drug tretments were first developed in the 194s. The currently recommended tretment for cses of drug-susceptible TB is 6-month regimen of four first-line drugs: isonizid, rifmpicin, ethmbutol nd pyrzinmide. The Globl TB Drug Fcility supplies complete 6-month course for bout US$ 4 per person. Tretment success rtes of t lest 85% for cses of drug-susceptible TB re regulrly reported to WHO by its 194 Member Sttes. Tretment for rifmpicin-resistnt TB (RR-TB) nd multidrugresistnt TB (MDR-TB) b is longer, nd requires more expensive ( US$ per person) nd more toxic drugs. The ltest dt reported to WHO show tretment success rte for MDR-TB of 55%, globlly. There re 2 TB drugs in clinicl trils, nd combintion regimens tht include new compounds s well s other drugs re lso being tested in clinicl trils. The bcille Clmette- Guérin (BCG) vccine, which ws developed lmost yers go nd hs been shown to prevent severe forms of TB in children, is still widely used. However, there is currently no vccine tht is effective in preventing TB disese in dults, either before or fter exposure to TB infection. There re 12 TB vccines in Phse I, Phse II or Phse III trils. b Tiemersm EW, vn der Werf MJ, Borgdorff MW, Willims BG, Ngelkerke NJ. Nturl history of tuberculosis: durtion nd ftlity of untreted pulmonry tuberculosis in HIV negtive ptients: systemtic review. PLoS One. 211;6(4):e1761 ( pubmed/ , ccessed 3 July 218). Defined s resistnce to isonizid nd rifmpicin, the two most powerful nti-tb drugs. 6

18 Chpter 1. Introduction Tuberculosis (TB) is n old disese studies of humn skeletons show tht it hs ffected humns for thousnds of yers. 1 The cuse remined unknown until 24 Mrch 1882, when Dr Robert Koch nnounced tht he hd discovered the bcillus Mycobcterium tuberculosis, n event tht is now commemorted every yer s World TB Dy. 2 The disese is spred when people who re sick with TB expel bcteri into the ir, for exmple by coughing. Bsic fcts bout TB re provided in Box 1.1. In the lte 18s, cuse-of-deth dt from ntionl vitl registrtion systems show tht TB ws one of the leding cuses of deth in some Europen countries. With socil nd economic development such s improvements in incomes, housing nd nutrition numbers of TB cses nd deths strted to decline in western Europe, North Americ nd some other prts of the world round the turn of the 2th century, lbeit slowly (1 2% per yer). 3,4 From the 194s, the discovery, development nd use of effective drug tretments substntilly ccelerted these trends, with ntionl cse rtes (per popultion) flling by up to 1% per yer nd mortlity rtes flling even fster. In countries tht hve experienced such reductions in disese burden, nd now hve only round 1 or fewer cses nd less thn 1 deth per popultion per yer, TB is often regrded s disese of the pst. For mny countries, however, the end of TB s n epidemic nd mjor public helth problem is still distnt relity. This is despite the fct tht, with timely dignosis nd correct drug tretment, most people who develop the disese cn be cured. Twenty five yers go, in 1993, WHO declred TB globl helth emergency. 5 1 Hershkovitz I, Donoghue HD, Minnikin DE, My H, Lee OY, Feldmn M, et l. Tuberculosis origin: the Neolithic scenrio. Tuberculosis (Edinb). 215;95 Suppl 1:S122 6 ( pubmed/ , ccessed 3 July 218). 2 Skul A. Robert Koch: centenry of the discovery of the tubercle bcillus, Thorx. 1982;37(4): ( gov/pubmed/618494, ccessed 3 July 218). 3 Styblo K, Meijer J, Sutherlnd I. The trnsmission of tubercle bcilli: its trend in humn popultion. Bull World Helth Orgn. 1969;41: ( ccessed 3 July 218). 4 Grnge JM, Gndy M, Frmer P, Zuml A. Historicl declines in tuberculosis: nture, nurture nd the biosocil model. Int J Tuberc Lung Dis. 21;5(3):28 12 ( ccessed 3 July 218). 5 World Helth Orgniztion. TB: globl emergency, WHO report on the TB epidemic (WHO/TB/94.177). Genev: WHO; 1994 ( iris/hndle/1665/58749, ccessed 21 June 218). There hs been mjor progress in subsequent yers more thn 6 million people hve been documented s treted nd cured since 2, nd cse nd deth rtes hve fllen stedily. Nevertheless, worldwide, round 1 million people still fll ill with the disese ech yer (more dults thn children, nd more men thn women), nd TB is one of the top 1 cuses of deth. It is lso the leding cuse of deth from single infectious gent, rnking bove HIV/AIDS. In 214 nd 215, ll Member Sttes of WHO nd the United Ntions (UN) committed to ending the TB epidemic. They did this by unnimously endorsing WHO s End TB Strtegy t the World Helth Assembly in My 214, nd by dopting the UN Sustinble Development Gols (SDGs) in September 215. The End TB Strtegy hs the overll gol of ending the globl TB epidemic, nd it defines the trgets (23, 235) nd milestones (22, 225) for reductions in TB cses nd deths needed to chieve tht gol. The SDGs include trget to end the TB epidemic by 23. In 217 nd 218, efforts to step up politicl commitment to the fight ginst TB hve intensified. The first globl ministeril conference on TB ws held in November 217. The UN s first high-level meeting (HLM) on TB, on 26 September 218 t its hedqurters in New York, includes heds of stte. The title is United to End TB: An Urgent Globl Response to Globl Epidemic. WHO hs published globl TB report every yer since This 218 edition is published in ssocition with the UN HLM. It provides comprehensive nd up-to-dte ssessment of the TB epidemic, nd of progress in the response, t globl, regionl nd country levels. This is bsed primrily on dt gthered by WHO from countries nd territories in nnul rounds of dt collection, nd dtbses mintined by other multilterl gencies. The topics covered in the min chpters of the report re: globl commitments to end TB nd multisectorl ccountbility; estimtes of TB disese burden 2 217; TB dignosis nd tretment; TB prevention services; finncing for TB prevention, dignosis nd tretment; universl helth coverge, socil protection nd socil determinnts of TB; nd TB reserch nd development. The report s nnexes describe WHO s online globl TB dtbse, present profiles for 3 high TB burden countries nd WHO s six regions, nd contin dt for key indictors for ll countries, for the ltest vilble yer. 7

19 Primry school children in villge in northern Lo People s Democrtic Republic Hdynyh / Getty Imges 8

20 Chpter 2. Globl commitments to end TB nd multisectorl ccountbility From 2 to 215, globl nd ntionl efforts to reduce the burden of tuberculosis (TB) disese were focused on chieving trgets set within the context of the Millennium Development Gols (MDGs). The MDGs were estblished by the United Ntions (UN) in 2, nd trgets were set for 215. Trget 6c of MDG 6 ws to hlt nd reverse TB incidence. The Stop TB Prtnership, estblished in 21, dopted this trget nd set two dditionl trgets: to hlve TB prevlence nd TB mortlity rtes by 215 compred with their levels in 199. The globl TB strtegy developed by WHO for the decde , the Stop TB Strtegy, hd the overll gol of reching ll three of these trgets. In October 215, WHO published its ssessment of whether the 215 globl TB trgets for reductions in TB incidence, prevlence nd mortlity hd been chieved. 1 In 216, the MDGs were succeeded by new set of gols, known s the Sustinble Development Gols (SDGs). Adopted by the UN in September 215 following 3 yers of consulttions, the SDG frmework of gols, trgets nd indictors covers the period Similrly, in 212 WHO initited work on new globl TB strtegy, which ws completed in 214. The End TB Strtegy ws unnimously endorsed by ll WHO Member Sttes t the 214 World Helth Assembly, nd covers the period The SDGs nd the End TB Strtegy provide the frmework for ntionl nd interntionl efforts to end the TB epidemic during the period This chpter provides n overview of both the SDGs (Section 2.1) nd the End TB Strtegy (Section 2.2). It then describes the Moscow Declrtion from the first globl ministeril conference on ending TB (Section 2.3), 4 which ws held in November 217 with the im of ccelerting progress towrds trgets set in the SDGs 1 World Helth Orgniztion. Globl tuberculosis report 215. Genev: WHO; 215 ( eng.pdf, ccessed 21 June 218). 2 United Ntions. Sustinble Development Gols ( sustinbledevelopment.un.org/topics/sustinbledevelopmentgols, ccessed 21 June 218). A short summry of the min findings is lso vilble in Chpter 2 of the 216 edition of the report. 3 Uplekr M, Weil D, Lönnroth K, Jrmillo E, Lienhrdt C, Dis HM, et l. WHO s new End TB Strtegy. Lncet. 215;385(9979): ( ccessed 21 June 218). 4 The conference ws titled Ending TB in the Sustinble Development Er: multisectorl response. nd End TB Strtegy through multisectorl response. The Moscow Declrtion includes commitments by WHO Member Sttes nd clls to prtner gencies, nd hs informed the first UN high-level meeting on TB t UN hedqurters in New York in September 218. In Section 2.3, specific ttention is given to the development of multisectorl ccountbility frmework to ccelerte progress towrds ending TB, which ws one of four topics fetured in the declrtion nd which hs been mjor focus of work for WHO, in collbortion with WHO Member Sttes nd prtner gencies, in 218. Given the multisectorl influences on the TB epidemic nd the multisectorl ctions needed to end it, WHO developed TB-SDG monitoring frmework in This is described nd explined in Section 2.4. The frmework is designed to focus ttention on, nd encourge nlysis of, SDG trgets nd indictors tht will influence the course of the TB epidemic, with findings then used to drive ction. Anlysis of the 14 indictors included in the frmework is prt of Chpter 7. 6 At the 218 World Helth Assembly, Member Sttes endorsed WHO s Generl Progrmme of Work (GPW) for The GPW is bsed on the foundtion of SDG 3, the helth gol of the SDGs, nd it includes TB trgets for 223 tht re consistent with those of the End TB Strtegy. Section 2.5 describes the GPW s three strtegic gols nd ssocited outcomes, nd its trgets for TB, highlighting how these gols, outcomes nd trgets link with the SDGs nd the End TB Strtegy. For the first 5 yers of the SDGs nd End TB Strtegy (216 22), WHO hs defined three lists of high-burden countries (HBCs): for TB, TB/HIV nd multidrug-resistnt TB (MDR-TB). Prticulr ttention is given to the countries in ech of these lists throughout this report. For this reson, they re presented nd explined in Section World Helth Orgniztion. Globl tuberculosis report 217 (WHO/HTM/ TB/217.23). Genev: WHO; 217 ( dle/1665/259366/ eng.pdf, ccessed 21 June 218). 6 In ddition, Annex 2 shows the ltest dt nd recent trends for ech indictor for the 3 high TB burden countries. For other countries, the sme dt re vilble in country profiles tht cn be ccessed online t 7 See: pdf?u=1 9

21 2.1 The Sustinble Development Gols The 17 SDGs re shown in Box 2.1. The consolidted gol for helth is SDG 3, which is defined s Ensure helthy lives nd promote well-being for ll t ll ges. Thirteen trgets hve been set for this gol (Box 2.2), nd 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, wter-borne diseses nd other communicble diseses. The lnguge of ending epidemics is lso now prominent element of globl helth strtegies developed by WHO nd the Joint United Ntions Progrmme on HIV/AIDS (UNAIDS) for the post- 215 er, 1 including the End TB Strtegy (Section 2.2). The TB indictor for Trget 3.3 is the TB incidence rte (new TB cses per popultion per yer). SDG 3 lso includes trget (Trget 3.8) relted to universl helth coverge (UHC) in which TB is explicitly mentioned. The WHO/World Bnk definition of UHC is tht ll people receive the helth services they need, while t the sme time ensuring tht the use of these services does not expose the user to finncil hrdship. 2,3 Trget 3.8 includes n indictor for the coverge of essentil prevention, tretment nd cre interventions. This is composite indictor bsed on the coverge of 16 so-clled trcer interventions, 4 one of which is TB tretment. The SDGs include considerble emphsis on disggregted nlysis nd reporting of dt (s well s reporting for n entire country). Depending on the indictor, exmples include disggregtion by ge, sex, loction nd economic sttus (e.g. bottom 4%, or bottom versus top income quintiles). Some indictors lso give prticulr ttention to specific subpopultions, such s pregnnt women, people with disbilities, victims of work injuries, nd migrnts. In support of the requirement for disggregtion for mny indictors, SDG 17 includes two trgets nd ssocited indictors under the subheding of Dt, monitoring nd ccountbility tht specificlly refer to disggregted dt nd the mechnisms needed to generte such dt (Tble 2.1). Emphsis is lso given to the importnce of deth registrtion within ntionl vitl registrtion systems, to llow for ccurte trcking 1 World Helth Orgniztion. Accelerting progress on HIV, tuberculosis, mlri, heptitis nd neglected tropicl diseses: new gend for Genev: WHO; 215 ( orgnigrm/htm/progress-hiv-tb-mlri-ntd/en/, ccessed 21 June 218). 2 World Helth Orgniztion/World Bnk Group. Trcking universl helth coverge: first globl monitoring report. Genev: WHO; 215 ( pps.who.int/iris/bitstrem/1665/174536/1/ _eng. pdf?u=1, ccessed 21 June 218). 3 World Helth Orgniztion/World Bnk Group. Trcking universl helth coverge: 217 globl monitoring report. Genev: WHO; 217 ( pps.who.int/iris/bitstrem/hndle/1665/259817/ eng.pdf, ccessed 21 June 218). 4 There re mny different prevention nd tretment interventions. SDG indictor is bsed on the coverge of 16 interventions tht hve been selected s trcers for ssessment of progress towrds UHC for ll interventions. Further detils re provided in Chpter 7. of cuses of deth (this is Prt b of Indictor ). Strengthening ntionl vitl registrtion systems s the bsis for direct mesurement of the number of TB deths is one of the five strtegic res of work of the WHO Globl Tsk Force on TB Impct Mesurement, s discussed in Chpter 3. Disggregtion is intended to inform nlysis of within-country inequlities nd ssocited ssessments of equity, with findings used to identify prticulr res or subpopultions where progress is lgging nd greter ttention is needed. Such disggregtion is lso n importnt considertion for the TB community, given the influence of sex, ge, socioeconomic sttus nd differentil ccess to helth cre on the risks for nd consequences of TB infection nd disese. Chpter 3 nd Chpter 4 of this report include nlyses of TB dt disggregted by ge nd sex. 2.2 The End TB Strtegy The End TB Strtegy t glnce is shown in Box 2.3. The overll gol is to End the globl TB epidemic, nd there re three high-level, overrching indictors nd relted trgets (for 23 linked to the SDGs nd for 235) nd milestones (for 22 nd 225). The three indictors re: the number of TB deths per yer; the TB incidence rte (new cses per popultion per yer); nd the percentge of TB-ffected households tht experience ctstrophic costs s result of TB disese. The 23 trgets re 9% reduction in TB deths nd n 8% reduction in the TB incidence rte, compred with levels in 215. The 235 trgets re 95% reduction in TB deths nd 9% reduction in the TB incidence rte, compred with levels in 215. The most immedite milestones, set for 22, re 35% reduction in TB deths nd 2% reduction in the TB incidence rte, compred with levels in 215. The trjectories of TB incidence nd TB deths tht re required to rech these milestones nd trgets re shown in Fig For the third indictor (the percentge of TB-ffected households tht experience ctstrophic costs s result of TB disese), the milestone for 22 is zero, to be sustined therefter. The Stop TB Prtnership hs developed Globl Pln to End TB, , 5 which focuses on the ctions nd funding needed to rech the 22 milestones of the End TB Strtegy. More detils bout this pln re provided in Chpter 6. Progress towrds UHC nd ctions to ddress helth-relted risk fctors for TB (s well s broder socil nd economic determinnts of TB) will be fundmentl to chieving the trgets nd milestones for 5 The Globl Pln to End TB, Genev: Stop TB Prtnership; 215 ( ccessed 21 June 218). 1

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

23 BOX 2.2 Sustinble Development Gol 3 nd its 13 trgets SDG 3: 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 live births 3.2 By 23, end preventble deths of newborns nd children under 5 yers of ge, with ll countries iming to reduce neontl mortlity to t lest s low s 12 per live births nd under-5 mortlity to t lest s low s 25 per live births 3.3 By 23, end the epidemics of AIDS, tuberculosis, mlri nd neglected tropicl diseses nd combt heptitis, wter-borne diseses nd other communicble diseses 3.4 By 23, reduce by one third premture mortlity from non-communicble diseses through prevention nd tretment nd promote mentl helth nd well-being 3.5 Strengthen the prevention nd tretment of substnce buse, including nrcotic drug buse nd hrmful use of lcohol 3.6 By 22, hlve the number of globl deths nd injuries from rod trffic ccidents 3.7 By 23, ensure universl ccess to sexul nd reproductive helth-cre services, including for fmily plnning, informtion nd eduction, nd the integrtion of reproductive helth into ntionl strtegies nd progrmmes 3.8 Achieve universl helth coverge, including finncil risk protection, ccess to qulity essentil helth-cre services nd ccess to sfe, effective, qulity nd ffordble essentil medicines nd vccines for ll 3.9 By 23, substntilly reduce the number of deths nd illnesses from hzrdous chemicls nd ir, wter nd soil pollution nd contmintion 3. Strengthen the implementtion of the World Helth Orgniztion Frmework Convention on Tobcco Control in ll countries, s pproprite 3.b Support the reserch nd development of vccines nd medicines for the communicble nd 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 reductions in TB cses nd deths, for two resons. First, reching the milestones for reductions in TB cses nd deths set for 22 nd 225 requires the nnul decline in the globl TB incidence rte to ccelerte from 1.5% per yer in 215 to 4 5% per yer by 22, nd then to 1% per yer by 225. A decline of 1% per yer is equivlent to the best-ever performnce to dte t ntionl level (e.g. in countries in western Europe during the 19s nd 196s), nd hs only been documented in the context of UHC combined with broder socil nd economic development. Second, the globl proportion of people with TB who die from the disese (the cse ftlity rtio, or CFR) needs to be reduced to 1% by 22 nd then to 6.5% by 225. A CFR of 6.5% is similr to the current level in mny high-income countries, but is only possible if ll those with TB disese cn ccess high-qulity tretment. Anlysis of CFRs t globl nd ntionl levels is included in Chpter 3. The percentge of TB ptients nd their households fcing ctstrophic costs is good trcer indictor for progress towrds UHC s well s socil protection. If UHC nd socil protection re in plce, then people with TB should be ble to ccess high-qulity dignosis nd tretment without incurring ctstrophic costs. 1 After 225, reching the 23 nd 235 trgets will require n unprecedented ccelertion in the rte t 1 This indictor, including results from recent ntionl surveys to mesure it, is discussed in more detil in Chpter 7. 12

24 TABLE 2.1 SDG 17, nd trgets nd indictors relted to dt, monitoring nd ccountbility SDG 17: Strengthen the mens of implementtion nd revitlize the globl prtnership for sustinble development TARGETS By 22, enhnce cpcity-building support to developing countries, including for lest developed countries nd smll islnd developing Sttes, to increse significntly the vilbility of high-qulity, timely nd relible dt disggregted by income, gender, ge, rce, ethnicity, migrtory sttus, disbility, geogrphic loction nd other chrcteristics relevnt in ntionl contexts By 23, build on existing inititives to develop mesurements of progress on sustinble development tht complement gross domestic product, nd support sttisticl cpcity-building in developing countries INDICATORS Proportion of sustinble development indictors produced t the ntionl level with full disggregtion when relevnt to the trget, in ccordnce with the Fundmentl Principles of Officil Sttistics Proportion of countries tht () hve conducted t lest one popultion nd housing census in the lst 1 yers; nd (b) hve chieved per cent birth registrtion nd 8 per cent deth registrtion 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% % 8% 9% % % % % PRINCIPLES 1. Government stewrdship nd ccountbility, with monitoring nd evlution 2. Strong colition with civil society orgniztions nd communities 3. Protection nd promotion of humn rights, ethics nd equity 4. Adpttion of the strtegy nd trgets t country level, with globl collbortion PILLARS AND COMPONENTS 1. INTEGRATED, PATIENT-CENTRED CARE AND PREVENTION A. Erly dignosis of TB including universl drug susceptibility testing, nd systemtic screening of contcts nd high-risk groups B. Tretment of ll people with TB including drug-resistnt TB, nd ptient support C. Collbortive TB/HIV ctivities, nd mngement of comorbidities D. Preventive tretment of persons t high risk, nd vccintion ginst TB 2. BOLD POLICIES AND SUPPORTIVE SYSTEMS A. Politicl commitment with dequte resources for TB cre nd prevention B. Enggement of communities, civil society orgniztions, nd public nd privte cre providers C. Universl helth coverge policy, nd regultory frmeworks for cse notifiction, vitl registrtion, qulity nd rtionl use of medicines, nd infection control D. Socil protection, poverty llevition nd ctions on other determinnts of TB 3. INTENSIFIED RESEARCH AND INNOVATION A. Discovery, development nd rpid uptke of new tools, interventions nd strtegies B. Reserch to optimize implementtion nd impct, nd promote innovtions Trgets linked to the Sustinble Development Gols (SDGs). 13

25 FIG. 2.1 Projected incidence nd mortlity curves tht re required to rech End TB Strtegy trgets nd milestones, Incidence rte per popultion per yer % reduction % reduction 8% reduction TARGET FOR 235 = 9% REDUCTION Deths (millions) % reduction 75% reduction 9% reduction TARGET FOR 235 = 95% REDUCTION which TB incidence flls globlly, to n verge of 17% per yer. Such n ccelertion will depend on technologicl brekthrough tht cn substntilly reduce the risk of developing TB disese mong the pproximtely 1.7 billion people 1 (pproximtely one qurter of the world s popultion) who re lredy infected with Mycobcterium tuberculosis. Exmples include n effective post-exposure vccine or short, efficcious nd sfe tretment for ltent TB infection. The ltest sttus of the development pipelines for new TB dignostics, drugs nd vccines is presented in Chpter 8. To chieve the trgets nd milestones, the End TB Strtegy hs four underlying principles nd three pillrs. The four 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 (including UHC, socil protection, nd ction on TB determinnts); nd intensified reserch nd innovtion. The 1 components of the three pillrs of the End TB Strtegy re shown in Box 2.3. WHO hs defined 1 priority indictors for monitoring of progress in implementing the End TB Strtegy. These re shown in Tble 2.2. The tble lso indictes the prticulr chpter of this report in which vilble dt for ech indictor cn be found. 1 Houben RM, Dodd PJ. The globl burden of ltent tuberculosis infection: re-estimtion using mthemticl modelling. PLoS Med. 216;13(1):e2152 ( ccessed 21 June 218). Dt for five of the 1 indictors cnnot be cptured routinely using the stndrd recording nd reporting forms for pper-bsed systems tht re included in the ltest revision of WHO s frmework for TB cse definitions nd reporting. 2 Collection of dt on the costs fced by TB ptients nd their households, nd ssessment of whether these re ctstrophic (Indictor 3 in Tble 2.2) requires periodic surveys of representtive smple of TB ptients; further detils re provided in Chpter 7. For the other four indictors (Indictors 4, 5, 6 nd 8 in Tble 2.2), dt my lredy be cptured routinely in countries tht hve electronic cse-bsed systems for recording nd reporting of dt; if this is not the cse, these systems cn be dpted to cpture the informtion. Alterntively, countries cn undertke periodic surveys of the medicl records or ptient crds of rndom smple of TB ptients. Further guidnce is provided in the WHO opertionl guidnce on the End TB Strtegy The Moscow Declrtion to end TB The first globl ministeril conference on ending TB ws held in Moscow in November 217. It ws orgnized by WHO nd the Ministry of Helth of the Russin Federtion, in recognition of the fct tht investments nd ctions hve been flling short of those needed to rech SDG nd End TB Strtegy trgets nd milestones. 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 21 June 218). 3 World Helth Orgniztion. Implementing the End TB Strtegy: the essentils. Genev: WHO, 216 ( publictions/215/the_essentils_to_end_tb/en/, ccessed 21 June 218). See in prticulr Prt II, Section

26 TABLE 2.2 Top 1 indictors (not rnked) for monitoring implementtion of the End TB Strtegy t globl nd ntionl levels, with recommended trget levels tht pply to ll countries. The trget level is for 225 t the ltest INDICATOR 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. TB tretment success rte Percentge of notified TB ptients who were successfully treted. The trget is for drug susceptible nd drug-resistnt TB combined, lthough outcomes should lso be reported seprtely. 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. 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. 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). 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. 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. 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. 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. Cse ftlity rtio (CFR) Number of TB deths divided by estimted number of incident cses in the sme yers, expressed s percentge. RECOMMENDED TARGET LEVEL MAIN RATIONALE FOR INCLUSION IN TOP 1 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 9% milestones nd trgets of the End TB Strtegy. % 9% 9% 9% % 9% % 5% 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 TBffected households. Accurte dignosis is fundmentl component of TB cre. Rpid moleculr dignostic tests help to ensure erly detection nd prompt tretment. Tretment of LTBI is the min tretment intervention vilble to prevent development of ctive TB disese in those lredy infected with Mycobcterium tuberculosis. Contct trcing is key component of TB prevention, especilly in children. Testing for drug susceptibility for WHO-recommended drugs is essentil to provide the right tretment for every person dignosed with TB. 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. 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. 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. Ctstrophic costs re provisionlly defined s totl costs tht exceed 2% of nnul household income. MAIN METHOD OF MEASUREMENT, AND RELEVANT CHAPTER OF THIS REPORT Routinely collected notifiction dt used in combintion with estimte of TB incidence. Chpter 4 Routinely collected dt. Chpter 4 Ntionl survey of notified TB ptients. Chpter 7 Routinely collected dt (s prt of cse-bsed surveillnce), or ntionl survey of medicl records or ptient crds of TB ptients. Chpter 4 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 As bove for LTBI. Routinely collected dt (s prt of cse-bsed surveillnce), or ntionl survey of medicl records or ptient crds of TB ptients. Chpter 4 As bove for DST. Routinely collected dt for ll TB ptients. Chpter 4 Mortlity divided by incidence. In countries with highperformnce surveillnce system, notifictions pproximte incidence. Chpter 3 15

27 16-17 NOVEMBER 217, MOSCOW, RUSSIAN FEDERATION The conference brought together over prticipnts, including ministers of helth nd other leders from 12 countries, nd over 8 prtners, including civil society. The key outcome of the conference ws the Moscow Declrtion to End TB, 1 which ws dopted by lmost 12 WHO Member Sttes represented t the conference. The declrtion ws developed through consulttions with prtners nd Member Sttes, led by the the Russin Federtion. The Declrtion includes both commitments by Member Sttes nd clls for ctions by globl gencies nd other prtners in four key res (Fig. 2.2): 2 Advncing the TB response within the SDG gend; Ensuring sufficient nd sustinble finncing; Pursuing science, reserch nd innovtion; Developing multisectorl ccountbility frmework. At the World Helth Assembly in My 218, ll Member Sttes committed to ccelerte their ctions to end TB, building on the commitments of the Moscow Declrtion. They lso welcomed drft version of multisectorl ccountbility frmework for TB, nd supported its further development, dpttion nd use (Box 2.4). FIRST WHO GLOBAL MINISTERIAL CONFERENCE ENDING TB IN THE SUSTAINABLE DEVELOPMENT ERA: A MULTISECTORAL RESPONSE MOSCOW DECLARATION TO END TB The topics of the Moscow Declrtion re prominently fetured in the UN high-level meeting on TB on 26 September 218, 3 which will seek further commitments from Heds of Stte. The title of the meeting ws United to End TB: An Urgent Globl Response to Globl Epidemic. In the months leding up to the UN high-level meeting, ministers nd heds of stte of mjor country blocs hve issued communiqués on the need for ction on TB, including drug-resistnt TB in the wider context of ntimicrobil resistnce (AMR). Exmples include the G2; the G7; Brzil, the Russin Federtion, Indi, Chin nd South Afric (BRICS); nd the Asi-Pcific Economic Coopertion (APEC). New commitments hve lso been mde by ministers from countries in the WHO South-Est Asi Region t the Delhi End TB Summit in Mrch 218 nd by Africn leders t summit of the Africn Union in July Moscow Declrtion to End TB; First WHO Globl Ministeril Conference on Ending TB in the Sustinble Development Er: A Multisectorl Response, November 217. WHO nd the Ministry of Helth of the Russin Federtion. Declrtion_to_End_TB_finl_ENGLISH.pdf?u=1, ccessed 21 June 218). 2 The SDG gend nd multisectorl ccountbility frmework for TB re discussed in this chpter. The topic of finncing is covered in Chpter 6 nd Chpter 7; reserch nd development is the subject of Chpter 8. 3 United Ntions Generl Assembly. Resolution dopted by the Generl Assembly on 4 April 218. A/RES/72/268. Scope, modlities, formt nd orgniztion of the high level meeting on the fight ginst tuberculosis ( RES/72/268, ccessed 21 June 218). 1 FIG. 2.2 The four outcome res of the Moscow Declrtion ADVANCING THE TB RESPONSE WITHIN THE SDG AGENDA ENSURING SUFFICIENT AND SUSTAINABLE FINANCING SCIENCE, RESEARCH AND INNOVATION 2.4 A TB-SDG monitoring frmework Monitoring of TB-specific indictors is well estblished t globl nd ntionl levels. For exmple, stndrdized monitoring of notifictions of TB cses nd their tretment outcomes t globl nd ntionl levels hs been in plce since 1995, nd WHO hs been publishing nnul estimtes of TB incidence nd mortlity for more thn decde. In the er of the End TB Strtegy nd SDGs, such monitoring needs to be sustined, longside continued efforts to strengthen notifiction nd vitl registrtion systems so tht they cn provide relible dt for direct mesurement of TB incidence nd TB deths (see lso Chpter 3), nd monitoring of the newer priority indictors (five of those listed in Tble 2.2 were introduced in the context of the End TB Strtegy). As explined in Section 2.2, chieving the End TB Strtegy trgets nd milestones requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. As explined in Section 2.1, the SDG frmework includes trgets nd indictors relted to these risk fctors nd determinnts, nd the globl ministeril conference on ending TB nd the ssocited Moscow Declrtion emphsized the need for multisectorl pproch nd multisectorl ccountbility frmework (Section 2.3). In this context, TB monitoring needs to include nlysis of selected SDG indictors tht will influence the course of the TB epidemic, with findings used to inform the multisectorl ctions needed to end the TB epidemic. WHO developed TB-SDG monitoring frmework in 217, bsed on previously published work tht identified cler linkges between vrious SDG indictors nd TB 16

28 BOX 2.4 Developing drft multisectorl ccountbility frmework to ccelerte progress to end TB Bckground The first WHO globl ministeril conference on TB, titled Ending TB in the Sustinble Development Er: multisectorl response, ws held in Moscow in November 217. The im ws to ccelerte implementtion of the End TB Strtegy, in recognition of the fct tht investments nd ctions hve, to dte, fllen short of those needed to rech SDG nd End TB Strtegy trgets, nd to inform the UN highlevel meeting on TB in September 218. The Moscow Declrtion to End TB includes both commitments by Member Sttes nd clls for ctions by globl gencies nd other prtners. It ddresses four key res for ction, one of which is multisectorl ccountbility. b Member Sttes committed to supporting the development of multisectorl ccountbility frmework in dvnce of the UN HLM on TB, nd clled on WHO to develop such frmework, working in close coopertion with Member Sttes nd prtners, for considertion by WHO s governing bodies (i.e. the Executive Bord nd World Helth Assembly). The rtionle for such frmework is tht strengthened ccountbility for the response to TB t ntionl nd globl levels should contribute to fster progress towrds the trgets nd milestones of the SDGs nd End TB Strtegy. The Executive Bord reiterted this request in its Jnury 218 meeting, in the form of decision point. c This included specific request, ddressed to the WHO Director-Generl, to develop drft frmework for considertion by Member Sttes t the World Helth Assembly in My 218, nd for presenttion t the UN HLM on ending TB in September 218. Definitions nd concepts Accountbility mens being responsible (or nswerble) for commitments mde or ctions tken. An ccountbility frmework defines who is ccountble (e.g. n individul, orgniztion or ntionl government, or the globl community), wht commitments nd ctions they re ccountble for, nd how they will be held to ccount. Brodly, mechnisms for how specific entities re held to ccount fll into two mjor ctegories: monitoring nd reporting, nd review. A generic illustrtion of n ccountbility frmework, represented s cycle of components, is shown in Fig. B d Conceptully, commitments should be followed by the ctions needed to keep or chieve them. Monitoring nd reporting re then used to trck progress relted to commitments nd ctions. Review is used to ssess the results from monitoring tht re documented in reports nd ssocited products, nd to mke recommendtions for future ctions. The cycle of ction, monitoring nd reporting, nd review cn be repeted mny times. The results from monitoring nd reporting, nd the recommendtions from reviews bsed on those results, should drive the next cycle of ctions. Periodiclly, new commitments or reinforcement of commitments my be required, bsed on reviews of progress. FIG. B2.4.1 Generic ccountbility frmework REVIEW Accountbility cn be strengthened by reinforcing one or more of the four components of the frmework. Exmples include dding new ctions or improving existing ones; incresing the qulity nd coverge of dt nd reports vilble to inform reviews of progress; elevting reviews to higher level; improving review processes (e.g. by mking them more independent, more trnsprent nd with wider prticiption); nd ensuring tht the results of reviews hve meningful consequences for ction. If ech of the ctions monitoring nd reporting review components of the cycle is strong, progress towrds commitments should be fster thn if one or more of those components is wek. Development process to dte COMMITMENTS ACTIONS MONITORING AND REPORTING WHO prepred bckground document on the development of multisectorl ccountbility frmework in Februry 218. e The bckground document ws used s the bsis for consulttions with Member Sttes nd other prtners, including in 2-dy consulttion held in Mrch 218. f Consulttions informed the development of drft multisectorl ccountbility frmework to ccelerte progress to end TB, which ws posted for public review in mid-april 218. Input from this review, from Member Sttes nd prtners, ws used to produce n updted drft. The drft multisectorl ccountbility frmework for TB tht ws submitted for the considertion of the 218 World Helth Assembly is vilble online; g brief outline is provided here. The frmework hs two mjor prts: globl nd regionl levels; nd ntionl (including locl) level. The four components of ech prt of the frmework re the sme s those in the generic frmework shown in Fig. B2.4.1 nmely, commitments, ctions, monitoring nd reporting, nd review. 17

29 The content of the frmework is bsed on the following principles: The SDGs nd the End TB Strtegy, nd ssocited politicl declrtions form the foundtion of the frmework, s do existing monitoring nd reporting systems, nd ssocited best prctices. Civil society, TB-ffected communities nd ptient groups hve fundmentl role to ply in ll spects of ccountbility. It is not possible to be exhustive in listing ll elements of relevnce under ech of the four mjor components, especilly t ntionl level; hence, mjor exmples re provided, using generic lnguge. The ntionl component of the frmework requires dpttion. For exmple, there re differences between low nd high TB burden countries, differences between countries tht fund their TB responses entirely from domestic resources nd those tht rely on externl resources for lrge shre of their totl funding, nd differences tht relte to ntionl dministrtive structures nd legisltive frmeworks. The globl nd regionl prt of the frmework defines commitments, ctions, monitoring nd reporting processes, nd review mechnisms tht pply to ll countries collectively or t regionl level. The ntionl prt of the frmework defines commitments, ctions, monitoring nd reporting processes, nd review mechnisms tht pply to individul countries, t ntionl nd locl levels. Discussions t the 218 World Helth Assembly nd next steps At the 218 World Helth Assembly, resolution (EB142.R3) tht included text on the UN HLM for TB nd the multisectorl ccountbility frmework ws presented for considertion by Peru nd the Russin Federtion. c With respect to the multisectorl ccountbility frmework specificlly, the resolution: welcomed the drft frmework; requested the Secretrit to continue to develop it, working with Member Sttes nd prtners; requested the Director-Generl of WHO to present the drft frmework t the UN HLM on TB in September 218; nd requested tht the Secretrit report on progress t the next World Helth Assembly in 219. The resolution ws unnimously endorsed by ll Member Sttes. Next steps for WHO include the following: 1. Presenttion of the drft frmework by the WHO Director- Generl t the UN HLM on TB. 2. Further work on the frmework, in consulttion with Member Sttes nd prtners. The first updtes to the frmework will be bsed on the content of the Politicl Declrtion from the UN HLM on TB. There my be need for dditionl consulttions on the review component of the drft frmework. 3. Submission of n updted version of the frmework for considertion by the World Helth Assembly in Provision of support to Member Sttes tht express interest in beginning to dpt nd use the drft multisectorl ccountbility frmework. b c d e f g Moscow Declrtion to End TB. Genev: WHO; 217 ( int/tb/moscow_declrtion_ministerilconference_tb/en/, ccessed 21 June 218). The others res for ction were dvncing the response within the 23 Agend for Sustinble Development; ensuring sufficient nd sustinble finncing; nd pursuing science, reserch nd innovtion. See resolution EB142.R3, opertive prgrph 1 ( gb/ebwh/pdf_files/eb142/b142_r3-en.pdf, ccessed 21 June 218). Also see WHA documents A71/15 nd A71/16 ( ebwh/pdf_files/wha71/a71_15-en.pdf nd ebwh/pdf_files/wha71/a71_16-en.pdf, ccessed 21 June 218). This figure is derived from the unified ccountbility frmework for women s, children s nd dolescents helth. Tht frmework depicts the ction monitoring review cycle in circle, s here, for the globl nd country levels seprtely. The ccountbility frmework for TB dds component for commitments nd highlights monitoring nd reporting in its third component. Developing drft TB multisectorl ccountbility frmework. Bckground document. Stkeholder consulttion convened by Globl TB Progrmme, World Helth Orgniztion, Chteu de Penthes, Genev, 1 2 Mrch 218. Genev: World Helth Orgniztion; 218 ( Consulttion1_2Mrch_BckgroundDocument_ pdf?u=1, ccessed 21 June 218). Developing drft TB multisectorl ccountbility frmework. Stkeholder consulttion convened by the Globl TB Progrmme, World Helth Orgniztion. Genev, 1 2 Mrch 218. Meeting report ( meetingreport_ pdf?u=1, ccessed 21 June 218). Developing multisectorl ccountbility frmework to ccelerte progress to end TB. Document submitted to the 218 World Helth Assembly (A71/16.Add.1.) 18

30 incidence, 1,2,3,4 nd further nlysis of the reltionship between SDG indictors nd TB incidence. 5 The frmework, which comprises 14 indictors under seven SDGs, is shown in Tble 2.3. For SDG 3, the seven indictors selected for monitoring re: coverge of essentil helth services; percentge of helth expenditures tht re out-ofpocket; helth expenditure per cpit; HIV prevlence; prevlence of smoking; prevlence of dibetes; nd prevlence of lcohol use disorder. For SDGs 1, 2, 7, 8, 1 nd 11, the seven indictors selected for monitoring re: proportion of the popultion living below the interntionl poverty line; proportion of the popultion covered by socil protection floors or systems; prevlence of undernourishment; proportion of the popultion with primry relince on clen fuels nd technology; gross domestic product (GDP) per cpit; Gini index for income inequlity; 6 nd proportion of the urbn popultion living in slums. The rtionle for the selection of these 14 indictors nd dt sources is provided in Tble 2.3, with comments on whether it is relevnt to collect dt for TB ptients specificlly. The frmework includes only indictors for which reltionship with TB incidence could be estblished. It excludes: indictors tht re sub-indictors of indictors tht hve lredy been included (e.g. sub-indictors relted to UHC, under SDG 3); nd 1 Lönnroth K, Jrmillo E, Willims B, Dye C, Rviglione M. Tuberculosis: the role of risk fctors nd socil determinnts. In: Bls E, Kurup A (editors), Equity, socil determinnts nd public helth progrmmes. Genev: WHO; 21 ( bitstrem/1665/44289/1/ _eng.pdf, ccessed 2 August 217). 2 Lönnroth K, Cstro KG, Chky JM, Chuhn LS, Floyd K, Glziou P, et l. Tuberculosis control nd elimintion 21 : cure, cre, nd socil development. Lncet. 21;375(9728): ( nih.gov/pubmed/ , ccessed 2 August 217). 3 Lienhrdt C, Glziou P, Uplekr M, Lönnroth K, Gethun H, Rviglione M. Globl tuberculosis control: lessons lernt nd future prospects. Nt Rev Microbiol. 212;1(6):47 16 ( pubmed/ , ccessed 2 August 217). 4 Lönnroth K, Jrmillo E, Willims BG, Dye C, Rviglione M. Drivers of tuberculosis epidemics: the role of risk fctors nd socil determinnts. Soc Sci Med. 29;68(12):224 6 ( pubmed/ , ccessed 2 August 217). 5 Monitoring nd evlution of TB in the context of the Sustinble Development Gols: Bckground Pper for WHO Ministeril Conference on TB in the context of the Sustinble Development Gols. Avilble on request. 6 The index cn tke vlues between nd 1, with representing perfect equlity nd 1 representing perfect inequlity. indictors tht re only remotely ssocited with TB risks, nd tht operte minly through other SDGs (e.g. eduction under SDG 4, gender equlity under SDG 5 nd resilient infrstructure under SDG 9). Importntly, collection nd reporting of dt for the 14 indictors shown in Tble 2.3 does not require ny dditionl dt collection nd reporting efforts by ntionl TB progrmmes. Nor does it require dt collection nd reporting efforts tht go beyond those to which countries hve lredy committed in the context of the SDGs. At the globl level, the UN hs estblished monitoring system for SDG indictors, nd countries re expected to report dt on n nnul bsis vi the pproprite UN gencies (including WHO). Therefore, nlysis of the sttus of, nd trends in, the 14 indictors relted to TB will be bsed primrily on ccessing the dt held in the UN s SDG dtbse, s shown in Tble In some cses, the SDG indictor is not considered the best metric, nd better (but closely relted) lterntive hs been identified nd justified (five indictors under SDG 3, one under SDG 8 nd one under SDG 1). In such cses, the dt sources re either WHO, the Orgnistion for Economic Co-opertion nd Development (OECD), UNAIDS or the World Bnk (lso shown in Tble 2.3). The dt for the indictors shown in Tble 2.3 tht will be vilble in the WHO, OECD, UN nd World Bnk dtbses will be for ntionl popultions. These dt will not be vilble for TB ptients specificlly, with the exception of dt on HIV prevlence, given tht HIV sttus mong TB ptients hs been routinely monitored s prt of ntionl TB surveillnce for more thn decde. This is not problem for monitoring of TB risk fctors nd determinnts, since it is the popultion-level prevlence tht influences popultion-level TB risks. For few of the indictors included in Tble 2.3, collection of dt for TB ptients specificlly could be considered. However, there is cler risk of mking routine TB surveillnce fr too complex, nd this risk needs to be voided. If the indictor is considered importnt enough to monitor mong TB ptients t country level, periodic surveys should be considered s n lterntive to routine surveillnce (in which dt would be collected for ll TB ptients). Anlysis of the indictors in the TB-SDG monitoring frmework for high TB burden countries is included in Chpter 7. The ltest sttus nd recent trends in ech indictor re lso shown for these countries on the second pge of the country profiles in Annex 2 (this informtion is shown for other countries in profiles tht re vilble online). 8 7 Further detils re provided in Annex

31 TABLE 2.3A TB-SDG monitoring frmework: indictors to monitor within SDG 3 SDG 3: Ensure helthy lives nd promote well-being for ll t ll ges SDG TARGETS FOR 23 SDG INDICATORS ALTERNATIVE INDICATORS TO MONITOR RATIONALE DATA SOURCE COLLECT DATA FOR TB PATIENTS SPECIFICALLY? 3.3 End the epidemics of AIDS, TB, mlri nd neglected tropicl diseses nd combt heptitis, wterborne diseses nd other communicble diseses Number of new HIV infections per uninfected popultion TB incidence per popultion HIV prevlence HIV is strong risk fctor for development of TB disese nd is ssocited with poorer tretment outcomes. HIV prevlence (rther thn incidence) will be monitored becuse it is directly mesured nd those newly infected with HIV re t lower risk of developing TB compred with those who hve been infected for more thn 1 yer. UNAIDS WHO Yes, lredy routinely collected. NA 3.4 Reduce premture mortlity by one third from non-communicble diseses nd promote mentl helth nd well-being Mortlity rte ttributed to crdiovsculr disese, cncer, dibetes or chronic respirtory disese Prevlence of dibetes Dibetes is strong risk fctor for development of TB disese, lthough link with TB incidence t the ntionl (s opposed to individul) level hs been difficult to estblish due to confounding. Dibetes prevlence is more relevnt thn mortlity for TB since it directly influences the risk of developing TB. WHO Could be considered t country level, to inform plnning of cre for comorbidities. 3.5 Strengthen prevention nd tretment of substnce buse, including nrcotic drug buse nd hrmful use of lcohol Alcohol consumption per cpit per yer (in litres of pure lcohol) mong those ged 15 yers (hrmful level defined ntionlly) Prevlence of lcohol use disorder Alcohol use is strong risk fctor for TB disese nd poorer tretment outcomes t the individul level, lthough link with TB incidence t the ntionl (s opposed to individul) level hs been hrd to estblish due to confounding. The prevlence of lcohol use disorder is the most relevnt indictor in the context of TB. WHO Could be considered t country level, to inform plnning of cre for comorbidities. 3.8 Achieve UHC, including finncil risk protection, ccess to qulity essentil helth-cre services nd ccess to sfe, effective, qulity nd ffordble essentil medicines nd vccines for ll 3. Strengthen implementtion of the WHO Frmework Convention on Tobcco Control Coverge of essentil helth services (defined s the verge coverge of essentil services bsed on trcer interventions tht include reproductive, mternl, newborn nd child helth, infectious diseses, non-communicble diseses nd service cpcity nd ccess, mong the generl nd the most disdvntged popultion) Proportion of popultion with lrge household expenditures on helth s shre of totl household expenditure or income 3..1 Agestndrdized prevlence of current tobcco use mong those ged 15 yers NA Percentge of helth expenditures tht re out-of-pocket Helth expenditure per cpit Prevlence of smoking mong those ged 15 yers (%) Achieving UHC is required to chieve the three highlevel trgets of the End TB Strtegy for reductions in the TB incidence rte, the number of TB deths nd eliminting ctstrophic costs for TB ptients nd their households. TB tretment coverge hs been monitored for yers nd is one of the 16 trcer indictors tht hve been selected to mesure SDG indictor Helth expenditure per cpit is correlted with TB incidence. Smoking is strong risk fctor for TB disese t the individul level, lthough link with TB incidence t the ntionl (s opposed to individul) level hs been difficult to estblish due to confounding. WHO WHO To ssess progress in elimintion of ctstrophic costs for TB ptients nd their households, periodic surveys of TB ptients re recommended. Could be considered (e.g. to inform ccess to smoking cesstion interventions). 2

32 TABLE 2.3B TB-SDG monitoring frmework: indictors to monitor beyond SDG 3 SDG 1: End poverty in ll its forms everywhere SDG TARGETS FOR Erdicte extreme poverty for ll people everywhere 1.3 Ntionlly pproprite socil protection systems nd mesures for ll, including floors SDG INDICATORS Proportion of popultion living below the interntionl poverty line Proportion of popultion covered by socil protection floors/systems ALTERNATIVE INDICATORS TO MONITOR NA NA RATIONALE Poverty is strong risk fctor for TB, operting through severl pthwys. Reducing poverty should lso fcilitte prompt helth-cre seeking. Countries with higher levels of socil protection hve lower TB burden. Progress on both indictors will help to chieve the End TB Strtegy trget to eliminte ctstrophic costs for TB ptients nd their households. DATA SOURCE UN SDG dtbse, World Bnk SDG 2: End hunger, chieve food security nd improved nutrition nd promote sustinble griculture 2.1 End hunger nd ensure ccess by ll people to sfe, nutritious nd sufficient food yerround Prevlence of undernourishment NA Under-nutrition wekens the body s defence ginst infections nd is strong risk fctor for TB t the ntionl nd individul level. SDG 7: Ensure ccess to ffordble, relible, sustinble, nd modern energy for ll 7.1 Ensure universl ccess to ffordble, relible nd modern energy services Proportion of popultion with primry relince on clen fuels nd technology NA Indoor ir pollution is risk fctor for TB disese t the individul level. There hs been limited study of mbient ir pollution but it is plusible tht it is linked to TB incidence. UN SDG dtbse COLLECT DATA FOR TB PATIENTS SPECIFICALLY? No Could be considered (e.g. to fcilitte ccess to socil protection). Could be considered (e.g. to pln food support). SDG 8: Promote sustined, inclusive nd sustinble economic growth, full nd productive employment nd decent work for ll 8.1 Sustin per cpit growth with t lest 7% growth in GDP per yer in the lest developed countries Annul growth rte of rel GDP per cpit GDP per cpit SDG 1: Reduce inequlity within nd mong countries 1.1 Achieve nd sustin income growth of the bottom 4% of the popultion t rte higher thn the ntionl verge Growth rtes of household expenditure or income per cpit, overll nd for the bottom 4% of the popultion Gini index for income inequlity Historic trends in TB incidence re closely correlted with chnges in the bsolute level of GDP per cpit (but not with the growth rte). TB is disese of poverty, nd decesing income inequlities combined with economic growth should hve n effect on the TB epidemic. SDG 11: Mke cities nd humn settlements inclusive, sfe, resilient nd sustinble 11.1 Ensure ccess for ll to dequte, sfe nd ffordble housing nd bsic services nd upgrde slums Proportion of urbn popultion living in slums, informl settlements or indequte housing NA Living in slum is risk fctor for TB trnsmission due to its link with overcrowding. It is lso risk fctor for developing TB disese, due to links with ir pollution nd under-nutrition. WHO World Bnk World Bnk OECD UN SDG dtbse No No No No 21

33 2.5 WHO s Generl Progrmme of Work WHO s GPW for ws drfted in 217; it ws then revised following review by WHO s Executive Bord in Jnury 218, nd finl version dopted by the World Helth Assembly in My The thirteenth in series of GPWs since WHO ws founded in 1948, the current GPW sets out the orgniztion s strtegic direction for the next 5 yers. The GPW for is bsed on the foundtion of the SDGs nd is relevnt to ll countries: low-, middlend high-income. In the context of SDG 3 in prticulr (Box 2.2), GPW 13 provides vision tht is rooted in Article 1 of WHO s Constitution: A world in which ll people ttin the highest possible stndrd of helth nd well-being. GPW 13 lso recognizes the influence of other SDGs on helth, nd the need for multisectorl pproches to ddress the socil, economic nd environmentl determinnts of helth. The GPW is structured round three strtegic priorities nd ssocited gols (Fig. 2.3). The three strtegic priorities re UHC, ddressing helth emergencies nd promoting helthier popultions. The ssocited gols for 223 re the so-clled triple billion gols : tht 1 billion more people re benefiting from UHC, 1 billion more people re better protected from helth emergencies, nd 1 billion more people re enjoying better helth nd well-being. WHO nd the World Bnk hve estimted tht only bout hlf the world s popultion hd ccess to essentil helth services in Achieving ll three gols depends on joint efforts by Member Sttes, WHO nd other prtners. The GPW gol relted to UHC is directly linked to SDG Trget 3.8 (Box 2.2). As explined in Section 2.2, progress towrds this gol will be crucil to reching End TB Strtegy milestones nd trgets. Similrly, progress in TB prevention nd cre will contribute to the UHC trget, with TB tretment being one of the trcer indictors for SDG Trget 3.8 (Section 2.1, Tble 2.3), nd to more people enjoying better helth nd well-being. Protecting people from the public helth thret posed by TB contributes to the helth emergencies gol. At the sme time, broder progress towrds the gols relted to helth emergencies nd better helth nd well-being contribute to progress towrds End TB Strtegy trgets nd milestones by positively influencing the determinnts of TB included in the TB-SDG monitoring frmework shown in Tble 2.3. GPW 13 includes 1 outcomes, one of which is bsed 1 World Helth Orgniztion. Report by the Director Generl. A71/4. Drft thirteenth generl progrmme of work ( gb/ebwh/pdf_files/wha71/a71_4-en.pdf?u=1, ccessed 21 June 218). 2 World Helth Orgniztion/World Bnk Group. Trcking universl helth coverge: 217 globl monitoring report. Genev: WHO; 217 ( pps.who.int/iris/bitstrem/hndle/1665/259817/ eng.pdf, ccessed 21 June 218). FIG. 2.3 WHO s 13th Generl Progrmme of Work: set of interconnected strtegic priorities nd gols to ensure helthy lives nd promote well-being for ll t ll ges 1 billion more people better protected from helth emergencies HEALTH EMERGENCIES 1 billion more people enjoying better helth nd well-being HEALTHIER POPULATIONS UNIVERSAL HEALTH COVERAGE 1 billion more people benefiting from universl helth coverge on the SDG 3 trget relted to ending epidemics. Outcome 5 is defined s Accelerted elimintion nd erdiction of high-impct communicble diseses. Under this outcome, there re two trgets for TB: tht the number of TB deths is reduced by t lest % between 218 nd 223, nd tht by 223 there is t lest 8% tretment coverge for people with drug-resistnt TB. Linked to the GPW, WHO s Globl TB Progrmme hs lso defined two other trgets: 4 million people with TB re reched with cre during the period , including 3.5 million children nd 1.5 million people with drug-resistnt TB; At lest 3 million people re reched with TB prevention services during the period TB trgets tht hve been ligned with the GPW re illustrted in Fig To ctlyze globl efforts to support the chievement of these trgets, WHO, the Stop TB Prtnership nd the Globl Fund to Fight AIDS, Tuberculosis nd Mlri hve lunched joint inititive, clled Find.Tret.All (Box 2.5). 2.6 Lists of high-burden countries being used by WHO during the period During the period , the concept of n HBC becme fmilir nd widely used in the context of TB. In 215, three HBC lists for TB, TB/HIV nd MDR-TB were in use. The HBC list for TB (22 countries) hd remined unchnged since 22; lso, the HBC lists for TB/HIV (41 countries) hd not been updted since 29, nd those for MDR-TB (27 countries) hd not been updted since

34 FIG. 2.4 Strtegic priorities nd trgets for TB ligned with WHO s Generl Progrmme of Work Achieve universl ccess to TB prevention, tretment nd cre services TARGETS At lest 4 million people with TB reched with cre in the period , including 3.5 million children nd 1.5 million people with drug-resistnt TB At lest 3 million people reched with TB prevention services in the period No TB-ffected households fcing ctstrophic costs due to TB by 22 Prevent TB s public helth thret nd contribute to protecting popultions from irborne infections TARGET Increse tretment coverge for MDR-TB to 8% of estimted incidence by billion more people benefiting from universl helth coverge UNIVERSAL HEALTH COVERAGE 1 billion more people better protected from helth emergencies HEALTHIER EMERGENCIES Protect popultions nd vulnerble groups from the socil nd economic impcts of TB infection nd disese TARGET Reduce TB deths by % by 223 compred with bseline of 218 (ligned to the End TB Strtegy, but with bseline nd trget yers tht correspond to the GPW) 1 billion more people enjoying better helth nd well-being HEALTHIER POPULATIONS BOX 2.5 FIND.TREAT.ALL: joint inititive to scle up the globl response towrds universl ccess to TB prevention nd cre, Following the first globl ministeril conference on TB in 217 nd in the dvnce of the UN high-level meeting on TB in 218, WHO, the Stop TB Prtnership, nd The Globl Fund to Fight AIDS, Tuberculosis nd Mlri hve lunched joint inititive to scle up the End TB response towrds universl ccess to TB prevention nd cre. The inititive is for the five-yer period The inititive includes trget to dignose, tret nd report 4 million people with TB, including 3.5 million children nd 1.5 million people with drug-resistnt-tb, between 218 nd 222. Achieving the trgets will require the efforts of mny stkeholders, including country leders, government ministries, civil society nd TB-ffected communities, the privte sector nd globl gencies. Globl, regionl nd ntionl responses will need to be trnsformed in terms of commitments, ctions to ccelerte ccess to prevention nd cre, nd mesurement of progress. The inititive encompsses ll countries, with priority given to the 3 high TB burden countries. It hs become flgship inititive t WHO. 23

35 FIG. 2.5 Countries in the three high-burden country lists for TB, TB/HIV nd MDR-TB being used by WHO during the period , nd their res of overlp Azerbijn Belrus Kzkhstn Kyrgyzstn Peru Republic of Moldov Somli Tjikistn Ukrine Uzbekistn Bngldesh DPR Kore Pkistn Philippines Russin Federtion Viet Nm MDR-TB TB Cmbodi Sierr Leone Angol Chin DR Congo Ethiopi Indi Indonesi Keny Mozmbique Mynmr Nigeri Ppu New Guine South Afric Thilnd Zimbbwe Brzil Centrl Africn Republic Congo Lesotho Liberi Nmibi UR Tnzni Zmbi TB/HIV Botswn Cmeroon Chd Eswtini Ghn Guine-Bissu Mlwi Ugnd Indictes countries tht re included in the list of 3 high TB burden countries on the bsis of the severity of their TB burden (i.e. TB incident cses per popultion per yer), s opposed to the top 2, which re included on the bsis of their bsolute number of incident cses per yer. Also see Tble 2.4. With 215 mrking the end of the MDGs nd new er of SDGs, s well s the lst yer of the Stop TB Strtegy before its replcement with the End TB Strtegy, it ws n idel time to revisit these three HBC lists. Following wide consulttion process, 1 in 215 WHO defined three HBC lists for the period : one for TB, one for MDR-TB nd one for TB/HIV (Fig. 2.5, Tble 2.4). 2 Ech list contins 3 countries (Tble 2.4). These re defined s the top 2 countries in terms of the bsolute number of estimted incident cses, plus the dditionl 1 countries with the most severe burden in terms of incidence rtes per cpit tht do not lredy pper in the top 2 nd tht meet minimum threshold in terms of their bsolute numbers of incident cses (1 per yer for TB, nd per yer for TB/HIV nd MDR-TB). The lists were defined using the ltest estimtes of TB disese burden vilble in October 215. Ech list ccounts for bout 9% of the globl burden, 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 ( publictions/globl_report/high_tb_burdencountrylists pdf, ccessed 21 June 218). 2 As explined in the lst row of Tble 2.4, the three lists hve lifetime of 5 yers, nd the countries included in ech list nd the criteri used to define ech list will be reviewed in June 22. with most of this ccounted for by the top 2 countries in ech list. There is overlp mong the three lists, but 48 countries pper in t lest one list. The 14 countries tht re in ll three lists (shown in the centrl dimond in Fig. 2.5) re Angol, Chin, the Democrtic Republic of the Congo, Ethiopi, Indi, Indonesi, Keny, Mozmbique, Mynmr, Nigeri, Ppu New Guine, South Afric, Thilnd nd Zimbbwe. 3 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 twopge profile for ech of the 3 high TB burden countries; the nnex hs 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. Country profiles for ll countries (with the sme content s those presented in Annex 2) re lso vilble online. 4 3 These 14 countries ccounted for 64% of the estimted globl number of incident TB cses in See: 24

36 TABLE 2.4 The three high-burden country lists for TB, TB/HIV nd MDR-TB being used by WHO during the period LIST THE 3 HIGH TB BURDEN COUNTRIES THE 3 HIGH TB/HIV BURDEN COUNTRIES THE 3 HIGH MDR-TB BURDEN COUNTRIES Purpose nd trget udience To provide focus for globl ction on TB in the countries where progress is most needed to chieve End TB Strtegy nd SDG trgets nd milestones, to help build nd sustin ntionl politicl commitment nd funding in the countries with the highest burden in terms of bsolute numbers or severity, nd to promote globl monitoring of progress in well-defined set of countries. To provide focus for globl ction on HIV-ssocited TB in the countries where progress is most needed to chieve End TB Strtegy, UNAIDS nd SDG trgets nd milestones, to help build nd sustin ntionl politicl commitment nd funding in the countries with the highest burden in terms of bsolute numbers or severity, nd to promote globl monitoring of progress in welldefined 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, > 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, > 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 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 popultion nd with minimum number of cses per yer (in lphbeticl order): Botswn Centrl Africn Republic Chd Congo Eswtini Ghn Guine-Bissu Liberi Nmibi Ppu New Guine The top 2 by estimted bsolute number (in lphbeticl order): Bngldesh Chin DPR Kore DR Congo Ethiopi Indi Indonesi Kzkhstn Keny Mozmbique Mynmr Nigeri Pkistn Philippines Russin Federtion South Afric Thilnd Ukrine Uzbekistn Viet Nm The dditionl 1 by estimted rte per popultion nd with minimum number of cses per yer (in lphbeticl order): Angol Azerbijn Belrus Kyrgyzstn Ppu New Guine Peru Republic of Moldov Somli Tjikistn Zimbbwe Shre of globl incidence in 217 (%) 84% 2.9% 83% 4.7% 87% 4.4% 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). 25

37 Trnsporting chest X-ry equipment during the 216 ntionl TB prevlence survey of the Philippines Rldy Benvente / FACE Inc (Philippines) 26

38 Chpter 3. TB disese burden KEY FACTS AND MESSAGES Worldwide, tuberculosis (TB) is one of the top 1 cuses of deth, nd the leding cuse from single infectious gent (bove HIV/AIDS); millions of people continue to fll sick with the disese ech yer. In 217, TB cused n estimted 1.3 million deths (rnge, million) mong HIV-negtive people, nd there were n dditionl 3 deths from TB (rnge, ) mong HIV-positive people. There were n estimted 1. million new cses of TB (rnge, million), equivlent to 133 cses (rnge, ) per popultion. TB ffects ll countries nd ll ge groups, but overll the best estimtes for 217 were tht 9% of cses were dults (ged 15 yers), 64% were mle, 9% were people living with HIV (72% of them in Afric) nd two thirds were in eight countries: Indi (27%), Chin (9%), Indonesi (8%), the Philippines (6%), Pkistn (5%), Nigeri (4%), Bngldesh (4%) nd South Afric (3%). Only 6% of cses were in the WHO Europen Region nd the WHO Region of the Americs, ech of which hd 3% of cses. The severity of ntionl epidemics vries widely. In 217, there were under 1 new cses per popultion in most high-income countries, 1 4 in most of the 3 high TB burden countries, nd bove in few countries including Mozmbique, the Philippines nd South Afric. Globlly in 217, there were n estimted 558 new cses (rnge, ) of rifmpicinresistnt TB (RR-TB), of which lmost hlf were in three countries: Indi (24%), Chin (13%) nd the Russin Federtion (1%). Among RR-TB cses, n estimted 82% hd multidrug-resistnt TB (MDR-TB). Globlly, 3.5% of new TB cses nd 18% of previously treted cses hd MDR/RR-TB, with the highest proportions (>% in previously treted cses) in countries of the former Soviet Union. Globlly, the bsolute number of deths from TB mong HIV-negtive people hs been estimted to hve fllen by 29% since 2, from 1.8 million in 2 to 1.3 million in 217, nd by 5% since 215 (the bseline yer for trgets set in the End TB Strtegy). The number of TB deths mong HIV-positive people hs fllen by 44% since 2, from 534 in 2 to 3 in 217, nd by 2% since 215. The TB mortlity rte (TB deths mong HIV-negtive people per popultion per yer) is flling t bout 3% per yer, nd the best estimte for the overll reduction during is 42%. The fstest regionl declines in mortlity rtes in the 5-yer period were in the WHO Europen Region nd WHO South-Est Asi Region (11% nd 4% per yer, respectively). Worldwide, TB incidence (new cses per popultion per yer) is flling t bout 2% per yer. The fstest regionl declines from 213 to 217 were in the WHO Europen Region (5% per yer) nd WHO Africn Region (4% per yer). In the sme 5 yers, prticulrly impressive reductions (4 8% per yer) occurred in southern Afric (e.g. Eswtini [formerly Swzilnd], Lesotho, Nmibi, South Afric, Zmbi, Zimbbwe) following pek in the HIV epidemic, nd the expnsion of TB nd HIV prevention nd cre, nd in the Russin Federtion (5% per yer) following intensified efforts to reduce the burden of TB. In 217, the best estimte of the proportion of people with TB who died from the disese (the cse ftlity rtio, CFR) ws 16%, down from 23% in 2. The CFR needs to fll to 1% by 22 to rech the first milestones of the End TB Strtegy. There is considerble country vrition in the CFR, from under 5% in few countries to more thn 2% in most countries in the WHO Africn Region, demonstrting lrge inequlities mong countries in ccess to TB dignosis nd tretment. Ntionl notifiction nd vitl registrtion systems need to be strengthened towrds the gol of direct mesurement of TB incidence nd mortlity in ll countries. Ntionl TB prevlence surveys provide n interim pproch to directly mesuring the burden of TB disese in n importnt subset of high TB burden countries; 25 surveys were completed between 27 nd the end of 217. 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). 27

39 The burden of tuberculosis (TB) disese cn be mesured in terms of: incidence the number of new nd relpse cses of TB rising in given time period, usully 1 yer; prevlence the number of cses of TB t given point in time; nd mortlity the number of deths cused by TB in given time period, usully 1 yer. Globl trgets nd milestones for reductions in the burden of TB disese hve been set s prt of the Sustinble Development Gols (SDGs) nd WHO s End TB Strtegy (Chpter 2). 1 SDG 3 includes trget to end the globl TB epidemic by 23, with TB incidence (new nd relpse cses per popultion per yer) defined s the indictor for mesurement of progress. The 23 trgets set in the End TB Strtegy re 9% reduction in TB deths nd n 8% reduction in TB incidence, compred with levels in 215. Trgets for 235 nd milestones for 22 nd 225 hve lso been defined (Tble 3.1). TABLE 3.1 Trgets for percentge reductions in TB disese burden set in WHO s End TB Strtegy INDICATORS Percentge reduction in the bsolute number of TB deths per yer (compred with 215 bseline) Percentge reduction in the TB incidence rte (new nd relpse cses per popultion per yer) (compred with 215 bseline) MILESTONES TARGETS This chpter hs five mjor sections. Section 3.1 nd Section 3.2 present the ltest WHO estimtes of TB incidence nd mortlity between 2 nd 217, nd highlight sources of dt nd ctions needed to improve mesurement of TB incidence nd mortlity. Section 3.3 focuses on the burden of drug-resistnt TB, including progress in globl surveillnce of resistnce to nti-tb drugs, nd estimtes of the incidence of multidrug-resistnt TB (MDR-TB) nd rifmpicin-resistnt TB (RR-TB). Section 3.4 discusses ntionl TB prevlence surveys. TB prevlence is not n indictor for which globl trget hs been set during the period Nevertheless, in mny countries, ntionl TB prevlence 1 World Helth Orgniztion. WHO End TB Strtegy: globl strtegy nd trgets for tuberculosis prevention, cre nd control fter 215. Genev: WHO; 215 ( ccessed 3 August 218). 2 This is in contrst to the period covered by the Stop TB Strtegy (26 215), when the trget ws to hlve prevlence by 215 compred with bseline of 199. surveys still provide the best method for estimting the burden of TB disese (including by ge nd sex) nd for plnning ctions needed to reduce tht burden. In ddition, results from ntionl TB prevlence surveys cn inform estimtes of TB incidence nd mortlity, nd thus contribute to monitoring of progress towrds SDG nd End TB Strtegy trgets. Finlly, Section 3.5 covers estimtes of TB incidence nd mortlity, disggregted by ge nd sex. This is in line with the incresing emphsis on the importnce of within-country disggregtion of key indictors in the SDGs nd the End TB Strtegy (Chpter 2). WHO updtes its estimtes of the burden of TB disese nnully, using the ltest vilble dt nd nlyticl methods. 3,4 Since 26, concerted efforts hve been mde to improve the vilble dt nd methods used, under the umbrell of the WHO Globl Tsk Force on TB Impct Mesurement (Box 3.1). A summry of the min updtes to vilble dt nd methods since the 217 globl TB report is provided in Box 3.2. To put these updtes in broder context, comprisons of the nnul updtes mde by WHO for TB re compred with those for HIV nd mlri, s well s with estimtes for TB tht re updted nnully by the Institute of Helth Metrics nd Evlution (IHME) t the University of Wshington, United Sttes of Americ (USA), in Box TB incidence Methods to estimte TB incidence TB incidence hs never been mesured t ntionl level becuse this would require long-term studies mong lrge cohorts (hundreds of thousnds) of people, which would involve high costs nd chllenging logistics. However, notifictions of TB cses provide good proxy indiction of TB incidence in countries tht hve high-performnce surveillnce systems (e.g. with little underreporting of dignosed cses), nd in which the qulity of nd ccess to helth cre mens tht few cses re not dignosed. 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) 5 nd universl helth coverge. A TB surveillnce checklist developed by the WHO Globl Tsk Force on TB Impct Mesurement (Box 3.1) defines the stndrds tht need to be met for 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 216 estimtes in this report nd the 216 estimtes in the previous report) re not pproprite. 5 Inventory studies cn be used to mesure the number of cses tht re dignosed but not reported. For guide to inventory studies, see World Helth Orgniztion. Assessing tuberculosis underreporting through inventory studies. Genev: WHO; 212 ( publictions/inventory_studies/en/, ccessed 15 August 218). 28

40 BOX 3.1 The WHO Globl Tsk Force on TB Impct Mesurement Estblishment nd progress mde, The WHO Globl Tsk Force on TB Impct Mesurement (herefter referred to s the Tsk Force) ws estblished in 26 nd is convened by the TB Monitoring nd Evlution unit of WHO s Globl TB Progrmme. Its originl im ws to ensure tht WHO s ssessment of whether 215 trgets set in the context of the Millennium Development Gols (MDGs) were chieved t globl, regionl nd country levels ws s rigorous, robust nd consensus-bsed s possible. Three strtegic res of work were pursued: strengthening routine surveillnce of TB cses (vi ntionl notifiction systems) nd deths (vi ntionl VR systems) in ll countries; undertking ntionl TB prevlence surveys in 22 globl focus countries; nd periodiclly reviewing methods used to produce TB disese burden estimtes. Work on strengthened surveillnce included the following: Development of TB surveillnce checklist of stndrds nd benchmrks (with 1 core nd three supplementry stndrds). This checklist cn be used to systemticlly ssess the extent to which surveillnce system meets the stndrds required for notifiction nd VR dt to provide direct mesurement of TB incidence nd mortlity, respectively. By the end of 215, 38 countries including 16 high TB burden countries hd used the checklist. The globl sttus of progress in using the checklist by August 218 is shown in Fig Electronic recording nd reporting. Cse-bsed electronic dtbses re the reference stndrd for recording nd reporting TB surveillnce dt. A guide ws produced in 211, b nd efforts to introduce such systems were supported. The globl sttus of progress in cse-bsed electronic surveillnce for TB by August 218 is highlighted in Chpter 4. Development of guide on inventory studies to mesure underreporting of detected TB cses, c nd support such studies in priority countries. An inventory study cn be used to quntify the number of cses tht re detected but not reported to ntionl surveillnce systems, nd cn serve s bsis for improving estimtes of TB incidence nd ddressing gps in reporting. The globl sttus of progress in implementtion of inventory studies by August 218 is shown in Fig An excellent recent exmple of ntionl inventory study, in Indonesi, is profiled in Chpter 4. Expnded use of dt from VR systems nd mortlity surveys to produce estimtes of the number of TB deths, nd contributions to wider efforts to promote VR systems. By 215, VR dt were used to produce estimtes of TB mortlity in 127 countries, up from three in 28. There ws substntil success in the implementtion of ntionl TB prevlence surveys in the period , which hs continued. Between 27 nd the end of 215, totl of 23 countries completed survey nd further two hd done so by the end of 217; this included 18 of the 22 globl focus countries. A Tsk Force subgroup undertook mjor review nd updte of methods between June 28 nd October 29. A second thorough nd comprehensive review ws undertken in 215, with consensus reched on methods to be used for the 215 trgets ssessment published in WHO s 215 globl TB report. d Updted strtegic res of work, In the context of new er of SDGs nd WHO s End TB Strtegy, the Tsk Force met in April 216 to review nd reshpe its mndte nd strtegic res of work for the post-215 er. An updted mndte nd five strtegic res of work for the period were greed. e The mndte ws defined s follows: To ensure tht ssessments of progress towrds End TB Strtegy nd SDG trgets nd milestones t globl, regionl nd country levels re s rigorous, robust nd consensus-bsed s possible. To guide, promote nd support the nlysis nd use of TB dt for policy, plnning nd progrmmtic ction. The five strtegic res of work re s follows: 1. Strengthening ntionl notifiction systems for direct mesurement of TB cses, including drug-resistnt TB nd HIV-ssocited TB specificlly. 2. Strengthening ntionl VR systems for direct mesurement of TB deths. 3. Priority studies to periodiclly mesure TB disese burden, including:. ntionl TB prevlence surveys b. drug-resistnce surveys c. mortlity surveys d. surveys of costs fced by TB ptients nd their households. 4. Periodic review of methods used by WHO to estimte the burden of TB disese nd ltent TB infection. 5. Anlysis nd use of TB dt t country level, including:. disggregted nlyses (e.g. by ge, sex nd loction) to ssess inequlities nd equity; b. projections of disese burden; nd c. guidnce, tools nd cpcity-building. The SDG nd End TB Strtegy trgets nd milestones referred to in the mndte re the trgets (23, 235) nd milestones (22, 225) set for the three high-level indictors; tht is, TB incidence, the number of TB deths nd the percentge of TBffected households tht fce ctstrophic costs s result of TB disese (Chpter 2). Strtegic res of work 1 3 re focused on direct mesurement of TB disese burden (epidemiologicl nd, in the cse of cost surveys, economic). The underlying principle for the Tsk Force s work since 26 hs been tht estimtes of the level of nd trends in disese burden should be bsed on direct mesurements from routine surveillnce nd surveys s much s possible (s opposed to indirect estimtes bsed on modelling nd expert opinion). However, strtegic re of work 4 remins necessry becuse indirect estimtes 29

41 will be required until ll countries hve the surveillnce systems or the periodic studies required to provide direct mesurements. Strtegic re of work 5 recognizes the importnce of nlysing nd using TB dt t country level (s well s generting dt, s in strtegic res of work 1 3), including the disggregted nlyses tht re now given much greter ttention in the SDGs nd End TB Strtegy. In the yers up to 22, the top priorities for the Tsk Force re strengthening of ntionl notifiction nd VR systems s the bsis for direct mesurement of TB incidence nd TB mortlity. Further detils bout the work of the Tsk Force re vilble online; f n up-to-dte summry is provided in the ltest brochure bout its work. g World Helth Orgniztion. Stndrds nd benchmrks for tuberculosis surveillnce nd vitl registrtion systems: checklist nd user guide. Genev: WHO; 214 ( stndrdsndbenchmrks/en/, ccessed 25 July 218). b c d e f g World Helth Orgniztion. Electronic recording nd reporting for tuberculosis cre nd control. Genev: WHO; 212 ( tb/publictions/electronic_recording_reporting/en/, ccessed 25 July 218). World Helth Orgniztion. Assessing tuberculosis underreporting through inventory studies. Genev: WHO; 212 ( publictions/inventory_studies/en/, ccessed 15 August 218). World Helth Orgniztion Globl Tsk Force on TB Impct Mesurement. Third meeting of the TB estimtes subgroup: methods to use for WHO s definitive ssessment of whether 215 globl TB trgets re met. Genev: WHO; 215 ( impct_mesurement_tskforce/meetings/consulttion_pril_215_ tb_estimtes_subgroup/en/, ccessed 8 August 218). World Helth Orgniztion Globl Tsk Force on TB Impct Mesurement. Report of the sixth meeting of the full Tsk Force; April 216, Glion-sur-Montreux, Switzerlnd. Genev: WHO; 216 ( meetings/tf6_report.pdf?u=1, ccessed 8 August 218). mesurement_tskforce/en/ pdf?u=1 notifiction dt to provide direct mesure of TB incidence. 1 By August 218, totl of 68 countries, including 26 of the 3 high TB burden countries (listed in Tble 3.1) hd completed the checklist, often in ssocition with ntionl TB epidemiologicl review (Fig. 3.1). Methods currently used by WHO to estimte TB incidence cn be grouped into four mjor ctegories, s follows (Fig. 3.2): Results from TB prevlence surveys. Incidence is estimted using prevlence survey results nd estimtes of the durtion of disese, with the ltter derived from model tht ccounts for the impct of HIV coinfection nd ntiretrovirl therpy (ART) on the distribution of disese durtion. 2 This method is used for 22 countries, of which 22 hve ntionl survey dt nd one Indi hs survey in one stte. The 23 countries ccounted for 6% of the estimted globl number of incident cses in 217. Notifictions djusted by stndrd fctor to ccount for underreporting, over-dignosis nd under-dignosis. This method is used for 144 countries tht re ll high-income countries except the Netherlnds nd the United Kingdom, plus selected middle-income countries with low levels of underreporting, including Brzil, Chin nd the Russin Federtion. For three countries (Frnce, Republic of Kore nd Turkey) the 1 World Helth Orgniztion. Stndrds nd benchmrks for tuberculosis surveillnce nd vitl registrtion systems: checklist nd user guide. Genev: WHO; 214 ( stndrdsndbenchmrks/en/, ccessed 25 July 218). One of the stndrds is tht levels of underreporting of detected TB cses should be miniml. 2 Estimtion of prevlence from incidence is not strightforwrd. For exmple, it requires ssumptions bout the durtion of disese for different ctegories of cse, nd since prevlence surveys focus on bcteriologiclly confirmed TB in dults, djustments to include children nd extrpulmonry TB re needed. djustment ws country specific, bsed on results from studies of underreporting. These 144 countries ccounted for 15% of the estimted globl number of incident cses in 217. Results from ntionl inventory studies tht mesured the level of underreporting of detected TB cses combined with cpture recpture nlysis. This method is used for six countries: Egypt, Indonesi (yielding best estimtes tht re lower but sttisticlly consistent with those previously derived from the ntionl TB prevlence survey), 3 Irq, the Netherlnds, the United Kingdom nd Yemen. These countries ccounted for 9% of the estimted globl number of incident cses in Cse notifiction dt combined with expert opinion bout cse-detection gps. Expert opinion, elicited through regionl workshops or country missions, is used to estimte levels of underreporting, over-dignosis nd under-dignosis. 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 3 The ntionl inventory study implemented in Indonesi in 217 is the lrgest of its kind to dte. Further detils re provided in Box 3.2 nd in Chpter 4, Box Cpture-recpture modelling is possible if six ssumptions re met: (i) ll cses should be observble; (ii) the proportion of mismtches nd mtching filures in record-linkge is low, which typiclly requires lrge smpling frction; (iii) closed popultion during the study period (typiclly 3 6 months); (iv) if S represents the number of cse lists or dt sources vilble, then t lest three dt sources should be vilble (S 3) nd their dependencies must be ccounted for in the model design, while the full S-wy interction between sources is ssumed null; (v) homogeneity of within-source observtion probbilities cross subpopultion groups, such s those defined by socioeconomic nd demogrphic chrcteristics; (vi) consistent cse definitions cross dt sources. Few high TB burden countries re expected to be ble to implement inventory studies tht will meet these 6 ssumptions to sufficient degree. 3

42 BOX 3.2 Updtes to estimtes of TB disese burden in this report nd nticipted updtes Updtes in this report Estimtes of TB incidence nd mortlity in this report cover the period Estimtes of incidence nd mortlity for drug-resistnt TB re for 217. The min country-specific updtes in this report re for estimtes of TB incidence in Indonesi nd South Afric. 1. Indonesi Indonesi conducted ntionl inventory study to mesure the underreporting of detected TB cses in the first qurter of 217. Cpture recpture modelling bsed on three seprte lists ws then used to updte incidence estimtes, using methods set out in WHO guidnce on inventory studies. The updted incidence estimtes re consistent with those previously derived from the results of the ntionl TB prevlence survey implemented in , but the best estimtes re lower (bout 15%) nd lso more precise (i.e. with nrrower uncertinty intervls). Detils re provided in Box 4.4 in Chpter 4. Estimtes of TB mortlity in Indonesi re bsed on those published by the Institute of Helth Metrics nd Evlution (IHME), University of Wshington, USA (see below). 2. South Afric Trends in TB incidence in South Afric hve been revised for two mjor resons. First, there is now cler, consistent nd sustined downwrd trend in TB cse notifictions, which is lso evident in other countries of southern Afric nd which cn be explined by the high coverge of ART mong people living with HIV (for further detils, see Box 3.4). Second, the vlues of the rtio of notified to estimted incident cses bsed on previously published trends, following further declines in notifictions, re now implusible. For recent yers, the revised estimtes of TB incidence re lower thn those previously published (e.g. the estimte for 216 in this report is 21% lower thn the estimte for 216 published lst yer). TB incidence will be ressessed when the results from the ntionl TB prevlence survey become vilble. Estimtes of TB mortlity in South Afric re bsed on those published by IHME (see next section). 3. Newly reported dt nd updted estimtes from other gencies New VR dt were reported to WHO between mid-217 nd mid-218. Severl countries reported historicl dt tht were previously missing, or mde corrections to previously reported dt. In totl, 1949 country-yer dt points were retined for nlysis. Updted estimtes of HIV prevlence nd mortlity were obtined from the Joint United Ntions Progrmme on HIV/AIDS (UNAIDS) in July 218. b (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. In 19 countries (shown in Fig. 3.1), estimtes of TB mortlity (HIV-negtive) were bsed on estimtes published by IHME. c These estimtes use dt from ntionl nd smple VR systems, nd verbl utopsy surveys. Estimtes of TB mortlity in South Afric re djusted by IHME for miscoding of deths cused by HIV nd TB. IHME estimtes used in this report were slightly djusted from those published by IHME to fit WHO estimtes of the totl number of deths (mortlity envelope). The medin country-yer envelope rtio (WHO/ IHME) ws 1.1 (interqurtile rnge: ) mong 319 dt points. 4. Findings from ntionl TB epidemiologicl reviews Smll djustments to incidence trjectories were mde for Belrus, Mlwi, Thilnd nd Turkmenistn, bsed on findings from recent ntionl TB epidemiologicl reviews. 5. Drug-resistnt TB The estimted incidence of rifmpicin-resistnt TB in 217 is bsed on the following formul: I rr = I[(1 f)p n ((1 r) + rρ) + fp r ] where I is overll TB incidence, I rr is the incidence of rifmpicin resistnce, f is the cumultive risk for incident cses to receive non-relpse retretment (following filure or return fter defult), r is the proportion of relpses, ρ is the reltive risk rtio in relpses compred with first episodes of TB, nd p n nd p r denote the proportion of rifmpicin-resistnt cses mong previously untreted nd previously treted ptients, respectively. Routine surveillnce dt for 217 on levels of drug resistnce were reported by 91 countries with continuous surveillnce systems (i.e. routine dignostic testing for drug resistnce). New dt from ntionl surveys becme vilble from seven countries since the publiction of the 217 globl TB report: Eritre, Eswtini, Indonesi, Lo People s Democrtic Republic, Sri Lnk, Togo nd the United Republic of Tnzni. Updtes nticipted in the ner future Updtes to estimtes of disese burden re expected towrds the end of 218 or in 219 for Eswtini, Mozmbique, Mynmr Nmibi, Nepl, South Afric nd Viet Nm, following the completion of ntionl TB prevlence surveys. Estimtes of TB burden in Indi will be updted once results from ntionl TB prevlence survey plnned for become vilble. b c World Helth Orgniztion. Assessing tuberculosis under-reporting through inventory studies. WHO, hndle/1665/7873, ccessed 15 August 218). Downloded from June

43 BOX 3.3 WHO estimtes for TB disese burden in the context of other estimtes The ltest globl estimtes published by WHO nd IHME re similr. For exmple, the best estimte for TB incidence in 216 in this report is 1.1 million (rnge, million), wheres the most recent best estimte from IHME is 1.4 million. The best estimte of the number of TB deths mong HIV-negtive people in 216 in this report is 1.3 million (rnge, million), wheres the best estimte from IHME is 1.2 million. There is generl consistency in mortlity estimtes in countries with VR systems nd stndrd coding of cuses of deths of good qulity, nd in incidence estimtes in countries with strong helthcre nd notifiction systems. Discrepncies re most pprent for countries where the underlying dt re weker, due to differences in the indirect estimtion methods tht re used. When nnul updtes for TB re published by both WHO nd IHME, entire time series (strting in 2 for WHO, nd 199 for IHME) re updted. New informtion or refinements to methods used to produce estimtes cn result in chnges to the estimtes published for erlier yers in previous publictions. This is norml prt of disese burden estimtion, nd lso occurs with disese burden estimtes published for other diseses, such s HIV nd mlri. For exmple, globl estimtes for 215 for HIV, mlri nd TB published by WHO, UNAIDS nd IHME in consecutive yers (215 nd 216) by the sme gency hve been within bout 2 8% of ech other. Globl estimtes of TB disese burden in 215 published by WHO in this nd the previous two globl TB reports re within 4 5% of ech other. Country-specific estimtes of TB disese burden published by WHO re generlly consistent from yer to yer. In WHO reports published in , updtes tht hve been pprent t globl level hve been due to updtes for three countries: Nigeri (214 report, following results from the country s first ntionl TB prevlence survey in 212); Indonesi (215 report, following completion of ntionl TB prevlence survey in ); nd Indi (216 report, following ccumulting evidence from both survey nd surveillnce dt). As the vilbility nd qulity of dt continue to improve, vribility for the sme yer in consecutive reports will decrese nd estimtes published by WHO should converge with those published by other gencies. Idelly, estimtes of TB incidence nd mortlity re bsed on ntionl notifiction nd vitl registrtion systems tht meet qulity nd coverge stndrds. Downloded from July 218. method is used for 43 countries tht ccounted for 16% of the estimted globl number of incident cses in 217. Of the four methods, the lst one is the lest preferred nd it is relied upon only if one of the other three methods cnnot be used. As explined in Box 3.1, the underlying principle for the WHO Globl Tsk Force on TB Impct Mesurement since its estblishment in 26 hs been tht estimtes of the level of nd trends in TB disese burden should be bsed on direct mesurements from routine surveillnce nd surveys s much s possible, s opposed to indirect estimtes tht rely on modelling nd expert opinion. Further detils bout these methods re provided in the online technicl ppendix. 1 1 The online technicl ppendix is vilble t Estimtes of TB incidence in 217 Globlly in 217, there were n estimted 1. million incident cses of TB (rnge, million), 2 equivlent to 133 cses (rnge, ) per popultion. Estimtes of bsolute numbers re shown in Tble 3.2 nd estimtes of rtes per cpit re shown in Tble 3.3. Most of the estimted number of cses in 217 occurred in the WHO South-Est Asi Region (44%), the WHO Africn Region (25%) nd the WHO Western Pcific Region (18%); smller proportions of cses occurred in the WHO Estern Mediterrnen Region (7.7%), the WHO Region of the Americs (2.8%) nd the WHO Europen Region (2.7%). The 3 high TB burden countries 3 ccounted for 87% of ll estimted incident cses worldwide, nd eight of these countries ccounted for two thirds of the globl totl: Indi (27%), Chin (9%), Indonesi (8%), the 2 Here nd elsewhere in the report, rnge refers to the 95% uncertinty intervl. 3 These countries re listed in Tble 3.2 nd Tble 3.3. For n explntion of how the list of 3 high TB burden countries ws defined, see Chpter 2. 32

44 FIG. 3.1 Strengthening ntionl TB surveillnce (sttus in August 218) Countries in which ntionl TB epidemiologicl review hs been undertken since July 212 Completed in Completed in Plnned for Not pplicble Countries in which checklist of stndrds nd benchmrks hs been completed since Jnury 213 Completed in Completed in Plnned for Not pplicble Countries in which ntionl inventory studies of the underreporting of detected TB cses hve been implemented since 2 Up to Ongoing/plnned Not pplicble 33

45 TABLE 3.2 Estimted epidemiologicl burden of TB in 217 for 3 high TB burden countries, WHO regions nd globlly. Number in thousnds. POPULATION BEST ESTIMATE HIV-NEGATIVE TB MORTALITY UNCERTAINTY INTERVAL BEST ESTIMATE HIV-POSITIVE TB MORTALITY b UNCERTAINTY INTERVAL BEST ESTIMATE TOTAL TB INCIDENCE UNCERTAINTY INTERVAL BEST ESTIMATE HIV-POSITIVE TB INCIDENCE UNCERTAINTY INTERVAL Angol Bngldesh Brzil Cmbodi Centrl Africn Republic Chin Congo DPR Kore DR Congo Ethiopi Indi c Indonesi Keny Lesotho Liberi Mozmbique d Mynmr d Nmibi d Nigeri Pkistn Ppu New Guine Philippines < Russin Federtion Sierr Leone South Afric d Thilnd UR Tnzni Viet Nm d Zmbi Zimbbwe High TB burden countries Afric The Americs Estern Mediterrnen Europe South-Est Asi Western Pcific GLOBAL Numbers shown to two significnt figures if under 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 Indi re interim, pending results from the ntionl TB prevlence survey plnned for 219/22. d Estimtes of TB incidence nd mortlity for Mozmbique, Mynmr, Nmibi, South Afric nd Viet Nm will be reviewed fter finl results from their respective ntionl TB prevlence surveys re vilble in

46 TABLE 3.3 Estimted epidemiologicl burden of TB in 217 for 3 high TB burden countries, WHO regions nd globlly. Rtes per popultion. HIV-NEGATIVE TB MORTALITY HIV-POSITIVE TB MORTALITY TOTAL TB INCIDENCE BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL HIV PREVALENCE IN INCIDENT TB (%) BEST ESTIMATE UNCERTAINTY INTERVAL Angol Bngldesh Brzil Cmbodi Centrl Africn Republic Chin Congo DPR Kore DR Congo Ethiopi Indi b Indonesi Keny Lesotho Liberi Mozmbique c Mynmr c Nmibi c Nigeri Pkistn Ppu New Guine Philippines < Russin Federtion Sierr Leone South Afric c Thilnd UR Tnzni Viet Nm c Zmbi Zimbbwe High TB burden countries Afric The Americs Estern Mediterrnen Europe South-Est Asi Western Pcific GLOBAL Deths mong HIV-positive TB cses re clssified s HIV deths ccording to ICD-1. b Estimtes of TB incidence nd mortlity for Indi re interim, pending results from the ntionl TB prevlence survey plnned for 219/22. c Estimtes of TB incidence nd mortlity for Mozmbique, Mynmr, Nmibi, South Afric nd Viet Nm will be reviewed fter finl results from their respective ntionl TB prevlence surveys re vilble in

47 FIG. 3.2 Min methods used to estimte TB incidence Min method Cpture-recpture Cse notifictions, expert opinion Cse notifictions, stndrd djustment Prevlence survey No dt Not pplicble FIG. 3.3 Estimted TB incidence in 217, for countries with t lest incident cses Chin Philippines Pkistn Number of incident cses Indi 1 2 Nigeri South Afric Bngldesh Indonesi 36

48 FIG. 3.4 Estimted TB incidence rtes, 217 Incidence per popultion per yer No dt Not pplicble Philippines (6%), Pkistn (5%), Nigeri (4%), Bngldesh (4%) nd South Afric (3%) (Fig. 3.3). The severity of ntionl TB epidemics in terms of the nnul number of incident TB cses reltive to popultion size (the incidence rte) vried widely mong countries in 217. There were under 1 incident cses per popultion in most high-income countries, 1 4 in most of the 3 high TB burden countries (Fig. 3.4), nd bove in few countries including the Democrtic People s Republic of Kore, Lesotho, Mozmbique, the Philippines nd South Afric (Tble 3.3). An estimted 9% (rnge, %) of the incident TB cses in 217 were mong people living with HIV (Tble 3.2, Tble 3.3). The proportion of TB cses coinfected with HIV ws highest in countries in the WHO Africn Region, exceeding % in prts of southern Afric (Fig. 3.5). The risk of developing TB in the 37 million people living with HIV ws 2 times higher thn the risk in the rest of the world popultion (rnge, 17 23), incresing with decresing prevlence of HIV in the generl popultion. Estimtes of the incidence of zoonotic TB re shown in Tble Estimted trends in TB incidence, Consistent with previous globl TB reports, the number of incident cses is flling slowly, in both bsolute terms nd per cpit (Fig. 3.6, Fig. 3.7). Globlly, the verge rte of decline in the TB incidence rte ws 1.5% per yer in the period 2 217, nd 1.8% between 216 nd 217. This needs to ccelerte to 4 5% per yer by 22 nd to 1% per yer by 225, to chieve the milestones for reductions in cses nd deths set in the End TB Strtegy (Chpter 2). Trends re shown for the six WHO regions in Fig. 3.8 nd for the 3 high TB burden countries in Fig The fstest declines in the 5-yer period were in the WHO Europen Region (on verge, 5% per yer). In the sme period, prticulrly impressive reductions (4 8% per yer) occurred in southern Afric (e.g. Eswtini [formerly Swzilnd], Lesotho, Nmibi, South Afric, Zmbi nd Zimbbwe) following pek in the HIV epidemic nd the expnsion of TB nd HIV prevention nd cre (Box 3.4), nd in the Russin Federtion (5% per yer) following intensified efforts to reduce the burden of TB nd scrutiny of progress from the highest politicl levels. 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). 2 When 1 Time series of estimtes for ll countries re vilble online. Annex 1 explins how to ccess nd downlod them. 2 World Helth Orgniztion. Interntionl sttisticl clssifiction of diseses nd helth relted problems, ICD-1. Genev: WHO; 216 ( ccessed 31 August 218). 37

49 FIG. 3.5 Estimted HIV prevlence in new nd relpse TB cses, 217 HIV prevlence in new nd relpse TB cses ll ges (%) No dt Not pplicble TABLE 3.4 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. WHO REGION INCIDENT CASES DEATHS BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL Afric The Americs Estern Mediterrnen Europe South-Est Asi Western Pcific GLOBAL Numbers shown to two significnt figures if under nd to three significnt figures otherwise. 38

50 FIG. 3.6 Globl trends in the estimted number of incident TB cses nd the number of TB deths (in millions), Shded res represent uncertinty intervls. TB incidence TB deths Millions per yer 1 5 All TB cses HIV-positive TB cses Notifictions of new nd relpse cses Millions per yer TB deths mong HIV-negtive people TB deths mong HIV-positive people FIG. 3.7 Globl trends in estimted TB incidence nd mortlity rtes, Shded res represent uncertinty intervls. TB incidence TB mortlity (HIV-negtive) Rte per popultion per yer 2 1 All TB cses HIV-positive TB cses Notifictions of new nd relpse cses Rte per popultion per yer n HIV-positive person dies from TB, the underlying cuse is clssified s HIV. For consistency with these interntionl clssifictions, this section mkes cler distinction between TB deths in HIV-negtive people nd TB deths in HIV-positive people Methods to estimte TB mortlity TB mortlity mong HIV-negtive people cn be mesured directly using dt from ntionl vitl registrtion (VR) systems, provided tht these systems hve high coverge nd tht cuses of deth re ccurtely determined nd coded ccording to ICD-1. Smple VR systems covering representtive res of the country (the pproch used, for exmple, in Chin) provide n interim solution. Mortlity surveys cn lso be used to estimte deths cused by TB. In 217, 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 through ecologicl modelling using mortlity dt from countries with VR systems. TB mortlity mong HIV-positive people is hrd to mesure, even when VR systems re in plce, becuse deths mong HIV-positive people re coded s HIV deths, nd contributory cuses (e.g. TB) re often not relibly ssessed nd recorded. TB deths mong HIVpositive people were estimted s the product of TB incidence nd the CFR, with the ltter ccounting for the protective effect of ART. Until 28, WHO estimtes of TB mortlity used VR or mortlity survey dt for only three countries. This ws substntilly improved to 89 countries in 29, lthough most of the dt were from countries in the WHO Europen Region nd the WHO Region of the Americs, which ccounted for less thn 1% of the world s TB cses. For the current report, VR or mortlity survey dt were used for 127 countries (Fig. 3.1), which collectively 39

51 FIG. 3.8 Regionl trends in estimted TB incidence rtes by WHO region, Totl TB incidence rtes re shown in green nd incidence rtes of HIV-positive TB re shown in red. Shded res represent uncertinty intervls. The blck lines show notifictions of new nd relpse cses for comprison with estimtes of the totl incidence rte. 4 Afric 4 The Americs 1 Estern Mediterrnen 3 3 Incidence rte per popultion per yer Europe South-Est Asi 1 Western Pcific ccounted for 57% of the estimted number of TB deths (mong HIV-negtive people) globlly in 217. For 19 countries, nlyses of VR dt nd resulting estimtes of TB deths published by the Institute of Helth Metrics nd Evlution (IHME) t the University of Wshington, USA, were used. 1 The WHO Africn Region hs the gretest need to introduce or strengthen VR systems in which cuses of deth re clssified ccording to ICD-1. Detils bout the methods used to produce estimtes of TB mortlity re provided in the online technicl ppendix Estimtes of TB mortlity in 217 Estimtes of the bsolute 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 1.3 million (rnge, million) deths from TB mong HIV-negtive people in 217 nd n dditionl 3 (rnge, ) deths from TB mong HIV-positive people. TB is the tenth leding cuse of deth worldwide, nd since 211 it hs been the leding cuse of deth from single infectious gent, rnking bove HIV/AIDS 1 Downloded from July The online technicl ppendix is vilble t (Fig. 3.11, Fig nd Fig. 3.13). 3 Most of these deths could be prevented with erly dignosis nd pproprite tretment (Chpter 1). For exmple, mong people whose TB ws detected, reported nd treted in 216, the tretment success rte ws 82% globlly (Chpter 4); nd in high-income countries with universl helth coverge, the proportion of people who die from TB cn be under 5% (Section 3.2.4). About 82% of TB deths mong HIV-negtive people occurred in the WHO Africn Region nd the WHO South- Est Asi Region in 217; these regions ccounted for 85% of the combined totl of TB deths in HIV-negtive nd HIV-positive people. Indi ccounted for 32% of globl TB deths mong HIV-negtive people, nd for 27% of the combined totl TB deths in HIV-negtive nd HIV-positive people. Estimtes of TB mortlity rtes (per 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 popultion ws 17 (rnge, 16 18) in 217, nd 21 (rnge, 2 22) when TB deths mong HIV-positive people were included. There ws considerble vrition 3 Globl Helth Estimtes 216: Deths by cuse, ge, sex, by country nd by region, Genev, World Helth Orgniztion;

52 FIG. 3.9 Trends in estimted TB incidence in the 3 high TB burden countries, TB incidence rtes re shown in green nd incidence rtes of HIV-positive TB re shown in red. Shded res represent uncertinty intervls. The blck lines show notifictions of new nd relpse cses for comprison with estimtes of the totl incidence rte. Angol Bngldesh Brzil Cmbodi Centrl Africn Republic Chin Congo DPR Kore DR Congo Ethiopi Incidence rte per popultion per yer Indi Indonesi Keny Lesotho Liberi Mozmbique b Mynmr b Nmibi b Nigeri Pkistn Ppu New Guine Philippines Russin Federtion Sierr Leone South Afric b Thilnd UR Tnzni Viet Nm b Zmbi Zimbbwe Estimtes of TB incidence for Indi re interim, pending results from the ntionl TB prevlence survey plnned for 219/22. b Estimtes of TB incidence for Mozmbique, Mynmr, Nmibi, South Afric nd Viet Nm will be reviewed fter finl results from their respective ntionl TB prevlence surveys re vilble in

53 BOX 3.4 Rpid decline in TB incidence in six countries in southern Afric In six countries in southern Afric, TB incidence is estimted to hve fllen rpidly in the period , with verge nnul rtes of decline of 18% in Eswtini, 1% in Zimbbwe, 8% in Botswn, 7% in Lesotho nd South Afric, nd 6% in Nmibi. Such ntionl rtes of decline in TB incidence re mong the fstest of recent decdes. TB cse notifictions in ll six countries hve lso declined in this period, t nerly the sme verge rtes. Since the 199s, TB incidence in southern Afric hs been strongly driven by the HIV epidemic. In 217, the estimted proportion of incident TB cses coinfected with HIV rnged from 36% in Nmibi to 71% in Lesotho. The prevlence of HIV in the generl popultion hs remined reltively stble in ll six countries since 21 (rnging from 8% in Nmibi to 17 19% in Eswtini). Wht hs chnged is tht the coverge of HIV cre in the generl popultion nd mong new TB cses in people living with HIV hs improved substntilly. In the generl popultion, ART coverge mong people living with HIV rpidly incresed in the period , with improvements rnging from 24% to 61% in South Afric nd from 3% to 84% in Zimbbwe (Fig. B3.4.1). In four of the six countries, ART coverge ws bove 8% of estimted prevlent HIV cses in 217, remrkble chievement. Trends in ART coverge mong new TB cses coinfected with HIV followed similr trends nd reched similr levels of coverge by 217, with the exception of Botswn (34%). The HIV pndemic hs hd mjor impct on the helth of people in southern Afric. HIV drove the nnul ntionl incidence of TB in the six fetured countries to some of the highest rtes ever globlly (e.g. to over 1% of the popultion per yer in Eswtini nd Lesotho, nd.9% of the popultion per yer in South Afric in 21). In 21, the estimted TB incidence rte rtio (TB incidence mong HIV-positive individuls divided by TB incidence in HIV-negtive individuls) rnged from 1 in Botswn to 32 in Zimbbwe. Those reltive risks nerly hlved within 8 yers, from 4.7 in Botswn to 18 in Zimbbwe in 217. The rpid increse in ART coverge mong people living with HIV in ll six countries led to tremendous reduction in TB incidence rtes over the pst 8 yers, confirming predictions mde in 21. b Further reductions will require ddressing other importnt determinnts of TB (Chpter 7) nd improving the coverge of preventive tretment (Chpter 5). Further detils on trends in cse notifictions re provided in Chpter 4 nd in country profiles. b Willims BG, Grnich R, De Cock KM, Glziou P, Shrm A, Dye C. Antiretrovirl therpy for tuberculosis control in nine Africn countries. PNAS 21; 17(45): ( pubmed/ , ccessed 31 August 218). FIG. B3.4.1 Trends in TB incidence rtes expressed s percentge of the best estimte for 21 (in red), overll ART coverge mong people living with HIV (solid blck line) nd ART coverge mong new TB cses coinfected with HIV (dshed line), in 6 selected countries in southern Afric, Botswn Eswtini Lesotho Percentge Nmibi South Afric Zimbbwe

54 FIG. 3.1 Min methods used to estimte TB mortlity in HIV-negtive people Min method Indirect estimte VR (IHME) VR (WHO) No dt Not pplicble Mortlity is estimted s the product of TB incidence nd the TB cse ftlity rtio. Further detils re provided in the online technicl ppendix. FIG Top cuses of deth worldwide in 216.,b Deths from TB mong HIV-positive people re shown in grey. FIG Estimted number of deths from HIV/AIDS nd TB in 217. Deths from TB mong HIV-positive people re shown in grey.,b b Ischemic hert disese Stroke Chronic obstructive pulmonry disese Lower respirtory infections Alzheimer disese nd other dementis Trche, bronchus, lung cncers Dibetes mellitus Rod injury Dirrhoel diseses Tuberculosis Millions (216) This is the ltest yer for which estimtes for ll cuses re currently vilble. See WHO estimtes, vilble t portl/uhc-fp-cbinet-wrpper-v2.jsp?id=1221 (ccessed 15 August 218). Deths from TB mong HIV-positive people re officilly clssified s deths cused by HIV/AIDS in the Interntionl clssifiction of diseses. HIV/AIDS b TB Millions (217) For HIV/AIDS, the ltest estimtes of the number of deths in 217 tht hve been published by UNAIDS re vilble t (ccessed 15 August 218). For TB, the estimtes for 217 re those published in this report. Deths from TB mong HIV-positive people re officilly clssified s deths cused by HIV/AIDS in the Interntionl clssifiction of diseses. 43

55 FIG Globl trends in the estimted number of deths cused by TB nd HIV (in millions), ,b Shded res represent uncertinty intervls. Millions of deths per yer b TB deths in HIV-negtive people HIV deths TB deths in HIV-positive people For HIV/AIDS, the ltest estimtes of the number of deths in 217 tht hve been published by UNAIDS re vilble t (ccessed 15 August 218). For TB, the estimtes for 217 re those published in this report. Deths from TB mong HIV-positive people re officilly clssified s deths cused by HIV/AIDS in the Interntionl clssifiction of diseses. mong countries (Fig. 3.14), rnging from less thn one TB deth per popultion in mny high-income countries, to 4 or more deths per popultion in much of the WHO Africn Region nd in four high TB burden countries in Asi (the Democrtic People s Republic of Kore, Indonesi, Mynmr nd Ppu New Guine). Estimtes of the number of deths cused by zoonotic TB re shown in Tble Estimted trends in TB mortlity, Globlly, the bsolute number of deths cused by TB mong HIV-negtive people hs been flling since 2, from best estimte of 1.8 million in 2 to 1.3 million in 217 (Fig. 3.6), reduction of 29%. The reduction since 215 (the bseline yer for milestones nd trgets set in the End TB Strtegy, s shown in Tble 3.1) ws 5%. The TB mortlity rte (TB deths mong HIV-negtive people per popultion per yer) fell by 42% globlly between 2 nd 217 (Fig. 3.7), nd by 3.2% between 216 nd 217. Mortlity rtes mong HIV-negtive people hve been flling in ll six WHO regions since 2, but the rte of decline vries (Fig. 3.15). For exmple, in the 5-yer period , the fstest verge rtes of decline were in the WHO Europen Region (11% per yer) nd the WHO South-Est Asi Region (4.3% per yer), nd the slowest rte ws in the WHO Africn Region (1.7% per yer). Trends lso vry mrkedly mong the 3 high TB burden countries (Fig. 3.16), rnging from substntil reductions (more thn %) since 2 (e.g. in Cmbodi, FIG Estimted TB mortlity rtes excluding TB deths mong HIV-positive people, 217 Mortlity per popultion per yer No dt Not pplicble 44

56 FIG Regionl trends in estimted TB mortlity rtes by WHO region, Estimted TB mortlity rtes excluding TB deths mong HIV-positive people re shown in blue nd estimted mortlity rtes of HIV-positive TB re shown in red. Shded res represent uncertinty intervls. Afric The Americs Estern Mediterrnen Mortlity rte per popultion per yer Europe South-Est Asi 1 1 Western Pcific Chin, Ethiopi, Mynmr, the Russin Federtion nd Viet Nm) to limited chnges (e.g. in Angol nd Congo). 1 High TB burden countries with rtes of decline in TB deths mong HIV-negtive people tht exceeded 6% per yer in the 5-yer period included the Russin Federtion (13% per yer), Ethiopi (12% per yer), Sierr Leone (1% per yer), Keny (8% per yer) nd Viet Nm (8% per yer). Globlly, the number of TB deths mong HIV-positive people hs fllen by 44% since 2, from 534 (rnge, ) in 2 to 3 (rnge, ) in 217, nd by 2% since 215. Most of this reduction ws in the WHO Africn Region (Fig. 3.15). In severl high TB burden countries, the number of deths cused by TB mong HIV-positive people hs fllen substntilly in recent yers; for exmple, in Cmbodi, Keny, Nmibi, South Afric, the United Republic of Tnzni nd Zimbbwe (Fig. 3.16) 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 1 Time series of estimtes for ll countries re vilble online. Annex 1 explins how to ccess nd downlod them. deths divided by the number of new cses 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 high-qulity 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 6.5% by 225 (Chpter 2). In 217, the globl CFR (clculted s the combined number of TB deths in HIV-negtive people nd HIVpositive people, divided by the totl number of incident cses in both HIV-negtive nd HIV-positive people) 2 ws 16%, down from 23% in 2. It vried widely mong countries (Fig. 3.17), from under 5% in few countries to more thn 2% in most countries in the WHO Africn Region. Intensified efforts re required to reduce the CFR to 1% globlly by The CFR ws clculted bsed on the combined totl of deths in HIV-negtive nd HIV-positive people for the purpose of cross-country comprisons; in prticulr, to illustrte the high CFRs in Africn countries, which could be reduced by effective detection nd cre progrmmes. CFRs restricted to HIV-negtive TB deths nd cses cn lso be clculted but re not shown here. At the subntionl level, CFRs cn lso be restricted to HIV-negtive TB deths, depending on the country nd its HIV burden. 45

57 FIG Trends in estimted TB mortlity rtes in the 3 high TB burden countries, TB mortlity rtes in HIV-negtive people re shown in blue nd mortlity rtes of HIV-positive TB re shown in red. The blck lines show observtions from vitl registrtion systems. Shded res represent uncertinty intervls. 12 Angol Bngldesh Brzil Cmbodi 6 6 Centrl Africn Republic Chin Congo DPR Kore DR Congo Ethiopi Mortlity rte per popultion per yer Indi Indonesi Keny Lesotho Liberi Mozmbique b Mynmr b Nmibi b Nigeri Pkistn Ppu New Guine Philippines Russin Federtion Sierr Leone South Afric b Thilnd UR Tnzni Viet Nm b Zmbi Zimbbwe Estimtes of TB mortlity for Indi re interim, pending results from the ntionl TB prevlence survey plnned for 219/22. b Estimtes of TB mortlity for Mozmbique, Mynmr, Nmibi, South Afric nd Viet Nm will be reviewed fter finl results from their respective ntionl TB prevlence surveys re vilble in

58 FIG Estimtes of the cse ftlity rtio (CFR), including HIV-negtive nd HIV-positive people, 217 CFR (%) No dt Not pplicble Estimted number of deths verted by TB tretment, The ctul numbers of TB deths (presented bove) cn be compred with the number of TB deths tht would hve occurred in the bsence of TB tretment, to estimte the number of deths verted by TB interventions. The number of deths tht would hve occurred ech yer in the bsence of TB tretment (nd without ART provided longside TB tretment for HIV-positive cses) cn be conservtively estimted s the number of estimted incident cses (Section 3.1) multiplied by the relevnt estimted CFR for untreted TB. 1 Estimtes re conservtive becuse they do not ccount for the impct of TB services or the vilbility of ART on the level of TB incidence, or for the indirect, downstrem impct of these interventions on future levels of infections, cses nd deths. Between 2 nd 217, TB tretment lone verted n estimted 45 million deths mong HIV-negtive people (Tble 3.5). Among HIV-positive people, TB tretment supported by ART verted n dditionl 9 million deths. 3.3 Drug-resistnt TB Drug-resistnt TB remins mjor public helth concern in mny countries. Three mjor ctegories re used for 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 globl surveillnce nd tretment. MDR-TB is TB tht is resistnt to both rifmpicin nd isonizid, the two most powerful nti-tb drugs; it requires tretment with second-line regimen. RR-TB lso requires tretment with second-line drugs. With incresing use of Xpert MTB/ RIF for simultneous detection of TB nd resistnce to rifmpicin, growing number of RR-TB cses (without further testing for isonizid resistnce) re being detected nd notified (Chpter 4). Extensively drug-resistnt TB (XDR-TB) is defined s MDR-TB plus resistnce to t lest one drug in both of the two most importnt clsses of medicines in n MDR-TB regimen: fluoroquinolones nd second-line injectble gents (mikcin, cpreomycin or knmycin). Estimtes of the disese burden cused by drug-resistnt TB presented in this chpter focus on MDR/RR-TB Globl surveillnce of nti-tb drug resistnce Since the lunch of the Globl Project on Antituberculosis Drug Resistnce Surveillnce in 1994, dt on drug resistnce hve been systemticlly collected nd nlysed from 16 countries worldwide (82% of the 194 WHO Member Sttes), which collectively hve more thn 97% of the world s popultion nd TB cses. This includes 91 countries tht hve continuous surveillnce systems bsed on routine dignostic drug susceptibility testing (DST) of Mycobcterium tuberculosis isoltes 47

59 TABLE 3.5 Cumultive number of deths verted by TB nd TB/HIV interventions (in millions), globlly nd by WHO region WHO REGION BEST ESTIMATE HIV-NEGATIVE PEOPLE HIV-POSITIVE PEOPLE TOTAL UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL Afric The Americs Estern Mediterrnen Europe South-Est Asi Western Pcific GLOBAL Numbers shown to two significnt figures. FIG Dt sources vilble to estimte levels of TB drug resistnce Source of dt Surveillnce Survey No dt Not pplicble 48

60 FIG Globl coverge of surveillnce dt on drug resistnce, Yer of most recent dt Ongoing in 218 Subntionl dt No dt Not pplicble obtined from ll TB ptients, nd 69 countries tht rely on epidemiologicl surveys of bcteril isoltes collected from representtive smples of ptients (Fig. 3.18). Surveys conducted bout every 5 yers represent the most common pproch to investigting the burden of drug resistnce in resource-limited settings where routine DST is not ccessible to ll TB ptients owing to lck of lbortory cpcity or resources. Progress towrds chieving globl coverge of drug-resistnce surveillnce dt is shown in Fig Among the 3 high TB burden countries nd the 3 high MDR-TB burden countries (which comprise totl of 4 countries, becuse of overlp between the two groups 1 ), 37 hve dt on levels of drug resistnce. The three countries tht hve never conducted drug-resistnce survey re Angol, Congo nd Liberi. Angol hs initited ntionl survey in 218. Among the other 37 high TB burden or high MDR-TB burden countries, four countries (Brzil, Centrl Africn Republic, Democrtic People s Republic of Kore nd Ppu New Guine) rely on drug-resistnce surveillnce dt gthered from subntionl res only. In , the first-ever ntionl drug resistnce surveys were completed in Eritre, Indonesi nd Lo People s Democrtic Republic, nd repet surveys were completed in Eswtini, Sri Lnk, Togo nd the United 1 For full list of the high TB burden nd high MDR-TB burden countries, see Chpter 2. Republic of Tnzni. In , drug-resistnce surveys were ongoing in 12 countries, with the first ntionwide surveys in five countries (Angol, Burundi, Hiti, Mli nd Timor-Leste) nd repet surveys in seven countries (Bngldesh, Cmbodi, Ethiopi, Mlwi, the Philippines, Thilnd nd Turkmenistn) Estimtes of the disese burden cused by MDR/RR-TB Globlly in 217, n estimted 3.5% (95% confidence intervl [CI]: %) of new cses nd 18% (95% CI: %) of previously treted cses hd MDR/RR-TB (Tble 3.6). The proportions of new nd previously treted TB cses with MDR/RR-TB t the country level re shown in Fig. 3.2 nd Fig There were n estimted 558 (rnge, ) incident cses of MDR/RR-TB in 217. This is slight downwrd revision from the best estimte published in the 217 edition of the WHO globl TB report, for resons explined in Box 3.2. As before, however, the proportion of cses estimted to hve MDR-TB ws 82% (46 out of 56 ) (Tble 3.6). The countries with the lrgest numbers of MDR/RR-TB cses (47% of the globl totl) were Chin, Indi nd the Russin Federtion (Fig. 3.22). There were bout 23 (rnge, ) deths from MDR/RR-TB in 217, similr to the best estimte for 216 tht ws published in the 217 edition of the WHO globl TB report. 49

61 TABLE 3.6 Estimted incidence of MDR/RR-TB in 217 for 3 high MDR-TB burden countries, WHO regions nd globlly ESTIMATED % OF NEW CASES WITH MDR/RR-TB BEST ESTIMATE UNCERTAINTY INTERVAL ESTIMATED % OF PREVIOUSLY TREATED CASES WITH MDR/RR-TB BEST ESTIMATE UNCERTAINTY INTERVAL NUMBER (IN s) UNCERTAINTY INTERVAL INCIDENCE OF MDR/RR-TB RATE b UNCERTAINTY INTERVAL Angol Azerbijn Bngldesh Belrus Chin DPR Kore DR Congo Ethiopi Indi Indonesi Kzkhstn Keny Kyrgyzstn Mozmbique Mynmr Nigeri Pkistn Ppu New Guine Peru Philippines Republic of Moldov Russin Federtion Somli South Afric Tjikistn Thilnd Ukrine Uzbekistn Viet Nm Zimbbwe MDR/RR HBCs Afric The Americs Estern Mediterrnen Europe South-Est Asi Western Pcific GLOBAL Numbers shown to two significnt figures if under nd to three significnt figures otherwise. Best estimtes re for the ltest vilble yer. b Rtes re per popultion. % OF MDR AMONG MDR/RR-TB

62 FIG. 3.2 Percentge of new TB cses with MDR/RR-TB Percentge of cses No dt Not pplicble Figures re bsed on the most recent yer for which dt hve been reported, which vries mong countries. Dt cover the period FIG Percentge of previously treted TB cses with MDR/RR-TB Percentge of cses 5.9 Figures re bsed on the most recent yer for which dt hve been reported, which vries mong countries. Dt cover the period The high percentges of previously treted TB cses with RR-TB in Belize, Gum nd So Tomé nd Principe refer to only smll number of notified cses (rnge: 1 8 notified previously treted TB cses) No dt Not pplicble 51

63 FIG Estimted incidence of MDR/RR-TB in 217, for countries with t lest incident cses Russin Federtion Chin Number of incident cses 1 Indi 1 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 using WHOrecommended dignostic tests. Globlly in 217, there were n estimted 33 (rnge, 31 3 ) MDR/RR-TB cses mong notified TB ptients Trends in drug resistnce Of the 4 countries with high TB or MDR-TB burden (or both), only 22 hve repeted survey t lest once to evlute trends in drug resistnce. Among these countries, 1 hve t lest 3 yers of dt: Belrus, Kzkhstn, Mynmr, Peru, Republic of Moldov, Russin Federtion, Tjikistn, Thilnd, Ukrine nd Viet Nm. For these settings, Fig shows trends in the number of new TB cses notified, the proportion of new TB cses with MDR, nd per cpit TB nd MDR-TB rtes. Bsed on these dt, there is slight trend for cses of MDR-TB to increse s proportion of ll TB cses in these countries, with the burden of MDR-TB either incresing fster or decresing more slowly thn the overll TB burden in ech country Resistnce to other nti-tb drugs Dt on resistnce to ll first-line nti-tb drugs (rifmpicin, isonizid, pyrzinmide nd ethmbutol) ws gthered from surveys conducted in six countries: Azerbijn, Bngldesh, Belrus, Pkistn, South Afric nd Ukrine. The verge level of resistnce to ll firstline nti-tb drugs ws 19% (95% CI: 18 2%) in new TB cses; in previously treted cses, the verge ws 43% (95% CI: 4 46%). Dt on levels of resistnce to isonizid without concurrent rifmpicin resistnce re vilble for 149 countries over the period The proportions of TB ptients resistnt to isonizid but susceptible to rifmpicin in ech country were weighted ccording to the number of new TB cses tht were notified in the country, to generte globl verge. The globl verges of isonizid resistnce without concurrent rifmpicin resistnce were 7.1% (95% CI: %) in new TB cses nd 7.9% (95% CI: 5.9 1%) in previously treted TB cses. By the end of 217, XDR-TB hd been reported by 127 WHO Member Sttes. Of these, 113 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 8.5% (95% CI: %), n increse from the 6.2% in 216 tht ws published in the 217 edition of the WHO globl TB report. Among the 4 countries with high TB or MDR-TB burden, 22 hve surveillnce dt on resistnce to second-line nti-tb drugs. The proportion of MDR/RR-TB 52

64 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 popultion. The red line shows the number of MDR-TB cses mong new TB ptients per popultion. Belrus Kzkhstn Mynmr -6% per yer -9% per yer 5% per yer 1 1-7% per yer 1 1-2% per yer 1 1 8% per yer Peru Republic of Moldov Russin Federtion -3% per yer -5% per yer -6% per yer TB nd MDR-TB cses per popultion (log scle) % per yer 1% per yer 1-3% per yer Tjikistn Thilnd Ukrine -6% per yer 3% per yer -1% per yer % per yer 1-12% per yer 1 1 5% per yer Viet Nm % per yer 1 1 4% per yer

65 cses with resistnce to ny fluoroquinolone for which testing ws done including ofloxcin, levofloxcin nd moxifloxcin ws 22% (95% CI: 17 28%). 3.4 Ntionl TB prevlence surveys The prevlence of TB disese is not n indictor in the SDGs or high-level indictor of the End TB Strtegy, nd no globl trget hs been set for the period Furthermore, indirect estimtes of prevlence suffer from considerble uncertinty, becuse they re derived from estimtes of incidence nd ssumptions bout disese durtion. Hence, indirect estimtes of TB prevlence (i.e. estimtes tht re not from ntionl TB prevlence survey) re not presented in this chpter. 2 Nonetheless, in n importnt subset of countries with lrge proportion of the world s TB burden, ntionl TB prevlence surveys continue to provide the best method for mesuring the burden of TB disese (both in bsolute terms nd to ssess trends when repet surveys re done, nd by ge nd sex). Findings cn inform ssessment of ctions needed to reduce this burden s well s estimtes of TB incidence (Fig. 3.2), thus contributing to the monitoring of progress towrds SDG nd End TB Strtegy trgets. The WHO Globl Tsk Force on TB Impct Mesurement hs retined ntionl TB prevlence surveys within its strtegic res of work for (Box 3.1), nd hs defined the group of countries where they continue to be relevnt s those with reltively high burden of TB (bout 1 incident cses per popultion) tht do not yet hve helth, ntionl notifiction nd VR systems of the qulity nd coverge required to provide relible nd routine direct mesurements of the number of TB cses nd deths. 3 The most recent exmple of prevlence survey tht hs informed understnding of trends in TB disese burden, estimtes of TB incidence nd identifiction of ctions required to reduce the burden of TB disese is the 216 survey in the Philippines. 4,5 1 This is in contrst to the er of the Millennium Development Gols (MDGs) nd Stop TB Strtegy, when one of the globl trgets for reductions in TB disese burden ws to hlve prevlence between 199 nd WHO will continue to produce indirect estimtes of TB prevlence. These cn be provided upon request to tbdt@who.int. 3 In the Tsk Force s April 216 meeting, epidemiologicl criteri for conducting survey were defined for two groups of countries: those tht implemented survey in nd in which repet survey could be considered; nd those tht hve never conducted survey. There were 24 countries in the first group nd 33 in the second group. For ny of these 57 countries, it ws emphsized tht fesibility criteri must lso be considered. In prticulr, the prerequisites for conducting survey defined in the WHO hndbook on ntionl TB prevlence surveys should be met. For further detils on the meeting, see World Helth Orgniztion Globl Tsk Force on TB Impct Mesurement. Report of the sixth meeting of the full Tsk Force; April 216, Glion-sur-Montreux, Switzerlnd. Genev: WHO; 216 ( int/tb/dvisory_bodies/impct_mesurement_tskforce/meetings/ tf6_report.pdf?u=1, ccessed 8 August 218). 4 World Helth Orgniztion. Globl Tuberculosis Report 217 (WHO/ HTM/TB/217.23). Genev: WHO; 217 ( publictions/globl_report/rchive/en/, ccessed 21 June 218). 5 The Philippines TB prevlence survey report ( ccessed 2 August 218). FIG Globl progress in implementing ntionl surveys of the prevlence of TB disese, ctul (2 218) nd expected (219) b c d 2 Chin Cmbodi 23 Mlysi 24 Indonesi 25 Eritre 26 Thilnd 27 Philippines Viet Nm 28 Bngldesh 29 Mynmr 21 Chin 211 Cmbodi Ethiopi Lo PDR Pkistn 212 Gmbi Nigeri Rwnd UR Tnzni Thilnd 213 Ghn Mlwi Sudn 214 Indonesi Zmbi Zimbbwe 215 Bngldesh Keny Mongoli Ugnd 216 DPR Kore Philippines 217 Mozmbique b Mynmr b Nmibi c South Afric b Viet Nm c 218 Botswn d Eswtini b Nepl b 219 Indi Lesotho The surveys in Bngldesh (28) nd Eritre (25) collected sputum smples from ll individuls (ged 15 yers), nd did not use chest X-ry nd/or symptom questionnire to screen individuls for sputum submission. Field opertions re ongoing s of August 218. Field opertions re completed nd nlysis is ongoing. Field opertions scheduled to strt in 218. Countries in which ntionl prevlence surveys were implemented in or re plnned for 219 re shown in Fig nd Fig An unprecedented number of surveys were implemented in , period in which the WHO Globl Tsk Force on TB Impct Mesurement defined ntionl TB prevlence surveys in 22 globl focus countries s one of its three strtegic res of work (Box 3.1). Between 27 nd the end of 217, totl of 25 surveys tht used the screening nd dignostic methods recommended in the second edition of the WHO hndbook on prevlence surveys 6 were completed. This included 13 surveys in Asin countries nd 12 in Africn countries. No surveys were completed in 217; however, in erly 218, field opertions were completed in the first ntionl survey in Nmibi nd repet survey in Viet Nm (following first survey in 27). It is expected tht Mynmr will finish its repet survey (following first survey in 29) in lte 218. As of August 218, field opertions were ongoing in five 6 World Helth Orgniztion. Tuberculosis prevlence surveys: hndbook (WHO/HTM/TB/21.17). Genev: WHO; 211 ( tb/dvisory_bodies/impct_mesurement_tskforce/resources_ documents/thelimebook/, ccessed 8 August 218). 54

66 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 218) No survey plnned Survey plnned b Survey ongoing c One survey completed d 1 repet survey completed e Not pplicble b c d e Screening methods include field chest X-ry; t lest culture ws used to confirm dignosis. The most recent surveys in Bngldesh, Keny, Nmibi, Mynmr, Mozmbique, Nepl, the Philippines nd Viet Nm used both culture nd Xpert MTB/RIF (or Xpert Ultr) to confirm dignosis. A country hs submitted t lest drft survey protocol nd budget pln to the WHO Globl Tsk Force on TB Impct Mesurement. Countries were implementing field opertions in August 218 or were undertking dt clening nd nlysis. A survey ws conducted in ccordnce with WHO recommendtions s outlined in Tuberculosis prevlence surveys: hndbook (211) nd t lest preliminry report hs been published. A repet ntionl survey is one in which prticipnts were screened with chest X-ry, nd (t lest) culture ws used to dignose TB cses. countries: Eswtini, Mozmbique, Mynmr, Nepl nd South Afric. Surveys in Botswn, Indi nd Lesotho re plnned in 219 or 22. A comprison of estimtes of TB prevlence before nd fter the implementtion of ntionl survey is shown for 25 countries in Fig Post-survey prevlence estimtes were lmost lwys more precise (i.e. hd nrrower uncertinty intervls). For 18 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. The distribution of TB disese by ge (in dults) nd sex bsed on prevlence survey dt is shown in Fig nd Fig In Asi nd some Africn countries (e.g. Ghn, Mlwi, Rwnd, the United Republic of Tnzni nd Zimbbwe), prevlence increses with ge. However, in severl Africn countries (e.g. Ethiopi, Gmbi, Nigeri, Sudn, Ugnd nd Zmbi), prevlence per popultion peks mong those ged yers. The mle to femle (M:F) rtio of cses for the sme set of surveys shows systemticlly higher burden of TB disese mong men, with rtios rnging from 1.2 (in Ethiopi) to 4.5 (in Viet Nm) for bcteriologiclly confirmed pulmonry TB. In most countries, the rtio ws in the rnge 2 4. The rtio of prevlence to notifictions (P:N) cn be used to ssess detection nd reporting gps (Fig. 3.29) nd vrition in these gps by sex (Fig. 3.29b). The P:N rtios from surveys implemented in suggest tht women re ccessing vilble dignostic nd tretment services more effectively thn men. The higher disese burden in men, combined with lrger gps in detection nd reporting, lso suggests tht there is need for strtegies to improve ccess to nd use of helth services mong men. 1 1 Horton KC, McPherson P, Houben RMGJ, White RG, Corbett EL. Sex differences in tuberculosis burden nd notifictions in low- nd middle-income countries: systemtic review nd met-nlysis. Metclfe JZ, ed. PLoS Medicine. 216;13(9) ( gov/pubmed/ , ccessed 31 August 218). 55

67 FIG Estimtes of TB prevlence (ll ges, ll forms of TB) for 25 surveys, before (in blue) nd fter (in red) results from ntionl TB prevlence surveys becme vilble since 27. Countries re ordered ccording to the before fter difference. Afric Asi UR Tnzni Mlwi Ghn Keny Nigeri Zmbi Ugnd Rwnd Sudn Ethiopi Zimbbwe Gmbi Philippines Mongoli Lo PDR Indonesi Cmbodi Philippines b Thilnd Chin Pkistn Mynmr DPR Kore Viet Nm Bngldesh c Prevlence per popultion (log scle) These dt relte to the repet prevlence survey conducted in 216. b These dt relte to the prevlence survey conducted in 27. c These dt relte to the prevlence survey conducted in FIG Age-specific prevlence rte rtio of bcteriologiclly confirmed TB in surveys implemented Afric 25 Asi Cmbodi Mlwi Lo PDR Mynmr Viet Nm 1 1 Bngldesh Chin Prevlence rtio Age group (yers) Sudn Ghn Zimbbwe Zmbi Ugnd Nigeri Keny Ethiopi Age group (yers) Age-specific prevlence rtios were clculted using the prevlence of the yer ge group s the bseline. Dt in the presented ge groups were not vilble for Gmbi nd Rwnd. Dt re not shown for UR Tnzni becuse lbortory chllenges during the survey ment tht it ws only possible to directly estimte the prevlence of smer-positive (s opposed to bcteriologiclly confirmed) TB. b These dt relte to the prevlence survey conducted in 27. c These dt relte to the repet prevlence survey conducted in Pkistn Indonesi Philippines b DPR Kore Thilnd Philippines c Mongoli 56

68 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. FIG The mle to femle rtio of bcteriologiclly confirmed dult TB cses detected in prevlence surveys implemented Methods to disggregte estimtes by ge nd sex Estimtes of TB incidence in children (ged <15 yers) were bsed on cse notifictions, djusted for underdignosis nd underreporting 1 nd combined with estimtes derived from dynmic modelling. 2 Results for the 14 yer ge group ( 4 nd 5 14 yers) in ech country were then further disggregted using outputs from n estblished deterministic model, 2 followed by disggregtion by sex using results from met-nlysis of the M:F notifiction rtio. Estimtes of TB incidence in dults were derived by first subtrcting incidence in children from incidence in ll ges. The estimte for dults ws then disggregted into six ge groups (15 24, 25 34, 35 44, 45 54, nd 65 yers) using dt from ntionl TB prevlence surveys implemented in (Section 3.4). Country-specific distributions were used for countries tht hd implemented survey; for other countries, the ge distribution ws predicted using prevlence survey dt. Disggregtion by sex ws bsed on ctul M:F rtios for countries tht hd implemented surveys; for other countries, this disggregtion ws bsed on regionl M:F rtios from systemtic review nd met-nlysis. 3 TB mortlity in children ws estimted for the two ge groups using previously published pproch derived from dynmic modelling, 4 nd then by sex, on the ssumption tht the pttern ws the sme s tht for incidence. If vilble, dt on TB deths mong dults were disggregted for six ge groups (15 24, 25 34, 35 44, 45 54, nd 65 yers) using VR dt. For countries whose mortlity estimtes were not bsed on VR dt, CFR ws pplied to the dult ge- nd sex-disggregted incidence. This CFR ccounted for differences between HIV-positive nd HIV-negtive TB cses, nd for vrition in HIV prevlence by ge nd sex. b c d Viet Nm Ugnd Rwnd Bngldesh b Gmbi Chin Mongoli Philippines c Thilnd Philippines d Mynmr Keny DPR Kore Lo PDR Indonesi Nigeri Cmbodi Sudn Zmbi Mlwi Pkistn Ghn Zimbbwe Ethiopi Sex rtio (mle:femle) A vlue is not shown for UR Tnzni becuse lbortory chllenges during the survey ment tht it ws only possible to directly estimte the prevlence of smer-positive (s opposed to bcteriologiclly confirmed) TB. These dt relte to the prevlence survey conducted in These dt relte to the repet prevlence survey conducted in 216. These dt relte to the prevlence survey conducted in 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 218). 2 Dodd PJ, Grdiner E, Coghln R, Seddon JA. Burden of childhood tuberculosis in 22 high-burden countries: mthemticl modelling study. Lncet Glob Helth. 214;2(8):e ( gov/pubmed/ , ccessed 24 August 218). 3 World Helth Orgniztion Globl Tsk Force on TB Impct Mesurement. Report of the sixth meeting of the full tsk force; April 216, Glion-sur-Montreux, Switzerlnd. Genev: WHO; 215 ( meetings/tf6_report.pdf?u=1, ccessed 8 August 218). 4 Dodd PJ, Yuen CM, Sismnidis C, Seddon JA, Jenkins HE. The globl burden of tuberculosis mortlity in children: mthemticl modelling study. Lncet Glob Helth. 217;5(9):e898-e96 ( nih.gov/pubmed/ , ccessed 24 August 218). 57

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

70 Detils of the methods used re provided in the online technicl ppendix TB incidence disggregted by ge nd sex Estimtes of TB incidence disggregted by ge nd sex re shown in Fig. 3.3 (globl), Fig (WHO regions) nd Fig (3 high TB burden countries), nd in Tble 3.7. There were cses in ll ge groups but, overll, 9% were dults nd 1% were children (ged <15 yers). Globlly, 64% of cses were mong men nd boys, nd 36% were mong women nd girls. 2 The higher shres of TB cses mong men shown in Fig. 3.33, Fig nd Fig re consistent with evidence from prevlence surveys, which show tht TB disese ffects men more thn women (Fig. 3.28), nd tht gps in cse detection nd reporting re higher mong men (Fig. 3.29). The M:F rtio of incident TB cses for ll ges rnged from 1.3 in the WHO Estern Mediterrnen Region to 2.1 in the WHO Western Pcific Region. In children, the M:F rtio ws close to 1. FIG. 3.3 Globl estimtes of TB incidence (blck line) nd cse notifictions disggregted by ge nd sex (femle in red; mle in green), 217 Age group (yers) Number of TB cses FIG Regionl estimtes of TB incidence (blck line) nd cse notifictions disggregted by ge nd sex (femle in red; mle in green), 217 Afric The Americs Estern Mediterrnen Age group (yers) Europe South-Est Asi Western Pcific Age group (yers) Number of TB cses Number of TB cses Number of TB cses 1 The online technicl ppendix is vilble t 2 Further brekdowns by HIV sttus re not possible, becuse dt on the HIV sttus of TB cses by ge nd sex re not vilble. 59

71 FIG Estimtes of TB incidence (blck line) nd cse notifictions disggregted by ge nd sex (femle in red, mle in green), 217, in the 3 high TB burden countries Angol Bngldesh Brzil Cmbodi Centrl Africn Republic Chin Congo DPR Kore DR Congo Ethiopi Indi b Indonesi Keny Lesotho Liberi Age group (yers) Mozmbique c,d Mynmr d Nmibi d Nigeri Pkistn Ppu New Guine Philippines Russin Federtion Sierr Leone South Afric d Thilnd UR Tnzni Viet Nm d Number of TB cses Zmbi Zimbbwe Age nd sex disggregted cse notifictions were not vilble. b Estimtes of TB incidence for Indi re interim, pending results from the ntionl TB prevlence survey plnned for 219/22. c No ge nd sex disggregted cse notifictions from 15 yers nd bove were vilble for Mozmbique. d Estimtes of TB incidence for Mozmbique, Mynmr, Nmibi, South Afric nd Viet Nm will be reviewed fter finl results from their respective ntionl TB prevlence surveys re vilble in 219.

72 TABLE 3.7 Estimted number of TB cses (in thousnds) in children nd dults, globlly nd for WHO regions, 217 WHO REGION BEST ESTIMATE TOTAL MALE FEMALE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL Afric The Americs Estern Mediterrnen Europe South-Est Asi Western Pcific GLOBAL WHO REGION BEST ESTIMATE TOTAL 15 YEARS MALE 15 YEARS FEMALE 15 YEARS UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL Afric The Americs Estern Mediterrnen Europe South-Est Asi Western Pcific GLOBAL WHO REGION BEST ESTIMATE TOTAL 14 YEARS MALE 14 YEARS FEMALE 14 YEARS UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL Afric The Americs Estern Mediterrnen Europe South-Est Asi Western Pcific GLOBAL Numbers shown to two significnt figures if under nd to three significnt figures otherwise TB mortlity disggregted by ge nd sex Estimtes of TB mortlity in 217 disggregted by ge nd sex re shown in Fig (globl), Fig (WHO regions) nd Fig (3 high TB burden countries), nd in Tble 3.8. 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). Globlly in 217, 63% of the TB deths mong HIVnegtive people were men nd boys, nd 37% were women nd girls. Children (ged <15 yers) ccounted for 15% of totl deths, higher thn their shre of estimted cses, suggesting poorer ccess to dignosis nd tretment. Globlly in 217, 57% of HIV-positive TB deths were men nd boys nd 43% were women nd girls. Children (ged <15 yers) ccounted for 1% of totl deths in HIVpositive people. 61

73 FIG Globl distribution of TB mortlity in HIV-negtive people by ge group nd sex (femle in red; mle in green), 217 Globl Age group (yers) The totl re represents globl TB mortlity nd ll rectngles re proportionl to their shre of totl TB mortlity. FIG Regionl distribution of TB mortlity in HIV-negtive people by ge group nd sex (femle in red; mle in green), 217 Afric The Americs Estern Mediterrnen Age group (yers) Europe South-Est Asi Western Pcific Age group (yers) The totl re represents TB mortlity nd ll rectngles re proportionl to their shre of totl TB mortlity by region

74 FIG Estimted distribution of TB mortlity in HIV-negtive people in the 3 high TB burden countries by ge group nd sex (femle in red; mle in green), 217 Angol Bngldesh Brzil Cmbodi Centrl Africn Republic Chin Congo DPR Kore DR Congo Ethiopi Age group (yers) Indi b Indonesi Keny Lesotho Liberi Mozmbique c Mynmr c Nmibi c Nigeri Pkistn b c Ppu New Guine Philippines Russin Federtion Thilnd UR Tnzni Viet Nm c The totl re represents TB mortlity nd ll rectngles re proportionl to their shre of totl TB mortlity by country. Estimtes of TB mortlity for Indi re interim in nture, pending results from the ntionl TB prevlence survey plnned for 219/22. Estimtes of TB mortlity for Mozmbique, Mynmr, Nmibi, South Afric nd Viet Nm will be reviewed fter finl results from their respective ntionl TB prevlence surveys re vilble in Sierr Leone Zmbi South Afric c Zimbbwe 63

75 TABLE 3.8 Estimted number of TB deths (in thousnds) by HIV sttus in children nd dults, globlly nd for WHO regions, 217 HIV-NEGATIVE WHO REGION BEST ESTIMATE TOTAL MALE 14 YEARS FEMALE 14 YEARS MALE 15 YEARS FEMALE 15 YEARS UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL Afric The Americs Estern Mediterrnen Europe South-Est Asi Western Pcific GLOBAL HIV-POSITIVE WHO REGION BEST ESTIMATE TOTAL MALE 14 YEARS FEMALE 14 YEARS MALE 15 YEARS FEMALE 15 YEARS UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL Afric The Americs Estern Mediterrnen Europe South-Est Asi Western Pcific GLOBAL Numbers shown to two significnt figures if under nd to three significnt figures otherwise. 64

76

77 A helth officer teching ptients bout TB nd multidrug-resistnt TB detection nd tretment in hospitl in Lim, Peru WHO / Pn Americn Helth Orgniztion 66

78 Chpter 4. Dignosis nd tretment: TB, HIV-ssocited TB nd drug-resistnt TB KEY FACTS AND MESSAGES Globlly in 217, 6.7 million people with tuberculosis (TB) were notified to ntionl TB progrmmes (NTPs) nd reported to WHO. Of these, just over 6.4 million hd n incident episode (new or relpse) of TB. The globl number of new nd relpse TB cses notified nd the notifiction rte per popultion hve both been incresing since 213, following 4 yers (29 212) in which million new cses were notified nnully. This increse is mostly explined by incresed notifictions in Indi (+44% between 213 nd 217) nd Indonesi (+21% between 216 nd 217). In 217, 3% (2. million) of the 6.7 million new nd previously treted TB cses notified globlly were reported to hve been tested for resistnce to rifmpicin. Coverge ws 24% for new TB ptients nd 7% for previously treted TB ptients. Globlly, cses of multidrug-resistnt TB nd rifmpicin-resistnt TB (MDR/RR-TB) were notified in 217 (up from in 216), nd cses were enrolled in tretment (up from in 216). Globlly in 217, 6% of notified TB ptients hd documented HIV test result, up from 58% in 216 nd representing 23-fold increse since 24. In the WHO Africn Region, where the burden of HIVssocited TB is highest, 86% of TB ptients hd documented HIV test result. A totl of TB cses mong HIV-positive people were reported; of these, 84% were on ntiretrovirl therpy (ART). Despite increses in notifictions of TB, progress in closing detection nd tretment gps is slow nd lrge gps remin. Globlly in 217, there ws gp of 3.6 million between notifictions of new nd relpse cses nd the best estimte of the number of incident cses (1. million). Ten countries ccounted for round 8% of this globl gp, with Indi (26%), Indonesi (11%), Nigeri (9%) nd the Philippines (7%) ccounting for more thn hlf of the globl totl. Gps between the estimted number of new cses nd the number ctully reported re due to mixture of underreporting of detected cses, nd underdignosis (either becuse people do not ccess helth cre or becuse they re not dignosed when they do). An informtive exmple is Indonesi. In 217, ntionl study found tht bout 2% of new cses were not dignosed; of the pproximtely 8% of new cses tht were detected, 41% were not reported. Actions to correct underreporting re being put in plce.. There re lso lrge gps in detection nd tretment of MDR/RR-TB nd HIV-ssocited TB. In 217, the number of MDR/RR-TB cses strted on tretment ws only 25% of the estimted incidence of 558 cses, while the number of notified HIV-positive TB cses ws only 51% of the estimted 92 new cses of TB mong people living with HIV. Ten countries ccounted for 75% of the gp between enrolments in MDR-TB tretment in 217 nd the estimted number of incident MDR/RR-TB cses in 217; two countries Chin nd Indi ccounted for 39% of the totl gp. Most of the gps in detection of HIV-positive TB cses nd provision of ART in 217 were ccounted for by the WHO Africn Region. The globl mle:femle (M:F) rtio for notifictions in 217 ws 1.7. Results from ntionl TB prevlence surveys of dults show higher M:F rtios, indicting tht notifiction dt understte the shre of the TB burden ccounted for by men in some countries. Globlly, children (ged <15 yers) ccounted for 7.1% of the new nd relpse cses tht were notified in 217. The WHO-recommended rpid dignostic (WRD) 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 lists of high burden countries, 32 hd dopted ntionl lgorithms positioning the WRD s the initil dignostic test for ll people suspected of hving pulmonry TB by the end of 217. The ltest tretment outcome dt show tretment success rtes of 82% for TB (216 cohort), 77% for HIV-ssocited TB (216 cohort), 55% for MDR/RR-TB (215 cohort) nd 34% for extensively drug-resistnt TB (XDR-TB) (215 cohort). As prt of efforts to improve outcomes for MDR/XDR-TB, 68 countries nd territories reported tht they hd strted using bedquiline nd 42 reported tht they hd strted using delmnid by the end of

79 Prompt nd ccurte dignosis of tuberculosis (TB), HIV-ssocited 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 TB. 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 (i.e. the proportion of people with TB who die from the disese) to fll to 1% by 22 nd to 6.5% by 225. The ltter is only fesible if ll people with TB re promptly dignosed nd effectively treted. Ptient-centred cre nd prevention bcked by bold policies nd supportive systems such s universl helth coverge (UHC) nd socil protection re Pillrs 1 nd 2 of the End TB Strtegy (Box 4.1). This chpter provides the ltest ntionl 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 217 on notifictions of TB cses nd ssocited coverge of dignostic testing, s well s trends since 2. It includes dt on the contribution of community enggement nd public public nd public privte mix (PPM) inititives to cse-finding efforts. Section 4.2 focuses on tretment coverge (nd on detection nd tretment gps) for ptients with TB, HIV-ssocited TB nd drug-resistnt TB, compring numbers detected nd treted with underlying estimtes of disese burden. Section 4.3 provides the most recent dt on tretment outcomes, for new nd relpse TB ptients, TB ptients living with HIV nd ptients with multidrug-resistnt TB nd rifmpicin-resistnt TB (MDR/RR-TB), s well s globl trends for these three groups between 212 nd 216. Throughout the chpter, dt re presented t globl, regionl nd country levels, giving prticulr ttention to high burden countries (HBCs). 1 Further country-specific detils for ll of the indictors covered in this chpter re provided in Annex 2 nd Annex 4. BOX 4.1 Pillrs 1 nd 2 of the End TB Strtegy Pillr 1 of the End TB Strtegy is Integrted, ptient-centred cre nd prevention. It hs four components: erly dignosis of TB including universl drug susceptibility testing (DST), nd systemtic screening of contcts nd high-risk groups; tretment of ll people with TB, including drugresistnt TB, nd ptient support; collbortive TB/HIV ctivities, nd mngement of comorbidities; nd preventive tretment of persons t high risk, nd vccintion ginst TB. The fourth component of Pillr 1 is the topic of Chpter 5. Pillr 2 of the End TB Strtegy is Bold policies nd supportive systems. This pillr lso hs four components: politicl commitment with dequte resources for TB cre nd prevention; enggement of communities, civil society orgniztions, nd providers of public nd privte cre; UHC policy nd regultory frmeworks for cse notifiction, vitl registrtion, qulity nd rtionl use of medicines, nd infection control; nd socil protection, poverty llevition nd ctions on other determinnts of TB. The components of Pillr 2 re primrily discussed in Chpter 7. For n overview of ll spects of the End TB Strtegy, see Chpter Cse notifictions nd testing coverge TB cse notifictions nd bcteriologicl confirmtion In 217, 6.7 million people with TB were notified to ntionl TB progrmmes (NTPs) nd reported to WHO (Tble 4.1). Of these, 6.4 million hd new or relpse (incident) episode of TB (shown s the totl of new nd relpse cses), nd n dditionl 26 hd been previously dignosed with TB but their tretment ws chnged to retretment regimen. The number of new nd relpse TB cses notified incresed between 2 nd 29, ws then stble t round million nnully during , nd 1 The three lists of HBCs (for TB, HIV-ssocited TB nd MDR-TB) re explined in Chpter 2. hs subsequently incresed (Fig. 4.1). 2 The increse since 213 is mostly explined by continuous increse in notifictions in Indi (+44% between 213 nd 217), following the introduction of ntionl policy of mndtory notifiction in 212 nd the rollout (lso since 212) 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. There ws lso n upturn in notifictions in Indonesi in 217 (n increse of 21% compred with 216), for resons discussed lter in this chpter (Section 4.2). 2 A similr pttern exists for cse notifiction rtes (new nd relpse cses per popultion per yer). See Fig. 3.7 nd Fig. 3.8 in Chpter 3. 68

80 TABLE 4.1 Notifictions of TB, HIV-positive TB nd MDR/RR-TB cses, globlly nd for WHO regions, 217 TOTAL NOTIFIED NEW AND RELAPSE PULMONARY NEW AND RELAPSE NUMBER OF WHICH BACTERIOLOGICALLY CONFIRMED (%) EXTRA- PULMONARY NEW AND RELAPSE (%) HIV-POSITIVE NEW AND RELAPSE MDR/RR-TB XDR-TB Afric % 16% The Americs % 15% Estern Mediterrnen % 24% Europe % 16% South-Est Asi % 15% Western Pcific % 8% Globl % 14% 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 Notifictions of TB cses (new nd relpse cses, ll forms) (blck) compred with estimted TB incident cses (green), 2 217, globlly nd for WHO regions. Shded res represent uncertinty bnds. 3 Afric The Americs Estern Mediterrnen Europe Millions per yer 8 South-Est Asi 3 Western Pcific 15 Globl The distribution of notified cses in 217 by ge nd sex is shown globlly nd for WHO regions in Fig The globl mle:femle (M:F) rtio for notifictions ws 1.7. In contrst, the M:F rtio in 25 ntionl TB disese prevlence surveys of dults in Africn nd Asin countries implemented in ws bout 2.5 overll, nd reched 4.5 in Viet Nm. This indictes tht notifiction dt understte the shre of the TB burden ccounted for by men in some countries (see Chpter 3 for further detils). Children (ged <15 yers) ccounted for 7.1% of the new nd relpse cses tht were notified globlly. In the WHO Estern Mediterrnen, South-Est Asi nd Western Pcific regions, the TB epidemic is mrkedly geing one, with progressive increse in the notifiction rte with ge, nd pek mong those ged 65 yers or over. Elsewhere, notifiction rtes were highest mong dults, most noticebly in the WHO Africn Region (in the yer ge ctegory) nd the WHO Europen Region (in the yer ge ctegory). In severl centrl nd estern Europen countries, s well s three high TB burden countries in Asi Chin, Thilnd nd Viet Nm less thn 2% of notified cses 69

81 FIG. 4.2 New nd relpse TB cse notifiction rtes by ge nd sex in 217, 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 popultion per yer Countries not reporting cses in these ctegories re excluded. Cses included ccount for 89% of reported cses. FIG. 4.3 Percentge of new nd relpse TB cses tht were children (ged <15), dt were used for 23 countries. Percentge No dt Not pplicble 7

82 FIG. 4.4 Percentge of new nd relpse pulmonry TB cses with bcteriologicl confirmtion, globlly nd for WHO regions, Afric The Americs Estern Mediterrnen Europe 8 6 Percentge bcteriologiclly confirmed South-Est Asi Western Pcific Globl The clcultion is for new pulmonry cses in yers prior to 213 bsed on smer results, except for the Europen Region where dt on confirmtion by culture ws lso vilble for the period were children (Fig. 4.3). Vrition mong countries in the child:dult nd M:F rtios of cses my reflect rel differences in epidemiology, differentil ccess to or use of helth-cre services, or differentil reporting prctices. Of the 5.5 million new nd relpse pulmonry TB ptients notified globlly in 217, 56% were bcteriologiclly confirmed. 1 The remining ptients were dignosed cliniclly; tht is, bsed on symptoms, bnormlities on chest rdiogrphy or suggestive histology. The percentge of pulmonry cses with bcteriologicl confirmtion worldwide hs declined slightly since 213 (Fig. 4.4), minly reflecting trends in the WHO South-Est Asi Region (67% to 59%) nd the WHO Western Pcific Region (43% to 39%). There ws n improvement in the WHO Africn Region (57% to 66%) nd the WHO Europen Region (59% to 64%). Considerble vrition in the percentge of new nd relpse pulmonry TB ptients tht re bcteriologiclly confirmed is evident, even mong countries with similr epidemiologicl profile (Fig. 4.5). Resons for low proportion of cses being bcteriologiclly confirmed should be ssessed t country level, s should reductions over time. The microbiologicl detection of TB is criticl for infection control becuse it llows ptients to be correctly dignosed nd strted on 1 A bcteriologiclly confirmed cse is one from whom biologicl specimen is positive by smer microscopy, culture or WHOrecommended rpid dignostic test, such s Xpert MTB/RIF. the most effective tretment regimen s erly s possible. Most clinicl fetures of TB nd bnormlities on chest rdiogrphy or histology results generlly ssocited with TB hve low specificity, which my led to flse dignoses of TB, nd hence to people being enrolled in TB tretment unnecessrily. Extrpulmonry TB represented 14% of the 6.4 million incident cses tht were notified in 217, rnging from 8% in the WHO Western Pcific Region to 24% in the WHO Estern Mediterrnen Region (Fig. 4.6 nd Tble 4.1). Enggement of ll cre providers in the public nd privte sectors should be integrl components of ntionl TB strtegies, nd PPM inititives hve prticulr relevnce to HBCs in Afric nd Asi. The contribution of PPM to totl notifictions in countries tht hve reported PPM dt for severl yers is shown in Box HIV testing for TB ptients, detection of HIVssocited TB nd screening for TB mong people living with HIV In 217, 168 countries reported 3.8 million notified new nd relpse TB ptients with documented HIV test result ( 4% increse from 216), equivlent to 6% of notified TB cses. This represented 23-fold increse in the number of people with TB tested for HIV since 24, when WHO first sked countries to report dt (Fig. 4.7). In 125 countries nd territories, t lest 75% of TB cses knew their HIV sttus (Fig. 4.8). Documenttion of 71

83 FIG. 4.5 Percentge of new nd relpse pulmonry TB cses with bcteriologicl confirmtion, 217 Percentge No dt Not pplicble 216 dt were used for 18 countries. FIG. 4.6 Percentge of extrpulmonry cses mong new nd relpse TB cses, dt were used for 18 countries. Percentge No dt Not pplicble 72

84 BOX 4.2 Trends in the contribution of public privte mix pproches to TB cse notifictions One of the mjor chllenges in ensuring universl ccess to qulity TB services is the lck of systemtic enggement of ll helth-cre providers, especilly those in the privte sector, which is where people with TB often seek cre initilly. In 217, bout 3.6 million of the estimted 1 million people with TB worldwide were either not reported or not dignosed (see Section 4.2); mny of these people re likely to hve been treted by public nd privte providers who re not linked to the NTP. The qulity of cre provided in these settings is difficult to scertin nd my be substndrd. WHO policies nd globl nd ntionl TB strtegies hve long cknowledged the need to engge ll cre providers, through PPM pproches. PPM encompsses diverse collbortive strtegies. Public public mix refers to enggement by the NTP of public sector providers of TB cre tht re not under the direct purview of the NTP (e.g. public hospitls, public medicl colleges, prisons or detention centres, militry FIG. B4.2.1 Contribution of public public mix to TB cse notifictions in eight countries, Contribution of public public mix to totl notifictions (%) Afghnistn Bngldesh Chin Indi Indonesi Philippines Thilnd Viet Nm FIG. B4.2.2 Contribution of public privte mix to TB cse notifictions in eight countries, Contribution of public privte mix to totl notifictions (%) Bngldesh Ethiopi Indi Indonesi Keny Mynmr Pkistn Philippines 3 3 fcilities, rilwys nd public helth insurnce orgniztions). PPM refers to enggement by the NTP of privte sector providers of TB cre (e.g. privte individul nd institutionl providers, the corporte or business sector, mission hospitls, nongovernmentl orgniztions nd fith-bsed orgniztions). Mny countries hve mde some progress in engging non-ntp public providers nd mjor non-profit fcilities, especilly those mnged by fith-bsed orgniztions tht hve historiclly hd close reltionships with ministries of helth. Gps in enggement re typiclly more evident in the cse of for-profit privte providers. Trends in the contribution of PPM to notifictions in selected countries where PPM hs been recognized s priority nd from which dt hve been reported to WHO for ech yer during re shown in Fig. B4.2.1 nd Fig. B The contribution of PPM to cse notifictions quntifies the enggement of different providers in the delivery of TB cre, nd the lignment of their TB mngement prctices with ntionl nd interntionl stndrds. Countries tht hve prioritized PPM such s Bngldesh, Indi, Indonesi, Keny nd Pkistn clerly show n incresing trend in the contribution of public non-ntp or privte sector enggement to TB cse notifictions. As electronic cse notifiction systems nd digitl technologies begin to be set up nd rolled out in countries (see lso Box 4.3), including for PPM pproches, contributions to cse notifictions from the privte sector nd from the currently unengged prts of the public sector will continue to increse. Inventory studies tht quntify the underreporting of detected TB cses in both public nd privte sectors cn help to identify where further PPM efforts re needed. An excellent recent exmple, from Indonesi, is highlighted in Box 4.4. Electronic systems for online reporting of limited number of vribles cn fcilitte more complete reporting of cses from the privte sector. Recent exmples include Bngldesh nd Pkistn. 73

85 FIG. 4.7 Percentge of new nd relpse TB cses with documented HIV sttus, , globlly nd for WHO regions b Afric The Americs Estern Mediterrnen Europe 8 6 Percentge with documented HIV sttus South-Est Asi Western Pcific Globl b The clcultion is for ll cses in yers prior to 215. Countries were excluded if the number with documented HIV sttus ws not reported to WHO. FIG. 4.8 Percentge of new nd relpse TB cses with documented HIV sttus, dt were used for 15 countries. Percentge No dt Not pplicble 74

86 HIV sttus verged 66% of TB ptients in the 3 high TB/HIV burden countries, but vried considerbly, from 13% in Congo to bove 8% in 16 high TB/HIV burden countries in the WHO Africn Region. 1 In the WHO Africn Region, which ccounted for 72% of the globl burden of HIV-ssocited TB in 217 (Chpter 3), 86% of TB ptients knew their HIV sttus. Globlly, cses of TB mong people living with HIV were notified in 217 (Tble 4.1), equivlent to 12% of TB ptients with n HIV test result. The number notified ws only 51% of the estimted number of incident cses mong people living with HIV (Fig. 4.9), 2 but n increse from 49% in 216. Overll, the percentge of TB ptients testing HIVpositive hs been flling globlly since 28. This decline is evident in ll WHO regions with the exception of the WHO Europen Region, where the proportion of TB ptients testing HIV-positive incresed from 3% in 28 to 13% in 217. Systemtic symptom screening for TB mong people living with HIV is recommended by WHO s n essentil component of the HIV cre pckge, together with linkge to dignostic services, s necessry. In 217, 92 countries reported nnul dt on the number of TB cses notified mong those newly enrolled in HIV cre (up from 9 countries in 216). In totl, 8% of the 1.5 million people who were reported to be newly enrolled in HIV cre in 217 were dignosed with TB during the sme yer; dt for the 17 high TB/HIV burden countries tht reported dt re shown in Tble Rpid testing for TB Incresing ptient ccess to erly nd ccurte dignosis using WHO-recommended rpid dignostic (WRD 3 ) is one of the three min objectives of TB lbortory strengthening efforts under the End TB Strtegy. As first step towrds reching this objective, countries should dopt policies tht include dignostic lgorithms in which WRD is the initil dignostic test for ll people with signs or symptoms of TB. They should lso dopt such policies s prt of working towrds the first indictor of the Frmework of indictors nd trgets for lbortory strengthening under the End TB Strtegy, 4 which ws lunched in 216. Such policies should be n especilly high priority for the 48 countries included in one or more of the lists of high TB, TB/HIV nd MDR-TB burden 1 Although the ntionl figure for Chin ws 55%, in the counties defined s hving high burden of HIV-ssocited TB the figure ws 87%. 2 See lso Tble 3.2 in Chpter 3 for the globl estimte of TB incidence mong people living with HIV. The best estimte ws 92 cses in 217 (9% of the totl number of incident cses). 3 WRDs use moleculr techniques to detect TB mong people with signs or symptoms of TB. They include the XpertMTB/RIF ssy (Cepheid, United Sttes) nd the LoopmpTM MTBC Detection Kit (Eiken Chemicl Compny Ltd, Jpn). 4 World Helth Orgniztion. Frmework of indictors nd trgets for lbortory strengthening under the End TB Strtegy (WHO/HTM/ TB/216.18). Genev: WHO; 216 ( lbindictors/en/, ccessed 15 August 218). FIG. 4.9 Globl numbers of notified new nd relpse cses known to be HIV-positive (blck), number strted on ntiretrovirl therpy (blue) nd estimted number of incident HIV-positive TB cses (red), Shded res represent uncertinty bnds. New nd relpse cses per yer (millions) The clcultion is for ll cses in yers prior to 215. TABLE 4.2 Number of people newly enrolled in HIV cre who were lso notified s TB cse in 217, 17 high TB/HIV burden countries tht reported nnul dt NUMBER OF PEOPLE NEWLY ENROLLED IN HIV CARE NUMBER NOTIFIED AS A TB CASE NOTIFIED TB CASES AS A PERCENTAGE OF THOSE NEWLY ENROLLED IN HIV CARE Angol Centrl Africn Republic Congo Eswtini Ethiopi Ghn Guine-Bissu Indi Indonesi Keny Mlwi Mynmr Nmibi Nigeri Ppu New Guine Thilnd Zmbi Totl Zimbbwe reported dt for July December only nd ws excluded from the tble. 75

87 countries; of these 48 countries, 32 reported hving policies tht included such n lgorithm by the end of 217 (Tble 4.3). The second indictor of the frmework is the percentge of new nd relpse TB cses ctully tested with WRD s the initil dignostic test. Of 19 reporting countries nd territories, 133 indicted tht their routine surveillnce system cptures the dt required to monitor this indictor. Among the 48 HBCs, 12 countries reported tht WRD hd been used s the initil dignostic test for more thn hlf of their notified TB cses. The Xpert MTB/RIF ssy (Cepheid, United Sttes) is currently the WRD used most frequently by countries worldwide; it simultneously detects both TB nd resistnce to rifmpicin. The ssy is performed using the GeneXpert pltform, modulr testing device tht cn detect multiple diseses. 1 Between 21 (when the test ws initilly recommended by WHO) nd 217, cumultive totl of 9449 GeneXpert instruments, comprising modules nd 34.4 million crtridges, were procured by the public sector in 13 of 145 countries eligible for concessionl pricing Drug susceptibility testing nd detection of drug-resistnt TB Drug-resistnt TB thretens globl TB cre nd prevention, nd it remins mjor public helth concern in mny countries. Three ctegories re used for globl surveillnce nd tretment: RR-TB, MDR-TB nd extensively drug-resistnt TB (XDR-TB). MDR-TB is TB tht is resistnt to both rifmpicin nd isonizid, the two most powerful nti-tb drugs; it requires tretment with second-line regimen. RR-TB lso requires tretment with second-line drugs. 2 With incresing use of Xpert MTB/RIF for simultneous detection of TB nd resistnce to rifmpicin, growing number of RR-TB cses (without further testing for isonizid resistnce) re being detected nd notified. 3 XDR-TB is defined s MDR-TB plus resistnce to t lest one fluoroquinolone nd second-line injectble gent (mikcin, cpreomycin or knmycin). The End TB Strtegy clls for universl ccess to drug susceptibility testing (DST). Drug susceptibility testing for first-line drugs nd detection of MDR/RR-TB Fig. 4.1 shows progress in DST coverge since 29, when WHO intensified efforts to trck progress in the 1 World Helth Orgniztion (217). Considertions for doption nd use of multidisese testing devices in integrted lbortory networks (WHO/HTM/TB/217.5). Genev: WHO ( publictions/217/considertions_multidisese_testing_devices_217/ en/, ccessed 15 August 218). 2 World Helth Orgniztion. WHO tretment guidelines for drug-resistnt tuberculosis (216 updte) (WHO/HTM/TB/216.4). Genev: WHO; 216 ( resources/en/, ccessed 3 July 218). 3 Surveillnce nd survey dt show tht bout 82% of RR-TB cses hve MDR-TB. Further detils re provided in Chpter 3. progrmmtic response to drug-resistnt TB. 4 In 217, 2. million (3%) of the 6.7 million new nd previously treted TB cses notified globlly were tested for rifmpicin resistnce, with coverge of 24% for new TB ptients nd 7% for previously treted TB ptients. These figures represent n improvement since 215, when 12% of new nd 53% of previously treted TB cses hd test result for rifmpicin resistnce. DST coverge incresed in four of the six WHO regions between 216 nd 217, with high of 57% in the WHO Europen Region in 217. DST coverge vried substntilly between countries (even within the sme region) nd mong the 3 high MDR-TB burden countries (Fig. 4.11). Globlly, cses of MDR/RR-TB were detected nd notified in 217 (Tble 4.1). This ws smll increse from in 216 (Fig. 4.12), lthough ggregte globl trends concel fster progress in some countries (Fig. 4.13). Between 216 nd 217, the number of reported MDR/RR-TB cses incresed by more thn 3% in six of the 3 high MDR-TB burden countries (Angol, Democrtic People s Republic of Kore, Indonesi, Nigeri, Somli nd Thilnd). The globl number of MDR/RR-TB cses notified in 217 ws 29% of the estimted 558 incident cses in 217 (Fig. 4.12; incidence estimtes re discussed in more detil in Chpter 3) nd 49% of the estimted 33 cses of MDR/RR-TB mong notified TB cses. Closing these lrge detection gps will require improvements in both overll TB detection (Section 4.2) nd coverge of dignostic DST. The ltter requires further strengthening of lbortory cpcity nd wider uptke of new rpid dignostics. Drug susceptibility testing for second-line drugs nd detection of XDR-TB Among MDR/RR-TB ptients notified in 217, % were tested for resistnce to both fluoroquinolones nd second-line injectble gents, considerble increse from the 39% tested in 216. Coverge vried widely mong countries (Fig. 4.14). A totl of 1 8 cses of XDR-TB were reported by 77 countries, (up from 814 cses reported by 72 countries in 216), with 88% of cses being from the WHO Europen nd South-Est Asi regions (Tble 4.1). The five countries tht reported the lrgest numbers of cses were Belrus (525), Indi (26), the Russin Federtion (3661), South Afric (747) nd Ukrine (197). 4 This hppened following ministeril conference for high MDR-TB burden countries, held in Beijing, Chin, in April 29. The conference preceded World Helth Assembly resolution the following month: WHA62.15: Prevention nd control of multidrug-resistnt tuberculosis nd extensively drug-resistnt tuberculosis. Sixty-second World Helth Assembly, Genev, My 29, Resolutions nd decisions; nnexes; 29 ( WHA62_REC1-en.pdf, ccessed 15 August 218). 76

88 TABLE 4.3 Ntionl policies nd their implementtion to increse ccess to rpid TB testing nd universl DST, 217 YES NO HIGH TB BURDEN HIGH TB/HIV BURDEN HIGH MDR-TB BURDEN NATIONAL POLICY AND ALGORITHM INDICATE A WRD AS THE INITIAL DIAGNOSTIC TEST FOR ALL PEOPLE PRESUMED TO HAVE TB PERCENTAGE OF NOTIFIED NEW AND RELAPSE TB CASES TESTED WITH A WRD AS THE INITIAL DIAGNOSTIC TEST NATIONAL POLICY AND ALGORITHM INDICATE UNIVERSAL ACCESS TO DST PERCENTAGE OF NOTIFIED BACTERIOLOGICALLY CONFIRMED TB CASES WITH DST RESULTS FOR RIFAMPICIN b PERCENTAGE OF NOTIFIED RIFAMPICIN- RESISTANT TB CASES WITH DST RESULTS FOR FLUOROQUINOLONES AND SECOND-LINE INJECTABLE AGENTS Angol 1.7 Azerbijn Bngldesh Belrus Botswn Brzil Cmbodi Cmeroon Centrl Africn Republic Chd Chin 45 Congo DPR Kore 4.5 DR Congo 1 16 Eswtini Ethiopi 3 Ghn Guine-Bissu 1.7 Indi Indonesi Kzkhstn 82 > Keny Kyrgyzstn Lesotho 89 Liberi Mlwi Mozmbique 24 Mynmr Nmibi 19 Nigeri Pkistn Ppu New Guine Peru > 55 Philippines Republic of Moldov Russin Federtion Sierr Leone Somli South Afric 66 > Tjikistn Thilnd Ugnd Ukrine 89 UR Tnzni Uzbekistn 67 > 8 Viet Nm Zmbi Zimbbwe Blnk cells indicte dt not reported. indictes vlue tht cnnot be clculted. 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 2.5 nd Tble 2.4). b Testing in cses with unknown previous tretment history is not included. The percentge my exceed % for severl resons, e.g. smples rther thn cses re counted in the numertor; lbortory specimen results re not linked to the denomintor dt source when enumerted; or there is incomplete reporting of bcteriologiclly confirmed cses in the denomintor. Bcteriologiclly confirmed extrpulmonry cses re not included in the denomintor becuse they cnnot be differentited from cliniclly dignosed ones in the wy dt re reported to WHO. 77

89 FIG. 4.1 Percentge of ll TB cses tested for RR-TB, globlly nd for WHO regions, Afric The Americs Estern Mediterrnen Europe Percentge of cses 8 South-Est Asi Western Pcific Globl FIG Percentge of ll TB cses tested for RR-TB, dt were used for 18 countries. Percentge No dt Not pplicble 78

90 FIG Globl number of MDR/RR-TB cses detected (green) nd number enrolled on MDR-TB tretment (purple), , compred with estimte for 217 of the number of incident cses of MDR/ RR-TB (uncertinty intervl shown in blue) nd the number of MDR/RR-TB cses mong notified pulmonry cses (uncertinty intervl shown in blck) Number of cses (thousnds) Electronic, cse-bsed surveillnce for TB A growing number of countries re cpturing dt for notified TB cses in electronic cse-bsed surveillnce systems. These systems hve severl dvntges compred with more trditionl pper-bsed reporting of ggregted dt, including enbling more timely ccess to dt (up to rel-time ) nd the vilbility of dt t the level of individul ptients up to ntionl level. They lso gretly fcilitte dt nlysis (including by ge, sex nd loction) to inform dpttion nd trgeting of response efforts, both geogrphiclly nd for specific popultion groups. Further detils, including of globl efforts to support the doption of cse-bsed surveillnce for TB, re provided in Box Tretment coverge The Sustinble Development Gols (SDGs) include trget to Achieve universl helth coverge, including finncil risk protection, ccess to qulity essentil helth-cre services nd ccess to sfe, effective, qulity nd ffordble essentil medicines nd vccines for ll (Chpter 2). One of the indictors for Trget 3.8 of SDG 3 is the coverge of essentil helth services; this is composite indictor bsed on 16 trcer indictors, one of which is TB tretment. Achieving UHC is fundmentl requirement for chieving the milestones nd trgets of the End TB Strtegy; hence, priority indictors for monitoring progress in implementing the End TB Strtegy include both TB tretment coverge nd the percentge of TB ptients nd their households tht fce ctstrophic costs s result of TB disese (Chpter 2). TB tretment coverge is defined s the number of new nd relpse cses detected nd treted in given yer, divided by the estimted number of incident TB cses in the sme yer, expressed s percentge. In this section, numbers of notified new nd relpse cses in 217 re used s the numertor for the indictor, becuse these re the dt tht re vilble. However, s discussed further below, there re people with TB who re treted but not notified to ntionl uthorities (nd in turn re not notified to WHO), nd people who re notified but who my not 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 217 (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 64% (rnge, 58 72%) in 217, up from 53% (rnge, 46 64%) in 21 nd 35% (rnge, 3 43%) in 2. Three WHO regions chieved levels bove 75%: the WHO Region of the Americs, the WHO Europen Region nd the WHO Western Pcific Region. High TB burden countries with high levels of tretment coverge in 217 (>8%) included Brzil, Chin, Nmibi, the Russin Federtion nd Viet Nm. The lowest levels, with best estimtes of % or less, were in Centrl Africn Republic, Lesotho, Nigeri nd the United Republic of Tnzni. Globlly in 217, there ws gp of bout 3.6 million cses between the 6.4 million new nd relpse cses tht were notified, nd the estimted 1 million incident TB cses in the sme yer (Fig. 4.1). The globl gp hs been nrrowing, especilly in the WHO Estern Mediterrnen Region nd the WHO Western Pcific Region, nd to lesser extent in the WHO South-Est Asi Region. 1 Ten countries ccount for 8% of the totl estimted globl gp between incidence nd notifictions (Fig. 4.17), with Indi (26%), Indonesi (11%), Nigeri (9%) nd the Philippines (7%) ccounting for more thn hlf of the globl totl. There re three min resons for gp between notifictions nd estimted incidence: Underreporting of detected TB cses. In mny countries, levels of underreporting my be high; this is especilly the cse for those countries tht lck policies on mndtory notifiction nd other mesures to ensure reporting of detected cses by ll cre providers nd lrge privte helth sectors. 1 Time trends in countries nd regions re shown in Annex 2 nd Annex 3, respectively. 79

91 FIG Number of MDR/RR-TB cses detected (green) nd enrolled on MDR-TB tretment (purple), , 3 high MDR-TB burden countries 4 2 Angol Azerbijn Bngldesh Belrus Chin DPR Kore DR Congo Ethiopi Indi Indonesi Number of cses Kzkhstn Keny Kyrgyzstn Mozmbique Mynmr Nigeri Pkistn Ppu New Guine Peru Philippines Republic of Moldov Russin Federtion Somli South Afric Tjikistn Thilnd Ukrine Uzbekistn Viet Nm Zimbbwe

92 FIG Percentge of MDR/RR-TB cses tested for susceptibility to second-line drugs, 217 Percentge No dt Not pplicble 216 dt were used for 18 countries. Underdignosis of people with TB. Underdignosis cn occur for resons such s poor geogrphicl nd finncil ccess to helth cre; lck of or limited symptoms tht dely seeking of helth cre; filure to test for TB when people do present to helth fcilities; nd dignostic tests tht re not sufficiently sensitive or specific to ensure ccurte identifiction of ll cses. Overestimtion of the level of TB incidence. In this report, estimtes of TB incidence for 44 countries with 19% 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 good evidence bout the resons for such gps, nd ctions to ddress them re being tken or re plnned. An excellent recent exmple is Indonesi. The ntionl TB prevlence survey showed high levels of underreporting of detected TB cses, 1 leding to recommendtions such s mndtory policy on notifiction (encted in Jnury 217), nd intensified en- 1 This confirmed erlier dt on extensive sles of drugs in the privte sector. ggement with public nd privte hospitls where mny people with TB were being treted. 2 The results from the ntionl TB prevlence survey lso led to decision to implement ntionl inventory study to mesure the level of underreporting of detected TB cses. This ws implemented in the first qurter of 217, nd the study proved to be lrge nd robust enough to llow the use of cpture recpture nlysis to ressess estimtes of incidence. 3 The key study results were tht 41% of detected cses were not reported to the ntionl surveillnce system, nd tht bout 2% of incident cses were not dignosed. In other words, lthough bout 8% of incident cses were estimted to be detected, only 59% of these detected cses were officilly reported. Bsed on cpture recpture nlysis (see lso Chpter 3), 2 For further detils, see Box 2.4 in World Helth Orgniztion. Globl tuberculosis report 215 (WHO/HTM/TB/215.22). Genev: WHO; 215 ( eng.pdf, ccessed 21 June 218). 3 Cpture-recpture modelling is possible if six ssumptions re met: (i) ll cses should be observble; (ii) the proportion of mismtches nd mtching filures in record-linkge is low, which typiclly requires lrge smpling frction; (iii) closed popultion during the study period (typiclly 3 6 months); (iv) if S represents the number of cse lists or dt sources vilble, then t lest three dt sources should be vilble (S 3) nd their dependencies must be ccounted for in the model design, while the full S-wy interction between sources is ssumed null; (v) homogeneity of within-source observtion probbilities cross subpopultion groups, such s those defined by socioeconomic nd demogrphic chrcteristics; (vi) consistent cse definitions cross dt sources. Few high TB burden countries re expected to be ble to implement inventory studies tht will meet these 6 ssumptions to sufficient degree. 81

93 BOX 4.3 Ntionl cse-bsed electronic surveillnce systems for TB: sttus of progress, globl efforts to support expnsion, broder context Cse-bsed electronic surveillnce systems for TB with ntionl coverge hve severl dvntges over more trditionl pper-bsed reporting of ggregted dt. For exmple, they enble more timely ccess to dt (up to reltime ) nd the vilbility of dt t the level of individul ptients up to ntionl level; lso, they gretly fcilitte dt nlysis (including by ge, sex nd loction) to inform dpttion nd trgeting of response efforts, both geogrphiclly nd for specific popultion groups. WHO hs promoted cse-bsed electronic surveillnce for TB for severl yers, with guidnce issued in 212. Sttus of progress in ntionl cse-bsed electronic surveillnce for TB, August 218 In August 218, dt on the type of TB surveillnce system in plce t ntionl level were vilble for 26 countries (Fig. B4.3.1). Of these, 136 hd cse-bsed surveillnce system tht covered ll TB cses (both drug-susceptible nd drug-resistnt TB). These countries ccounted for 67% of globl TB notifictions in 217. A further 24 countries, minly in the WHO Africn Region nd the WHO South-Est Asi Region, hd cse-bsed surveillnce system for ll cses of drug-resistnt TB. These countries re in trnsition phse between ggregte pperbsed reporting nd cse-bsed electronic surveillnce. The initil prioritiztion of MDR-TB is explined by the dditionl complexity of monitoring tretment nd tretment outcomes compred with drug-susceptible TB, which is much esier to mnge with cse-bsed surveillnce; nd by the fct tht FIG. B4.3.1 Ntionl TB surveillnce systems in plce in August 218 Cse-bsed (ll TB ptients) Cse-bsed (MDR/RR-TB ptients only) Web-bsed (ggregte dt) Pper No dt Not pplicble Dt source: WHO globl TB dtbse 218, supplemented with informtion provided during WHO workshops on nlysis nd use of TB dt nd ntionl TB epidemiologicl reviews. often the numbers of tretment centres nd lbortories tht need to be involved re smller, mking introduction more fesible from logistics perspective. About hlf of the countries in the WHO Africn Region still hve pper-bsed systems for recording nd reporting of dt. Globl efforts to support further expnsion of ntionl cse-bsed electronic surveillnce for TB Building on the WHO guidnce issued in 212, WHO s Globl TB Progrmme hs been working with other WHO deprtments nd the University of Oslo to develop modules in the DHIS2 softwre b for electronic mngement of dt in both ggregted formt (s n interim step for countries not yet redy to trnsition to cse-bsed surveillnce) nd csebsed dt. Both modules re bsed on the WHO recording nd reporting frmework c nd both llow extensive dt nlysis t different levels of the helth system. To fcilitte the routine nlysis nd use of TB dt, stndrd dshbords hve been developed s prt of these DHIS2 modules; these include grphs, tbles nd mps for Understnding nd dt tuberculosis using HANDBOOK core surveillnce (e.g. notifictions, coverge of testing for drug resistnce nd HIV, nd tretment outcomes) indictors nd dt qulity indictors (e.g. completeness nd internl consistency), bsed on WHO guidnce on nlysis nd use of TB dt, d nd the WHO TB surveillnce checklist of stndrds nd benchmrks. e The modules were developed in DHIS2 becuse mny countries re lredy using this softwre within their helth informtion systems, it is open-source softwre with no license fees, nd it is being supported by wide rnge of technicl nd funding prtners. WHO nd the University of Oslo hve lredy supported six countries to implement, optimize nd use their own TB module for ggregted dt in DHIS2: Ghn, Guine-Bissu, Liberi, Mynmr, Ugnd nd the United Republic of Tnzni. An dditionl 24 countries re being supported to use the DHIS2 module for ggregted dt. By August 218, ggregted dt down to the regionl or district level for t lest five yers hd been compiled nd stored in DHIS2 TB pltform developed by WHO f for 44 countries (Fig. B4.3.2), with more limited dt vilble for n dditionl four countries. g These dt cn be esily trnsferred into ntionl DHIS2 dtbses once these hve been dopted nd implemented. 82

94 A DHIS2 TB module for csebsed dt tht enbles electronic mngement of dt for both drugsusceptible nd drug-resistnt TB in one system is currently in the pilot-testing phse in the Lo People s Democrtic Republic. FIG. B4.3.2 Subntionl, ggregted dt stored in the DHIS2 pltform developed by WHO (sttus in August 218) Broder context: the WHO Globl Tsk Force on TB Impct Mesurement nd the Helth Dt Collbortive Efforts to expnd ntionl csebsed electronic surveillnce systems for TB re prt of wider efforts to support the strengthening of ntionl helth informtion systems, nd the ssocited nlysis nd use of dt. Two of the five strtegic res of work of the WHO Globl Tsk Force on TB Impct Mesurement re strengthening ntionl notifiction systems for direct mesurement of TB incidence (within which one of the priorities is cse-bsed electronic surveillnce), nd nlysis nd use of TB-relevnt dt t country level (for further detils, see Box 3.1 in Chpter 3). The Helth Dt Collbortive (HDC) h is joint effort of multiple globl helth prtners to work longside countries to improve the vilbility, qulity nd use of dt for locl decision-mking nd the trcking of progress towrds the helth-relted SDGs. The Secretrit sits with the Deprtment of Informtion, Evidence nd Reserch (IER) t WHO hedqurters. The role of the HDC is to build on existing efforts by estblishing network of working groups tht will ddress specific technicl issues nd identify nd fill technicl gps. Under the umbrell of the HDC, WHO s Globl TB Progrmme is working with IER s well s the Globl HIV nd Heptitis Progrmme, the Globl Mlri Progrmme, the Deprtment of Immunistion nd the University of Oslo on 3-yer workpln (217 22). The workpln covers three mjor topics: Strengthening country helth informtion systems (in generl nd for specific diseses). This includes support for the development nd mngement of Helth Mngement Informtion Systems (HMIS) nd DHIS2 modules. Exmples include WHO helth dt pps for DHIS2 (cross-cutting nd disese specific) i, which include stndrd indictors, dshbords nd outputs, nd cpcitybuilding for cse-bsed surveillnce. Strengthening nlysis nd use of the dt generted by country informtion systems. Exmples include curriculum for routine nlysis nd use of helth fcility dt (curriculum content on TB includes dt fcility nlysis guide j nd n exercise book k ), ntionl b c d e f g h i j k District/fcility (t lest 5 yers) n=25 Region (t lest 5 yers) n=18 Limited dt n=4 No dt Not pplicble epidemiologicl reviews, nd ntionl nd regionl workshops. Ensuring qulity in the dt generted by country helth informtion systems nd in the nlysis nd use of dt. Exmples include guidnce documents nd tools; reviews of plns nd investments relted to monitoring nd evlution; estblishment of pool of trined consultnts, ntionl professionl officers nd in-country stff nd institutions to provide technicl ssistnce; nd peer review of the qulity of tools, plns, investments nd reviews. World Helth Orgniztion. Electronic recording nd reporting for tuberculosis cre nd control. Genev: WHO; 212 ( tb/publictions/electronic_recording_reporting/en/, ccessed 25 July 218). 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 21 June 218). World Helth Orgniztion. Understnding nd using TB dt: hndbook (WHO/HTM/TB/214.9). Genev: WHO; 214 ( who.int/tb/publictions/understnding_nd_using_tb_dt/en/, ccessed 24 August 216). World Helth Orgniztion. Stndrds nd benchmrks for tuberculosis surveillnce nd vitl registrtion systems: checklist nd user guide. Genev: WHO; 214 ( stndrdsndbenchmrks/en/, ccessed 25 July 218). Exmple mps presenting some district level TB surveillnce dt indictors cn be found here: en/ ExerciseBook_TB.pdf?u=1 83

95 FIG Cse notifiction rtes (new nd relpse cses, ll forms) (blck) compred with estimted TB incidence rtes (green), 2 217, 3 high TB burden countries. Shded res represent uncertinty bnds. 6 Angol 3 Bngldesh 6 Brzil 8 Cmbodi 1 Centrl Africn Republic Chin Congo DPR Kore DR Congo Ethiopi Indi Indonesi Keny Lesotho Liberi 2 Rte per popultion per yer Mozmbique b Mynmr b Nmibi b Nigeri Pkistn Ppu New Guine Philippines Russin Federtion Sierr Leone South Afric b Thilnd UR Tnzni Viet Nm b Zmbi Zimbbwe b Estimtes of TB incidence for Indi re interim, pending results from the ntionl TB prevlence survey plnned for 219/22. Estimtes of TB incidence for Mozmbique, Mynmr, Nmibi, South Afric nd Viet Nm will be reviewed fter finl results from their respective ntionl TB prevlence surveys re vilble in

96 FIG Estimted TB tretment coverge (new nd relpse ptients s percentge of estimted TB incidence) in 217, 3 high TB burden countries, WHO regions nd globlly Russin Federtion Brzil Chin Viet Nm Nmibi DPR Kore Thilnd Ppu New Guine Zimbbwe Sierr Leone South Afric Pkistn Mynmr Ethiopi Bngldesh Cmbodi Indi b Zmbi DR Congo Philippines Liberi Keny Indonesi Mozmbique Angol Congo Centrl Africn Republic Lesotho UR Tnzni Nigeri The Americs Europe Western Pcific Estern Mediterrnen South-Est Asi Afric Globl 1 Tretment coverge (%) b Estimtes of TB incidence for Mozmbique, Mynmr, Nmibi, South Afric nd Viet Nm will be reviewed fter finl results from their respective ntionl TB prevlence surveys re vilble in 219. Estimtes of TB incidence for Indi re interim in nture, pending results from the ntionl TB prevlence survey plnned for 219/22. estimtes of incidence were revised to best estimte of 842 cses (rnge, ) in 217 (less thn the previous best estimte of round 1 million, lthough still consistent with the rnge tht ws estimted bsed on the prevlence survey). 1 Actions re now being tken to correct the high level of underreporting, with results lredy evident from the notifictions reported for the whole of 217 (Fig. 4.15). A fuller description of the study, including methods, results nd lessons lerned, is provided in Box 4.4. In Indi, multiple sources of evidence from surveys nd surveillnce hve shown lrge underreporting of detected TB cses, especilly in the privte sector. 2 Three exmples of ctions tht hve been tken to close reporting gps re mndtory notifiction, simplified ntionl electronic reporting system tht fcilittes reporting of 1 See lso Box 3.2 in Chpter 3. 2 For further detils, see Box 3.3 in World Helth Orgniztion. Globl tuberculosis report 216 (WHO/HTM/TB/216.13). Genev: WHO; 216 ( eng.pdf, ccessed 11 July 218). cses, nd further efforts to engge ll cre providers through PPM schemes, ll of which hve lredy hd n effect on notifiction trends (Section 4.1.1; Fig. 4.15). A good exmple of country where underdignosis is mjor chllenge is Nigeri. The 212 prevlence survey in Nigeri 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 screening, dignostic nd tretment services of high qulity. 3 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 underreport- 3 For further detils, see Box 2.2 in World Helth Orgniztion. Globl tuberculosis report 214 (WHO/HTM/TB/214.8). Genev: WHO; 214 ( ccessed 15 August 218). 85

97 FIG The ten countries with the lrgest gps between notifictions of new nd relpse (incident) TB cses nd the best estimtes of TB incidence, 217 Chin Bngldesh Philippines Pkistn 8 Nigeri DR Congo Indi UR Tnzni Indonesi 1 South Afric The ten countries rnked in order of the size of the gp between notified cses nd the best estimtes of TB incidence in 217 re Indi, Indonesi, Nigeri, the Philippines, Pkistn, Bngldesh, Chin, DR Congo, South Afric nd UR Tnzni. Estimtes of TB incidence for Indi re interim in nture, pending results from the ntionl TB prevlence survey plnned for 219/22. Estimtes of TB incidence for South Afric will be reviewed fter finl results from its ntionl TB prevlence survey is vilble in 219. ing, s in Indonesi. 1 Other high TB burden countries tht hve lredy implemented n inventory study re Indi, Keny, Pkistn nd Viet Nm. 2 Four more re underwy or being plnned, in Chin, the Philippines, South Afric nd the United Republic of Tnzni. When this type of study is done prospectively (s opposed to retrospectively, using electronic dtbses tht re lredy vilble), the mpping of providers tht is required t the beginning cn subsequently help with efforts to engge ll cre providers, including in reporting (Box 4.4). Exmples of mechnisms to ensure reporting of ll detected cses include linking reimbursement from helth insurnce schemes to notifiction of cses (s is done in the Philippines nd the Republic of Kore) nd linking the supply of first-line drugs to notifiction of cses (s is done in Brzil). Recent ntionl TB prevlence surveys 3 hve lso shown tht, in both Afric nd Asi, detection nd reporting gps re systemticlly higher for men thn for 1 For guide to inventory studies, see World Helth Orgniztion. Assessing tuberculosis under-reporting through inventory studies. Genev: WHO; 212 ( studies/en/, ccessed 15 August 218). 2 Results from these studies hve been used to inform estimtes of TB incidence. 3 See tskforce/meetings/tf6_p6_prevlence_surveys_29_215.pdf women (Chpter 3). This suggests tht specific efforts re needed to improve ccess to TB dignosis nd tretment for men. Systemtic screening for ctive TB mong specific popultions cn lso help to ensure erly dignosis nd reduce levels of underdignosis. WHO recommends such screening for contcts of bcteriologiclly confirmed cses, people living with HIV nd people exposed to silic dust. 4,5 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 cn lso dd vlue to efforts to improve cse detection nd ptient support (Box 4.5). 4 World Helth Orgniztion. Systemtic screening for ctive tuberculosis: principles nd recommendtions (WHO/HTM/TB.213.4). Genev: WHO; 213 ( ccessed 15 August 218). 5 The dt requested s prt of WHO s globl monitoring focus on screening mong people living with HIV nd close contcts. Hence, the dt requested in WHO s nnul round of globl TB dt collection focus on screening mong people living with HIV nd close contcts. These dt re presented in Chpter 5. 86

98 BOX 4.4 The 217 ntionl TB inventory study in Indonesi: min results, lessons lerned, policy nd progrmmtic implictions Indonesi is country with lrge privte helth sector tht is not yet firmly linked to the reporting network of the NTP. Furthermore, some of the secondry nd tertiry level fcilities of the public helth sector do not hve functioning nd sustined reporting links with the NTP. In 216, totl of TB cses were notified to ntionl uthorities, while the estimted TB incidence ws 1 2 (95% confidence intervl [CI]: ). To ddress underreporting, Helth Ministeril Decree ws encted in 217, mking notifiction of TB mndtory ntionwide. A ntionl TB inventory study ws implemented in 217 under the ledership of the NTP nd the Ntionl Institute of Helth Reserch nd Development. The im ws to directly mesure the level of underreporting of detected TB cses to the ntionl TB surveillnce system (SITT, System Informsi Tuberkolosis Terpdu) mintined by the NTP for the different types of helth fcilities, nd to identify best-prctice methods for ddressing TB underreporting. Methods nd min results The study methods from design through implementtion, nlysis nd reporting of results followed the recommendtions of the WHO Globl Tsk Force on TB Impct Mesurement. The study employed rndom, ntionlly representtive smple of 23 districts (out of totl of 514) from cross the country, using smpling design with strtifiction by urbn or rurl sttus nd three regions Sumter, Jv/Bli nd other provinces (Fig. B4.4.1). The 23 districts ccounted for 1% of the ntionl popultion of 26 million. In ech of the smpled districts, ll helth-cre providers of TB services were mpped, strting from existing but outdted lists of helth-cre providers, which were then confirmed by study enumertors (Fig. B4.4.2). A totl of 427 helth-cre providers were enumerted in the 23 districts, of which 1687 were eligible (defined s fcility tht reported hving dignosed or treted t lest one TB ptient in the FIG. B4.4.1 Districts selected for the ntionl inventory study Sumter District Not selected Selected Jv nd Bli previous 3 months). Of the eligible helth-cre providers, 99% prticipted in the study testment to the success of district-level workshops nd meetings with ll stkeholders. Phrmcies were not included in the smpling frme of the study. During the study period (the first qurter of 217), ptient records for totl of unique TB ptients were detected overll. Of these, unique TB ptients were notified nd registered in SITT. Probbilistic mtching llowed linkge of records from the TB cse lists, mesuring their overlp nd corresponding underreporting (Fig. B4.4.3). The overll level of underreporting of detected TB cses (i.e. the proportion of detected cses not in SITT) ws estimted to be 41% (95% CI: 36 46%), rnging from 15% (95% CI: 11 2%) underreporting by primry helth-cre puskesms units (which re prt of the existing NTP network) to 65% underreporting by hospitls to 96% underreporting by the combined ctegory of generl prctitioners (GPs), clinics nd lbortories. Ptients with cliniclly dignosed nd extrpulmonry TB, s well s children, were more likely to be underreported (Tble B4.4.1). Incidence ws estimted using cpture recpture modelling of the three TB cse lists (SITT, study public nd study privte), ccording to recommendtions (see lso section 4.2.1). It ws estimted tht 18% (95% CI: 15 21%) of incident cses were not detected. The nnul incidence rte for 217 ws estimted t 319 (95% CI: ) per popultion per yer. b This updted best estimte of TB incidence is lower but sttisticlly consistent with the previously published estimte derived from the 213/214 prevlence survey (Fig. B4.4.4). Study results nd updted estimtes were discussed nd greed upon in ntionl consensus meeting held in April 218. c The excellent prticiption rte of helth-cre providers, in ddition to the consistency of key results through sensitivity nlyses, show tht the study ws implemented to high stndrd nd hs produced robust results. Others During the course of 217, the NTP lredy strted to tke corrective ction to reduce underreporting. This led to substntil increse in TB notifictions in 217 compred with 216. While the mesure of underreporting in the study during the first qurter of 217 ws 41%, in the subsequent three qurters of 217 the NTP reduced this; the overll level of underreporting for 217 ws 36% (Fig. B4.4.5). 87

99 FIG. B4.4.2 Helth fcility mpping Initil informtion List development Mpping process List from Centre of Dt nd Informtion, Ministry of Helth (215) Hospitl: 195, PHC: 81 List from District Helth Office Clinic: 1 51 Lbortory: 85 Helth Fcilities List: Hospitl: 195 PHC: 81 Clinics: 1 51 Certified MD: Lbortory: 85 Found: Hospitl: 156 PHC: 77 Clinics: 977 GPs: 993 Lbortory: 49 Newly found: Hospitl: 55 PHC: 19 Clinics: 546 GPs: 66 Lbortory: 45 List from Indonesi Medicl Assocition Certified MD: MD medicl doctor PHC primry helth cre GPs generl prctitioners Enumerted: 4 27 Eligible: (4.1%) Prticipted: (99.6%) FIG. B4.4.3 Mtching results of TB cses found from the study nd registered in the ntionl TB surveillnce system (SITT) during the first qurter of 217 b c d SOURCE n SITT (unique) Study (unique) Non lbortory public Non lbortory privte b Lbortory c 1 1 SITT d Study (unique) Primry helth cre, hospitls, clinics Hospitls, clinics, generl prctitioners Public nd privte Ntionl tuberculosis surveillnce system Non lbortory privte 4345 SITT Lbortory 422 Non lbortory public 88 Lessons lerned The key lessons lerned from the study were s follows: 1. TB underreporting in Indonesi up to the first qurter of 217 ws very high. 2. Out of incident TB cses missed from the TB surveillnce system, two thirds were not reported nd the remining one third were not detected. 3. An up-to-dte mster list of helth fcilities (both for the public nd privte sectors) needs to be mintined for efficient monitoring of the effectiveness of the policy of mndtory cse notifiction. 4. Record linkge should occur routinely (t lest once yer) between the dtbse of the NTP (SITT) nd other dtbses of TB cses. 5. A unique identifier (e.g. helth insurnce number) strongly fcilittes disese surveillnce in generl, nd record linkge in prticulr. 6. More thn 95% of TB cses identified during the study were treted using drug regimen tht ws consistent with ntionl TB guidelines, indicting tht high qulity of TB cre is provided by different types of helth providers. The low level of drug resistnce mong TB cses found in the recent ntionl survey of drug resistnce (see Chpter 3) is consistent with this finding. Policy nd progrmmtic implictions The mjor implictions of study results, some of which require high-level policy ction, include the following: 1. All helth-cre providers need to be mde wre tht ll TB cses must be reported. Previously, emphsis ws given to reporting of pulmonry, bcteriologiclly confirmed cses. 2. Humn resource cpcity for dt collection nd mngement needs to be incresed. Dedicted stff re required to work on dt entry nd reporting, especilly

100 FIG. B4.4.4 Trends in estimted rtes of TB incidence nd cse notifictions, Updted time series of incidence rtes for re shown in blue, previous estimtes for tht were bsed on the ntionl TB prevlence survey re shown in ornge nd cse notifictions re shown in blck. Shded res represent uncertinty bnds. Incidence rte per popultion per yer FIG. B4.4.5 TB incidence in Indonesi, 217 broken down into those cses detected nd notified, those detected nd not notified (or underreported) nd those not detected t ll TABLE B4.4.1 Level of TB under-reporting (%) by type of helth cre provider, type of TB cse, ge, sex nd strt, ccounting for smpling design MEAN PERCENTAGE (95% CONFIDENCE INTERVAL) Totl 41 (36 46) By type of helth provider Primry helth cre ( puskesms ) Non-primry helth cre Hospitl Other By TB cse type Bcteriologiclly confirmed Cliniclly dignosed By site of disese Pulmonry Extr-pulmonry By ge <15 yers 15 yers By sex Femle Mle By strt Sumter Bli/Jv Other Clinics, generl prctitioners, lbortories. 15 (11 2) 71 (61 79) 62 (52 72) 96 (92 98) 21 (16 26) 55 (49 61) 38 (33 44) 58 (49 66) 54 (44 64) 39 (34 44) 41 (36 47) 41 (36 46) 4 (24 59) 42 (18 47) 39 (28 51) Undetected 18% Notified 53% Incident cses Detected not notified 29% in support of enggement with privte sector helth-cre providers. 3. Dt recording nd reporting needs to be simplified, especilly for privte sector helth-cre providers. Chllenge TB Indonesi hs developed n ndroid ppliction clled WifiTB, which is designed to simplify nd fcilitte cse notifiction by the privte sector. d 4. Estblishment of integrted informtion systems, especilly in hospitls, needs to be promoted. 5. The NTP needs to increse the involvement nd enggement of professionl orgniztions nd lbortory networks t district level, to promote dherence with ntionl dignostic nd reporting requirements. In 217 nd 218, the NTP, with prtners including Chllenge TB Indonesi nd the Globl Fund, hs been strengthening models of enggement with ll cre providers. This hs been bsed on the model of district PPM, in which district stff engge with hospitls nd puskesms stff engge with locl GP networks. The inventory study provided dditionl ides for how to strengthen pproches to working with these cre providers. Conclusions nd next steps The 217 ntionl TB inventory study in Indonesi is the lrgest study of its kind ever conducted globlly. It generted high-qulity dt, s well s importnt evidence with cler policy nd progrmmtic implictions. Following officil nd wide dissemintion of findings in April 218, results re now being used to help to develop ntionl nd district level responses for further rollout. A study report is being finlized nd results will be summrized in pper for peer-reviewed journl. b c d World Helth Orgniztion. Assessing tuberculosis underreporting through inventory studies. Genev: WHO; 212 (vilble on who.int/tb/publictions/inventory_studies/en, ccessed 15 August 218). When using popultion estimtes from the Sttistics Bureu, Indonesi insted of popultion estimtes from the United Ntions Popultion Division the estimted TB incidence rte is 322 (95% CI: ) per popultion per yer. Further discussions were lso held between WHO nd the NTP during the drfting nd finliztion of this box. Chllenge TB Indonesi. Notifiction through WiFi TB ppliction for privte providers: Updte nd expnsion pln. pdf_docs/paswtn.pdf 89

101 BOX 4.5 Community contributions to TB notifictions nd tretment support The WHO End TB Strtegy clls for close collbortion with ffected communities nd civil society orgniztions in plnning, implementtion, nd monitoring nd evlution. FIG. B4.5.1 Percentge of bsic mngement units in which there is community contribution to new cse finding nd/or to tretment dherence support, 217 Community-bsed TB ctivities include wide rnge of ctivities tht contribute to prevention, dignosis, tretment nd cre, nd cn positively influence TB outcomes. They re delivered primrily by community helth workers (CHWs) nd community volunteers (CVs) who re drwn from within the community nd re, therefore, both ccessible nd cceptble to community members. In the current er of the SDGs nd in the context of UHC, primry helth cre is receiving greter ttention. An incresing number of countries re tking steps to bsorb cdres of CHWs into the workforce of ntionl helth systems. This will help to strengthen community-bsed service delivery nd lso help to rech those who re otherwise unble to ccess helth services. In WHO s 218 round of globl TB dt collection, 61 countries reported dt bout the contribution of communities through CHWs or CVs to TB notifictions or tretment support. This represents nerly fivefold increse in reporting since 213, when dt were first collected on the two core indictors (contributions to new notifictions nd to tretment support) used to monitor community contributions to TB outcomes. The contribution of community referrls to TB notifictions ws reported by 57 countries. The percentge of notified TB ptients ttributed to community referrls verged 27% (rnging from less thn 1% in Irn nd Sri Lnk, to % in Bulgri, Congo, Gbon, Hiti, Prguy, nd So Tome nd Principe). The tretment success rtes for people who benefited from ny form of community tretment support could be clculted for 44 of these 57 countries. The verge tretment success rte ws 87%, rnging from 39% in Burkin Fso to % in Burundi, Hondurs nd Serbi. In 218, 112 countries were sked to report dt on community contributions to TB cre, of which 91 (81%) reported implementing community-bsed TB ctivities. In these 91 countries, the men coverge of communitybsed TB ctivities ws 74% of ll bsic mngement units FIG. B4.5.2 Number of countries reporting on WHO community enggement indictors, Number of countries (Fig. B4.5.1). However, 3 of the 91 countries did not hve dt on community contributions to TB outcomes (Fig. B4.5.2). Further efforts re needed to include the core community indictors in ntionl dt recording systems. Percentge Dt only requested from 111 countries. CHWs nd CVs re defined here: World Helth Orgniztion. ENGAGE- TB Approch: Opertionl guidnce integrting community-bsed tuberculosis ctivities into the work of nongovernmentl nd other civil society orgniztions (WHO/HTM/TB/212.8). Genev: WHO; 212 ( ccessed 14 August 218). The guidnce is currently being revised. 75 Dt not requested No dt Not pplicble 9

102 4.2.2 Tretment coverge of ART for HIV-positive TB cses WHO recommends ART for ll HIV-positive TB ptients within the first 8 weeks of strting TB tretment, nd within two weeks in profoundly immunosuppressed HIV-positive TB ptients with low CD4 counts less thn. The number of notified HIV-positive TB ptients on ART hs grown in recent yers (Fig. 4.18); it reched in 217, equivlent to 84% of the notified TB ptients known to be HIV-positive (Tble 4.1). 1 In the 3 high TB/HIV burden countries, overll, 85% of the TB ptients known to be HIV-positive were on ART. Eight of these countries (Eswtini, Keny, Mlwi, Mozmbique, Nmibi, Ppu New Guine, Ugnd nd the United Republic of Tnzni) mintined coverge of t lest 9% in both 216 nd 217. In contrst, there were six high TB/HIV burden countries (Angol, Botswn, Brzil, Guine-Bissu, Indonesi nd Liberi) in which less thn % of HIV-positive TB ptients were strted on ART in 217. Cmeroon, Chd nd Chin did not report dt on ART for TB ptients for 217. 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 HIVpositive incident TB cses (Fig. 4.19). This comprison reveled lrger gps. Globlly in 217, the number of HIV-positive TB ptients on ART ws 41% of the estimted globl number of incident HIV-positive TB cses; this is lower thn the globl ART coverge of 59% mong ll people living with HIV in 217. There ws considerble vrition mong the high TB/HIV burden countries nd, ccording to best estimtes, only eight countries chieved ART coverge of more thn % (Eswtini, Ethiopi, Mlwi, Nmibi, South Afric, Ugnd, Zmbi nd Zimbbwe). Improvements re still needed in the detection of ctive TB disese mong HIV-positive people, the coverge of HIV testing mong TB ptients, nd the enrolment of HIV-positive TB ptients in ART. A recent exmple of efforts to ddress gps in the cscde of cre in Indi is provided in Box 4.6. An overview of progress nd gps in TB preventive tretment mong people living with HIV is provided in Chpter Tretment coverge for MDR/RR-TB Trends in the number of ptients enrolled in MDR-TB tretment globlly nd in the 3 high MDR-TB countries since 29 re shown in Fig nd Fig. 4.13, respectively. The number of people enrolled in tretment globlly ws in 217, representing more thn fourfold increse since 29 (when WHO first sked countries to report dt) nd up from in There my be discrepncies in dt on provision of ART to HIV-positive TB ptients tht re reported by NTPs nd ntionl HIV progrmmes. These discrepncies hve reduced in recent yers nd hve mostly been resolved through follow-up nd vlidtion efforts. Between 216 nd 217, there were notble increses in enrolments in the Democrtic People s Republic of Kore (from 814 to 1732), Indonesi (from 1879 to 342) nd Angol (from 334 to 534), nd modest increses in severl other high MDR-TB burden countries. However, the number of enrolments fell in nine high MDR-TB burden countries (Fig. 4.13). Globlly, the ptients strting second-line MDR-TB tretment in 217 represented 25% of the 558 estimted MDR/RR-TB incident cses in 217 (Fig. 4.2). The highest levels of tretment coverge mong high MDR-TB burden countries were in Kzkhstn (82%) nd South Afric (73%). Ten countries ccounted for bout 75% of the gp between enrolments in MDR-TB tretment in 217 nd the estimted number of incident MDR/RR-TB cses in 217; nd Chin nd Indi ccounted for 4% of the totl gp (Fig. 4.21). Tretment coverge will not improve globlly unless there is n intensifiction of efforts in the countries with the lrgest burden, prticulrly Chin, Indi nd Indonesi. The number of cses strting MDR-TB tretment in 217 ws equivlent to 87% of the MDR/RR-TB ptients notified in 217 (Fig. 4.12). The figure exceeded 9% in 17 high MDR-TB burden countries (Fig. 4.13) nd in the WHO Europen Region nd the WHO Region of the Americs; however, it ws much lower in the WHO Africn Region nd the WHO Western Pcific Region. 2 Enrolments represented no more thn 6% of the number of notified MDR/RR-TB cses in two high MDR-TB burden countries in 217: Chin (45%) nd Indonesi (6%). These low percentges show tht progress in detection is outstripping the cpcity to provide tretment; they my lso reflect weknesses in dt collection systems. In these settings, the risk of trnsmission of drug-resistnt TB is high, nd efforts re needed to rpidly close gps in enrolment nd notifiction. In mny countries, one of the brriers to dequte ccess to tretment of drug-resistnt TB is tht the network for the progrmmtic mngement of drug-resistnt TB (PMDT) is too centrlized nd too relint on hospitl-bsed models of cre. Greter decentrliztion nd more use of outptient models of cre re needed. Globlly, 873 ptients with XDR-TB were enrolled in tretment in 7 countries nd territories, smll (2%) increse compred with 216. In 2 of these countries, the number of XDR-TB cses enrolled in tretment ws less thn the number notified. Only one high MDR-TB burden country (Thilnd) nd three other countries (Algeri, Bhutn nd Ugnd) reported prescribing morphine to tret pin or terminl dyspnoe in ptients for whom second-line TB tretment regimens did not work, suggesting tht there re widespred unmet needs in terms of end-of-life cre s well s indequte dt gthering on this issue. 2 For dt for WHO regions, see Annex 3. 91

103 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 15 Botswn Brzil Cmeroon Centrl Africn Republic Chd Chin Congo DR Congo Eswtini b New nd relpse cses per yer (thousnds) Ethiopi Ghn Guine-Bissu Indi c Indonesi Keny Lesotho Liberi Mlwi Mozmbique b Mynmr b Nmibi b Nigeri Ppu New Guine South Afric b Thilnd Ugnd UR Tnzni Zmbi Zimbbwe The clcultion is for ll cses in yers prior to 215. b Estimtes of TB incidence for Eswtini, Mozmbique, Mynmr, Nmibi nd South Afric will be reviewed fter finl results from their respective ntionl TB prevlence surveys re vilble in 219. c Estimtes of TB incidence for Indi re interim in nture, pending results from the ntionl TB prevlence survey plnned for 219/

104 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 217, 3 high TB/HIV burden countries, WHO regions nd globlly Nmibi Eswtini Mlwi Zimbbwe South Afric Ethiopi Zmbi Ugnd Mozmbique Keny UR Tnzni Lesotho Thilnd DR Congo Mynmr Brzil Indi Botswn Centrl Africn Republic Ppu New Guine Nigeri Liberi Ghn Guine-Bissu Angol Indonesi Congo Chin Cmeroon Chd Europe Afric The Americs South-Est Asi Western Pcific Estern Mediterrnen Globl Tretment coverge (%) No dt. 4.3 Tretment outcomes This section summrizes the ltest results of tretment for new nd relpse cses of TB who strted tretment on first-line regimen in 216 (including people with HIV-ssocited TB), nd people detected with RR-TB, MDR-TB or XDR-TB who strted second-line MDR-TB regimen in Tretment outcomes for new nd relpse TB ptients Dt on tretment outcomes for new nd relpse cses of TB in 216 re shown for the world, the six WHO regions nd the 3 high TB burden countries in Fig The globl trend is shown in Fig Globlly, the tretment success rte for the 5.9 million new nd 1 For definitions of tretment outcomes, see World Helth Orgniztion. Definitions nd reporting frmework for tuberculosis 213 revision (updted December 214) (WHO/HTM/TB/213.2). Genev: WHO; 213 ( ccessed 21 June 218). relpse cses who were treted in the 216 cohort ws 82%. This is reduction from 86% in 213 nd 83% in 215; the min explntion is tht in countries where notifictions hve incresed (notbly Indi), reporting of tretment outcomes hs not kept pce with notifictions. In Indi, tretment outcome dt were not reported for 22% of cses notified in 216. The bsolute number of TB ptients reported to hve been successfully treted hs risen substntilly over the pst 16 yers, both globlly nd in ll WHO regions (Fig. 4.24). Among the six WHO regions, the highest tretment success rtes in 216 were in the WHO Estern Mediterrnen Region (92%) nd the WHO Western Pcific Region (91%). The lowest rtes (t 75%) were in the WHO South-Est Asi Region (due to high proportions of unevluted cses, especilly in Indi), the WHO Region of the Americs (due to high levels of loss to follow-up nd missing dt) nd the WHO Europen Region (due to high rtes of tretment filure nd deth, influenced by the high frequency of MDR/RR-TB). 93

105 BOX 4.6 Cscde of TB cse-finding mong people ttending HIV cre in Indi, 217 For the pst yer, the Revised Ntionl TB Control Progrmme (RNTCP) nd Ntionl AIDS Control Orgniztion (NACO) in Indi hve been cpturing dt to evlute TB cse-finding ctivities mong people ttending ART centres. According to dt reported by the RNTCP for 217, n estimted 58% (n = 49 [95% CI: 21 ~84 ]) of people with HIV-ssocited TB were not reported to hve reched TB cre. Resons for missing people with TB include poor ccess to services, weknesses in service delivery, gps in recording nd reporting, nd limited enggement of the privte sector. Identifying the size nd nture of these gps requires dt bout ech prt of the cscde of cre, from initil evlution for TB signs nd symptoms to the strt of tretment. For HIV-ssocited TB, nlysis should lso be conducted on the HIV cre cscde mong TB ptients. Depending on the degree of integrtion between country s TB nd HIV services nd their respective monitoring nd evlution systems, the ptient pthwy for HIV-ssocited TB cn be more complex to trck, since there my be need for referrl from one progrmme to nother. Close collbortion between the TB nd HIV services is therefore criticl for reducing loss to follow-up nd preventble mortlity. To strengthen integrtion, the Government of Indi hs rolled out TB service delivery from ll HIV clinics since December 216. Although reporting of HIV cse-bsed dt for the TB cse-finding cscde hs not yet been possible in Indi, the RNTCP nd NACO hve been ble to report dt bsed on clinic visits. People living with HIV mde lmost 11 million visits to ART centres in 217. In 83% of these visits, the clinic ttendees received n evlution for TB. Of those who were evluted, 6% hd TB symptoms. FIG. B4.6.1 Cscde of TB cse-finding mong people living with HIV (PLHIV) ttending ntiretrovirl therpy (ART) clinics, Indi, 217 Number of ART clinic visits PLHIV with TB symptoms PLHIV referred for TB dignosis PLHIV received TB dignostic test PLHIV dignosed with TB Fig. B4.6.1 depicts the next stges of the TB csefinding cscde. In consulttions, 65% of those ttending ART centres in whom TB symptoms were identified were referred for TB dignosis; of those, 85% underwent TB dignostic test, of whom 14% were found to hve TB. These extensive ntionwide efforts help to identify gps in referrl nd dignosis to prompt follow-up s necessry. Cpturing dt for ech step in the cscde cn be chllenging, unless robust, integrted nd preferbly electronic, cse-bsed recording nd reporting system is in plce tht communictes the informtion cross the progrmmes. In the bsence of electronic recording nd reporting systems, periodic ptient record surveys of people ttending HIV cre is recommended, to evlute the gps in the TB csefinding continuum, which in turn helps to inform nd improve progrmming, recording nd reporting, nd client follow-up. Only nine of the 3 high TB burden countries reched or exceeded 9% tretment success rte. However, in severl high TB burden countries, the completeness of outcome reporting ws low. In five countries (Angol, Brzil, Centrl Africn Republic, Liberi nd Ppu New Guine), loss to follow-up exceeded 1%, nd in four countries (Angol, Congo, Indi nd Ppu New Guine), the tretment outcome ws not documented for more thn 1% of cses Tretment outcomes for new nd relpse TB ptients coinfected with HIV A totl of 124 countries reported tretment outcomes for the 216 ptient cohort disggregted by HIV sttus; collectively, these countries ccounted for 94% of the HIV-positive TB ptients reported by NTPs in 216. These 124 countries included 24 of the 3 high TB/HIV burden countries; no dt were reported by Chd, Congo, the Democrtic Republic of the Congo, Ethiopi, Liberi nd Ppu New Guine (Fig. 4.25). Overll, the tretment success rte ws 77%, n increse from 68% in 212 (Fig. 4.23), lthough still worse thn the level of 82% for ll new nd relpse TB ptients. 94

106 FIG. 4.2 Estimted tretment coverge for MDR/RR-TB (ptients strted on tretment for MDR-TB s percentge of the estimted incidence of MDR/RR-TB) in 217, 3 high MDR-TB burden countries, WHO regions nd globlly Kzkhstn South Afric Peru Russin Federtion Republic of Moldov Belrus Ukrine Azerbijn Viet Nm DPR Kore Uzbekistn Kyrgyzstn Indi Tjikistn Thilnd Philippines Mynmr Zimbbwe Ppu New Guine Keny Angol Indonesi Ethiopi Pkistn DR Congo Bngldesh Mozmbique Chin Nigeri Somli Europe The Americs South-Est Asi Afric Western Pcific Estern Mediterrnen Globl 1 Tretment coverge (%) Globlly, the proportion of HIV-positive TB ptients who died during tretment ws 11%, similr to previous yers nd bout three times the level mong ll new nd relpse cses (4%). In the WHO regions, the reltive difference ws smllest in the WHO Africn Region (9% versus 5%) nd highest in the WHO Estern Mediterrnen Region (14% versus 2%). In the WHO Region of the Americs nd the WHO Europen Region, the proportion of HIV-positive TB ptients who died ws 2% nd 22%, respectively. Resons for comprtively poor outcomes for HIV-positive TB ptients include lte detection of HIVssocited TB nd MDR-TB, nd delys in strting ART or TB tretment. To reduce excessive TB mortlity in people who re HIV-positive, WHO recommends routine HIV testing mong presumptive nd dignosed TB cses, TB screening mong people living with HIV, erly ART, improved infection control nd provision of TB preventive tretment. Options tht could help to ensure erlier dignosis nd reduce mortlity include strtegic plcement of WHO-recommended rpid moleculr TB dignostics such s Xpert MTB/RIF within HIV cre settings, nd uptke of the lterl flow urine liporbinmnnn ssy (LF-LAM) for seriously ill people living with HIV Tretment outcomes for TB ptients with MDR/RR-TB nd XDR-TB A totl of 144 countries nd territories reported tretment outcomes for people strted on MDR-TB tretment in The number of cses reported in nnul cohorts hs stedily incresed over time, reching cses globlly in the 215 cohort. Overll, the proportion of MDR/RR-TB ptients in the 215 cohort who successfully completed tretment (i.e. cured or tretment completed) ws 55%: in 8% the tretment filed, 15% died, 14% were lost to follow-up nd for 7% there ws no outcome informtion (Fig. 4.26). Globlly, tretment success hs incresed slightly in recent yers (Fig. 4.23). In the 215 cohort, the tretment success rte ws highest in the WHO Estern Mediterrnen Region (62%) nd ws lowest in the WHO 1 This is the ltest yer for which dt on tretment outcomes for drug-resistnt TB hve been reported to WHO. There is longer lg time for reporting of dt due to the longer durtion of tretment for drug-resistnt TB. 95

107 FIG The ten countries with the lrgest gps between the number of ptients strted on tretment for MDR-TB nd the best estimtes of MDR/RR-TB incidence, 217 Ukrine Russin Federtion Chin Philippines Pkistn 7 Nigeri Indi Mynmr Indonesi Mozmbique The ten countries rnked in order of the size of the gp between the number of ptients strted on MDR-TB tretment nd the best estimte of MDR/RR-TB incidence in 217 re Indi, Chin, Russin Federtion, Pkistn, Nigeri, the Philippines, Indonesi, Ukrine, Mynmr nd Mozmbique. South-Est Asi Region (%). In contrst, tretment filure ws highest in the WHO Europen Region (12%), nd the deth rte ws highest in the WHO Africn Region (2%). Loss to follow-up ws highest in the WHO Region of the Americs (26%), while the WHO Western Pcific Region hd the highest percentge of cses without outcome dt (17%). Among the 3 high MDR-TB burden countries, 15 hd MDR/RR-TB cohorts in 215 with more thn cses; mong these, only Kzkhstn nd Mynmr reported tretment success of more thn 75%. Tretment success ws less thn % in Chin, Indi, Indonesi, Mozmbique, the Republic of Moldov nd Zimbbwe. This ws due to high rtes of deth nd loss to follow-up in Indi (2% nd 19%) nd Indonesi (16% nd 31%), high rtes of loss to follow-up or missing dt bout tretment outcome in Chin (13% nd 32%), high deth rte nd missing dt bout tretment outcome in Mozmbique (26% nd 13%) nd Zimbbwe (17% nd 32%), nd high rtes of loss to follow-up nd filure in the Republic of Moldov (2% nd 18%). Among 8399 ptients strted on tretment for XDR-TB in 215, in 49 countries nd territories for which outcomes were reported, 34% completed tretment successfully, 26% died, tretment filed for 19%, nd 21% were lost to follow-up or their tretment outcome ws not evluted. Indi, the Russin Federtion nd Ukrine ccounted for 74% of the 215 XDR-TB cohort. Among seven countries with XDR-TB cohorts of more thn individuls, mortlity ws highest in Indi nd Uzbekistn (42% nd 41%). Although improving in some countries, the tretment success rte for MDR/RR-TB globlly remins uncceptbly low. The wider use of more effective MDR-TB tretment regimens designed on the bsis of the ltest vilble evidence, nd the use of more ptient-centred models of cre, re expected to help improve this sitution. New guidnce relted to the tretment of drug-resistnt TB ws recently reviewed by WHO Guidelines Development Group, nd WHO will issue updted guidnce lter in 218 (Box 4.7). By the end of 217, 62 countries, mostly in Afric nd Asi, reported hving used shorter MDR-TB regimens (Fig. 4.27). These regimens hve been reported to chieve high tretment success rtes (87 9%) in selected MDR/RR-TB ptients. By the end of 217, 68 countries reported hving imported or strted using bedquiline, nd 42 countries hd used delmnid (Fig nd Fig. 4.29). Most (79%) of the ptients treted with bedquiline were reported by two countries: the Russin Federtion nd South Afric. With the introduction of new drugs nd regimens, there is need for ctive TB drug-sfety monitoring nd mngement (DSM). DSM is defined s the ctive nd systemtic clinicl nd lbortory ssessment of 96

108 FIG Tretment outcomes for new nd relpse TB cses in 216, 3 high TB burden countries, WHO regions nd globlly FIG Tretment outcomes for new nd relpse TB cses, new nd relpse HIV-positive TB cses, nd MDR/RR-TB cses, globlly Pkistn Cmbodi Bngldesh Chin Viet Nm Philippines Mozmbique UR Tnzni Ethiopi Sierr Leone DR Congo Mynmr Zmbi Nigeri Indonesi Nmibi Thilnd South Afric Keny Zimbbwe Centrl Africn Rep Lesotho Congo Liberi Brzil Russin Federtion Indi Ppu New Guine Angol DPR Kore Yer strted on tretment Yer strted on tretment New nd relpse TB cses New nd relpse HIV-positive TB cses Estern Mediterrnen Western Pcific Afric Europe The Americs South-Est Asi Globl Percentge of cohort (%) Yer strted on tretment MDR/RR-TB cses Tretment outcomes re for new cses only. Percentge of cohort (%) Tretment success Filure Died Lost to follow up Not evluted No dt reported MDR/RR-TB nnul tretment cohorts re reported one yer lter thn other TB cohorts. 97

109 98 BOX 4.7 WHO revises its guidnce on the tretment of MDR/RR-TB Since WHO lst issued MDR/RR-TB tretment guidelines in 216, new ptient dt hve emerged. These include finl results from the first-ever Phse III rndomized controlled trils of delmnid nd the 9-month shorter MDR-TB regimen. In 218, WHO convened Guideline Development Group (GDG) to dvise on the revision of its guidnce. The scope of the new guidelines covered the use of the shorter MDR- TB regimen, the composition nd durtion of longer MDR- TB regimens, nd the use of culture to monitor tretment response in these regimens. Before meeting of the GDG in July 218, WHO issued public cll for individul ptient dt from trils, s well s observtionl studies nd progrmmtic cohorts. Systemtic reviews nd met-nlyses were undertken using the Grding of Recommendtions Assessment, Development nd Evlution (GRADE) pproch, in ccordnce with WHO s requirements for the formultion of evidence-bsed helth policy. Bsed on the ltest evidence, the GDG recommended significnt chnges to the design of longer MDR-TB tretment regimens. The listing of medicines to choose from s first priority include three tht hve shown the most dvntgeous blnce between effectiveness nd toxicity: lter genertion fluoroquinolones (levofloxcin or moxifloxcin), bedquiline nd linezolid. The regimen is completed with other gents, in order of reltive potency. Unlike the previous lgorithms, the systemtic inclusion of injectble medicines is no longer required, nd ll-orl longer regimens re now n option for mny ptients, subject to individul need. Some of the older TB medicines, such s the injectble gents knmycin nd cpreomycin, re no longer recommended for use. b As result of these modifictions, nd s globl ccess to the most effective gents in longer regimens improves, the role of the shorter MDR-TB tretment regimen in progrmmtic TB cre is destined to chnge. All ptients on longer nd shorter MDR-TB regimens should receive pproprite counselling nd be informed of their options before enrolment on tretment. DSM for ll ptients enrolled in tretment is essentil. The full guidelines will be relesed in lte 218, long with revised decision ids nd prcticl dvice (e.g. drug dosge schedules for dults nd children) in n updte of the WHO MDR-TB implementtion mnul. c b c World Helth Orgniztion. WHO tretment guidelines for drugresistnt tuberculosis (216 updte) (WHO/HTM/TB/216.4). Genev: WHO; 216 ( ccessed 3 July 218). World Helth Orgniztion. Rpid Communiction: Key chnges to tretment of multidrug- nd rifmpicin-resistnt tuberculosis (MDR/RR-TB) (WHO/HTM/TB/ ). Genev: WHO; 218 ( RpidCommunictionMDRTB.pdf?u=1, ccessed 28 August 218). World Helth Orgniztion. Compnion hndbook to the WHO guidelines for the progrmmtic mngement of drug-resistnt tuberculosis (WHO/HTM/TB/214.11). Genev, World Helth Orgniztion; 215. Avilble from: bitstrem/1665/13918/1/ _eng.pdf, ccessed 15 August 216). FIG Tretment outcomes for new nd relpse TB cses (bsolute numbers), 2 216, 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 succcess Not evluted The Americs Europe Cohorts before 212 included new cses only Western Pcific Filure/Died/Lost to follow-up

110 FIG Tretment outcomes for new nd relpse HIV-positive TB cses in 216, 3 high TB/HIV burden countries, WHO regions nd globlly FIG Tretment outcomes for MDR/RR-TB cses strted on tretment in 215, 3 high MDR-TB burden countries, WHO regions nd globlly Mozmbique Zmbi UR Tnzni Eswtini South Afric Mlwi Botswn Nmibi Cmeroon Zimbbwe Ghn Nigeri Keny Indi Ugnd Lesotho Centrl Africn Republic Guine-Bissu Mynmr Thilnd Indonesi Brzil Chin Angol Chd Congo DR Congo Ethiopi Liberi Ppu New Guine DR Congo Mynmr Bngldesh Kzkhstn Nigeri Ethiopi Somli Viet Nm Keny DPR Kore Angol Ppu New Guine Belrus Pkistn Thilnd Azerbijn Uzbekistn Tjikistn South Afric Peru Philippines Kyrgyzstn Russin Federtion Ukrine Republic of Moldov Mozmbique Indonesi Indi Zimbbwe Chin Afric South-Est Asi Europe Estern Mediterrnen The Americs Western Pcific Estern Mediterrnen Afric Europe The Americs Western Pcific South-Est Asi Globl Percentge of cohort (%) Globl Percentge of cohort (%) Tretment success Filure Died Lost to follow-up Not evluted No dt reported These countries reported less thn MDR/RR-TB cses who strted second line TB tretment in 215. ptients on tretment with new TB drugs, novel MDR-TB regimens or XDR-TB regimens to detect, mnge nd report suspected or confirmed drug toxicities. 1 In 217, 16 of the 3 high MDR-TB burden countries reported dt on dverse events collected from their TB informtion systems. 1 World Helth Orgniztion. Active tuberculosis drug-sfety monitoring nd mngement (DSM): frmework for implementtion (WHO/HTM/ TB/215.28). Genev: WHO; 215 ( bitstrem/1665/24465/1/who_htm_tb_215.28_eng.pdf, ccessed 15 August 218). 99

111 FIG Countries tht hd used shorter MDR-TB tretment regimens by the end of 217 Country response Used Not used Don't know No response Not pplicble FIG Countries tht hd used bedquiline for the tretment of M/XDR-TB s prt of expnded ccess, compssionte use or under norml progrmmtic conditions by the end of 217 Country response Used Not used Don't know No response Not pplicble

112 FIG Countries tht hd used delmnid for the tretment of M/XDR-TB s prt of expnded ccess, compssionte use or under norml progrmmtic conditions by the end of 217 Country response Used Not used Don't know No response Not pplicble 11

113 A young TB ptient wits with his mother to see doctor t clinic in New Delhi, Indi Gry Hmpton / WHO nd Vitl Strtegies 12

114 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), prevention of trnsmission of M. tuberculosis through infection prevention nd control, nd vccintion of children with the bcille Clmette-Guérin (BCG) vccine. WHO guidelines published before 218 identified four priority groups in which testing nd tretment for LTBI ws strongly recommended: people living with HIV (ll countries), children ged under 5 yers who re household contcts of bcteriologiclly confirmed pulmonry TB cses (ll countries), people ged five yers or more who re household contcts of pulmonry TB cses (upper middle-income nd high-income countries with low incidence of TB) nd clinicl risk groups (upper middle-income nd high-income countries with low incidence of TB). Updted guidnce published in 218 includes n dditionl recommendtion to consider testing nd tretment for people ged 5 yers or more who re household contcts of bcteriologiclly confirmed pulmonry TB cses in countries with high incidence of TB; it lso expnds the recommendtion for clinicl risk groups to ll countries. Globlly in 217, 67 countries reported inititing TB preventive tretment for totl of people living with HIV; this included people who were newly enrolled in HIV cre, in 6 countries. South Afric ccounted for 39% of the totl. Of the 3 high TB/HIV burden countries, 15 reported providing TB preventive tretment to people newly enrolled in HIV cre in 217, up from 11 in 216. Coverge rnged from 1% in Eswtini (formerly Swzilnd) to 53% in South Afric. Overll, in the 59 countries for which it could be clculted, coverge ws 36%. There were n estimted 1.3 million children ged under 5 yers who were household contcts of bcteriologiclly confirmed pulmonry TB cses nd thus eligible for tretment ccording to WHO recommendtions. The number of children in this ge group reported to hve been strted on TB preventive tretment incresed to in 217, up 79% from in 216, nd more thn three-fold increse from in 215, but ws still only 23% of those estimted to be eligible. Improvements to routine surveillnce re needed to cpture complete nd relible dt on the provision of TB preventive tretment. 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 prevention nd control in helth fcilities. In 217, totl of 9299 helth-cre workers from 65 countries were reported with TB; Chin ccounted for 35% of these cses. In six countries (Brunei Drusslm, Colombi, Dominicn Republic, Hondurs, Prguy nd Zimbbwe), the number of TB cses per 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 217, 158 countries reported providing BCG vccintion s stndrd prt of these progrmmes, of which 12 reported coverge of t lest 9%, up from 111 countries in

115 Prevention of new infections of Mycobcterium tuberculosis nd their progression to tuberculosis (TB) disese is criticl to reduce the burden of disese nd deth cused by TB, nd to chieve the End TB Strtegy trgets set for 23 nd The trgets of n 8% reduction in TB incidence from the 215 level by 23, nd of 9% reduction by 235, will require historiclly unprecedented ccelertion in the rte t which TB incidence flls fter 225 (Chpter 2). This ccelerted rte (n verge of 17% per yer between 225 nd 235) is possible only if the probbility of progression from ltent TB infection (LTBI) to ctive TB disese mong the pproximtely 1.7 billion people lredy infected worldwide 2 is substntilly reduced. 3 Helth-cre interventions tht could help to cut the risk of progression from LTBI to ctive TB disese include more effective drug tretments for LTBI, nd development of vccine to prevent rectivtion of LTBI in dults. Action on the broder determinnts of TB could lso cut the risk; these re discussed further in Chpter 7. Currently, three mjor ctegories of helth interventions re vilble for TB prevention: tretment of LTBI; prevention of trnsmission of M. tuberculosis through infection prevention nd control; nd vccintion of children with the bcille Clmette- Guérin (BCG) vccine. The three min sections of this chpter present nd discuss progress in provision of these services. Prticulr ttention is given to the 3 high TB burden countries nd the 3 high TB/HIV burden countries (Chpter 2). middle-income nd high-income countries with low incidence of TB). 4,5,6 Updted guidnce published in 218 includes n dditionl recommendtion to consider testing nd tretment for people ged 5 yers or more who re household contcts of bcteriologiclly confirmed pulmonry TB cses in countries with high incidence of TB; it lso expnds the recommendtion for clinicl risk groups to ll countries. 7 Further detils, including estimtes of the number of people eligible for tretment bsed on the updted guidnce, re provided in Box 5.1. Dt on the provision of TB preventive tretment for people living with HIV (specificlly, those newly enrolled in HIV cre 8 ) hve been collected nnully by WHO for more thn decde, nd for children ged under 5 yers since 216. In 218, dt for people ged 5 yers or more were requested for the first time. The rest of this section presents nd discusses the vilble dt for these three priority groups. Dt for clinicl risk groups such s ptients strting nti-tumour necrosis fctor (TNF) therpy nd those prepring for orgn trnsplnttion re currently not requested s prt of WHO s nnul rounds of globl TB dt collection. Countries re nevertheless encourged to monitor tretment initition nd completion, either routinely or through specil surveys. Routine collection of dt bout TB preventive tretment remins chllenging. To fcilitte fster, systemtic nd more complete dt collection, WHO hs developed mobile phone ppliction (pp) which cn be dpted t country level to record nd report cse-bsed dt on TB preventive tretment Tretment of ltent TB infection LTBI is defined s stte of persistent immune response to M. tuberculosis without cliniclly mnifested evidence of ctive TB disese. WHO guidelines published before 218 identified four priority groups in which testing nd tretment for LTBI ws strongly recommended: people living with HIV (ll countries); children ged under 5 yers who re household contcts of bcteriologiclly confirmed pulmonry TB cses (ll countries); people ged 5 yers or more who re household contcts of pulmonry TB cses (upper middle-income nd high-income countries with low incidence of TB); nd clinicl risk groups (upper 1 World Helth Orgniztion. WHO End TB Strtegy: globl strtegy nd trgets for tuberculosis prevention, cre nd control fter 215. Genev: WHO; 215 ( ccessed 3 July 218). 2 Houben RM, Dodd PJ. The globl burden of ltent tuberculosis infection: re-estimtion using mthemticl modelling. PLoS Med. 216;13(1):e2152 ( ccessed 3 July 218). 3 In n rticle published in 2, the lifetime risk ws estimted t 5 1%. See Vynnycky E, Fine PE. Lifetime risks, incubtion period, nd seril intervl of tuberculosis. Am J Epidemiol. 2; Aug 1;152(3): People living with HIV Trends in the nnul number of people living with HIV provided with TB preventive tretment re shown in Fig Globlly, the number ws low until 29; it then grew substntilly to rech in 214, nd hs subsequently levelled off. The number in World Helth Orgniztion. Guidelines for intensified tuberculosis cse-finding nd isonizid preventive therpy for people living with HIV in resource-constrined settings. Genev: WHO; 211 ( int/iris/bitstrem/1665/44472/1/ _ng.pdf, ccessed 3 July 218). 5 World Helth Orgniztion. Recommendtions for investigting contcts of persons with infectious tuberculosis in low- nd middle-income countries. Genev: WHO; 212 ( publictions/212/contct_investigtion212/en/, ccessed 3 July 218). 6 World Helth Orgniztion. Guidelines on the mngement of ltent tuberculosis infection. Genev: WHO; 215 ( publictions/ltbi_document_pge/en/, ccessed 3 July 218). 7 World Helth Orgniztion. Ltent tuberculosis infection: updted nd consolidted guidelines for progrmmtic mngement. Genev: WHO; 218 ( ccessed 3 July 218). 8 The indictor focuses on people newly enrolled in HIV cre to help monitor trends in the progrmmtic mngement of LTBI. However, ll people living with HIV should be regulrly ssessed for TB disese, nd be offered preventive TB tretment if they re eligible for it. 9 en/ 14

116 BOX 5.1 Updted WHO guidnce on the progrmmtic mngement of ltent TB infection issued in 218, nd ssocited estimtes of the number of people eligible for TB preventive tretment from WHO issued updted nd consolidted guidelines for the progrmmtic mngement of LTBI in 218. The document brings together guidnce tht ws previously vilble in seprte guidelines; it lso includes updtes to previous guidnce. Recommendtions in the guidelines re bsed on the probbility of progression to ctive TB disese in specific risk groups, the level nd distribution of TB disese burden, the vilbility of resources, the likelihood of brod public helth impct, nd the reltive benefits nd risks of tretment provision. The guiding principle is tht individul benefits should outweigh risks. The 218 guidelines define three priority groups in which testing nd tretment for LTBI is strongly recommended, in ll countries: people living with HIV; infnts nd children ged under 5 yers who re household contcts of bcteriologiclly confirmed pulmonry TB cses; nd clinicl risk groups, including ptients inititing nti-tnf tretment, receiving dilysis, or prepring for orgn or hemtologicl trnsplnttion, nd those with silicosis. In low-incidence settings, tretment for LTBI is lso strongly recommended for HIV-negtive people ged 5 yers or more who re household contcts of bcteriologiclly confirmed pulmonry TB cses. In high-incidence settings, the guidelines recommend considering testing nd tretment for LTBI for HIV-negtive people ged 5 yers or more who re contcts of bcteriologiclly confirmed pulmonry TB ptients, tking into ccount resource vilbility nd helth system cpcity. Compred with erlier guidnce, this conditionl recommendtion substntilly increses the potentil number of people eligible for tretment. Active TB disese should lwys be ruled out by screening for symptoms before prescribing preventive tretment. Chest rdiogrphy my lso be considered for ruling out ctive TB disese mong people living with HIV who re on ART, nd mong HIV-negtive household contcts ged 5 yers or more. The guidelines recommend testing for LTBI using either tuberculin skin test or interferon-gmm relese ssy, in ll countries. Lck of ccess to chest rdiogrphy, tuberculin skin testing, or interferongmm relese ssy should not be brrier to initition of tretment of LTBI. The guidelines include four options for tretment of LTBI, including new shorter drug regimens: A weekly dose of rifpentine nd isonizid for 3 months. A dily dose of rifmpicin plus isonizid dily for 3 months. A dily dose of 3 4 months of rifmpicin. A dily dose of isonizid for t lest six months. Shorter regimens re expected to help ptients to dhere to nd complete tretment. Bsed on the updted guidnce, WHO estimtes tht t lest 3 million people would be eligible for TB preventive tretment between 218 nd 222. This represents n enormous increse compred with the numbers reported to hve received TB preventive tretment in 217 (Section 5.1). World Helth Orgniztion. Ltent tuberculosis infection: updted nd consolidted guidelines for progrmmtic mngement. Genev: WHO; 218 ( publictions/218/ltent-tuberculosis-infection/en/, ccessed 3 July 218). ws , bsed on dt from 67 countries; 1 this included people who were newly enrolled in HIV cre, in 6 countries. 2 1 These 67 countries ccounted for 72% of the estimted number of TB cses mong people living with HIV in Countries hve regulrly reported chllenges in cpturing dt on TB preventive tretment mong people newly enrolled in HIV cre. In 218, if countries could not report dt for this group, they were sked to provide dt on the number of people currently enrolled in HIV cre who were strted on TB preventive tretment. As in previous yers, South Afric ccounted for the lrgest shre (39%) of the globl totl. Lrge bsolute increses in numbers compred with 216 were reported in Nigeri (+29 ) nd Indi (+1 ). For three of the 3 countries with high burden of HIV-ssocited TB Angol, Nmibi nd Ppu New Guine dt were reported for the first time in t lest 4 yers. Despite progress in some countries, much remins to be done. For exmple, only 15 of the 3 high TB/HIV 15

117 FIG. 5.1 Provision of TB preventive tretment to people newly enrolled in HIV cre, Number of people (thousnds) 7 2 Rest of world For seven countries, dt re for people currently enrolled in HIV cre: Congo, Ecudor, Grend, Keny, Mozmbique, Nepl nd Ukrine. burden countries reported some provision of TB preventive tretment to people living with HIV in 217. Coverge mong those newly enrolled in HIV cre vried from 1% in Eswtini (formerly Swzilnd) to 53% in South Afric (Tble 5.1). Overll, in the 59 countries for which it could be clculted, coverge ws 36%. Gps in the provision of TB preventive tretment to people living with HIV for selected high TB burden countries or high TB/HIV burden countries re illustrted in Fig Children ged under 5 yers who re household contcts of TB cses Globl Rest of Afric South Afric There were 189 countries tht reported t lest one notified bcteriologiclly confirmed pulmonry TB cse in 217, of which 138 (73%) reported dt bout the number of household contcts ged under 5 yers who were strted on TB preventive tretment. Among these 138 countries, 124 reported tht t lest one child ws strted on preventive tretment in 217 (up from 11 countries in 216). This included 28 of the 38 high TB or high TB/HIV burden countries (Tble 5.1) n increse from 2 countries in 216. Of these countries, dt were reported to WHO for the first time by Botswn, Congo, Eswtini, Ethiopi, South Afric, Thilnd nd Zmbi. A totl of children ged under 5 yers were reported to hve been initited on TB preventive tretment in 217, n increse of 79% from in 216 nd more thn three-fold increse from in 215. The lrgest numbers were reported by the WHO Africn Region (47% of the globl totl; 32 countries) nd the WHO South-Est Asi Region (25% of the globl totl; 9 countries). In the 28 high TB nd TB/HIV burden countries tht reported dt, children strted TB preventive tretment (68% of the globl totl). At country level, Indi reported the lrgest number (38 745), followed by South Afric (32 14) (Tble 5.1). Globlly, the children strted on TB preventive tretment in 217 represented 23% of the pproximtely 1.3 million children estimted to be eligible for tretment. Higher levels of coverge were estimted for 2 countries in the WHO Europen Region (of which 13 reched coverge of 75%), followed by 23 countries in the WHO Region of the Americs (of which 13 reched coverge of 75%) nd 16 countries in the Estern Mediterrnen Region (of which 9 reched coverge of 75%) (Fig 5.3). The children strted on tretment in the 28 high TB nd TB/HIV burden countries tht reported dt represented 18% of the 1.1 million children estimted FIG. 5.2 Gps in TB prevention nd TB detection for people who were newly enrolled in HIV cre in 217, selected countries 8 Percentge (%) b Centrl Africn Republic Eswtini Indi Angol Nmibi Ppu New Guine Indonesi Mynmr Cmbodi Sierr Leone Nigeri Ethiopi Philippines Strted on preventive tretment Detected nd notified with ctive TB disese Gp in TB detection nd TB prevention b The selected countries re high TB or TB/HIV burden countries tht reported on ll three of the following: the number of people newly enrolled on HIV cre; the number of TB cses detected mong people newly enrolled on HIV cre; nd the number of people newly enrolled on HIV cre who were strted on TB preventive tretment. In high TB burden countries, testing for LTBI is not requirement for initition of TB preventive tretment, such tht ll those without ctive TB disese re eligible for TB preventive tretment. The gp represents people living with HIV who should hve undergone complete evlution for TB disese or TB preventive tretment. 16

118 TABLE 5.1 TB preventive tretment for people living with HIV nd children under 5 yers of ge who were household contcts of bcteriologiclly confirmed pulmonry TB cse, high TB or TB/HIV burden countries, 217 TREATMENT PEOPLE LIVING WITH HIV NEWLY ENROLLED IN CARE PEOPLE LIVING WITH HIV NEWLY ENROLLED IN CARE STARTED ON TB PREVENTIVE NUMBER COVERAGE (%) ESTIMATED NUMBER OF CHILD CONTACTS UNDER 5 YEARS OF AGE ELIGIBLE FOR TB PREVENTIVE TREATMENT BEST ESTIMATE UNCERTAINTY INTERVAL Angol ( ) CHILDREN UNDER 5 YEARS OF AGE STARTED ON TB PREVENTIVE TREATMENT NUMBER BEST ESTIMATE COVERAGE b (%) UNCERTAINTY INTERVAL Bngldesh 54 4 ( ) (19 23) Botswn 781 (711 8) 556 ** Brzil 2 86 ( ) Cmbodi ( ) (4 48) Cmeroon 1 3 ( ) (.79.95) Centrl Africn Republic ( ) Chd 4 52 ( ) Chin 1 4 ( ) Congo * 2 41 ( ) ( ) DPR Kore 9 4 ( ) ** DR Congo 84 4 ( ) (14 17) Eswtini ( ) ( ) Ethiopi (25 3 ) (9.9 12) Ghn 3 71 ( ) Guine-Bissu 2 6 ( ) (18 21) Indi ( ) (1 12) Indonesi ( ) 6 8 ** Keny * 24 9 ( ) (24 29) Lesotho 1 76 ( ) Liberi 2 3 (2 2 51) ( ) Mlwi ( ) 3 68 ** Mozmbique * 21 ( ) > Mynmr ( ) ( ) Nmibi ( ) (31 37) Nigeri ( ) ** Pkistn 17 ( ) Ppu New Guine ( ) Philippines ( 2 6 ) ** Russin Federtion (1 2 29) 1 96 ** Sierr Leone ( ) South Afric ( ) (72 86) Thilnd 5 51 (5 2 6 ) ( ) Ugnd 2 7 ( ) ( ) UR Tnzni 21 ( ) (32 38) VietNm ( ) (24 29) Zmbi ( ) ( ) Zimbbwe ** 7 61 ( ) (22 26) Blnk cells indicte dt not reported. Estimtes re shown to three significnt figures. b Resons for higher thn expected coverge might be tht the numertor did not exclude non-household contcts or children of five yers nd older. * Coverge ws not clculted becuse reported dt on people living with HIV is for ll enrolled in cre, not just those newly enrolled in cre. ** Coverge ws not clculted becuse the numertor included contcts ged 5 yers or older (Botswn, DPR Kore nd Nigeri), those who were non-household contcts of TB cses (Indonesi nd the Russin Federtion), or those household contcts of cliniclly dignosed TB cses (Mlwi nd the Philippines), or the number of PLHIV on TB preventive tretment ws provided for the period July December 217 only (Zimbbwe). 17

119 FIG. 5.3 Coverge of TB preventive tretment mong eligible children ged under 5 yers, 217 Coverge (%) No dt Not pplicble Children ged <5 yers who were household contcts of bcteriologiclly confirmed pulmonry TB cses. Estimted coverge ws not clculted becuse the numertor included contcts ged 5 yers or older (Botswn, DPR Kore nd Nigeri), those who were non-household contcts of TB cses (Indonesi nd the Russin Federtion), or those household contcts of cliniclly dignosed TB cses (Mlwi nd the Philippines). to be eligible for tretment in the 38 high TB or TB/HIV burden countries. The highest coverge levels ( 75%) in this group of countries were in Mozmbique nd South Afric (Fig 5.3 nd Tble 5.1) Household contcts ged 5 yers nd older In WHO s 218 round of globl TB dt collection, dt on provision of TB preventive tretment to household contcts ged 5 yers or more were requested for the first time. Of the 189 countries tht reported t lest one notified bcteriologiclly confirmed pulmonry TB cse in 217, 78 (41%) reported dt bout the number of household contcts ged 5 yers or more who were strted on TB preventive tretment. Of the 78 countries, 7 reported tht t lest one contct ged 5 yers or more ws strted on preventive tretment. This included eight countries tht re in the lists of high TB burden, high multidrug-resistnt TB (MDR-TB) or high TB/HIV burden countries: Azerbijn, Kzkhstn, Kyrgyzstn, Republic of Moldov, Tjikistn, Thilnd, Ukrine nd Uzbekistn. A totl of household contcts ged 5 yers or more were reported to hve been initited on TB preventive tretment in 217. The lrgest numbers were reported by the WHO Europen Region (56 335, 55% of the globl totl) nd the WHO Estern Mediterrnen 1 Annex 1 explins how to ccess dt reported by other countries. Region (29 331, 28% of the globl totl). At country level, Afghnistn reported the lrgest number (22 939), followed by Ukrine (15 811) nd Turkey (11 94). 5.2 TB infection prevention nd control TB infection prevention nd control is one of the components of Pillr 2 of the End TB Strtegy (Chpter 2); it is lso one of the collbortive TB/HIV ctivities tht flls under Pillr 1. The risk of TB trnsmission is high in helth-cre nd other congregte settings. This puts helth-cre workers t greter risk of TB infection nd disese, nd nosocomil outbreks of MDR-TB nd extensively drug-resistnt TB (XDR-TB) mong people living with HIV hve been documented in the literture. 2,3 TB infection prevention nd control should be prt of ntionl infection prevention nd control policy. In helthcre fcilities nd congregte settings, comprehensive set of infection control mesures comprising dministrtive, environmentl nd personl protection mesures 2 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):

120 FIG. 5.4 Notifiction rte rtio of TB mong helth-cre workers compred with the dult popultion (15 65 yers), 217 Notifiction rte rtio No dt Not pplicble Dt from 3 countries were excluded where the number of helth-cre workers reported ws less thn. should be implemented. 1 Periodic ssessment of TB infection prevention nd control in helth-cre fcilities is essentil to ensure tht pproprite mesures re in plce. 2 The risk of TB mong helth-cre workers reltive to the risk in the generl dult popultion is one of the indictors recommended by WHO for mesuring the impct of TB infection prevention nd control ctivities in helthcre fcilities. 3 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 217, 9299 TB cses mong helth-cre workers were reported from 65 countries; Chin ccounted for 35% of these cses nd Brzil for 11%. The notifiction rte mong helth-cre workers could be clculted for 58 of the 65 countries; it rnged from zero to 685 cses 1 World Helth Orgniztion. WHO policy on TB infection control in helth-cre fcilities. Genev: WHO; 29 ( publictions/29/infection_control/en/, ccessed 3 July 218). 2 World Helth Orgniztion. Checklist for periodic evlution of TB infection control in helth-cre fcilities. Genev: WHO; 215 ( periodic_evlution_of_tb_infection_control_in_helth_fcilities.pdf, ccessed 3 July 218). 3 World Helth Orgniztion. A guide to monitoring nd evlution for collbortive TB/HIV ctivities: 215 revision (WHO/HTM/TB/215.2). Genev: WHO; 215 ( ccessed 3 July 218). per helth-cre workers, with the highest rte observed in Mozmbique. The notifiction rte mong the generl dult popultion in ech country ws clculted bsed on the number of notified TB cses in dults nd the estimted size of the dult popultion from the United Ntions popultion division (217 revision), 4 restricted to those ged for comprbility with the helth workforce. 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 two in four countries (Brunei Drusslm, Dominicn Republic, Prguy nd Zimbbwe) nd bove three in Colombi nd Hondurs. The rtio ws below one in four high TB burden countries: Chin, Nmibi, Nigeri nd Thilnd. 5.3 TB vccintion There is cler need for vccine tht is more effective thn the BCG vccine, in prticulr to reduce the risk of infection with M. tuberculosis nd the risk of progression from infection to ctive TB disese in dults. Although there re 12 new cndidtes in the pipeline, it is unlikely tht new TB vccine will be vilble in the immedite future (Chpter 8). To promote the development of

121 FIG. 5.5 BCG vccintion policy by country Policy BCG recommendtion only for specific groups Current ntionl BCG vccintion policy for ll Pst ntionl BCG vccintion for ll No dt Not pplicble Source: The BCG World Atls 2nd Edition, ccessed 19 July 218. FIG. 5.6 Coverge of BCG vccintion, 217 Percentge 49 The trget popultion of BCG coverge vries depending on ntionl policy, but is typiclly for the number of live births in the yer of reporting. Source: ccessed 3 July No dt Not pplicble 11

122 vccines with optiml effectiveness nd suitbility in low- nd middle-income countries, in 218 the WHO Preferred Product Chrcteristics for New Tuberculosis Vccines ws developed through multi-stkeholder process led by WHO s Inititive for Vccine Reserch. 1 BCG vccintion hs been shown to prevent disseminted disese; this ctegory includes TB meningitis nd miliry TB, which re ssocited with high mortlity in infnts nd young children. Currently, WHO recommends tht, in countries with high TB burden, single dose of the BCG vccine should be provided to ll infnts s soon s possible fter birth s prt of childhood immuniztion progrmmes. In countries with low TB incidence rtes, provision of the BCG vccine my be limited to neontes nd infnts in recognized high-risk groups, or to older children who re skin-test negtive for TB infection. Fig. 5.5 summrizes ntionl policies on BCG vccintion. 2 Among 18 countries for which dt were collected, 154 recommended universl BCG vccintion; 2 reported hving hd ntionl BCG policy for everyone in the pst, nd the remining six countries hd policies of selective vccintion for t-risk individuls in high-risk groups. The ltest dt on BCG coverge 3 (for 217) re shown in Fig In the 158 countries for which dt re vilble, 12 reported coverge of t lest 9%. Among the 3 high TB burden countries, coverge rnged from 53% in Nigeri to 99% in Bngldesh, Brzil, Chin, Mozmbique, Thilnd, the United Republic of Tnzni nd Zmbi; 21 reported coverge of t lest 9%, up from 12 in 216. In ddition to Nigeri, coverge ws below 8% in five other high TB burden countries: Centrl Africn Republic, Keny, Lesotho, Ppu New Guine nd South Afric. 1 World Helth Orgniztion. WHO preferred product chrcteristics for new tuberculosis vccine. Genev: WHO; 218 ( immuniztion/documents/who_ivb_18.6/en/, ccessed 3 July 218). 2 The BCG world tls, 2nd edition, dtbse of globl BCG vccintion policies nd prctices, 2nd edition. 217 ( ccessed 19 July 218). 3 World Helth Orgniztion. Reported estimtes of BCG coverge. ( pps.who.int/immuniztion_monitoring/globlsummry/timeseries/ tscovergebcg.html, ccessed 19 July 218). 111

123 Volunteers sign in ptients t TB clinic in Dr es Slm, United Republic of Tnzni INTERFOTO / Almy Stock Photo 112

124 Chpter 6. Finncing for TB prevention, dignosis nd tretment KEY FACTS AND MESSAGES Finncing for tuberculosis (TB) prevention, dignosis nd tretment continues to fll short of the mount needed nd commitments from both domestic nd interntionl donor sources need to be stepped up. The Stop TB Prtnership s Globl Pln to End TB, (the Globl Pln) estimtes tht, in low- nd middle-income countries, US$ 1.4 billion is required in 218, incresing to US$ 12.3 billion in 22. Bsed on dt reported to WHO by 119 low- nd middle-income countries with 97% of the world s notified TB cses, US$ 6.9 billion is vilble for TB prevention, dignosis nd tretment in 218, representing shortfll of US$ 3.5 billion. The Globl Pln estimtes tht n dditionl US$ 2 billion per yer is needed for TB reserch nd development. Of the totl of US$ 6.9 billion vilble in 119 low- nd middle-income countries in 218, US$ 4.8 billion is for drug-susceptible TB nd US$ 2. billion is for MDR-TB; the reminder is for TB/HIV interventions or miscellneous items. Of the totl of US$ 6.9 billion vilble in 119 low- nd middle-income countries in 218, US$ 6. billion (86%) is from domestic sources. However, this ggregte figure is strongly influenced by the BRICS group of countries (Brzil, the Russin Federtion, Indi, Chin nd South Afric). BRICS ccounted for 54% of the vilble funding for TB in 218 (nd 46% of the world s TB cses), with 96% (rnge 91 %) of the group s funding coming from domestic sources. In other countries with high TB burden, interntionl donor funding remins crucil; for exmple, it ccounted for 39% of the funding vilble in the 25 high TB burden countries outside BRICS (which hve 4% of the world s notified TB cses) nd for 57% of the funding in low-income countries. Interntionl donor funding reported by ntionl TB progrmmes (NTPs) dropped to US$.9 billion in 218, flling fr short of the US$ 2.6 billion nnul requirement estimted in the Globl Pln. The single lrgest source (74% of the totl) of funding reported by NTPs is the Globl Fund to Fight AIDS, Tuberculosis nd Mlri (the Globl Fund). Interntionl donor funding documented in the Orgnistion for Economic Co-opertion nd Development (OECD) creditor reporting system includes funding tht flows through NTPs s well s other recipients. The totl mount recorded in 216 (the ltest yer for which dt re vilble) ws US$.9 billion, of which 69% ws from the Globl Fund (the Fund s contribution verged 66% from 26 to 216). This ws much less thn funding for HIV (US$ 6.8 billion) nd mlri (US$ 1.9 billion). To provide some context for these mounts, the ltest estimtes (for 216) of the burden of disese in terms of disbility-djusted life yers (DALYs) lost due to illness nd deth re 58 million for HIV/AIDS, 56 million for mlri nd 44 million for TB. The medin cost per ptient treted in 217 ws US$ 1224 for drug-susceptible TB nd US$ 7141 for MDR-TB. The ltter figure ws lower thn in previous yers, following expnded use of lower cost shortened tretment regimen tht ws first recommended by WHO in 216. Helth finncing dt from ntionl helth ccounts provide importnt insights into the current sttus of progress towrds universl helth coverge, s discussed in Chpter 7. The Globl Pln to End TB, Genev: Stop TB Prtnership; 215 ( ccessed 21 June 218). 113

125 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, nd hs published findings 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 the finncil resources required to chieve the 22 milestones of the End TB Strtegy (Section 6.1). It then presents nd discusses trends in funding for TB prevention, dignosis nd tretment by ctegory of expenditure nd source of funding for the period , both globlly nd for mjor country groupings (Section 6.2). More detiled country-specific dt for 218 re lso presented for the 3 high TB burden countries. The third section nlyses funding gps reported by ntionl TB progrmmes (NTPs) to WHO, with brekdowns by ctegory of expenditure nd country group (Section 6.3). The finl section provides the ltest estimtes (for 217) of the unit costs of tretment for drug-susceptible TB nd multidrug-resistnt TB (MDR-TB) (Section 6.4). As highlighted in the previous three editions of the Globl tuberculosis report, 2,3,4 nlysis of helth finncing dt cn provide importnt insights into progress towrds universl helth coverge (UHC), which is necessry to chieve the End TB Strtegy milestones set for 22 nd 225 (Chpter 2). Mesurement of costs fced by TB ptients nd their households is lso required to ssess progress towrds one of the three high-level indictors of the End TB Strtegy; tht is, the percentge of TB ptients nd their households who fce ctstrophic costs s result of TB disese. The 22 milestone of zero set for this indictor requires progress towrds UHC nd socil protection (included under Pillr 2 of the End TB Strtegy). These two topics nlysis of helth finncing dt, nd mesurement of costs fced by TB ptients nd their households re discussed in Chpter 7. Further country-specific dt on TB finncing cn be found in finnce profiles tht re vilble online Estimtes of funding required to chieve the 22 milestones of the End TB Strtegy The 22 milestones of the End TB Strtegy re 35% reduction in TB deths compred with deths in 215, 2% reduction in the TB incidence rte compred with 215, nd tht no TB ptients nd their households fce ctstrophic costs s consequence of TB disese (Chpter 2). Estimtes of the funding required to chieve these milestones hve been set out in the Stop TB Prtnership s Globl Pln to End TB, (the Globl Pln). 6 Worldwide, the totl mount required for implementtion of TB prevention, dignostic nd tretment interventions is US$ 58 billion for the period , rising from US$ 9.5 billion for the yer 216 to US$ 14 billion for the yer 22. An dditionl US$ 9. billion is needed for globl TB reserch nd development in the sme period. 7 Of the US$ 58 billion required over the 5 yers from 216 to 22 (excluding reserch nd development), n estimted US$ 52 billion is required in low- nd middleincome countries, growing from US$ 8.3 billion in 216 to US$ 12 billion in 22 (Fig. 6.1). In 218, n estimted totl of US$ 1.4 billion is required: US$ 7.7 billion (74%) for dignosis nd tretment of drug-susceptible TB, US$ 2.5 billion for drug-resistnt TB 8 nd the reminder for TB/ FIG. 6.1 Estimtes of funding required for TB prevention, dignosis nd tretment in low- nd middleincome countries in the Globl Pln to End TB US$ billions 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):e15 15 ( pubmed/ , ccessed 11 July 218). 2 World Helth Orgniztion. Globl tuberculosis report 215 (WHO/HTM/ TB/215.22). Genev: WHO; 215 ( bitstrem/1665/19112/1/ _eng.pdf, ccessed 21 June 218). 3 World Helth Orgniztion. Globl tuberculosis report 216 (WHO/HTM/ TB/216.13). Genev: WHO; 216 ( m/1665/2441/1/ eng.pdf, ccessed 11 July 218). 4 World Helth Orgniztion. Globl tuberculosis report 217 (WHO/HTM/ TB/217.23). Genev: WHO; 217 ( dle/1665/259366/ eng.pdf, ccessed 21 June 218). 5 TB/HIV collbortive ctivities MDR-TB Drug-susceptible TB Funding estimtes for TB/HIV exclude the cost of ntiretrovirl therpy (ART) for TB ptients living with HIV. Such costs re included in globl estimtes of the funding required for HIV, published by UNAIDS. Source: Stop TB Prtnership Globl Pln to End TB The Globl Pln to End TB, Genev: Stop TB Prtnership; 215 ( ccessed 21 June 218). 7 Funding for TB reserch nd development, which is monitored by the Tretment Action Group, is discussed further in Chpter 8. 8 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). 114

126 FIG. 6.2 The 119 low- nd middle-income countries included in nlyses of TB finncing, Countries were included in trend nlyses if t lest three yers of high-qulity finnce dt were vilble in the period Lowincome (33/34), lower-middle income (44/46), nd upper-middle income (42/56) countries representing 14%, 61% nd 22% of 217 notified cses, respectively, were included. The following 17 low- nd middle-income countries were excluded: Albni, Azerbijn, Cost Ric, Dominic, Algeri, Egypt, Equtoril Guine, Grend, Irn, Liby, St Luci, Muritius, West Bnk nd Gz Strip, Syrin Arb Republic, Turkmenistn, St Vincent nd Grendines, Smo. HIV interventions. The mount for TB/HIV interventions is comprtively smll becuse it does not include the funding needed for ntiretrovirl therpy for HIV-positive TB ptients; this figure is insted included in estimtes of funding required for HIV, published by the Joint United Ntions Progrmme on HIV/AIDS (UNAIDS). 1 In 218, in the context of preprtions for the UN high-level meeting on TB, Globl Pln projections of funding requirements were extended to 222, suggesting tht t lest US$ 13 billion will be needed in 222. In the Globl Pln, estimtes of the funding tht could be mobilized from domestic nd interntionl donor sources were restricted to countries eligible to pply to the Globl Fund to Fight AIDS, Tuberculosis nd Mlri (the Globl Fund). 2 For eligible countries, the funding required over 5 yers mounted to US$ 29 billion. Of this totl, it ws estimted tht bout US$ 16 billion could be mobilized from domestic sources, nd tht the reminder (n verge of US$ 2.6 billion per yer) would need to be provided by interntionl donors. The Globl Pln did not ttempt to ssess the broder 1 World Helth Orgniztion. Globl tuberculosis report 216 (WHO/HTM/ TB/216.13). Genev: WHO; 216 ( globl_report/rchive/en/, ccessed 11 July 218). 2 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. investments required to increse the overll coverge nd qulity of helth-cre services or the funding required to remove finncil brriers to ccessing cre. Such investments re needed for mny essentil preventive, tretment nd cre interventions, not only those relted to TB. Progress on these fronts is criticl, s reflected in Pillr 2 of the End TB Strtegy. The costings in the Globl Pln cn thus be seen s the finncil resources required for Pillrs 1 nd 3 of the End TB Strtegy. Recent estimtes of the funding required in low- nd middle-income countries to mke progress towrds UHC by 23 re presented nd discussed in Chpter TB funding, overll nd by ctegory of expenditure nd source of funding, Dt reported by NTPs to WHO since 26 were used to nlyse funding trends for in 119 low- nd middle-income countries (Fig. 6.2). These countries ccounted for 97% of the globl number of TB cses notified in 217. The methods used to compile, review, vlidte nd nlyse finncil dt re summrized in Box 6.1. In these 119 low- nd middle-income countries, funding for TB prevention, dignosis nd tretment reched US$ 6.9 billion in 218, n increse from US$ 6.2 billion 115

127 BOX 6.1 Methods used to compile, review, vlidte nd nlyse finncil dt reported to WHO 116 Overview WHO begn monitoring government nd interntionl donor finncing for TB in 22. All dt re stored in the WHO globl TB dtbse. The stndrd methods used to compile, review, vlidte nd nlyse these dt hve been described in detil elsewhere;,b this box provides summry. Ech yer, WHO sks NTPs in 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 218 round of globl TB dt collection, the fiscl yers were 218 (for funding needs) nd 217 (for expenditures). Ctegories of expenditure used to report TB budget nd expenditure dt hve been kept consistent s fr s possible, to enble monitoring of trends. Ctegories used for reporting of budgets nd expenditures from 22 to 218 The ctegories used for nnul reporting of funding needs (current fiscl yer) nd expenditures (lst fiscl yer) by NTPs in low- nd middle-income countries re summrized below. 1. Drug-susceptible TB 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; for exmple, 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. Opertionl reserch, including surveys. Ptient support this ctegory ws first introduced s stnd-lone ctegory in 215, to reflect the emphsis on finncil nd socil protection in the End TB Strtegy. 2. MDR-TB Second-line drugs. Progrmme costs specificlly relted to MDR-TB. 3. TB/HIV Collbortive TB/HIV ctivities, including TB preventive tretment for people newly enrolled in HIV cre. This ctegory excludes ny budget items tht re finnced by HIV progrmmes, such s ntiretrovirl therpy for TB ptients living with HIV. An other ctegory is used to cpture miscellneous items tht do not fit in one of the ctegories listed bove. Sources of funding Low- nd middle-income countries report on the brekdown of the totl mount of vilble or committed funding by source, using four stndrd ctegories. These ctegories re domestic funding excluding lons; externl lons, lso considered domestic funding; the Globl Fund; nd grnt finncing from sources other thn the Globl Fund. High-income countries As in previous yers, in 218, ll high-income countries were sked to report their funding requirements nd expenditures in totl, without ny brekdown by ctegory of expenditure or source of funding. However, of the 73 high-income countries, only seven reported expenditures nd only 23 reported the mount of funding needed in 218. Totl TB funding trends for re vilble for eight of the 73 high-income countries; however, those countries re not fetured in this chpter given its focus on low- nd middle-income countries. Averge cost of drugs per ptient (since 214) Since 214, n extr question bout the verge cost of drugs per ptient treted hs been sked, to llow reviewers to better ssess the vlidity of budgets reported for first-line nd second-line drugs, nd to identify whether reported budgets include funding for buffer stocks. Use of generl helth services (22 218) Annully since 22, ll countries (irrespective of income level) hve been sked to report on the use of inptient nd outptient cre for tretment of people with drug-susceptible TB nd MDR-TB on per-ptient bsis (i.e. the verge number of dys spent in hospitl, nd the verge number of outptient visits to helth fcility). These dt cn be bsed on ctul use of services (preferble where vilble), or on the expected use of services bsed on the typicl pproch used to deliver tretment (which my be defined in ntionl policy documents nd protocols). These dt on helth service use re then 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). Dt vlidtion by WHO s Globl TB Progrmme The core methods used to review nd vlidte dt hve remined consistent since 22. They include the following: 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 these include estimtes of unit costs from independent economic

128 evlutions (Box 6.3) c nd dt extrcted by the Globl Fund from funding pplictions submitted to them (comprehensive budgets for ntionl strtegic plns for TB re n essentil requirement for funding pplictions to the Globl Fund); further detils bout the comprisons with other dt sources re vilble from WHO upon request. In review nd vlidtion of dt, prticulr ttention hs lwys been given to the high TB burden countries. In 218, specific efforts to improve the qulity of finncil dt reported to WHO included discussions with NTP stff during workshop on TB budgeting; nd individul nd customized follow-up with in-country stff involved in the development of ntionl strtegic plns nd reporting of finncil dt. Except for the Russin Federtion, Chin, South Afric in 218 nd Viet Nm in 217, TB funding reported by NTPs in 217 nd 218 did not include the finncil costs ssocited with the inptient nd outptient cre required during TB tretment. Since mny detiled costing studies in numerous countries show tht these costs cn ccount for lrge shre of the cost of treting someone with TB, WHO nlyses of TB finncing hve lwys included estimtes of the funding required for both inptient nd outptient cre. These costs hve been estimted from provider perspective only, nd do not include the costs fced by TB ptients nd their households. Incresing ttention is now being given to costs fced by TB ptients nd their households, s discussed in Chpter 7. Estimtes of the costs of inptient nd outptient cre for ptients with drug-susceptible TB or MDR-TB To estimte the funding used to provide inptient nd outptient cre for TB ptients, WHO multiplies the number of outptient visits nd dys of inptient cre per ptient (reported by NTPs ech yer, s explined bove) by the cost per bed dy nd per clinic visit vilble from the WHO CHOosing Interventions tht re Cost-Effective (WHO-CHOICE) dtbse, d nd then by the reported number of TB ptients notified or projected to be notified. These estimtes re done seprtely for drug-susceptible TB nd MDR-TB. In 218, costs per bed dy nd per clinic visit were estimted using the CHOICE regression model nd the ltest dt vilble from the World Bnk. For two countries (Indi nd Thilnd), WHO- CHOICE estimtes were replced with estimtes of unit costs obtined directly from ntionl helth ccount dt, or from recent studies nd discussions with experts supporting the costing of ntionl strtegic plns. Where possible, estimtes re compred with hospitl nd clinic expenditure dt for drug-susceptible TB nd MDR-TB tht re being trcked through the System of Helth Accounts (SHA). e In 218, SHA dt were vilble for 27 countries for 1 or 2 yers, including six high burden countries (Cmbodi, the Democrtic Republic of the Congo, Nmibi, the Philippines, Sierr Leone nd the United Republic of Tnzni). f After review, the SHA dt were used in preference to estimtes bsed on the combintion of reported use nd WHO-CHOICE unit cost estimtes. The WHO Helth Governnce nd Finncing Deprtment hs initited process to ssess the vlidity of the ltest results from the new SHA, including disese-specific results. Expnded implementtion of SHA nd vlidtion ginst existing disese-specific trcking systems my fcilitte more comprehensive reporting of domestic funding for TB. In prticulr, it my fcilitte reporting of the contributions from subntionl dministrtive levels tht re not lwys known or compiled t the ntionl level. Although much of this contribution is probbly for delivery of inptient nd outptient cre (which is included in current WHO estimtes of domestic funding for TB, s explined bove), reporting of funding from these levels (including TB-specific budgets) is prticulr chllenge in lrge countries with decentrlized systems for TB tretment (e.g. Indonesi, Nigeri nd South Afric). Estimtes of the cost per ptient treted for drugsusceptible TB nd MDR-TB Since 214, WHO hs been reporting estimtes of the costs per ptient treted for drug-susceptible TB nd MDR-TB. Costs re clculted seprtely for drug-susceptible TB nd MDR-TB. In ech cse, the numertor is 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 with dt vlidted s described bove. Ctegories of expenditure considered s costs for MDR-TB were second-line drugs nd ll other inputs used or ctivities implemented for the progrmmtic mngement of MDR-TB. All other ctegories (except collbortive TB/HIV ctivities) were ssumed to be for drug-susceptible TB. An exception ws mde for the Russin Federtion, for which expenditures for stff nd infrstructure were llocted by WHO to drug-susceptible TB (33%) nd MDR-TB (67%), bsed on the proportion of bed dys used for these two ctegories of ptients. Unit costs were then clculted s the sum of 217 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 c d e f Floyd K, Pntoj A, Dye C. Finncing tuberculosis control: the role of globl finncil monitoring system. Bull World Helth Orgn. 27;85(5):334 4 ( ccessed 12 July 218). 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):e15 15 ( ncbi.nlm.nih.gov/pubmed/ , ccessed 11 July 218). Globl Helth Cost Consortium unit cost study dt repository, ccessed 12 July 218 ( 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 12 July 218). OECD/Eurostt/WHO. A system of helth ccounts. OECD Publishing; 211 ( ccessed 12 July 218). Helth ccounts. Genev: World Helth Orgniztion; dt shred by WHO Helth Governnce nd Finncing Deprtment. 117

129 FIG. 6.3 Funding for TB prevention, dignosis nd tretment in totl nd by ctegory of expenditure, , 119 countries with 97% of reported cses US$ billions (constnt vlues for 218) Other TB/HIV Totl Drug-susceptible TB MDR-TB where downturn fter 214 is explined by decreses in funding in the Russin Federtion ( ) nd in South Afric ( nd ). Funding for MDR-TB in other countries decresed from 214 to 217 nd then incresed in 218 (Fig. 6.4). Although the gp between the funding vilble in 218 nd the requirement of US$ 2.5 billion in 218 estimted in the Globl Pln is reltively smll (US$.5 billion), it hs widened over the pst 2 yers. This is consistent with the need to increse the coverge of dignosis nd tretment for MDR-TB, which currently flls fr short of Globl Pln trgets both overll nd in most countries with high burden of MDR-TB (for detils, see Chpter 4). It is lso evident from the Globl Pln estimtes of funding required in future yers: the nnul funding required for MDR-TB will rech US$ 3.6 billion FIG. 6.4 Funding for drug-susceptible TB nd MDR-TB, , by country group US$ millions (constnt vlues for 218) 2 1 BRICS (n=5) 25 TB HBCs outside BRICS Other countries (n=89) 12 1 Drug-susceptible TB Drug-susceptible TB 7 Drug-susceptible TB MDR-TB 2 MDR-TB MDR-TB BRICS ccounted for 46% of the totl number of TB cses notified globlly in 217. The 25 high TB burden countries outside BRICS ccounted for 4%. The remining countries (n=89) included in finncing nlyses ccounted for 11% of the TB cses notified globlly in 217. in 217 nd more thn double the US$ 3.4 billion tht ws vilble in 26 (Fig. 6.3; ll figures re in constnt 218 US dollrs). Despite this growth in funding, mounts continue to fll short of wht is needed. Moreover, the shortfll compred with the Globl Pln estimte (Section 6.1) hs widened compred with 216 nd 217, incresing from US$ 2.3 billion in 217 to US$ 3.5 billion in 218 (US$ 6.9 billion vilble compred with n estimted requirement of US$ 1.4 billion). Of the totl of US$ 6.9 billion vilble in 218, US$ 4.8 billion (69%) is for the dignosis nd tretment of drug-susceptible TB. This is US$ 2.9 billion less thn the requirement of US$ 7.7 billion estimted in the Globl Pln. Funding for MDR-TB reched US$ 2. billion in 218; the nnul mount incresed stedily from 26 to 214, declined from 214 to 216, nd hs been incresing since 216 (Fig. 6.3). This ggregte trend reflects the pttern in the BRICS group of countries (Brzil, Russin Federtion, Indi, Chin nd South Afric) (Fig. 6.4), in 22, substntilly higher thn the mount of US$ 2. billion vilble in 218. Overll, most funding during the period hs been provided from domestic sources, nd this remins the cse in 218 (Fig. 6.5). 1 In 218, US$ 6. billion (86%) of the totl funding of US$ 6.9 billion for TB is from domestic sources. However, ggregted figures for the 119 low- nd middle-income countries re strongly influenced by BRICS, nd they concel substntil vrition mong countries in the shre of funding from domestic nd interntionl sources (Fig. 6.6). BRICS ccounted for 54% of the vilble funding for 1 Domestic funding includes both funding for TB-specific budgets, nd funding for inptient nd outptient cre (usully funded through more generl budget lines), s lso explined in Box 6.1. In Fig. 6.5 nd Fig. 6.6, it is ssumed tht funding for inptient nd outptient cre is provided domesticlly rther thn by interntionl donors. This is justified on the bsis tht most (99%) of the funding estimted to be used for inptient nd outptient cre for TB ptients is ccounted for by middle-income countries, where interntionl donor funding for such components of cre is unlikely (such support is more likely to occur in low-income countries, vi generl budget support to the helth sector). 118

130 FIG. 6.5 Funding for TB prevention, dignosis nd tretment by funding source, , 119 countries with 97% of reported cses US$ billions (constnt vlues for 218) Totl Domestic funding Interntionl donor funding Domestic funding includes TB-specific budgets nd the estimted resources used for inptient nd outptient cre (see Box 6.1). 93% of the funding of US$ 2.3 billion for inptient nd outptient cre for 218 is ccounted for by middle-income countries; such countries do not typiclly receive interntionl donor funding for inptient nd outptient cre services. TB in 218 (nd 46% of the world s notified TB cses), with 96% (rnge 91 %) of their funding coming from domestic sources. As highlighted in the 217 Globl tuberculosis report, 1 in Indi there hs been prticulrly striking increse in the TB-specific budget nd domestic funding for this budget since 216 (Fig. 6.7). Between 216 nd 218, domestic funding for the ntionl budget for TB in Indi more thn qudrupled, from US$ 11 million in 216 to US$ 458 million in 218. Domestic funding lso domintes in seven of the nine (not mutully exclusive) country groups shown in Fig. 6.6, rnging from 6% in Afric to 97% in upper-middle-income countries. In contrst, interntionl donor funding continues to exceed funding from domestic sources in low-income countries (57% of the totl in 218). In the 25 high TB burden countries excluding BRICS, 2 the shre of funding from domestic sources incresed to 61% in 218, up from 55% in 217. In this group, the countries with notble increses in funding from domestic sources between 217 nd 218 were Cmbodi, Indonesi, Lesotho, Ppu New Guine nd Philippines. 3 Interntionl donor funding reported by NTPs to WHO mounted to US$.9 billion in 218, slight decline compred with 217. Of this mount, most (74%) ws provided by the Globl Fund. The importnce of interntionl donor funding in high TB burden countries is prticulrly evident when consid- 1 World Helth Orgniztion. Globl tuberculosis report 217 (WHO/HTM/ TB/217.23). Genev: WHO; 217 ( dle/1665/259366/ eng.pdf, ccessed 21 June 218). 2 The list of 3 high TB burden countries being used by WHO during the period is explined in Chpter 2. The countries re those listed in Fig. 6.8, Tble 6.1 nd Tble These figures exclude domestic funding for inptient nd outptient cre during tretment. For further detils for these countries, see the country profiles in Annex 2. ering only the TB-specific budgets included in ntionl strtegic plns for TB (Fig. 6.8, Tble 6.1 nd Tble 6.2). In 17 of the 3 high TB burden countries, more thn % of vilble funding for the TB-specific budgets included in ntionl strtegic plns for TB is from interntionl donors in 218. Both Fig. 6.7 nd Fig. 6.8 illustrte the potentil to increse domestic funding in some high TB burden countries. 4 In the group of nine low-income high TB burden countries, the proportion of the TB budget funded from domestic sources in 218 rnges from % in Zimbbwe to 14% in Centrl Africn Republic. In the group of 15 lower-middle-income high TB burden countries, the proportion rnges from 3% in Pkistn to 79% in Indi. In the group of six upper-middle-income countries, the proportion rnges from 85% in Brzil to % in the Russin Federtion. Funding reported by NTPs to WHO does not cpture ll interntionl donor funding for TB. 5 For this reson, complementry nlysis bsed on donor reports to the Orgnistion for Economic Co-opertion nd Development (OECD) is provided in Box Funding gps reported by ntionl TB progrmmes, Mny NTPs reported shortfll in the funding required for full implementtion of their ntionl strtegic plns (Fig. 6.8, Fig. 6.9 nd Tble 6.2). 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 incresed, nd in 218 they mounted to reported totl of US$ 1.2 billion. This is lmost third of the gp of US$ 3.5 billion tht exists between the US$ 1.4 billion estimted to be needed in low- nd middle-income countries in 218 ccording to the Globl Pln (Section 6.1) nd the US$ 6.9 billion vilble in 218 (Section 6.2). The difference cn be explined by the fct tht, in mny countries, ntionl strtegic plns for TB re less mbitious thn the trgets set in the Globl Pln (Section 6.1). Of the US$ 1.2 billion funding gp reported by NTPs in 218, US$.99 billion (8%) is for drug-susceptible TB nd US$.24 billion (2%) is for MDR-TB. Reltive to totl funding needs, the funding gp is lrger for drug-susceptible TB thn for MDR-TB. Lower-middle-income countries ccount for the lrgest reported funding gp (US$ 826 million) in Sustined nd incresed finncing ws one of the four topics of the Moscow Declrtion to End TB; First WHO Globl Ministeril Conference on Ending TB in the Sustinble Development Er: A Multisectorl Response, November 217. Genev: WHO nd the Ministry of Helth of the Russin Federtion; 217 ( Declrtion_MinisterilConference_TB/en/, ccessed 21 June 218). 5 Donor funding is lso provided to entities other thn NTPs, including interntionl nd ntionl orgniztions, both governmentl nd nongovernmentl. 6 Out-of-pocket expenditures re lso not included in the finncing dt reported by NTPs. These re discussed in more detil in Chpter

131 TABLE 6.1 Reported budget in ntionl strtegic plns for TB, by intervention re nd estimted cost of inptient nd outptient cre for drug-susceptible (DS-TB) nd MDR-TB, 3 high TB burden countries, 218 (current US$ millions) TOTAL BUDGET IN NATIONAL STRATEGIC PLAN FOR TB DS-TB MDR-TB TB/HIV INPATIENT AND OUTPATIENT CARE (DS-TB) INPATIENT AND OUTPATIENT CARE (MDR-TB) ESTIMATED TOTAL RESOURCES REQUIRED FOR TB CARE Angol Bngldesh < Brzil Cmbodi Centrl Africn Republic <.1.6 < 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 c < UR Tnzni Viet Nm Zmbi Zimbbwe high TB burden countries Subtotls do not lwys dd to the totl due to rounding. indictes vlues tht cnnot be clculted. No mounts for the dditionl resources required for inptient nd outptient cre re shown for Chin, the Russin Federtion nd South Afric 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 (33%) nd MDR-TB (67%) by WHO bsed on the proportion of beddys used by DS-TB nd MDR-TB ptients. c In 218, the budget reported by Thilnd ws for the centrl level only. 12

132 TABLE 6.2 Reported budget in ntionl strtegic plns for TB, vilble funding for this budget from domestic nd interntionl donor sources nd funding gp, 3 high TB burden countries, 218 (current US$ millions) TOTAL BUDGET IN NATIONAL STRATEGIC PLAN FOR TB DOMESTIC FUNDING (A) INTERNATIONAL DONOR FUNDING (B) SHARE OF AVAILABLE FUNDING (A+B) PROVIDED FROM DOMESTIC SOURCES (%) SHARE OF AVAILABLE FUNDING (A+B) PROVIDED BY INTERNATIONAL DONORS (%) Angol 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 3 < high TB burden countries Subtotls do not lwys dd to the totl due to rounding. In 218, the budget reported by Thilnd ws for the centrl level only. b The funding gp reflects the nticipted gp for the yer t the time country reported dt to WHO in the 218 round of globl TB dt collection. FUNDING GAP b 121

133 FIG. 6.6 Funding for TB prevention, dignosis nd tretment from domestic sources nd interntionl donors, , 9 country groups 4. BRICS b. HBCs excluding BRICS c. Rest of world US$ billions (constnt vlues for 218) d. Low-income countries e. Low-middle-income countries f. Upper-middle-income countries g. Afric h. Asi b i. Other regions c Domestic funding Interntionl donor funding b c Rest of world includes 89 countries tht re not in the list of 3 high TB burden countries. Asi includes the WHO regions of South-Est Asi nd the Western Pcific. Other regions consist of three WHO regions: the Estern Mediterrnen Region, the Europen Region, nd the Region of the Americs. 122

134 FIG. 6.7 Ntionl budget for TB nd sources of funding in Indi, US$ millions (constnt vlues for 218) Funding gp Interntionl donor funding Domestic funding (Fig. 6.9). Compred with 217, funding gps incresed in ll country groupings. In 218, the lrgest funding gps mong low-income countries were for high TB burden countries: the Democrtic People s Republic of Kore (US$ 77 million), Ethiopi (US$ 52 million), the Democrtic Republic of the Congo (US$ 37 million) nd the United Republic of Tnzni (US$ 33 million) (Tble 6.2). Funding gps incresed for upper-middle-income countries in 218 (US$ 154 million). This increse is mostly explined by lrge funding gps reported by Chin (US$ 67 million) nd Guteml (US$ 16 million). Hlf of the totl reported funding gp in 218 is ccounted for by countries in the WHO Africn Region (US$ 6 million), with Nigeri ccounting for hlf of the region s gp (US$ 312 million), followed by Ethiopi (US$ 52 million), Angol (US$ 37 million) nd the Democrtic Republic of the Congo (US$ 37 million). Most of the remining gp ws reported by countries in the WHO South-Est Asi Region, primrily Indonesi (US$ 145 million) nd the Democrtic People s Republic of Kore (US$ 77 million), nd by countries in the WHO Western Pcific Region, primrily Chin (US$ 68 million) nd the Philippines (US$ 66 million) (Fig. 6.9). 6.4 Unit costs of tretment for drugsusceptible TB nd multidrug-resistnt TB, 217 The cost per ptient treted in 217 for drug-susceptible TB nd MDR-TB ws estimted for 113 countries nd 85 countries, respectively. 1 All 3 countries in the lists of high TB burden countries nd high MDR-TB burden countries were included in the nlyses. 2 Unit cost estimtes re shown in Fig. 6.1 nd Fig. 6.11, nd nlyticl methods re summrized in Box Anlysis for drug-susceptible TB ws limited to countries tht notified t lest TB cses in 217. For MDR-TB, estimtes were restricted to countries tht reported t lest 2 ptients on second-line tretment for MDR-TB in For further detils bout both lists, see Chpter 2. A recent globl inititive to improve the vilbility nd qulity of unit cost dt for TB is summrized in Box Drug-susceptible TB The medin cost per ptient treted for drug-susceptible TB in 217 ws US$ 1224 (Fig. 6.1). 3 In generl, bout 68% of this cost ws ccounted for by reported NTP expenditures, with the reminder being costs for inptient nd outptient cre. There ws positive reltionship between the cost per ptient treted nd the gross domestic product (GDP) per cpit, nd negtive reltionship with the size of the ptient cselod (indicting economies of scle, e.g. in Chin nd Indi). In 29 of the 3 high TB burden countries included in the nlysis, the cost per ptient treted for drug-susceptible TB ws less thn the GDP per cpit; the exceptions were Sierr Leone nd Nmibi. The cost per ptient treted ws typiclly higher in the 17 countries included from the WHO Europen Region. Countries in Estern Europe nd Centrl Asi (EECA) hve reltively high costs due to extensive use of hospitliztion for ptients in the intensive phse of tretment, with hospitl dmissions verging 56 dys per person in 217. High progrmme costs reltive to smller pool of ptients lso help to explin comprtively high per-ptient costs in some countries (e.g. in Bosni nd Herzegovin, nd Mcedoni). However, it is lso evident tht some EECA countries hve mrkedly reduced the use of hospitliztion nd hve chnged the model of cre for ptients with drug-susceptible TB. From 214 to 217, 15 of the 17 EECA countries reduced the number of bed dys per ptient treted for drug-susceptible TB (see Box 6.1 for estimtion method); the exceptions were Ukrine (12% increse) nd Kyrgyzstn (1% increse) Multidrug-resistnt TB For MDR-TB, the medin cost per ptient treted ws US$ 7141 in 217 (Fig. 6.11). As with drug-susceptible TB, the cost per ptient treted ws positively correlted with GDP per cpit. New shortened regimens of 9 12 months cost bout US$ per person. These regimens hve been recommended since 216 by WHO for ptients (other thn pregnnt women) with rifmpicin-resistnt or MDR pulmonry TB who do not hve resistnce to second-line drugs. 4 The uptke of such regimens hs contributed to decrese in the unit cost of tretment for MDR-TB in Medin vlues re cited rther thn mens becuse of extreme vlues for few countries. 4 For further detils bout this recommendtion, see Chpter

135 BOX 6.2 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 during were nlysed. Funding for TB tht flows from one OECD member to n institution or government within the OECD, such s grnts from the United Sttes (US) Ntionl Institutes for Helth flowing to the United Kingdom, is not cptured in the CRS. Also, government contributions to multilterl orgniztions re not ttributed to the government of origin, only to the multilterl orgniztion. b Fig. B6.2.1 shows trends in interntionl donor funding between 26 nd 216, from four mjor sources s totl nd by four mjor regions of the world. The totl from ll sources in 216 ws US$ 871 million, big increse from US$ 221 million in 26. In 216, 69% of interntionl donor funding ws provided by the Globl Fund. The second lrgest contributor ws the US government (21%, US$ 179 million). c Given tht bout one third of the contributions to the Globl Fund re from the US government, bout 44% of interntionl donor funding for TB globlly originted from the US government in 216. From 26 to 216, the Globl Fund ws consistently the lrgest provider of interntionl donor funding (with the shre verging 66% in this period). There ws mrked drop between 213 (US$ 71 million) nd 214 (US$ 398 million), period in which new funding model ws introduced. This ws followed by recovery to US$ 483 million in 215 nd to US$ 63 million in 216. Disbursements from the US government stedily incresed from 26 to 214, peking t US$ 253 million in 214 before declining to US$ 179 million in 216. c The regionl pnels show tht Afric nd Asi receive the vst mjority of interntionl donor funding. Fig. B6.2.2 shows the proportion nd mounts of funding from 26 to 216 from individul countries to non-oecd countries, including their estimted funding for TB vi contributions to the Globl Fund. Over this period, 46% of this funding cme from the United Sttes of Americ. The next lrgest individul country contributors were Frnce (1%), the United Kingdom (9.%), Germny (6.2%), Jpn (5.9%) nd Cnd (5.6%). FIG. B6.2.1 Interntionl donor funding for TB prevention, dignosis nd tretment by source, globlly nd by region, Globl Afric Americs US$ millions (constnt vlues for 216) 2 Asi Europe Globl Fund United Kingdom United Sttes Other 124

136 FIG. B6.2.2 Interntionl donor funding (in 216 US$ millions) for TB prevention, dignosis nd tretment from individul countries, Austrli 93 Belgium 12 Cnd 451 Germny 496 Itly 183 Other countries 199 Russin Federtion 53 Spin 142 Sweden 185 United Sttes 3712 Jpn 474 Frnce 823 United Kingdom 719 Netherlnds 198 Norwy 148 Funding mounts include bilterl funding s well s estimted funding for TB vi contributions to the Globl Fund (estimted bsed on the ssumption tht 18% of contributions re for TB). Dt re shown for countries tht provided t lest US$ million in the time period All other countries re combined in the Other countries box. FIG. B6.2.3 Interntionl donor funding for TB, HIV nd mlri, US$ billions (constnt vlues for 216) HIV mlri TB Fig. B6.2.3 shows tht interntionl funding for TB is less thn hlf tht for mlri nd bout one eighth tht for HIV. To provide some context for these mounts, the disbilitydjusted life yers (DALYs) lost due to illness nd deth for these three diseses in 217 were 58 million for HIV/AIDS, 56 million for mlri nd 44 million for TB. d This trnsltes into US$ 119 of interntionl donor finncing per DALY lost for HIV, US$ 34 for mlri, nd US$ 2 for TB. b c d As opposed to commitments, which my not mterilize. An importnt exmple is funding from the Globl Fund to non-oecd countries, which is ttributed to the Globl Fund nd not to the governments or other entities tht contribute to the Globl Fund. Disbursements from the US government cptured in the OECD dtbse re lower thn officil lloctions. Source: ccessed 8 July

137 FIG. 6.8 Sources of funding nd funding gps for the TB-specific budgets included in ntionl strtegic plns for TB in 218, 3 high TB burden countries Centrl Africn Republic Ethiopi DPR Kore Mozmbique UR Tnzni Liberi DR Congo Sierr Leone Zimbbwe Indi Congo Ppu New Guine Philippines Indonesi Keny Lesotho Zmbi Bngldesh Cmbodi Viet Nm Nigeri Angol Mynmr Pkistn Russin Federtion South Afric Chin Thilnd Brzil Nmibi Low-income Lower-middle-income Upper-middle-income Percentge Domestic funding Globl Fund Interntionl donor funding (excluding Globl Fund contributions) Budget gp 126

138 BOX 6.3 The Unit Cost Study Repository of the Globl Helth Cost Consortium: new resource to estimte the cost of TB nd HIV interventions Plnning nd finncing for TB prevention, dignosis nd tretment requires relible dt on the costs of TB services. Reporting of TB expenditures hs improved substntilly in recent yers, nd cn be combined with dt on the costs of specific TB services to inform TB budgeting nd improve the efficiency of TB progrmmes. However, cost studies re timeconsuming, nd funding is required to implement them. It hs been recognized for severl yers tht there is globl scrcity of cost dt for TB services, b nd tht vilble dt were lso becoming out of dte. Exmples of gps in dt vilbility include the cost of implementing new dignostics, shortened tretment regimens for MDR-TB, innovtive wys of providing TB services (e.g. public privte mix) nd interventions to improve the qulity of TB cre. Mny high TB burden countries do not hve dt on the unit cost of ech of the TB interventions being provided. FIG. B6.3.1 Cost per ptient treted for drug-susceptible TB or MDR-TB: current vilbility of unit cost dt from independent costing studies, Number vilble No dt The Unit Cost Study Repository (UCSR) is centrlized source of costing dt for TB nd HIV interventions tht is esily ccessible to policy nlysts, country officils nd implementing orgniztions vi n online ppliction for desktop or mobile devices. It provides stndrdized unit cost dt t the intervention nd service output levels, with disggregtion of the unit cost vilble by input (e.g. personnel nd cpitl) nd for different ctegories of ctivity. An ssessment of the qulity of ech estimte is included, bsed on the reference cse publiction. As of July 218, totl of 174 TB studies were included in the UCSR, bsed on systemtic review of costing studies implemented during the period (Fig. B.6.3.1). Of these, 67 studies reported only costs incurred by ptients, 6 reported provider costs, nd 47 reported costs from societl perspective (i.e. both ptient nd provider costs were considered). The interventions tht were costed in ech study vried. Not pplicble As collection of new dt tkes plce nd dt producers shre their dt with the GHCC, the UCSR will be enriched nd, ultimtely, this resource will improve the cost dt vilble for use by the TB community. UCSR dt will be used by WHO s Globl TB Progrmme to tringulte its estimtes of the cost per ptient treted for drug-susceptible TB nd MDR- TB (Fig. 6.1 nd Fig. 6.11); in prticulr, the unit cost estimtes for inptient stys nd outptient visits. Also, the Globl TB Progrmme my use the UCSR dt in preference to the dt sources tht re currently relied upon. Source: Unit Cost Study Repository, ccessed on 19 July 218. The Globl Helth Cost Consortium (GHCC) ws estblished in 216, with funding from the Bill & Melind Gtes Foundtion, to help to ddress these gps. The im of the GHCC is to improve the resources vilble to estimte the costs of both TB nd HIV interventions. c To dte, it hs focused on two things: stndrds nd methods for costing, nd the development of repository of unit cost dt. The Reference cse for estimting the globl helth services nd interventions provides set of stndrdized principles nd methods tht cn ssist with both collecting nd evluting cost dt. d It lso provides detiled costing guidelines nd tools for costing TB services. b c d 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):e15 15 ( ncbi.nlm.nih.gov/pubmed/ , ccessed 11 July 218). Lurence YV, Griffiths UK, Vssll A. Costs to helth services nd the ptient of treting tuberculosis: systemtic literture review. Phrmcoeconomics. 215;33(9): ( pubmed/259391, ccessed 12 July 218). Globl Helth Cost Consortium 216 website, vilble from ghcosting.org/. Vssll A, Sweeney S, Khn J, Gomez GB, Bollinger L, Mrseille E et l. Reference cse for estimting the costs of globl helth services nd interventions. Globl Helth Cost Consortium; 217 ( org/pges/stndrds/reference_cse, ccessed 12 July 218). 127

139 FIG. 6.9 Reported funding gps for TB by income group nd by WHO region, Totl gp in 218 = US$ 1.2 billion 6 Totl gp in 218 = US$ 1.2 billion US$ millions (constnt vlues for 218) US$ millions (constnt vlues for 218) Low-income countries Lower-middle-income countries Upper-middle-income countries Afric The Americs Estern Mediterrnen Europe South-Est Asi Western Pcific FIG. 6.1 Estimted cost per ptient treted for drug-susceptible TB in 113 countries, 217 Cost per ptient treted (218 US$, log scle) TB cselod (notified TB cses) 1 2 Centrl Africn Republic Mozmbique Sierr Leone DPR Kore Ethiopi Liberi DR Congo UR Tnzni Cmbodi Lesotho Mynmr Pkistn Zimbbwe Zmbi Nigeri Indi Keny Bngldesh Angol Ppu New Guine Viet Nm Philippines Congo Indonesi Nmibi South Afric Thilnd WHO region Afric Chin The Americs Russin Federtion Estern Mediterrnen Brzil Europe South-Est Asi Western Pcific GDP per cpit (218 US$, log scle) Limited to countries with t lest ptients on first-line tretment in

140 FIG Estimted cost per ptient treted for MDR-TB in 85 countries, 217 MDR-TB cselod (notified cses) 3 Cost per ptient treted (218 US$, log scle) DR Congo Mozmbique Somli DPR Kore Ppu New Guine Ukrine Nigeri Keny Moldov Uzbekistn Kyrgyzstn Philippines Tjikistn Indi Angol Indonesi Bngldesh Viet Nm Mynmr Pkistn Belrus South Afric Kzkhstn Peru WHO region Afric Chin Thilnd The Americs Estern Mediterrnen GDP per cpit (218 US$, log scle) Limited to countries with t lest 2 ptients on second-line tretment in 217. Russin Federtion Europe South-Est Asi Western Pcific 129

141 The Prisópolis fvel in São Pulo, Brzil, nd the neighbouring district of Morumbi Tuc Vieir 13

142 Chpter 7. Universl helth coverge, socil protection nd socil determinnts KEY FACTS AND MESSAGES Achieving the tuberculosis (TB) trgets nd milestones of the End TB Strtegy nd the TB trget set in the Sustinble Development Gols (SDGs) requires provision of TB cre nd prevention within the broder context of universl helth coverge (UHC), nd multisectorl ction to ddress the socil nd economic determinnts nd consequences of TB. UHC mens tht everyone irrespective of their living stndrds or their prticulr disese or helth needs receives the helth services they need, nd tht using helth services does not cuse finncil hrdship. SDG trget 3.8 is to chieve UHC by 23. The SDGs include two indictors for monitoring progress towrds UHC. The first is the coverge of essentil helth services, mesured s n index (with vlues from to ). The second is the proportion of households in the generl popultion tht fce ctstrophic helth expenditures, defined s household expenditures on helth tht exceed certin percentge of totl household expenditure or income; the denomintor includes mny households tht did not use helth services or hd only very minor contct with the helth system. The ltest estimtes published by WHO nd the World Bnk suggest tht t lest hlf of the world s popultion lcks ccess to essentil helth services nd tht nnully round 8 million people lmost 1% of the world s popultion experience ctstrophic expenditures on helth. All high TB burden countries still fce significnt chllenges to ensure both spects of UHC. In 217, WHO published estimtes of the resources needed to mke progress towrds UHC nd rech other SDGrelted helth trgets by 23. These suggested tht most middle-income countries could mobilize the required resources domesticlly, but tht this is unlikely in low-income countries. Socil protection for people with TB nd their households is prt of Pillr 2 of the End TB Strtegy, nd socil protection more brodly is n indictor under SDG 1. TB-specific socil support is in plce in some countries: exmples include csh trnsfers, food pckges nd ssistnce with costs relted to trnsport. There re lso exmples of TB ptients being linked to more generl socil protection schemes. Since 216, considerble progress hs been mde in mesuring costs fced by TB ptients nd their households. In ntionl fcility-bsed surveys completed to dte, best estimtes of the percentge of TB ptients nd their households fcing direct nd indirect costs tht exceeded 2% of their nnul household income rnged from 27% to 71%. Survey results should be used to help develop pproches to finncing, service delivery nd socil protection tht will reduce these costs. Exmples of countries where this hs been done in 218 re Ghn nd Keny. Mny new cses of TB re ttributble to undernourishment, HIV infection, smoking, dibetes nd lcohol use. A recent modelling study lso shows how poverty is n importnt underlying driver of ntionl TB epidemics, nd tht eliminting extreme poverty nd providing socil protection (both trgets under SDG 1) could substntilly reduce TB incidence. 131

143 The End TB Strtegy nd the Sustinble Development Gols (SDGs) include common im: to end the globl tuberculosis (TB) epidemic. Specific trgets set in the End TB Strtegy include 9% reduction in TB deths nd n 8% reduction in the TB incidence rte (new cses per popultion per yer) by 23 compred with 215; more immedite milestones for 22 re reductions of 35% nd 2%, respectively. As highlighted elsewhere in this report, in prticulr in Chpter 2, chieving these trgets requires provision of TB cre nd prevention within the broder context of universl helth coverge (UHC), multisectorl ction to ddress the socil nd economic determinnts nd consequences of TB, nd technologicl brekthrough by 225 so tht incidence cn fll much fster thn it hs done historiclly. This chpter hs four mjor sections. Section 7.1 provides n overview of the sttus of globl progress towrds UHC, nd summry of recent WHO estimtes of the resources required for progress towrds UHC nd other SDG helth trgets during the period Section 7.2 discusses the role of socil protection in improving cre nd support to TB ptients nd their households, nd wht is known bout the current sttus of such protection in high TB burden countries. Section 7.3 presents the sttus of progress in implementing ntionl surveys of costs fced by TB ptients nd their households s of July 218, nd survey results from eight countries. It highlights the implictions of such costs, including for pproches to TB service delivery, finncing nd socil protection. Section 7.4 covers the broder determinnts of TB, including nlysis of 14 indictors (under seven SDGs) tht re ssocited with TB incidence. 7.1 Globl progress towrds UHC UHC mens tht everyone irrespective of their living stndrds receives the helth services they need, nd tht using helth services does not cuse finncil hrdship. 1 The SDG trgets re for 23, nd SDG Trget 3.8 is defined s Achieve UHC, including finncil risk protection, ccess to qulity essentil helth-cre services nd ccess to sfe, effective, qulity nd ffordble essentil medicines nd vccines (Chpter 2). Two SDG indictors hve been defined to monitor progress towrds SDG Trget 3.8. The first (Indictor 3.8.1) is the coverge of essentil helth services; this is composite index (with vlues from to ) bsed on 16 trcer indictors (one of which is TB tretment 2 ). The 1 World Helth Orgniztion/World Bnk. Trcking universl helth coverge: 217 globl monitoring report. Genev: WHO; 217 ( pps.who.int/iris/bitstrem/hndle/1665/259817/ eng.pdf, ccessed 21 June 218). See pp xii. 2 The indictor used in the WHO/World Bnk report is effective TB tretment coverge. It ws clculted s tretment coverge multiplied by the tretment success rte, to cpture qulity dimension of cre. This differs from the definition of tretment coverge in the list of priority End TB Strtegy indictors (see Chpter 2). second (Indictor 3.8.2) is the proportion of the popultion with lrge household expenditures on helth s shre of totl household expenditure or income. Lrge is defined using two thresholds: 1% nd 25%. When these thresholds re surpssed, expenditures re clssified s ctstrophic. Since this mesure is popultion-bsed, the denomintor includes mny people who did not use helth services or hd only very minor contct with the helth system. The WHO/World Bnk report on trcking progress towrds UHC, published in December 217, ws the first to publish dt on the two SDG indictors for UHC. 3,4 Key findings from the report re summrized here Coverge of essentil helth services The vlue of the UHC service coverge index in 215, by country, is shown in Fig There ws gret del of vrition mong countries, with vlues rnging from low of 22 in Somli to 8 or bove, nd medin vlue of 65. The highest vlues were in high-income countries in Asi, Europe nd North Americ. The lowest vlues were predominntly in countries in the WHO Africn Region; other countries with vlues below 4 were Afghnistn nd Yemen. Overll, t lest hlf of the world s popultion lcked ccess to essentil helth services in Finncil protection The estimted proportion of the generl popultion fcing ctstrophic helth spending, using the cut-off of more thn 1% of household expenditure or income, is shown in Fig Compred with the service coverge index, there is more geogrphicl vribility in this indictor, including within regions. Countries with the highest levels of ctstrophic spending on helth ( 15% of the generl popultion fcing ctstrophic spending on helth) include the countries tht rnk first (Indi) nd second (Chin) in terms of their totl number of TB cses, most countries in Ltin Americ nd severl countries in the WHO Africn Region. Countries with the lowest levels ( 3%) include mix of high-income, middle-income nd low-income countries. It is importnt to highlight tht some countries my hve low levels of mesured spending on helth becuse people do not ccess helth cre t ll, or becuse cpcity to spend household resources on helth is very low. One exmple is Mozmbique, for which the vlue of the service coverge index ws 42 while the estimted proportion of households fcing ctstrophic expenditures on helth ws 1.2% (bsed on dt for 28). Globlly, WHO nd the World Bnk estimted tht, in 3 World Helth Orgniztion/World Bnk. Trcking universl helth coverge: 217 globl monitoring report. Genev: WHO; 217 ( pps.who.int/iris/bitstrem/hndle/1665/259817/ eng.pdf, ccessed 21 June 218). 4 For Indictor 3.8.2, estimtes in the report re bsed primrily on the cut-off of 1% of totl household income. 132

144 FIG. 7.1 UHC service coverge index by country, 215 Score < No dt Not pplicble Source: WHO Universl Helth Coverge dt portl. FIG. 7.2 Percentge of the generl popultion fcing ctstrophic helth expenditures, ltest vilble yer of dt b b Percentge of popultion 2.9 Defined s 1% of totl household income or household consumption. The ltest vilble yer rnges from 1993 to 215, consistent with the WHO/World Bnk report on trcking universl helth coverge published in 217. ( ccessed 21 June 218). Dt cn be obtined from the WHO Globl Helth Observtory: (ccessed 15 August 218) No dt Not pplicble 133

145 21, totl of 88 million people (12% of the world s popultion) incurred ctstrophic expenditures on helth Sttus of the two UHC indictors in the 3 high TB burden countries The sttus of the two SDG indictors for UHC (3.8.1 nd 3.8.2) in the 3 high TB burden countries, strtified by income group, 1 is shown in Tble 7.1. There is generl trend for the service coverge index to improve with income, but the level of ctstrophic helth spending vries considerbly within ech income bnd. The countries with the highest service coverge index (bove 7) re (in descending order) Brzil, Chin, Thilnd nd Viet Nm. The countries with the worst (highest) vlues for levels of ctstrophic spending on helth were middle-income countries (for exmple Brzil, Indi nd Nigeri), while those with the lowest vlues (<2%) included both lowincome countries nd severl middle-income countries. As explined bove, some countries my hve low vlues for the percentge of the popultion fcing ctstrophic expenditures on helth becuse people do not ccess helth cre t ll, or becuse cpcity to spend household resources on helth is very low. (including buildings nd medicl equipment) to rech recommended benchmrks. The reminder ws for specific priorities, including TB. The lrgest shre of investments needed for specific diseses or progrmmes ws ccounted for by noncommunicble diseses. Overll, helth expenditure (in both the moderte nd optimistic scenrios) ws projected to be sufficient to cover mbitious scenrio investment needs in middle-income countries. However, given uneven cpcity to mobilize dditionl resources, some countries were expected to fce gps, especilly in the first few yers. In the period , it ws predicted tht bout five out of the 39 middle-income countries included in the nlysis would fce funding gps. Overll, projected helth expenditures were not sufficient to cover investment needs in low-income countries, even in the optimistic scenrio for helth expenditures nd the progress scenrio for resource needs. Improved revenue genertion nd mngement of public expenditures, nd incresed public helth budgets were needed, in both low- nd middle-income countries UHC finncing prospects, In 217, WHO published estimtes of the resources needed during the period to mke progress towrds UHC nd to rech other SDG-relted helth trgets, nd compred these with projected totl helth expenditures in the sme time period. Referred to in shorthnd s the WHO SDG Helth Price Tg, 2 the estimtes re for 67 lownd middle-income countries tht ccount for 75% of the world s popultion, nd they focus on the dditionl (or incrementl) resources needed compred with levels in 214. Two scenrios were considered for resource needs (termed mbitious nd progress ), nd two scenrios (referred to s moderte nd optimistic ) were lso considered for totl helth expenditures. Key findings included the following: In the mbitious scenrio for resource needs (bsed on chievement of the 23 SDG trgets), the dditionl investment (compred with 214) required per yer grew from US$ 134 billion in 216 to US$ 371 billion (equivlent to n extr US$ 58 per person) in 23. Most of the incresed investment required (75% of the totl) ws for expnding nd strengthening the helth workforce nd helth services infrstructure 1 Income groups re bsed on the clssifiction of 218 for consistency with Chpter 6 of this report. However, estimtes of the incidence of ctstrophic helth spending in the WHO/World Bnk report, on monitoring UHC, re for erlier yers. 2 Stenberg K, Hnssen O, Tn-Torres Edejer T et l. Finncing trnsformtive helth systems towrds chievement of the helth Sustinble Development Gols: model for projected resource needs in 67 low-income nd middle-income countries. Lncet Glob Helth. 217;5(9):e875 e87 ( ccessed 11 July 218). Further nlyses bsed on the WHO SDG Helth Price Tg, focusing on comprisons of totl (s opposed to incrementl) investment needs with projections of totl helth expenditures, re shown in Fig. 7.3 nd Fig These illustrte the sme key messges in terms of the extent to which the resources needed to chieve UHC nd other SDG-relted helth trgets cn be mobilized in low- nd middle-income countries. In ddition, they indicte tht, by 23, totl verge helth spending would need to increse to US$ 112 per cpit in low-income countries, US$ 146 per cpit in lower-middle-income countries nd US$ 536 per cpit in upper-middle-income countries (Fig. 7.4). Totl funding needs s percentge of gross domestic product (GDP) would rise from 5.6% in 214 to 7.5% by 23 cross ll 67 countries (dt not shown), with much greter increse needed in low-income countries (from n verge of 6% in 214 to round 12% by 224). 7.2 Socil protection in the context of the TB response Socil protection refers to n integrted set of policies nd progrmmes tht provide support to those in need. Mjor elements include: socil ssistnce progrmmes; socil insurnce schemes; nd lbour mrket interventions, for exmple to fcilitte ccess to employment nd development of skills. Socil protection floors re bsic minimum set of policies nd progrmmes tht provide sfety net in the 134

146 TABLE 7.1 UHC service coverge indictor (SDG 3.8.1) nd percentge of generl popultion fcing ctstrophic helth expenditures (SDG 3.8.2), 3 high TB burden countries, strtified by income group b COUNTRY SERVICE COVERAGE INDEX CATASTROPHIC HEALTH EXPENDITURE c LOW INCOME Ethiopi Mozmbique DR Congo Liberi UR Tnzni Sierr Leone 36 1 Zimbbwe 55 Centrl Africn Republic 33 DPR Kore 68 LOWER MIDDLE INCOME Zmbi Pkistn 4 1. Lesotho Congo Indonesi Keny Philippines Viet Nm Angol Bngldesh Indi Nigeri Mynmr 6 Cmbodi 55 Ppu New Guine 41 UPPER MIDDLE INCOME South Afric Thilnd Russin Federtion Chin Brzil Nmibi 59 Dt were not vilble. Dt of UHC service coverge re from 215, nd dt of ctstrophic helth expenditures cover the period b Countries re listed within ech income group (s per 218 World Bnk clssifiction) ccording to the level of ctstrophic helth expenditure (from lowest to highest). c Defined s 1% of totl household income or household consumption. The ltest vilble yer for dt on ctstrophic helth expenditures rnges from 28 to 215 for 16 of the 3 countries; this time period is consistent with the yers of dt used for joint nlysis of service coverge nd ctstrophic expenditures in the WHO/World Bnk report on UHC monitoring ( ccessed 21 June 218). For 7 countries, however, the vlues shown in the tble re for erlier yers: Chin (27), DR Congo (24), Ethiopi (24), Keny (25), Lesotho (22), Liberi (27) nd Sierr Leone (23). No dt re vilble for Cmbodi, Centrl Africn Republic, DPR Kore, Mynmr, Nmibi, Ppu New Guine nd Zimbbwe. Dt cn be obtined from the WHO Globl Helth Observtory: (ccessed 15 August 218). 135

147 FIG. 7.3 Funding needs to progressively expnd services towrds UHC nd rech other SDG helth trgets in 67 low- nd middle-income countries compred with projected totl helth expenditures, US$ billions (constnt vlues for 214) Low-nd middle-income countries (n=67) Low-income countries (n=28) Lower-middle-income countries (n=22) Upper-middle-income countries (n=17) Totl helth expenditure (moderte scenrio) Totl helth expenditure (optimistic scenrio) Helth sector resource needs (mbitious scenrio) Source: Dt from Stenberg K, Hnssen O, Tn-Torres Edejer T et l. Finncing trnsformtive helth systems towrds chievement of the helth Sustinble Development Gols: model for projected resource needs in 67 low-income nd middle-income countries. Lncet Globl Helth 217; 5: e FIG. 7.4 Funding needs (per cpit) to progressively expnd services towrds UHC nd rech other SDG helth trgets by 23, by country income group US$ (constnt vlues for 214) per cpit Low-income countries (n=28) Lower-middle income countries (n=22) Upper-middle income countries (n=17) Additionl helth sector resource needs by 23 Current helth expenditure per cpit (214) Income groups re defined s of July 216. Per person helth costs re reported s popultion-weighted men vlues per income group per yer. Source: Dt from Stenberg K, Hnssen O, Tn-Torres Edejer T et l. Finncing trnsformtive helth systems towrds chievement of the helth Sustinble Development Gols: model for projected resource needs in 67 low-income nd middle-income countries. Lncet Globl Helth 217; 5: e event of unforeseen shocks. Although this is protective, the im of comprehensive socil protection is for poverty reduction, nd sustinble nd inclusive economic growth. Socil protection is n indictor under SDG 1, which is End poverty in ll its forms everywhere. SDG Trget 1.3 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. 1 Poverty nd TB re intrictely linked. People with TB cn fce severe direct nd indirect finncil nd economic costs tht ffect their bility to ccess cre nd complete tretment, while poverty is well-recognized risk fctor for TB. As such, socil protection for people with TB nd their households is prt of Pillr 2 of the End TB Strtegy (Chpter 2). The 216 nd 217 editions of the Globl tuberculosis report, 2,3 nd the 215 WHO guide to implementing the 1 The inclusion of trget for socil protection floors in the SDGs follows recommendtions on the topic by the Interntionl Lbour Orgniztion (ILO) in 212. For further detils, see Interntionl Lbour Orgniztion. R22 Socil protection floors recommendtion, 212 (no. 22). Genev: ILO (11st ILC session); 212 ( normlex/en/f?p=normlexpub:12:::no::p12_instrument_ ID:365524, ccessed 11 July 218). 2 World Helth Orgniztion. Globl tuberculosis report 216 (WHO/HTM/ TB/216.13). Genev: WHO; 216 ( m/1665/2441/1/ eng.pdf, ccessed 11 July 218). 3 World Helth Orgniztion. Globl tuberculosis report 217 (WHO/HTM/ TB/217.23). Genev: WHO; 217 ( dle/1665/259366/ eng.pdf, ccessed 11 July 218). 136

148 TABLE 7.2 Socil protection policy nd csh trnsfer schemes in 3 high TB burden countries YES NOT IDENTIFIED STRATEGY/POLICY REGISTRY b TARGETINGc POOR AND VULNERABLE Angol Bngldesh Brzil Cmbodi Centrl Africn Republic Chin DR Congo Congo DPR Kore Ethiopi Indi Indonesi Keny Lesotho Liberi Mozmbique Mynmr Nmibi Nigeri Pkistn Ppu New Guine Philippines Russin Federtion Sierr Leone South Afric Thilnd UR Tnzni Viet Nm Zmbi Zimbbwe DISABLED b c Strtegy/policy indictes whether ntionl strtegy, nd/or policy/legisltive frmework for socil protection ws identified. Registry indictes whether socil nd/or beneficiry registry system for socil ssistnce progrmmes is in plce. Trgeting indictes whether there re ny identified non-contributory csh trnsfer schemes specificlly for poor nd vulnerble groups nd the disbled. Poor nd vulnerble groups include trnsfers to individuls nd households bsed on socio-economic criteri nd my include children, the elderly, poor people with disbilities, nd those fcing food insecurity; disbled refers to persons hving disbility regrdless of socio-economic sttus. Sources: WHO Globl TB Progrmme Country Socil Protection Briefs; dditionl informtion on registries: The stte of socil sfety nets 215 ( documents.worldbnk.org/curted/en/ /the-stte-of-socil-sfety-nets-215); Socil registries for socil ssistnce nd beyond: guidnce note & ssessment tool ( End TB Strtegy, 1 explined core principles relted to socil protection in the context of TB. They lso provided country exmples of steps being tken to estblish nd/ or strengthen socil protection systems in generl, including socil ssistnce schemes of prticulr relevnce to TB-ffected households nd communities. 1 World Helth Orgniztion. Implementing the End TB Strtegy: the essentils (WHO/HTM/TB/215.31). Genev: WHO; 215 ( who.int/tb/publictions/215/end_tb_essentil.pdf?u=1, ccessed 11 July 218). The need for expnded policy nd legl frmeworks, finncing nd progrmme strengthening to ensure tht support is vilble on systemtic nd sustinble bsis ws highlighted. In ddition, exmples were provided of socil support in the context of TB tretment services, such s trnsport, vouchers, food pckges, nd psychosocil support, nd csh-trnsfer schemes (including those in which TB ptients re linked to generl schemes). Documenttion on socil protection for TB ptients is incresing. 137

149 138 A summry of the elements of socil protection of prticulr relevnce to TB ptients nd their households tht re in plce in the 3 high TB burden countries is provided in Tble 7.2, using informtion compiled by WHO s Globl TB Progrmme in 217 nd 218. The focus is on three mjor elements of socil protection schemes tht my be of substntil relevnce to efforts to improve socil protection for TB ptients nd households. These re: the existence of overll policy, strtegy or legisltive frmeworks; register of trget popultions or beneficiries; nd some level of coverge of csh trnsfers for specific poor or vulnerble popultions or disbled persons. Of the 3 countries, 26 hve policy document, strtegy or relevnt legisltion for socil protection, nd most hve some form of csh trnsfer system. Dt on coverge levels of csh trnsfers re not esy to obtin, but vilble dt suggest tht coverge in mny of the 3 high TB burden countries remins low nd frgmented. More positively, Indi is n exmple of country tht took mjor steps in to expnd TB-specific csh trnsfers nd linkges to broder nutrition schemes. Stkeholder workshops to discuss the results from ntionl surveys of costs fced by TB ptients nd their households (Section 7.3) provide n opportunity to discuss how to improve socil protection for people with TB, for exmple through improved models of cre, direct socil support nd better linkge to socil services nd other forms of socil protection. 7.3 Ntionl surveys of costs fced by TB ptients nd their households (TB ptient cost surveys) One of the three high-level trgets of the End TB Strtegy is tht no TB ptients or their households should fce costs due to TB tht re ctstrophic (Chpter 2). Monitoring of progress towrds this trget cn lso inform monitoring of progress towrds UHC. The distinction between the indictor of ctstrophic totl costs due to TB disese nd the broder indictor of ctstrophic spending on helth (Section 7.1.2) is explined in Box 7.1. In 215, WHO estblished stndrdized protocol 1 for conducting ntionl survey to ssess the direct nd indirect costs incurred by TB ptients nd their households (TB ptient cost surveys). Bsed on experience in pthfinding countries tht conducted the first surveys, the protocol ws refined nd expnded into hndbook in World Helth Orgniztion. Protocol for survey to determine direct nd indirect costs due to TB nd to estimte proportion of TB-ffected households experiencing ctstrophic costs due to TB: field testing version. Genev: WHO; 215 ( impct_mesurement_tskforce/meetings/tf6_bckground_5_ ptient_cost_surveys_protocol.pdf, ccessed 21 June 218). 2 World Helth Orgniztion. Tuberculosis ptient cost surveys: hndbook. Genev: WHO; 217 ( ptient_cost_surveys/en/, ccessed 11 July 218). TB ptient cost surveys hve two primry objectives: to document the mgnitude nd min drivers of different types of costs incurred by TB ptients (nd their households), in order to guide policies to reduce finncil brriers to ccessing cre nd minimize the dverse socioeconomic impct of TB; nd to determine the bseline nd periodiclly mesure the percentge of TB ptients (nd their households) treted in the NTP network who incur ctstrophic totl costs due to TB. In the context of these surveys, ctstrophic costs for TB ptients nd their households hve been defined s direct medicl nd non-medicl costs plus income losses tht sum to 2% or more of household income. WHO recommends conducting bseline survey by 22 t the ltest, especilly in high TB burden countries Globl progress in implementtion of surveys The sttus of progress in implementing survey plnning nd implementtion is shown in Fig By July 218, 11 countries hd completed ntionl surveys: 3 Chin (216), Fiji (217), Ghn (216), Keny (217), Mongoli (217), Mynmr (215), Nigeri (217), the Philippines (216), Republic of Moldov (216), Timor-Leste (217) nd Viet Nm (216). 4 In July 218, surveys were underwy in four countries: Indi, Sudn, Ugnd nd Zimbbwe. There re 13 countries in which surveys re scheduled to strt in 218 or in 219: Brzil, Burkin Fso, Colombi, Dominicn Republic, the Democrtic Republic of the Congo, Ethiopi, Indonesi, Lo People s Democrtic Republic, Ppu New Guine, Romni, Solomon Islnds, South Afric, nd the United Republic of Tnzni. The min survey results for eight countries re shown in Fig The number in the centre of the circle shows the best estimte of the percentge of TB ptients nd their households tht fced ctstrophic costs, nd the outer ring shows the distribution of costs using three mjor cost ctegories. The percentge of TB-ffected households tht experienced totl costs tht were ctstrophic rnged from 27% (95% confidence intervl [CI]: 21 32%) in Keny to 71% (95% CI: 68 73) in Nigeri. The distribution of costs vried mong countries. Nonetheless, it is evident tht despite the widespred norm of free TB cre policies the direct medicl costs fced by TB-ffected households cn be high, nd such costs ccounted for lrge proportion of totl costs in some countries (e.g. in Mongoli nd Mynmr). Minimizing direct medicl costs borne by TB ptients should be high priority for NTPs nd ministries of helth. 3 Defined s hving completed survey field work, nlysis of dt, nd documenttion of results (e.g. in report). 4 The yer indictes the yer in which dt collection ws done.

150 BOX 7.1 The difference between ctstrophic totl costs for TB ptients nd their households, nd the SDG indictor of ctstrophic expenditures on helth It is importnt to distinguish between the indictor of ctstrophic spending on helth used within the SDG monitoring frmework (SDG 3.8.2) nd the indictor of ctstrophic totl costs due to TB. The former is popultion-bsed indictor tht mesures the shre of the popultion incurring ctstrophic spending on helth, with threshold defined s exceeding 1% nd 25% of household s totl consumption expenditure or income. Helth expenditures re defined s direct expenditures on medicl cre. The denomintor of the SDG indictor includes mny people who hd no contct with the helth system nd thus hd zero expenditures on helth. The TB-specific indictor incorportes not only direct medicl pyments for dignosis nd tretment, but lso direct non-medicl pyments (e.g. for trnsporttion nd lodging) nd indirect costs (e.g. lost income). In ddition, the TB-specific indictor is restricted to prticulr popultion: dignosed TB ptients who re users of helth services tht re prt of NTP networks. As consequence of these differences, the percentge of TB ptients fcing costs tht re lrge in reltion to their household expenditure or income is expected to be much higher thn the percentge of the generl popultion fcing ctstrophic expenditures on helth. The two indictors should not be compred directly. FIG. 7.5 Ntionl surveys of costs fced by TB ptients nd their households since 216: progress nd plns (s of July 218) Completed (n=11) Ongoing (n=4) Plnned (n=13) Not plnned Not pplicble 139

151 FIG. 7.6 Results from selected ntionl surveys of costs fced by TB ptients nd their households, implemented The number in the centre of the circle is the best estimte of the percentge of TB ptients nd their households tht experienced totl costs tht were bove 2% of their nnul income (i.e. ctstrophic totl costs). The outer ring shows the distribution of costs in three mjor ctegories. The number of TB ptients included in ech survey is shown fter the country nme. Fiji (n=224) Ghn (n=691) Keny (n=1335) 4% 64% 27% Mongoli (n=81) Mynmr (n=965) Nigeri (n=119) 68% 6% 71% Policy nd strtegy implictions of survey results Results from TB ptient cost surveys cn inform policy nd strtegy in two mjor wys. First, costs cn be mitigted by improving pproches to TB service delivery nd finncing, such s removl of user fees nd the introduction of more ptient-centred models of cre. Second, ny costs tht remin fter the optimiztion of helth-cre delivery cn be mitigted by improved socil protection mesures, in collbortion with stkeholders cross the socil sector. Survey results should be used to stimulte the enggement of multisectorl prtners nd to fcilitte policy discussion on both topics. A multi-stkeholder consulttion cn be n effective wy to initite discussions bout survey results nd the ctions needed in response. An erly exmple ws multisectorl meeting in Viet Nm in Mrch 217, which ws used to disseminte findings nd formulte joint ction pln with the country s Ministry of Lbour nd Socil Affirs. Similr dissemintion nd stkeholder consulttions hve subsequently been held in Mynmr (217), Keny (July 218) nd Ghn (August 218), resulting in multisectorl ction to improve socil support to TB ptients nd their households. The two most recent exmples, in Ghn nd Keny, re described in more detil in Box 7.2. Philippines (n=188) Viet Nm (n=735) 35% 63% Direct non medicl costs Income loss Direct medicl costs The surveys lso show tht ctions to eliminte the indirect costs of cre nd to reduce income losses re needed. The combined cost of trnsporttion, food, nutritionl supplements nd other non-medicl expenditures ( direct non-medicl costs ) ccounted for the lrgest shre of totl costs in Fiji, Ghn, Nigeri, the Philippines nd Viet Nm. Income losses ssocited with loss of employment or time lost while seeking or stying in cre ccounted for the lrgest single shre of totl costs in Mongoli, Mynmr nd Timor-Leste. All cost ctegories re influenced by the model of cre, such s the extent to which hospitliztion or outptient cre re relied upon, nd the frequency with which ttendnce t helth fcilities is requested. 7.4 Addressing broder determinnts of the TB epidemic The influence of vrious socil nd economic determinnts on the TB epidemic hs long been recognized. In the lte 18s, cuse-of-deth dt from ntionl vitl registrtion systems show tht TB ws one of the leding cuses of deth in some Europen countries. With socil nd economic development such s improvements in incomes, housing nd nutrition numbers of TB cses nd deths strted to decline in western Europe, North Americ nd some other prts of the world round the turn of the 2th century, lbeit slowly (1 2% per yer). 1, 2 From the 194s, the discovery, development nd use of effective drug tretments substntilly ccelerted these trends, with ntionl cse rtes (new cses per popultion per yer) flling by up to 1% per yer nd mortlity rtes flling even fster. The fstest historic declines in western Europe occurred during the 19s nd 196s, in the context of UHC, rpid socil nd economic development nd the vilbility of effective drug tretments. 1 Styblo K, Meijer J, Sutherlnd I. The trnsmission of tubercle bcilli: its trend in humn popultion. Bull World Helth Orgn. 1969;41: ( ccessed 3 July 218). 2 Grnge JM, Gndy M, Frmer P, Zuml A. Historicl declines in tuberculosis: nture, nurture nd the biosocil model. Int J Tuberc Lung Dis. 21;5(3):28 12 ( ccessed 3 July 218). 14

152 BOX 7.2 Ntionl surveys of costs fced by TB ptients nd their households in Ghn nd Keny: results nd policy trnsltion Ghn Ghn is lower-middle-income country in which there hs been economic growth for more thn two decdes nd reductions in the proportion of the popultion living in poverty. However, socil nd helth inequlities persist. Severl socil protection progrmmes hve been implemented, nd Ntionl Helth Insurnce Scheme (NHIS) ws introduced through n Act of Prliment in 23. In 217, ctive membership of the NHIS ws estimted t 4% of the ntionl popultion. In 216, the NTP worked with the London School of Hygiene nd Tropicl Medicine to conduct the first ntionl survey of costs fced by TB ptients nd their households, ccording to the guidnce in the WHO hndbook on TB ptient cost surveys. Ghn ws the first country in Afric to implement such survey. The cross-sectionl survey involved 691 ptients with either drug-susceptible or multidrug-resistnt (MDR) TB who were receiving tretment in helth fcilities in the public sector, cross 25 clusters. The questionnire included questions on costs, time losses, coping mesures nd sset ownership. Totl costs were expressed s percentge of nnul household income; if totl costs exceeded 2% of household income, the household ws clssified s experiencing ctstrophic totl costs. The medin cost tht ptients incurred per TB episode ws US$ 455, equivlent to bout 25% of the verge nnul household income reported by survey prticipnts. The shre ws significntly higher for MDR-TB ptients. Non-medicl costs (nd prticulrly food) nd lost income ccounted for the lrgest shre of the totl cost, while medicl costs ccounted for less thn 2%. Overll, 64% (95% CI: 61 68%) of TBffected households, nd 73% (95% CI: 61 82%) of households of ptients with MDR-TB experienced totl costs tht were ctstrophic. People with MDR-TB were pushed significntly further bove the threshold for ctstrophic costs thn those with drug-susceptible TB. The survey lso found tht TB-ffected households were more likely thn the generl popultion to be poor t the time of dignosis (46% versus 24%), nd tht the costs ssocited with TB cre incresed the proportion of TB-ffected households living below the poverty line (from 46% to 6%). More thn hlf (52%) of ll ptients were unble to py for TB tretment from their existing income sources, nd hd to rely on svings, borrowing or sle of ssets. Among survey prticipnts, 45% were enrolled in the NHIS t the time of dignosis. A further 35% enrolled fter dignosis, nd the remining 2% were uninsured throughout. Only four ptients (<1%) benefited from the Livelihood Empowerment Aginst Poverty (LEAP) progrmme, which provides conditionl csh trnsfers to extremely poor households, with the im of lleviting short-term poverty, nd supporting long-term resiliency nd humn cpcity development. Shortly fter the survey ws completed, the NTP engged key government gencies, to inform them bout the findings nd the need for multisectorl ction to mitigte costs fced by TB ptients nd their households, including through socil support. Subsequently, stkeholders meeting ws used to disseminte survey findings nd lunch ntionl ction pln to reduce nd compenste for costs fced by TB ptients nd their households. The meeting ws ttended by representtives from the Ntionl Helth Insurnce Authority; the Ministry of Gender, Children nd Socil Protection; the Ghn Helth Service; the Ghn AIDS Commission; the Ministry of Monitoring nd Evlution; the Ntionl Development Plnning Commission; representtives of TB ptients nd civil society; nd locl nd interntionl prtners. Key intervention res identified in the ction pln to reduce direct medicl costs re the inclusion of TB ptients s one of the groups exempt from pying the NHIS premium under the ctegory of indigent people, nd further decentrliztion of TB services through the estblishment of closer linkges with the Community-Bsed Helth Plnning nd Services strtegy. Interventions to reduce indirect costs include the expnsion of existing socil protection interventions to include TB ptients, including their enrolment in LEAP, by mking TB one of the criteri for eligibility; nd the design of socil support pckge trgeting the specific needs of TB ptients, such s nutritionl support nd trnsport vouchers. Further detils re vilble in recent publiction. b Keny In 217, the Keny Ntionl Tuberculosis, Leprosy nd Lung Disese Progrmme (NTLD) conducted the country s first ntionl survey of costs fced by TB ptients nd their households. The NTLD survey included 171 ptients with drug-susceptible TB nd 282 ptients with drug-resistnt TB. The medin cost ws US$ 256 for those with drug-susceptible TB nd US$ 1434 for those with drug-resistnt TB. The medin vlue for totl household nnul expenditure ws US$ 25. The overll proportion of TB-ffected households tht fced ctstrophic costs ws 27% (95% CI: 21 32%), but this proportion ws three times higher for those ffected by drugresistnt TB (86%; 95% CI: 79 94%). Direct non-medicl costs, prticulrly expenses on food nd nutritionl supplements beyond the ptient s norml diet, were the lrgest cost driver, followed by productivity losses. Significnt predictors for experiencing ctstrophic costs were being in low income quintile, hving no eduction, hving smll household size, nd drug-resistnt TB. More thn hlf (59%) of the ptients in the survey were either severely or modertely mlnourished, nd only 14% were covered by the Ntionl Helth Insurnce Fund (NHIF) during their TB tretment. Bsed on survey results, stkeholder consulttion ws held in July 218. This ws used to disseminte survey findings nd to discuss the ctions needed to chieve the gol of eliminting ctstrophic costs for TB ptients nd their households in Keny. Government stkeholders represented t the consulttion included the Ministry of Tresury nd Plnning, the Ministry of Devolution nd ASAL (Arid nd Semi Arid Lnds), the Ministry of Lbour nd Socil Protection, nd the helth committee of the ntionl prliment. Also 141

153 prticipting were representtives from the NHIF nd civil society, nd former TB ptients. Six priority ctions were identified, s follows: 1. Addition of TB s n eligibility criterion for existing socil protection progrmmes, prticulrly csh-trnsfer progrmmes nd systemtic identifiction of TB ptients eligible for socil protection. 2. Ensuring systemtic ssessment of nutritionl sttus nd ssocited counselling for ll TB ptients, with provision of food support ccording to need, including for mlnourished children of TB-ffected households. 3. Inclusion of TB cre in the NHIF benefit pckge, nd incresed NHIF coverge mong TB ptients through fsttrck, premium-free enrolment. 4. Development nd implementtion of policies nd lws to eliminte discrimintion nd ensure job security for TB ptients, in collbortion with ntionl uthorities in the lbour sector. 5. Enggement of ll cre providers in the provision of timely nd qulity-ssured TB cre, to reduce delys in ccessing dignosis nd tretment. 6. Estblishment of high-level multi-stkeholder coordinting mechnism nd forum for the implementtion of the End TB Strtegy. During the consulttion, the representtive of the helth committee of the ntionl prliment pledged high-level politicl support to ensure implementtion of the policy chnges needed to eliminte ctstrophic costs for TBffected households in Keny. b World Helth Orgniztion. Tuberculosis ptient cost surveys: hndbook. Genev: WHO; 217 ( ptient_cost_surveys/en/, ccessed 11 July 218). Pedrzzoli D, Sirok A, Bocci D, Bonsu F, Nrtey K, Houben R et l. How ffordble is TB cre? Findings from ntionwide TB ptient cost survey in Ghn. Trop Med Int Helth. 218; ( pubmed/ , ccessed 11 July 218). The links between TB nd poverty, socil protection, the prevlence of undernutrition, dibetes, HIV, lcohol use, smoking, indoor ir pollution nd income per cpit hve been nlysed, reviewed nd summrized in recent publictions (further detils re provided in Chpter 2). 1,2 As explined in Chpter 2, WHO hs developed TB- SDG monitoring frmework tht focuses ttention on 14 indictors (from seven SDGs) tht re ssocited with TB incidence. Monitoring of these indictors cn be used to identify key influences on the TB epidemic t ntionl level nd inform the multisectorl ctions required to end the TB epidemic. For SDG 3 (helth), the seven indictors selected for TB-SDG monitoring re: coverge of essentil helth services; percentge of totl helth expenditures tht re outof-pocket; helth expenditure per cpit; HIV prevlence; prevlence of smoking; prevlence of dibetes; nd prevlence of lcohol use disorder. For SDGs 1, 2, 7, 8, 1 nd 11, the seven indictors selected for monitoring re: 1 Lönnroth K, Jrmillo E, Willims B, Dye C, Rviglione M. Tuberculosis: the role of risk fctors nd socil determinnts. In: Bls E & Kurup A, editors. Equity, socil determinnts nd public helth progrmmes, WHO. 21 ( bitstrem/1665/44289/1/ _eng.pdf, ccessed 21 June 218). 2 Lönnroth K, Cstro KG, Chky JM, Chuhn LS, Floyd K, Glziou P et l. Tuberculosis control nd elimintion 21 : cure, cre, nd socil development. Lncet. 21;375(9728): ( nih.gov/pubmed/ , ccessed 21 June 218). proportion of the popultion living below the interntionl poverty line; proportion of the popultion covered by socil protection floors or systems; prevlence of undernourishment; proportion of the popultion with primry relince on clen fuels nd technology; GDP per cpit; Gini index for income inequlity; 3 nd proportion of the urbn popultion living in slums. Collection nd reporting of dt for the 14 indictors does not require ny dditionl dt collection nd reporting efforts by NTPs. Nor does it require dt collection nd reporting efforts tht go beyond those to which countries hve lredy committed in the context of the SDGs. Dt re vilble from globl dtbses, primrily those mintined by the United Ntions (UN), WHO, the World Bnk nd the Joint United Ntions Progrmme on HIV/ AIDS (UNAIDS) (for further detils, see Annex 1). The most recent dt for five of the seven SDG 3 indictors listed bove re shown for the 3 high TB burden countries in Tble For ll of the indictors shown, lower level is more desirble. The most recent dt for six of the seven selected SDG indictors beyond SDG 3 in the 3 high TB burden countries re shown in Fig In this figure, the outer edge 3 The index cn tke vlues between nd 1, with representing perfect equlity nd 1 representing perfect inequlity. 4 Coverge of helth services is not included becuse this indictor is covered in Section 7.1; helth expenditure per cpit is lso not shown, but dt re included in Annex 2. 5 GDP per cpit is not included in Fig. 7.7 becuse it is the only indictor tht is not mesured on scle of. However, the ltest vlue nd recent trends in this indictor re shown in the country profiles in Annex

154 TABLE 7.3 Sttus of selected SDG 3 indictors, 3 high TB burden countries, ltest vilble yer COUNTRY OUT-OF-POCKET HEALTH EXPENDITURE (% OF CURRENT HEALTH EXPENDITURE) HIV PREVALENCE (% OF POPULATION AGED YEARS) SMOKING PREVALENCE (% OF POPULATION AGED 15 YEARS) Angol Bngldesh 72.1 Brzil 28.6 Cmbodi 59.6 Centrl Africn Republic 4 4. Chin 32 Congo DPR Kore DR Congo 37.7 Ethiopi Indi 65.3 Indonesi 48.4 Keny Lesotho Liberi Mozmbique Mynmr 74.8 Nmibi Nigeri Pkistn 66.1 Ppu New Guine Philippines 54.1 Russin Federtion 36 Sierr Leone South Afric Thilnd UR Tnzni Viet Nm 43.4 Zmbi Zimbbwe indictes dt not vilble Both sexes Mle Femle DIABETES PREVALENCE (% OF POPULATION AGED 18 YEARS) ALCOHOL USE DISORDERS, 12 MONTH PREVALENCE (% OF POPULATION AGED 15 YEARS) Sources: World Bnk Sustinble Development Gols Dtbse ( nd WHO Globl Helth Observtory (

155 FIG. 7.7 Sttus of selected SDG indictors beyond SDG 3, 3 high TB burden countries, ltest vilble yer Angol Bngldesh Brzil Cmbodi Centrl Africn Republic Not in slums Not in slums Clen fuels Income Clen fuels equlity Income equlity Not in slums 75 Clen fuels 25 Income equlity Not in slums 75 Clen fuels 25 Income equlity Not in slums 75 Clen fuels 25 Income equlity Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Not in poverty Not in poverty Not in poverty Not in poverty Not in poverty Clen fuels Chin Congo DPR Kore DR Congo Ethiopi Not in slums Income equlity Not in slums 75 Clen fuels 25 Income equlity Not in slums 75 Clen fuels 25 Income equlity Not in slums Not in slums Clen fuels Income Clen fuels equlity Income equlity Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Not in poverty Not in poverty Not in poverty Not in poverty Not in poverty Clen fuels Indi Indonesi Keny Lesotho Liberi Not in slums Not in slums Income Clen fuels equlity Income equlity Not in slums 75 Clen fuels 25 Income equlity Not in slums 75 Clen fuels 25 Income equlity Not in slums 75 Clen fuels 25 Income equlity Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Not in poverty Not in poverty Not in poverty Not in poverty Not in poverty Mozmbique Mynmr Nmibi Nigeri Pkistn Not in slums Not in slums Clen fuels Income Clen fuels equlity Income equlity Not in slums 75 Clen fuels 25 Income equlity Not in slums Not in slums Clen fuels Income Clen fuels equlity Income equlity Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Not in poverty Not in poverty Not in poverty Not in poverty Not in poverty Philippines Ppu New Guine Russin Federtion Sierr Leone South Afric Not in slums 75 Clen fuels 25 Income equlity Not in slums Not in slums Not in slums Clen fuels Income Income Clen fuels Clen fuels equlity equlity Income equlity Not in slums 75 5 Clen fuels 25 Income equlity Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Not in poverty Not in poverty Not in poverty Not in poverty Not in poverty Thilnd UR Tnzni Viet Nm Zmbi Zimbbwe Not in slums 75 Clen fuels 25 Income equlity Not in slums 75 Clen fuels Income equlity 25 Not in slums 75 Clen fuels Income equlity 25 Not in slums 75 Clen fuels 25 Income equlity Not in slums 75 5 Clen fuels 5 25 Income equlity Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Nutrition Socil protection Not in poverty Not in poverty Not in poverty Not in poverty Not in poverty Not in slums: Percentge of urbn popultion not living in slums. Income equlity: An inverse GINI index is shown where is perfect inequlity nd is perfect equlity. Socil protection: Percentge of popultion covered by socil protection nd lbour progrmmes. Not in poverty: Percentge of popultion living bove the interntionl poverty line. Nutrition: Percentge of popultion not undernourished. Clen fuels: Percentge of popultion with ccess to clen fuels nd technologies for cooking. Red dot indictes tht there re no dt for the selected indictor. Source: World Bnk Sustinble Development Gols Dtbse ( 144

156 of the hexgon () is the idel vlue for ech indictor. Therefore, better performnce corresponds to lrger shded-in region. To chieve this representtion visully, the indictors proportion of the urbn popultion living in slums nd proportion of the popultion living below the interntionl poverty line re inverted in Fig It should be highlighted tht ll indictor vlues in Fig. 7.7 re for the generl popultion, s opposed to people with TB. Vlues for TB ptients specificlly (such s out-ofpocket expenditure nd ccess to socil protection) my differ from these generl vlues. Poverty is n underlying driver of ntionl TB epidemics, influencing severl of the other indictors ssocited with TB incidence. This is illustrted by recent modelling study, which showed tht eliminting extreme poverty nd providing socil protection (both trgets under SDG 1) could substntilly reduce TB incidence. The min results re summrized in Box 7.3. Tble 7.3 nd Fig. 7.7 show tht mny high TB burden countries, especilly those in the low-income ctegory, still fce significnt chllenges to chieve rnge of TB-relted SDG trgets. Furthermore, vlues for poor popultions nd vulnerble groups most t risk of developing TB re likely to be worse thn ntionl verges. BOX 7.3 The impct of socil protection nd poverty elimintion on globl TB incidence: modelling study SDG 1 is to end poverty in ll its forms everywhere, nd ssocited trgets include eliminting extreme poverty nd ensuring ntionlly pproprite socil protection systems nd mesures for ll (including floors). Achievement of SDG 1 is likely to ffect the TB epidemic through rnge of pthwys, s illustrted in Fig. B A recent study used dt from the SDG dt repository nd the WHO globl TB dtbse for 192 countries to explore how chievement of SDG 1 could ffect TB incidence. Anlyses were used to ssess the strength of the ssocition between the SDG 1 trgets nd TB incidence, s bsis for defining simplified frmework for modelling in which SDG 1 indictors were linked to TB incidence. It ws estimted tht ending extreme poverty could reduce globl TB incidence by 33% by 235 (95% confidence intervl: 16 45%), while expnding socil protection coverge could reduce incidence by 76% (45 9%) by 235. Together, both pthwys were estimted to be ble to reduce TB incidence by 84% (55 95%). Full chievement of SDG 1 could thus hve substntil impct on the globl burden of TB. FIG. B7.3.1 Conceptul frmework linking SDG 1 indictors to TB incidence Poverty SDG 1.1 Extreme poverty SDG trgets nd subtrgets SDG Socil insurnce SDG 1.2 Multidimensionl poverty Socil protection SDG Socil ssistnce TB risk fctors Helth behviour Mlnutrition HIV/AIDS Smoking Dibetes TB incidence SDG Lbour mrket interventions Housing qulity Unclen fuels Urbn slums Crter DJ, Glziou P, Lönnroth K, Sirok A, Floyd K, Weil D, Rviglione M, Houben RMG, Bocci D. The impct of socil protection nd poverty elimintion on globl tuberculosis incidence: sttisticl modelling nlysis of Sustinble Development Gol 1. Lncet Glob Helth. 218 My;6(5):e ( ccessed 11 July 218). 145

157 FIG. 7.8 Estimted number of TB cses ttributble to five risk fctors, 3 high TB burden countries, 217 Alcohol Smoking Dibetes HIV Undernourishment Angol Bngldesh BrzilCmbodi Dt not vilble Centrl Africn Republic Dt not vilble Chin Congo DPR Kore DR Congo Ethiopi Alcohol Smoking Dibetes HIV Undernourishment Dt not vilble Alcohol Smoking Dibetes HIV Undernourishment Indi Indonesi Keny Lesotho Liberi Alcohol Smoking Dibetes HIV Undernourishment Mozmbique Mynmr Nmibi Nigeri Pkistn Ppu New Guine Philippines Russin Federtion Sierr Leone South Afric Alcohol Smoking Dibetes HIV Undernourishment Alcohol Smoking Dibetes HIV Undernourishment Thilnd UR Tnzni Viet Nm Zmbi Zimbbwe Cses (thousnds) Sources: Lönnroth K, Cstro KG, Chky JM et l. Tuberculosis control nd elimintion 21 : cure, cre, nd socil development. Lncet. 21 My 22;375(9728): ; World Bnk; nd WHO Globl TB Progrmme. 146

158 TABLE 7.4 TB cses ttributble to selected risk fctors, 217 RISK FACTOR RELATIVE RISK EXPOSED (MILLIONS IN 217) GLOBAL POPULATION ATTRIBUTABLE FRACTION (%) ATTRIBUTABLE TB CASES (MILLIONS IN 217) Undernourishment HIV infection Smoking Dibetes Hrmful use of lcohol Source: Lönnroth K, Cstro KG, Chky JM et l. Tuberculosis control nd elimintion 21 : cure, cre, nd socil development. Lncet. 21 My 22;375(9728): The reltive risk for HIV infection is bsed on dt from UNAIDS nd estimtes from this Globl TB report. Although it is typiclly not possible for NTPs to mke progress on these issues lone, the UN high level meeting on TB in September 218 (Chpter 1) nd dpttion nd use of the multisectorl ccountbility frmework for TB developed in 218 (Chpter 2) provide bsis for rising wreness nd tking ction on these issues. Estimtes of the number of incident TB cses ttributble to five selected risk fctors in 217 re shown in Tble 7.4. An estimted 1.9 million were ttributble to undernourishment,.88 million to HIV infection,.83 million to smoking,.79 million to dibetes nd.49 million to lcohol buse. Applying the sme method, country-specific estimtes of the number of incident TB cses ttributble to the five risk fctors in the 3 high TB burden countries re shown in Fig This figure shows tht lthough vrious fctors (undernutrition, the prevlence of lcohol use disorder, dibetes, HIV nd smoking) contribute to the TB epidemic in the 3 high TB burden countries, there is considerble vrition mong countries in the reltive contribution of these fctors, nd thus lso vrition in which fctors need to be prioritized s prt of ntionl efforts to reduce the burden of TB disese. 147

159 A hndheld DNA sequencer being used in Mdgscr to identify TB resistnce in sputum smples Institut Psteur de Mdgscr 148

160 Chpter 8. TB reserch nd development KEY FACTS AND MESSAGES Tuberculosis (TB) reserch nd development is essentil to chieve the globl TB trgets set in the Sustinble Development Gols nd the End TB Strtegy. A mjor technologicl brekthrough is required by 225, so tht the rte t which TB incidence flls cn be drmticlly ccelerted compred with historic levels, to n verge of 17% per yer between 225 nd 235. Priorities for TB reserch nd development include vccine to lower the risk of infection, vccine or new drug tretment to cut the risk of TB disese in the 1.7 billion people lredy ltently infected, rpid dignostics for use t the point of cre nd simpler, shorter drug regimens for treting TB disese. Intensified reserch nd innovtion is the third pillr of the End TB Strtegy. A substntil increse in investment in TB reserch nd development is needed. Funding hs incresed in recent yers nd reched pek of US$ 724 million in 216, but this is only 36% of the estimted requirement of US$ 2 billion per yer. The dignostic pipeline is reltively stgnnt. A smll number of technologies emerged in nd severl hve not demonstrted dequte performnce in field evlution studies. There is still no single rpid, ccurte nd robust TB dignostic test suitble for use t the point of cre. There re 2 drugs in Phse I, II or III trils for the tretment of drug-susceptible TB, multidrug-resistnt TB or ltent TB infection. There re 11 new compounds (n increse of 3 since August 217): contezolid, delpzolid, GSK , mcozinone, OPC , pretomnid, Q23, SQ19, sutezolid, TBA-7371 nd TBI-166. Two other drugs, bedquiline nd delmnid, hve lredy received ccelerted or conditionl regultory pprovl bsed on Phse IIb results. The seven repurposed drugs undergoing further testing re clofzimine, linezolid, levofloxcin, moxifloxcin, nitzoxnide, rifmpicin (high dose) nd rifpentine. Vrious combintion regimens with new or repurposed drugs re in Phse II or Phse III trils. Twelve vccine cndidtes re in clinicl trils: four in Phse I, six in Phse II nd two in Phse III. They include cndidtes to prevent the development of TB infection nd disese, nd cndidtes to help improve the outcomes of tretment for TB disese. The globl TB trgets set in the Sustinble Development Gols (SDGs) nd the End TB Strtegy cnnot be chieved without tuberculosis (TB) reserch nd development. The SDG trget is to end the epidemic by 23; more specific trgets for 23 set in the End TB Strtegy re 9% reduction in TB deths nd n 8% reduction in TB incidence compred with levels in 215, with trgets for further reductions (95% nd 9%, respectively) by 235. Reching these trgets requires mjor technologicl brekthrough by 225, so tht the rte t which TB incidence flls cn be drmticlly ccelerted compred with historic levels, to n verge of 17% per yer from (Chpter 2). Priorities for TB reserch nd development include vccine to lower the risk of infection, vccine or new drug tretment to cut the risk of TB disese in the 1.7 billion people lredy ltently infected, 1 rpid dignostics for use t the point of cre nd simpler nd shorter drug regimens for treting TB disese. 2,3 1 Houben RM, Dodd PJ. The globl burden of ltent tuberculosis infection: re-estimtion using mthemticl modelling. PLoS Med. 216;13(1):e2152 ( ccessed 3 July 218). 2 Shortening tretment regimens s well s decresing tretment toxicity re prticulrly high priorities for drug-resistnt TB. 3 WHO, in collbortion with prtners hs developed Trget Product Profiles for TB tretment regimens (referred to s Trget Regimen Profiles or TRPs). For further detils, see: World Helth Orgniztion. Trget Regimen Profiles for TB Tretment (WHO/HTM/TB/216.16). Genev: WHO; 216. ( le/1665/244/ eng. pdf;jsessionid=5f679c669bb46e43153c2b4df6?sequence=1, ccessed 3 July 218). 149

161 Intensified reserch nd innovtion is one of the three pillrs of the WHO End TB Strtegy. The two min components of this pillr re discovery, development nd rpid uptke of new tools, interventions nd strtegies nd reserch to optimize implementtion nd impct, nd promote innovtions (Chpter 2). Technologicl brekthroughs nd optiml use of vilble interventions require greter investment in TB reserch nd development. The Stop TB Prtnership s Globl Pln to End TB estimtes tht bout US$ 2 billion per yer is needed. 1 To dte, funding hs not come close to this mount. In the 5 most recent yers for which dt hve been published, nnul funding ws in the rnge of US$ 6 7 million, reching pek of US$ 724 million in This ws equivlent to only bout 4% of the mount required. Although TB ccounts for nerly 2% of disbility-djusted life-yers (DALYs) lost, it receives only.25% of the estimted US$ 265 billion spent on medicl reserch nnully, 3 nd less support thn other globl helth threts such s HIV nd mlri. Further detils bout recent funding for TB reserch nd development re provided in Box 8.1. Recognizing the need to ccelerte efforts in TB reserch nd development, Pursuing science, reserch nd innovtion ws one of the four mjor topics of the Moscow Declrtion to End TB. The commitments from Member Sttes nd the clls to prtners included in the declrtion re listed in Box 8.2. In April 218, TB reserch nd development ws one of the topics prioritized for discussion t the first United Ntions (UN) high-level meeting on TB in September This chpter is not intended s n exhustive overview of current or recently completed TB reserch. As in previous globl TB reports, it focuses on providing n overview of progress in the development of new TB dignostics (Section 8.1), drugs (Section 8.2) nd vccines (Section 8.3), which ccount for most of the funding invested in TB reserch nd development in recent yers (Box 8.1). The sttus of the pipelines s of August 218, bsed on recent publictions s well s communictions with the secretrits of the relevnt working groups of the Stop TB Prtnership nd other stkeholders, is described nd discussed. The lst prt of the chpter (Section 8.4) highlights how globl nd intercountry collbortions cn help to expedite progress in TB reserch. 1 The Globl Pln to End TB, Genev: Stop TB Prtnership; 215 ( ccessed 21 June 218). 2 Tretment Action Group. The scent begins: tuberculosis reserch funding trends, New York: Tretment Action Group; 215 ( ccessed 28 June 218). 3 Moses H, Mtheson DH, Cirns-Smith S, George BP, Plisch C, Dorsey ER. The ntomy of medicl reserch: US nd interntionl comprisons. JAMA. 215;313(2): ( pubmed/ , ccessed 9 July 218). 4 United Ntions Generl Assembly. Resolution dopted by the Generl Assembly on 4 April 218. A/RES/72/268. Scope, modlities, formt nd orgniztion of the high level meeting on the fight ginst tuberculosis ( RES/72/268, ccessed 9 July 218). BOX 8.1 Globl investments in TB reserch nd development: recent nlysis As prt of preprtions for the first Globl Ministeril Conference on TB held in November 217, recent investments in TB reserch nd development were ssessed. Key findings were s follows: A totl of US$ 4.6 billion ws invested from , mostly for development of new dignostics, drugs nd vccines (61%). The rest ws for bsic reserch (21%), opertionl reserch (1%) nd infrstructure or unspecified projects (8%). Most funding from 29 to 216 ws from few countries, led by the United Sttes of Americ (USA, with US$ 1.8 billion), followed by the Europen Union nd United Kingdom (US$ 269 million ech). Contributions from other countries did not exceed US$ 62 million. The two lrgest funders were the US Ntionl Institutes of Helth (NIH) nd the Bill & Melind Gtes Foundtion. Combined, they ccounted for 37% of totl investments from 25 to 215. Spending by the phrmceuticl industry decresed considerbly, following the withdrwl of severl compnies from the field nd the mturtion of clinicl development progrmmes for new TB drugs. Between 211 nd 215, the top five recipients of funding were either product-development prtnerships or reserch institutes nd universities in the USA. Other recipients in the top 15 included the Medicl Reserch Council (United Kingdom), the Foundtion for Innovtive New Dignostics (FIND, Switzerlnd), the University of Cpe Town (South Afric), the Interntionl Union Aginst Tuberculosis nd Lung Disese (bsed in Frnce) nd the Ntionl Institute for Reserch in Tuberculosis (Indi). Insufficient investment in opertionl reserch hs compromised the scle-up of new technologies nd pproches, limiting their impct on the TB epidemic. Consistent with this finding, only 13% of ll TB reserch publictions in the pst decde were relted to opertionl or public helth reserch. World Helth Orgniztion. Globl investments in tuberculosis reserch nd development pst, present, nd future. Genev: WHO; 217 ( bitstrem/hndle/1665/259412/ eng. pdf, ccessed 28 June 218). 1

162 BOX 8.2 Commitments by Member Sttes nd clls to prtners listed under the heding Pursuing science, reserch nd innovtion in the Moscow Declrtion to End TB Commitments by Member Sttes Incresing ntionl or regionl cpcity nd funding, s needed, to urgently expnd multidisciplinry TB reserch nd innovtion, nd pplied helth reserch, by estblishing nd strengthening ntionl TB reserch networks, including civil society nd community-bsed mechnisms, considering TB reserch s centrl element of ntionl TB nd reserch nd development strtegies, expnding existing networks to integrte TB reserch, nd reducing reserch- nd implementtion-relted regultory impediments. Working, when relevnt, cross ministries, donors, the scientific community, the privte sector, cdemi nd other key stkeholders for the purpose of reserch: for development nd evlution of rpid point-of-cre dignostics; new nd more effective drugs; nd shorter, high-qulity nd cost-effective tretment regimens for ll forms of TB including ltent TB infection nd drug-resistnt TB nd; sfe nd effective TB vccines by 225; nd on environmentl nd socil determinnts of TB nd effective interventions strtegies. Improving, s pproprite, the coordintion of reserch efforts ntionlly nd globlly, nd ensuring tht the emerging knowledge is promptly put into ction, including by putting in plce pproprite policy frmeworks nd implementing new medicl technologies. Strengthening, s pproprite, surveillnce systems, improving dt collection nd reporting t ll levels, using innovtive pproches nd including surveillnce in TB reserch gends. Clls to prtner gencies WHO in collbortion with globl prtners, reserch orgniztions, donors, the scientific community nd countries to consider developing Globl Strtegy for TB Reserch, tking into considertion ongoing nd new efforts, such s the TB Reserch Network stted in the BRICS Leders Ximen Declrtion. b,c WHO in collbortion with globl helth nd reserch prtners nd countries to mke further progress in enhncing coopertion nd coordintion of TB reserch nd development, considering (where possible) drwing on existing reserch networks to integrte TB reserch, such s the new ntimicrobil resistnce (AMR) R&D collbortion hub proposed in the 217 G2 Leders Declrtion, d in prticulr, to fcilitte rpid scle-up of innovtive pproches nd tools for TB prevention, dignosis, tretment nd cre. A TB resolution dopted t the World Helth Assembly in My 218 reinforced the Moscow Declrtion s cll for the development of globl strtegy for TB reserch nd innovtion, nd requested WHO to develop such strtegy in collbortion with other stkeholders. e The im of the strtegy is to ccelerte progress in TB reserch nd development, through strtegic pproches such s fostering globl collbortions, stimulting the development of innovtive finncing mechnisms for the most urgent priorities, promoting the shring of dt nd informtion, nd fcilitting the rpid scle-up of new tools. b c d e Moscow Declrtion to End TB; First WHO Globl Ministeril Conference on Ending TB in the Sustinble Development Er: A Multisectorl Response, November 217. WHO nd the Ministry of Helth of the Russin Federtion. int/tb/fetures_rchive/moscow_declrtion_to_end_tb_ finl_english.pdf?u=1, ccessed 21 June 218). The BRICS countries re Brzil, Russin Federtion, Indi, Chin nd South Afric. BRICS Leders Ximen Declrtion. Chin: Ministry of Foreign Affirs of the People s Republic of Chin; 217 ( t21798_221.html, ccessed 11 July 218). G2 Ntions. G2 Leders Declrtion: Shping n interconnected world. Hmburg: G2 Ntions; 217 ( html, ccessed 11 June 218). World Helth Orgniztion. Preprtion for high-level meeting of the Generl Assembly on ending tuberculosis (WHA7.13), Seventy-first World Helth Assembly. Genev: WHO; 218 ( A71_R3-en.pdf, ccessed 11 July 218). 151

163 8.1 New dignostics for TB This section strts by providing n overview of the TB dignostics pipeline, with prticulr ttention to progress mde in 218. It then describes dignostic tests, products nd methods relted to the detection of TB infection, disese nd drug resistnce tht were reviewed by WHO in 218, or tht re scheduled for evlution in An overview of the dignostics pipeline Although the TB dignostics pipeline ppers robust, with severl technologies in development, no new pltform hs emerged in 218. Despite the promise from severl mnufcturers, there is still no single rpid, ccurte nd robust TB dignostic test suitble for use t the point of cre. This reflects serious underinvestment (especilly in bsic science), nd persistent scientific nd technicl chllenges tht ffect the development of new TB dignostics. An overview of the pipeline for TB dignostics in August 218 is shown in Fig The list of technologies is not necessrily complete, but does reflect technologies tht hve been documented in previous reports published by the Tretment Action Group 1 nd Unitid. 2 Technologies under development re primrily moleculr-bsed; they include tests to detect TB for dignosis nd tretment monitoring, to detect drug resistnce mong confirmed TB cses, nd to detect TB nd drug resistnce simultneously in centrlized high-throughput lbortories. The pipeline remins lrgely unchnged from the one published in the 217 edition of the globl TB report, 3 nd highlights the urgent need for new technologies to minimize brriers to helth-cre ccess, ensure qulity testing for difficult-to-dignose groups, expnd the spectrum of drug susceptibility testing (DST), nd reduce the costs of dignostic pltforms nd their mintennce. The development of the Cepheid close-to-cre pltform GeneXpert Omni (Omni) continues to be delyed nd is not expected to be vilble before 219. Cepheid hs developed n lterntive to Omni the GeneXpert Edge (Edge). The Edge is single-module GeneXpert instrument connected to tblet device for trnsfer of dt; its specific fetures include n uxiliry bttery tht llows opertion in more decentrlized settings, t the sme level s microscopy. The instrument is being developed to fcilitte wider ccess to rpid moleculr testing for TB nd rifmpicin resistnce, nd virology prmeters for HIV nd heptitis C virus, for 1 Lessem E. The tuberculosis dignostics pipeline. Tretment Action Group; 217 ( Pipeline-Report-TB-Dignostics.pdf, ccessed 22 June 218). 2 Unitid. Tuberculosis dignostics technology lndscpe, 5th edition. Genev: WHO; 217 ( Dignostics-Technology-Lndscpe.pdf, ccessed 22 June 218). 3 World Helth Orgniztion. Globl tuberculosis report 217 (WHO/HTM/ TB/217.23). Genev: WHO; 217 ( dle/1665/259366/ eng.pdf, ccessed 21 June 218). exmple. The Edge is expected to be vilble from November 218. The next-genertion Xpert MTB/RIF Ultr (Ultr) crtridge hs shown significntly better performnce (incresed sensitivity) thn the current Xpert MTB/RIF crtridge in detecting Mycobcterium tuberculosis in specimens with low numbers of bcilli. This ws prticulrly the cse for smer-negtive, culture-positive specimens (e.g. those from people living with HIV), extrpulmonry specimens (notbly cerebrospinl fluid) nd specimens from children. 4 Despite the improved performnce of the Ultr crtridge, s confirmed by WHO, the trnsition to this next-genertion crtridge hs been limited, in prt, due to the short shelf-life of the crtridge. South Afric is the only high TB burden country currently using Ultr s the initil TB dignostic test. WHO hs commissioned n updted systemtic review of the performnce of Ultr for use in the dignosis of pulmonry nd extrpulmonry TB in dults nd children, nd expects to refine nd updte policy guidelines for the use of Ultr in 219. Two crtridge-bsed technologies being developed in Chin nd Indi, respectively, re in the pipeline. These technologies hve the potentil to be used s n lterntive to the GeneXpert pltform in primry helthcre fcilities. Both re similr to Xpert MTB/RIF in tht they trget the multicopy IS611 nd single-copy gene trget. Evidence bout the performnce of both technologies from well-designed vlidtion studies is needed to enble WHO to review nd ssess their performnce; ncillry solutions in res such s mintennce nd connectivity would lso be needed to support roll-out.. The first of these two ssys, the Truent MTB ssys (Molbio Dignostics, Bnglore, Indi), uses chip-bsed rel-time polymerse chin rection (PCR) for the detection of TB. A reflex ssy hs been developed to detect resistnce to rifmpicin in smples with positive results for M. tuberculosis. The Indin Council of Medicl Reserch hs recommended Truent MTB to the Indin Centrl TB Division, bsed on locl dt. The Foundtion for Innovtive New Dignostics (FIND) is plnning multicentre study of dignostic ccurcy t the level of peripherl microscopy centres, to ssess the performnce chrcteristics of the test in different epidemiologicl nd geogrphicl settings; the results will inform WHO review. Ustr Biotechnologies (Chin) hs developed the EsyNAT TB ssy bsed on isotherml cross-priming mplifiction. The ssy uses preloded regents in single crtridge for integrted extrction, mplifiction nd detection, using two seprte chmbers. Testing, 4 WHO meeting report of technicl expert consulttion: non-inferiority nlysis of Xpert MTB/RIF Ultr compred to Xpert MTB/RIF. Genev: World Helth Orgniztion; 217 (WHO/HTM/TB/217.4; who.int/iris/bitstrem/1665/254792/1/who-htm-tb eng. pdf, ccessed 1 My 218). 152

164 FIG. 8.1 An overview of progress in the development of TB dignostics, August 218 TECHNOLOGIES IN DEVELOPMENT Moleculr detection of TB nd drug resistnce Gendrive MTB/RIF ID, Epistem, UK Xpert XDR-TB crtridge, Cepheid, USA TruArry MDR-TB, Akkoni, USA INFINITIMTB Assy, AutoGenomics, USA FluoroType XDR-TB ssy, Hin Lifescience, Germny MeltPro TB ssy, Zeesn Biotech, Chin QuntuMDx, POC, UK Tests for ltent TB infection Diskin test, Generium, Russin Federtion C-Tb test, Serum Institute of Indi, Indi ON THE MARKET (EVIDENCE FOR USE NOT SUBMITTED TO WHO FOR EVALUATION) Moleculr detection of TB nd drug resistnce icubte System, icubte, USA Genechip, TB drug resistnce rry, Cpitl Bio, Chin EsyNAT TB Dignostic kit, Ustr Biotechnologies, Chin Truelb/Truent MTB, Molbio/bigtec Dignostics, Indi Culture-bsed drug susceptibility testing Sensititre TM MYCOTBI plte; ThermoFisher Scientific Inc., USA TECHNOLOGIES ENDORSED BY WHO Moleculr detection of TB nd drug resistnce Line probe ssys for the detection of Mycobcterium tuberculosis (MTB), isonizid nd rifmpicin resistnce in cid-fst bcilli smer positive sputum or MTB cultures (FL-LPA), Hin Lifescience, Germny nd Nipro, Jpn Line probe ssys for the detection of resistnce to fluoroquinolones nd second-line injectble gents (SL- LPA), Hin Lifescience, Germny TB LAMP for detection of TB, Eiken, Jpn Nonmoleculr technologies Inteferon gmm relese ssy (IGRAs) for the dignosis of ltent TB infection (LTBI) Oxford Immunotec, UK, Qigen, USA Culture-bsed technologies Commercil liquid culture systems nd rpid specition Culture-bsed phenotypic DST using 1% criticl proportion in LJ,7H1,7H11 nd MGIT medi. Microscopy Light nd light-emitting diode microscopy (dignosis nd tretment monitoring) SCHEDULED FOR WHO EVALUATION IN 218/19 Moleculr detection of TB nd drug resistnce Moleculr technologies for genotypic drug resistnce testing (including sequencing technologies) FluoroType MTBDR, Hin Lifescience, Germny m2 RelTime MTB System, Abbott, USA BD Mx MDR-TB, Becton Dickinson, USA Roche cobs MTB system, Roche Dignostics, Bsel, Switzerlnd Rdiology Computer ided detection (CAD) WHO POLICY UPDATES SCHEDULED FOR 218/219 Moleculr detection of TB nd drug resistnce Alere Determine TB-LAM, Alere, USA (TB detection in people seriously ill with HIV) Xpert MTB/RIF Ultr for detection of TB nd rifmpicin resistnce in pulmonry, extr pulmonry nd peditric smples, Cepheid, USA The list of technologies is not necessrily complete, but does reflect technologies tht hve been documented in previous reports published by the Tretment Action Group 1 nd Unitid Lessem E. The tuberculosis dignostics pipeline. Tretment Action Group; 217 ( ccessed 27 June 218). Unitid. Tuberculosis dignostic technology lndscpe, 5th edition. Genev: World Helth Orgniztion; 217 ( ccessed 27 June 218). which is currently limited to detection of TB (drug resistnce cnnot be detected), cn be performed by loding crtridges into bttery-operted device for testing two smples simultneously Criticl concentrtions for phenotypic drugsusceptibility testing of medicines used in the tretment of drug-resistnt TB In My 218, WHO nd FIND relesed technicl report with updted lbortory prmeters for DST of medicines used to tret drug-resistnt TB. 1 Culture-bsed phenotypic testing is the current reference method for DST of nti-tb medicines, nd it relies on the testing of so-clled criticl concentrtions of drugs, tht is, the lowest concentrtion of n nti-tb medicine in vitro tht will inhibit the growth of 99% of phenotypiclly wild-type strins of M. tuberculosis. The report summrizes the current evidence used to 1 Technicl report on criticl concentrtions for drug susceptibility testing of medicines used in the tretment of drug-resistnt tuberculosis. Genev: WHO; 218 (WHO/CDS/TB/218.5) ( who.int/iris/bitstrem/1665/2647/1/who-cds-tb eng.pdf ccessed 1 My 218). determine criticl concentrtions in different culture medi for performing DST for specific medicines used in the tretment of drug-resistnt TB. Criticl concentrtions for the new nd repurposed nti-tb gents bedquiline, delmnid, linezolid nd clofzimine re included, in ddition to revised consensus criticl concentrtions for fluoroquinolones nd second-line injectble gents TB dignostic tests, products nd methods tht my be evluted by WHO in 219 In 219, there my be sufficient dt for WHO to ressess the criticl concentrtions to use when testing for resistnce to isonizid nd rifmpicin, nd to determine the role of DNA-sequencing technologies in the dignosis of drug-resistnt TB. There my lso be sufficient dt to review the performnce of the lterl flow liporbinomnnn ssy (LF-LAM), centrlized high-throughput testing pltforms, moleculr sequencing s reference stndrd for DST, nd new test for extensively drug-resistnt TB (XDR-TB). 2 2 XDR-TB is defined s MDR-TB plus resistnce to t lest one fluoroquinolone nd second-line injectble. 153

165 Criticl concentrtions for phenotypic drugsusceptibility testing of isonizid nd rifmpicin Anti-TB medicines such s isonizid nd the rifmycins (rifmpicin, rifpentin nd rifbutin) re essentil for TB tretment. There is emerging evidence tht some of the criticl concentrtions used to test for resistnce to these medicines, estblished historiclly in solid culture medi, my not necessrily pply to commercil liquid culture systems. Therefore, WHO hs commissioned FIND to undertke systemtic review of vilble minimum inhibitory concentrtion dt for phenotypiclly wild-type nd non wild-type strins, including sequencing dt for relevnt resistnce genes. The gol of the review is to evlute the vilble evidence nd, if indicted, to revise the criticl concentrtions used to test for resistnce to these first-line nti-tb medicines on selected medi. Role of DNA-sequencing technologies The successful dignosis nd tretment of drug-resistnt TB depends upon universl ccess to ccurte DST. Conventionlly, the dignosis of drug resistnce in M. tuberculosis strins hs relied hevily upon culture nd DST in liquid or solid medi in TB continment lbortories. Phenotypic results re only obtined fter weeks to months of incubtion, nd estblishing the stringent lbortory biosfety conditions required for these culture-bsed methods is chllenge. Drug resistnce in the Mycobcterium tuberculosis complex is minly conferred through point muttions in specific gene trgets in the bcteril genome. Given the chllenges ssocited with performing phenotypic DST, moleculr tests re incresingly being used to llow more rpid testing nd thus erlier initition of pproprite tretment for drug-resistnt TB. Rpid moleculr tests such s Xpert MTB/RIF nd line probe ssys (LPAs) llow for the detection of set of common resistnce muttions in few gene regions. However, for mny drugs used in the tretment of drug-resistnt TB, the muttions re spred over multiple gene regions. Moreover, not ll muttions conferring resistnce hve been identified, nd limited informtion is vilble for identifying the high-confidence muttions tht would ccurtely predict clinicl tretment outcomes. An dvntge of sequencing technologies, compred with the rpid moleculr tests tht re currently vilble, is tht they re ble to provide detiled informtion on resistnce muttions for multiple gene regions. A first step tht hs been tken is to grde muttions ccording to the level of confidence in the ssocition between resistnce muttions nd the conferred phenotypic drug resistnce. FIND hs recently completed systemtic review of the ssocition between M. tuberculosis strins with specific muttions nd miniml inhibitory concentrtions dt for drugs of interest. It is nticipted tht WHO will be ble to use this review to ssess evidence bout the ccurcy of genotypic DST compred with current phenotypic reference stndrds, nd to develop relted list of priority muttions (so-clled high-confidence muttions), which could lso be used to id test development. WHO nd FIND re prepring technicl guide tht summrizes the chrcteristics of vilble DNAsequencing technologies, long with current knowledge of the genetic bsis of TB drug resistnce. This guide will provide foundtion for building dditionl knowledge relted to the moleculr bsis of resistnce, nd will inform future WHO policy guidelines on the use nd interprettion of DNA-sequencing technologies. The Reltionl Sequencing TB Knowledgebse (ReSeqTB) is globl, clinicl knowledge bse tht curtes, stndrdizes nd unifies genotypic nd phenotypic DST dt, long with metdt on drug-resistnt TB. 1 The dtbse is regrded s living knowledge bse, in which sequencing, phenotypic nd clinicl outcome dt for existing, repurposed nd new TB drugs re continully gthered from countries nd other stkeholders. Lterl flow liporbinomnnn ssy Tests bsed on the detection of the mycobcteril liporbinomnnn (LAM) ntigen in urine re vilble s potentil point-of-cre tests for TB. Urinry LAM ssys re unsuitble for use s generl screening tests for TB due to suboptiml sensitivity. However, compred with trditionl dignostic methods, they hve demonstrted improved sensitivity for the dignosis of TB mong individuls coinfected with HIV, especilly mong ptients with low CD4 counts. The urine LAM strip-test (Determine -TB Alere, USA) is currently recommended by WHO in HIV-positive dults with CD4 counts less thn or equl to cells/ul nd with signs nd symptoms of TB. 2 Since 215, new evidence hs emerged tht might justify the use of the test in broder group of people living with HIV. WHO hs initited review of the evidence nd ssocited guidnce, nd meeting to review the evidence is due to be held before the end of 218. Centrlized high-throughput testing pltforms Severl mnufcturers hve developed centrlized testing PCR-bsed pltforms suitble for high lbortory throughput. If sufficient evidence becomes vilble, the performnce of these pltforms could be ssessed before the end of 218. Exmples of the pltforms in development re the RelTime pltform, developed by Abbott; the FluoroType MTBDR, lunched by Hin 1 (ccessed 19 April 218). 2 World Helth Orgniztion. The use of lterl flow urine liporbinomnnn ssy (LF-LAM) for the dignosis nd screening of ctive tuberculosis in people living with HIV: policy guidnce (WHO/ HTM/TB/215.25). Genev: WHO; 215; bitstrem/1665/193633/1/ _eng.pdf?u=1&u=1, ccessed 1 My 218). 154

166 Lifescience in erly 217; nd pltforms being developed by Becton Dickinson nd Roche. WHO, in consulttion with FIND, hs developed twostep evlution process for this purpose. The first step includes verifiction of the ccurcy of the ssys in detecting M. tuberculosis s well s resistnce to rifmpicin nd isonizid, bsed on independent evlution of stndrdized pnel of strins, conducted t one or more WHO TB suprntionl reference lbortories (SRLs). The second step is evlution of the clinicl vlidity of the ssys, bsed on testing of the pltforms in two or three ntionl reference lbortories in high TB burden settings, nd compring results with the reference stndrds of culture, phenotypic DST nd moleculr sequencing, s well s with Xpert MTB/RIF. Tests for extensively drug-resistnt TB Moleculr LPAs for second-line nti-tb medicines re currently the only rpid moleculr tests recommended by WHO for detecting whether ptients with confirmed multidrug-resistnt TB (MDR-TB) or rifmpicin-resistnt TB hve XDR-TB. However, LPAs require sophisticted lbortory infrstructure nd equipment tht is normlly only vilble in centrlized lbortories. Cepheid is continuing to develop n XDR-TB crtridge to detect resistnce to isonizid, injectble gents nd fluoroquinolones. If sufficient dt become vilble, WHO will evlute the XDR-TB crtridge using the sme two-step pproch described bove for centrlized high-throughput testing pltforms. Computer-ided detection systems Chest rdiogrphy, or chest X-ry (CXR), is n importnt tool for TB triging nd screening, nd is lso useful id in the dignosis of TB. A mjor limittion of CXR is tht it requires experienced interpreters (usully rdiologists or technicins) for interpreting the imges. Even mong trined reders, vrition between reders is common, which further ffects the ccurcy of CXR. In mny countries, few experienced CXR reders re vilble. In recent yers, computer-ided detection (CAD) systems hve been developed tht use digitl technology to detect physiologicl nd pthologicl conditions, including TB. These CAD systems incorporte computer lgorithms tht nlyse digitl CXR nd produce stndrdized interprettion of the imge. A score or report is generted tht estimtes the likelihood tht the imge is from n individul with ctive TB disese. CAD systems re trined on thousnds of imges, using mchine-lerning techniques. A reserch gend to ssess CAD systems is underwy 1. FIND is estblishing n rchive of digitl x-rys to ssess the performnce 1 Ahmd Khn F, Pnde T, Tessem B, Song R, Benedetti A Pi M et l. Computer-ided reding of tuberculosis chest rdiogrphy: Moving the reserch gend forwrd to inform policy. Europen Respirtory Journl 217; (1) ( long, ccessed 9 July 218). of commercilly vilble CAD solutions. If sufficient dt become vilble, WHO will evlute the use of CAD systems for detecting TB in erly 219. Biomrkers for tretment monitoring DNA-bsed moleculr dignostic tools provide rpid results for the dignosis of ctive TB disese. Tests such s the Xpert MTB/RIF ssy hve sensitivity pproching tht of culture, lthough they remin unsuitble for tretment monitoring becuse they detect ded bcilli. 2 St Andrew s University, Scotlnd hs developed novel pproch for rel-time monitoring of ptient s response to TB tretment. The Moleculr Bcteril Lod Assy (MBLA) is rel-time reverse trnscriptse quntittive PCR (RT-qPCR) tht uses 16S-ribosoml RNA (rrna) trgets to quntify the M. tuberculosis bcillry lod over the course of tretment. The 16S-rRNA trgets re more bundnt nd stble thn messenger RNA (mrna), nd yet re reduced during TB tretment, which mkes this ssy more sensitive for M. tuberculosis detection nd monitoring of the response to tretment. Its bility to quntify ptient s bcillry lod of M. tuberculosis in rel time, nd void the chllenges relted to culture e.g. time to results nd contmintion concerns, gives MBLA the potentil to eventully replce microscopy nd culture s test for tretment monitoring. To dte, the ssy hs been evluted in four high TB burden, low-resource settings in Afric. 3 The next crucil step is the development of design-locked product tht llows stndrdized evlution. Lbortory-bsed studies of nlyticl sensitivity nd stbility need to be performed to further ssess the limits of detection of the ssy, nd the correltion with currently recommended technologies for monitoring TB tretment response (especilly culture). If the lbortory-bsed studies demonstrte good performnce, clinicl evlution studies will be needed to ssess the MBLA s possible replcement for microscopy nd culture monitoring during tretment. 8.2 New drugs nd drug regimens to tret TB The pipeline for new nti-tb drugs in August 218 is shown in Fig The pipeline hs expnded in recent months, nd there re now 2 drugs in Phse I, II or III trils, compred with 17 in August There re 2 World Helth Orgniztion. Automted rel-time nucleic cid mplifiction technology for rpid nd simultneous detection of tuberculosis nd rifmpicin resistnce: Xpert MTB/RIF ssy for the dignosis of pulmonry nd extrpulmonry TB in dults nd children policy updte (WHO/HTM/TB/213.16). Genev: WHO; 213 ( pps.who.int/iris/bitstrem/1665/112472/1/ _eng.pdf, ccessed 1 My 218). 3 Gillespie SH, Sbiiti W, Orvcov K. Mycobcteril lod ssy. Methods Mol Biol. 217;1616:89 15 ( pubmed/286763, ccessed 9 July 218). 4 P 139 of World Helth Orgniztion. Globl tuberculosis report 217 (WHO/HTM/TB/217.23). Genev: WHO; 217 ( bitstrem/hndle/1665/259366/ eng.pdf, ccessed 21 June 218). 155

167 FIG. 8.2 The globl clinicl development pipeline for new nti-tb drugs nd regimens, August 218 Phse I Phse II Phse III Contezolid (MRX-1) b GSK b Mcozinone (PBTZ169) b OPC Q23 b TBA-7371 b TBI-166 Delpzolid (LCB1-371) SQ19 Sutezolid (PNU-48) b Linezolid dose-rnging Nitzoxnide High dose rifmpicin for DS-TB (PANACEA) Bedquiline nd delmnid (ACTG A5343 DELIBERATE tril) Bedquiline Pretomnid Moxifloxcin Pyrzinmide (BPMZ) regimen Bedquiline nd pretomnid with existing nd re-purposed nti-tb drugs for MDR-TB (TB PRACTECAL Phse 2/3 tril) Delmnid, linezolid, levofloxcin, nd pyrzinmide for quinolone sensitive MDR-TB (MDR-END tril) Levofloxcin with OBR c for MDR-TB (OPTI-Q) Bedquiline (TMC-27) b Delmnid (OPC-67683) b Pretomnid (PA-824) Clofzimine High dose rifmpicin for tretment of DS-TB Rifpentine for tretment of DS-TB Bedquiline Pretomnid Linezolid (NiX-TB tril) Bedquiline Pretomnid Linezolid (ZeNix tril) Linezolid optimiztion Bedquiline with two optimised bckground regimens (orl, 9 months; with orl nd injectbles, 6 months) (STREAM tril) Bedquiline Linezolid Levofloxcin with OBR c for MDR-TB (NExT tirl) Bedquiline nd delmnid with vrious existing regimens for MDR-TB nd XDR-TB (endtb tril) Pretomnid Moxifloxcin Pyrzinmide regimen (STAND tril) Rifpentine Moxifloxcin for tretment of DS-TB (TB Tril Consortium Study 31/A5349) b c New drug compounds re listed first, followed by repurposed drugs nd then by regimens. New chemicl clss. Optimized bckground regimen. Source: Adpted from the Working Group on New TB Drugs pipeline. More informtion on these products nd other ongoing projects cn be found t 11 new compounds (up by three since August 217): contezolid, delpzolid, GSK , mcozinone, OPC , pretomnid, Q23, SQ19, sutezolid, TBA-7371 nd TBI Two other drugs (bedquiline nd delmnid) hve lredy received ccelerted or conditionl regultory pprovl bsed on Phse IIb tril results. Seven repurposed drugs re undergoing further testing: clofzimine, linezolid, levofloxcin, moxifloxcin, nitzoxnide, rifmpicin (high dose) nd rifpentine. The 2 compounds re described in more detil in Section nd Section New TB regimens re lso being tested. These re described in Section New compounds Bedquiline WHO issued interim policy guidnce on the use of bedquiline for the tretment of dults with MDR-TB in 213, bsed on Phse IIb tril results. 2 The recommendtion to use bedquiline s prt of longer MDR-TB tretment regimens ws conditionl upon proper ptient selection, regimen design following WHO recommendtions, close 1 Most of the new compounds re being developed by not-for-profit orgniztions, cdemic institutions, smll businesses or government gencies tht lck the secure funding nd resources vilble to mjor phrmceuticl compnies. This mkes the process of progression through trils nd then registrtion more uncertin. 2 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 12 June 218). monitoring of tretment, ctive TB drug sfety monitoring nd mngement, nd informed consent ccording to locl requirements. The recommendtion ws mintined following review of dt from observtionl studies in In 218, dditionl dt for ptients treted with bedquiline-contining regimens were nlysed s prt of mjor updte to WHO guidnce on the tretment of drug-resistnt TB. 4 The sfety nd efficcy of bedquiline when used s prt of short MDR-TB regimens (i.e. 6 nd 9 months durtion), compred with the updted current stndrd of cre recommended by WHO (i.e. shortened regimen) is being investigted in the second stge of the Phse III Stndrdised Tretment Regimen of Anti-TB Drugs for Ptients with MDR-TB (STREAM) tril. 5 Recruitment strted in Mrch 216, nd the first results re expected in 22. A study on the use of bedquiline to tret children with MDR-TB is being implemented in the Philippines, the Russin Federtion nd South Afric. Bedquiline is lso being used in trils of ll-orl tretment regimens (Section 8.2.3), nd investigtion of its use in the tretment of drug-susceptible TB hs strted. 3 World Helth Orgniztion. Report of the Guideline Development Group Meeting on the use of bedquiline in the tretment of multidrugresistnt tuberculosis, 216 revision (WHO/HTM/TB/217.1). Genev: WHO; 217 ( WHO-HTM-TB eng.pdf, ccessed 9 July 218). 4 Further detils re provided in Box 4.2 in Chpter 4. 5 Moodley R, Godec TR, Tem ST. Short-course tretment for multidrugresistnt tuberculosis: the STREAM trils. Eur Respir Rev. 216;25(139):29 35 ( ccessed 12 June 218). 156

168 Contezolid MRX4, prodrug 1 of Contezolid (MRX-I), is in Phse 1 tril in the USA. MRX-1 is n oxzolidinone ntibiotic tht is potent ginst Grm-positive pthogens. Orlly dministered MRX-1 hs shown the sme or better efficcy thn linezolid in systemic nd locl-infection mouse models. Delmnid WHO issued interim policy guidnce on the use of delmnid for the tretment of dults with MDR-TB in 214, bsed on Phse IIb tril results. 2 A conditionl recommendtion ws mde to use delmnid s prt of longer MDR-TB tretment regimens for dults. The recommendtion to use delmnid s prt of longer MDR-TB tretment regimens ws conditionl upon proper ptient selection, regimen design following WHO recommendtions, close monitoring of tretment, ctive TB drug sfety monitoring nd mngement, nd informed consent ccording to locl requirements. Following the relese of results for children nd dolescents treted for MDR-TB using delmnid in 216, WHO s guidnce on the use of delmnid in dults ws expnded to include ptients ged 6 17 yers. 3 In November 217, finl results from Phse III tril ssessing the sfety nd efficcy of delmnid s n ddition to n optimized bckground regimen for dults with MDR-TB were reported to WHO by the mnufcturer Otsuk Phrmceuticl, Jpn. WHO conducted n expedited externl expert review of the new dt nd issued position sttement in Jnury 218, 4 which stted tht the conditionl guidnce on delmnid remined vlid, but tht delmnid should only be dded to longer MDR-TB tretment regimen when the regimen cnnot otherwise be composed ccording to WHO recommendtions. In 218, dditionl dt from the Phse III tril were nlysed by WHO longside dt from other studies of ptients treted with delmnid-contining regimens s prt of mjor updte to WHO guidnce on the tretment of drug-resistnt TB. 5 As with bedquiline, delmnid is being used in trils 1 A prodrug is derivtive of drug molecules tht undergo trnsformtion into phrmcologiclly ctive drug once inside the body. From: Rutio J, Kumpulinen H, Heimbch T, Oliyi R, Oh D, Jrvinen T et l. Prodrugs: design nd clinicl pplictions. Nt Rev Drug Discov. 28;7(3):255 7 ( ccessed 9 July 218). 2 World Helth Orgniztion. The use of delmnid in the tretment of multidrug-resistnt tuberculosis. Interim policy guidnce (WHO/HTM/ TB/214.23). Genev, WHO ( bitstrem/1665/137334/1/who_htm_tb_214.23_eng.pdf, ccessed 12 June 218). 3 World Helth Orgniztion. The use of delmnid in the tretment of multidrug-resistnt tuberculosis in children nd dolescents: interim policy guidnce (WHO/HTM/TB/216.14). Genev, WHO ( pps.who.int/iris/bitstrem/1665/2614/1/ eng.pdf; ccessed 12 June 218) 4 World Helth Orgniztion. WHO position sttement on the use of delmnid for multidrug-resistnt tuberculosis (WHO/CDS/TB/218.1). Genev: WHO; 218 ( WHOPositionSttementDelmnidUse.pdf, ccessed 21 June 218). 5 Further detils re provided in Box 4.2 in Chpter 4. of ll-orl tretment regimens (Section 8.2.3). The use of delmnid in ddition to n optimized bckground regimen to tret children less thn 6 yers old is lso being investigted in other trils. Studies of its use in the prevention of drug-resistnt TB mong contcts of people with MDR-TB re plnned. Delpzolid (LCB1 371) Delpzolid is new oxzolidinone developed by LegoChem BioSciences. It entered Phse II tril in the Republic of Kore in 217. GSK GSK is new oxborole compound developed by GlxoSmithKline. A Phse I tril strted in Mrch 217. Mcozinone Mcozinone (formerly PBTZ169) is benzothizinone developed by Nermedic Plus. A Phse I tril hs been completed nd Phse II tril hs been strted in the Russin Federtion. A Phse I study with new formultion ws strted in 218 in Switzerlnd. OPC OPC is crbostyril developed by Otsuk tht is bctericidl ginst both growing nd intrcellulr bcilli. A single scending dose study hs been completed. A multiple scending dose nd erly bctericidl ctivity (EBA) study of OPC lone nd in combintion with delmnid is plnned in 218. Pretomnid Pretomnid is nitroimidzole being developed by the Globl Allince for TB Drug Development (the TB Allince). It is currently being tested s prt of combintion regimens for the tretment of both drug-susceptible nd drug-resistnt TB, including XDR-TB (Section 8.2.3). Q23 Q23 is n imidzopyridine tht hs been developed by Qurient (Republic of Kore). Single doses of vrious sizes hve been tested in Phse I trils, nd Phse II tril is plnned. SQ19 SQ19 is new, smll-molecule drug discovered by scientists t Sequell Inc. (USA) nd the US Ntionl Institutes of Helth (NIH). A Phse IIb/III tril in which the drug ws dded to stndrd regimen for MDR-TB hs been completed in seven clinicl centres in the Russin Federtion, nd positive results in terms of sfety, efficcy nd tolerbility were reported in press relese in Mrch 217. A Phse II tril in the USA is in the plnning stges. Sutezolid Sutezolid (PNU-48) is n oxzolidinone nd n nlogue of linezolid. Results from n EBA study presented 157

169 in 212 showed significnt reduction in colony-forming unit counts compred with the bseline level fter 14 dys of tretment. In Jnury 217, the Medicines Ptent Pool nnounced tht it hd signed licence with Johns Hopkins University to fcilitte the clinicl development of sutezolid in combintion with other drugs. On World TB Dy 217, the TB Allince nd the Medicines Ptent Pool nnounced licensing greement for the clinicl development of sutezolid. remins unknown, the TB Allince hs implemented Phse II tril to evlute the mycobctericidl ctivity, sfety, tolerbility nd phrmcokinetics of five doses of linezolid in dults with pulmonry TB. Moxifloxcin Moxifloxcin is included in severl trils of new regimens for tretment of both drug-susceptible nd drug-resistnt TB (Section 8.2.3). TBA-7371 TBA-7371 is n inhibitor of the enzyme DprE1, which is essentil in the synthesis of components of mycobcteril cell wlls. This inhibitor hs shown to be ctive ginst strins of M. tuberculosis resistnt to known TB drugs. The TB Allince is implementing Phse I study in the USA. TBI-166 TBI-166 ws identified through led optimiztion effort by the TB Allince in prtnership with the Institute of Mteri Medic, the Chinese Acdemy of Medicl Sciences nd the Peking Union Medicl College in Beijing. This riminophenzine compound hs improved physicochemicl nd phrmcokinetic properties (to void discolortion of skin), nd hs efficcy similr to clofzimine. A Phse I clinicl tril strted in Jnury 218 in Chin Approved drugs being tested for new purposes Clofzimine Clofzimine is riminophenzine tht is used to tret leprosy. Its use in MDR-TB tretment is being explored in preclinicl models of TB infection, to better understnd its nti-tb effects. Novrtis, the compny tht mnufctures the drug, hs withdrwn support for Phse II trils; however, clofzimine continues to be tested s prt of tretment regimens for MDR-TB in Phse III trils. Levofloxcin Levofloxcin is being tested in Phse II study clled Opti-Q, which is investigting the best dose of levofloxcin to use for tretment of MDR-TB in dults with smer- nd culture-positive pulmonry TB. Four doses re being tested (11, 14, 17 nd 2 mg/kg/dy) s prt of n optimized bckground regimen. Tril enrolment nd follow-up (in Peru nd South Afric) hs been completed. Dt nlysis is underwy. Linezolid Linezolid is mrketed oxzolidinone with potent ctivity ginst TB. It hs been widely used in the tretment of drug-resistnt TB, nd there is good evidence tht it improves culture conversion nd cure rtes when dded to tretment regimens. Since the medicine hs nrrow therpeutic window, nd the optiml dosing strtegy Nitzoxnide Nitzoxnide is n nti-prsitic drug. Its ctivity ginst M. tuberculosis is being tested in Phse II tril in Hiti. Rifmpicin (high dose) Findings from the multi-rm, multi-stge TB (MAMS-TB) tril of the Pn-Africn Consortium for the Evlution of Antituberculosis Antibiotics (PnACEA) were published in These showed tht 35 mg/kg of rifmpicin given over 12 weeks is sfe, nd shortens the time to stble culture conversion from 62 to 48 dys. The other tril rms which included vrious combintions of 1 mg/ kg or 2 mg/kg of rifmpicin, moxifloxcin nd SQ19 did not chieve significnt improvements compred with the control rm. When ll the dt re tken into considertion, the tril suggests tht 35 mg/kg dose of rifmpicin given for 12 weeks is likely to improve tretment outcomes. This tril is the first multi-rm dptive tril design to be successfully implemented in multiple sites in countries with high burden of TB. It my help to pve the wy for ccelerted testing of new TB tretment regimens t reduced cost. Rifpentine The effectiveness of rifpentine in the tretment of drug-susceptible TB is being studied in three trils. The TB Tril Consortium (TBTC) Study 31/ACTG A5349 is Phse III tril tht is investigting the use of rifpentine, with or without moxifloxcin, to shorten the tretment of drug-susceptible pulmonry TB to 4 months. TBTC Study 35, Phse II study of the phrmcokinetics of new wter-dispersible peditric formultions of rifpentine, is scheduled to strt t two sites in South Afric in 218. TBTC Study 37 is Phse III tril of the sfety nd efficcy of 6 weeks of dily rifpentine for the tretment of ltent TB infection (LTBI) in HIV-negtive people in settings with low burden of TB. It is being compred with loclly vilble 3 4 month rifmycin-bsed regimen. 1 Boeree MJ, Heinrich N, Arnoutse R, Dicon AH, Dwson R, Rehl S et l. High-dose rifmpicin, moxifloxcin, nd SQ19 for treting tuberculosis: multi-rm, multi-stge rndomized controlled tril. Lncet Infect Dis. 217;17(1):39 49 ( ccessed 12 June 218). 158

170 8.2.3 New regimens for the tretment of drugsusceptible or drug-resistnt TB New combintions of drugs re being tested in Phse II or Phse III trils. ACTG A5343 DELIBERATE The ACTG A5343 DELIBERATE tril is testing the crdiotoxicity of regimens contining delmnid nd bedquiline lone, nd in combintion in phrmcokinetic nd drug drug interction studies. The tril is sponsored by NIH nd the Ntionl Institute of Allergy nd Infectious Diseses (NIAID). endtb The endtb tril strted in 217. It is compring severl tretment regimens for MDR-TB or XDR-TB with the current longer tretment regimen for MDR-TB recommended by WHO. The regimens being tested include bedquiline or delmnid (or both), moxifloxcin or levofloxcin, nd pyrzinmide plus linezolid or clofzimine (or both), in vrious combintions. MDR-END The MDR-END tril is investigting 9 12 month regimen of delmnid, linezolid, levofloxcin nd pyrzinmide for the tretment of MDR-TB mong TB ptients without resistnce to fluoroquinolones. NeXT The NeXT tril is testing 6 9 month injection-free regimen of bedquiline, ethionmide or high-dose isonizid, linezolid, levofloxcin nd pyrzinmide for ptients with MDR-TB, compred with the months tretment regimen. Recruitment strted in South Afric in 216. STREAM The STREAM Stge 1 tril is compring 9-month regimen for MDR-TB with longer regimens of months in Ethiopi, Mongoli, South Afric nd Viet Nm. It is Phse III tril for which enrolment nd follow-up were completed in Following the relese of preliminry results, WHO conducted n expedited review of dt provided by the STREAM tril consortium. 2 The nlysis showed tht fvourble outcome ws slightly higher in ptients treted with longer regimens thn in ptients on the shorter regimen; non-inferiority s defined by the study protocol could not be shown. The externl experts who reviewed the interim findings recommended tht ntionl TB progrmmes nd other stkeholders should continue to use the shorter MDR-TB regimen under the sme conditions s those recommended in WHO guidnce issued in The finl results from the STREAM Stge 1 tril were used to inform n updte of WHO guidnce on the tretment of MDR-TB in TB-PRACTECAL The TB-PRACTECAL tril is Phse II/III tril to evlute the sfety nd efficcy of 6-month regimens tht contin bedquiline, pretomnid nd linezolid, with or without moxifloxcin or clofzimine, for the tretment of dults with MDR-TB or XDR-TB. Primry outcomes include 8-week culture conversion, nd the development of unfvourble outcomes (tretment filure or recurrence, deth, discontinution or loss to follow-up during 72-week follow-up period). It is being implemented by Médecins sns Frontières nd other collbortors in Belrus, South Afric nd Uzbekistn. NiX-TB, ZeNix nd BPMZ The NiX-TB tril is investigting the sfety nd efficcy of 6-month ll-orl regimen combining bedquiline, pretomnid nd linezolid in ptients with XDR-TB, nd in ptients who could not tolerte MDR-TB tretment or for whom this tretment filed. It is being implemented by the TB Allince in South Afric. The primry end-point is bcteriologicl filure, relpse or clinicl filure during 6 month follow-up period fter completion of tretment. A cure rte of 87% hs been reported for the first 15 ptients. A follow-on tril clled ZeNix is exploring lower doses nd shorter durtions of linezolid to minimize toxicity. A Phse IIc/III tril (clled SimpliciTB) of bedquiline, pretomnid, moxifloxcin nd pyrzinmide (BPMZ), trgeting ptients with both drug-susceptible or MDR- TB, is lso being implemented. The primry end-point is culture conversion t 2 months. A previous Phse IIb study of this BPMZ regimen showed lmost % culture conversion t 2 months in ptients with MDR-TB. 8.3 New vccines to prevent TB The bcille Clmette-Guérin (BCG) vccine, first used in the 192s, remins the only licensed vccine for preventing TB. Despite high coverge of BCG vccintion s prt of childhood immuniztion progrmmes (Chpter 5), the slow decline in TB incidence globlly highlights the need for much more effective vccine tht provides protection ginst ll forms of TB in ll ge groups. The sttus of the pipeline for new TB vccines in August 218, including the nmes of vccine developers, 1 Nunn AJ, Rusen ID, Vn Deun A, Torre G, Phillips PP, Ching CY et l. Evlution of stndrdized tretment regimen of nti-tuberculosis drugs for ptients with multi-drug-resistnt tuberculosis (STREAM): study protocol for rndomized controlled tril. Trils. 214;15:353 ( ccessed 12 June 218). 2 World Helth Orgniztion. WHO issues position sttement on the continued use of the shorter MDR-TB regimen following n expedited review of the STREAM Stge 1 preliminry results. Genev: WHO; 218 ( MDRTB-regimen/en/; ccessed 12 June 218). 3 World Helth Orgniztion. WHO tretment guidelines for drug-resistnt tuberculosis, 216 updte. Genev: WHO; 216 ( res-of-work/drug-resistnt-tb/tretment/resources/en/, ccessed 3 July 218). 4 Further detils re provided in Box 4.2 in Chpter

171 FIG. 8.3 The globl development pipeline for new TB vccines, August 218 Phse I Phse II Phse IIb Phse III MTBVAC Biofbri, TBVI, Zrgoz RUTI Archivel Frm, S.L DAR-91 booster Drtmouth, GHIT Vcce Anhui Zhifei Longcom AEC/BC2 Anhui Zhifei Longcom H56:IC31 SSI, Vlnev, Aers M72/AS1E GSK, Aers VPM2 SII, Mx Plnck, VPM, TBVI Ad5 Ag85A McMster, CnSino ChAdOx185A-MVA85A (ID/IM/Aerosol) University of Oxford ID93 + GLA-SE IDRI, Wellcome Trust, Aers TB/FLU-4L RIBSP Virl Vector Protein/Adjuvnt Mycobcteril Whole Cell or Extrct Mycobcteril Live Informtion ws self-reported by vccine sponsors, nd the Stop TB Prtnership Working Group on New TB Vccines supported the review of their feedbck. is shown in Fig There re 12 vccines in Phse I, II or III trils. Their min chrcteristics re summrized below Phse I trils There re four vccine cndidtes in Phse I trils. Ad5 Ag85A Ad5 Ag85A is n denovirus serotype 5 vector expressing Ag85A. It hs been evluted for sfety nd immunogenicity in both BCG-nive nd previously BCG-immunized helthy volunteers in Cnd. Overll, intrmusculr dministrtion ws found to be sfe, well tolerted nd immunogenic in both tril groups, with more potent immunogenicity observed in volunteers who hd been previously vccinted with BCG. A sfety nd immunogenicity study of erosol dministrtion in BCG-vccinted helthy volunteers hs strted. AEC/BC2 AEC/BC2 is freeze-dried recombinnt vccine expressing Ag85B nd fusion protein ESAT6-CFP1. A Phse I study ssessing sfety nd immunogenicity is underwy in Chin, with sponsorship from Anhui Zhifei Longcom Biologic Phrmcy Co., Ltd. ChAdOx185A MVA85A (ID/IM/Aerosol) ChAdOx185A is simin denovirus nd MVA85A is recombinnt pox virus both express ntigen 85A. These cndidtes re being developed with the overll im of generting joint heterologous prime-boost regimen delivered through both systemic nd mucosl routes. A Phse I tril of intrmusculr dministrtion of ChAdOx185A in BCG-vccinted dults in the United Kingdom, both lone nd s prt of prime-boost strtegy with MVA85A, hs been completed. Phse I trils of erosol dministrtion of ChAdOx185A in BCG-vccinted dults re scheduled to strt in the third qurter of 218. Two studies of erosol dministrtion of MVA85A in BCG-vccinted individuls hve been completed, nd further study in people with LTBI is being implemented. MTBVAC MTBVAC is live strin of M. tuberculosis, ttenuted vi deletions of the phop nd fdd26 genes. The primry trget popultion is neontes (s BCG replcement vccine); the secondry trget popultion is dolescents nd dults (s booster vccine). A Phse Ib tril in neontes ws completed in 218. Phse II trils in both trget popultions will strt in Phse II nd Phse III clinicl trils There re eight vccines in Phse II or Phse III trils. Another vccine (H4:IC31) ws in development until recently, nd for this reson it is lso described below. DAR-91 booster DAR-91 is whole-cell, het-inctivted, nontuberculous mycobcteril vccine booster. It represents new sclble mnufcturing method for SRL172, cndidte vccine tht showed efficcy mong dults living with HIV in Phse II/III tril in the United Republic of Tnzni. It is now being tested in Phse IIb prevention of (estblished) infection tril mong BCG-primed dolescents, lso in the United Republic of Tnzni. The tril is scheduled for completion in 219. H4:IC31 H4:IC31 is subunit vccine tht contins fusion protein of Ag85B nd TB1.4, formulted with IC31 djuvnt. A pre-proof-of-concept Phse II tril to evlute prevention of (estblished) infection mong IGRA-negtive, 16

172 HIV-negtive dolescents who hd undergone neontl BCG vccintion ws recently completed in South Afric. 1 The results showed tht H4:IC31 induced incresed immunogenicity specific to M. tuberculosis compred with plcebo. However, sttisticl significnce in preventing initil or sustined infection (mesured using the QuntiFERON-TB Gold In-Tube test) ws not shown. In the sme study, BCG revccintion rm showed sttisticlly significnt reduction in the rte of sustined conversion compred with the plcebo rm. Due to indequte efficcy, further development nd testing of the H4:IC31 cndidte hs been terminted. For this reson it is not shown in Fig H56:IC31 H56:IC31 is n djuvnted subunit vccine tht combines three M. tuberculosis ntigens (Ag85B, ESAT-6 nd Rv266c) with the IC31 djuvnt, from Vlnev Austri GmBH (Vienn Austri). Three Phse I or I/II trils of sfety nd immunogenicity hve been completed. Two of these were in HIV-negtive, BCG-vccinted dults with nd without LTBI, nd without history or ny evidence of TB disese. The other ws in HIV-negtive pulmonry TB ptients who hd recently completed tretment. The trils showed tht the vccine hd n cceptble sfety profile nd ws immunogenic t ll studied doses. Anlysis of Phse Ib tril evluting the sfety nd immunogenicity of H4:IC31, H56:IC31 nd BCG revccintion in dolescents is underwy. In 218, Phse 2b tril ssessing H56:IC31 for prevention of recurrence will be initited in the United Republic of Tnzni nd South Afric, co-sponsored by the Sttens Serum Institut (SSI) nd Aers, with support from the Europen nd Developing Countries Clinicl Tril Prtnership (EDCTP). ID93 + GLA-SE The ID93 + GLA-SE vccine comprises four M. tuberculosis ntigens ssocited with virulence (Rv268, Rv3619 nd Rv362) or ltency (Rv1813), nd the djuvnt GLA- SE. A Phse II tril in HIV-negtive TB ptients tht hve recently completed tretment for pulmonry TB disese hs been completed in South Afric, in preprtion for Phse IIb tril tht will investigte the prevention of recurrence of disese in the sme popultion. A Phse II tril in BCG-vccinted helthy helth-cre workers, to ssess prevention of infection, is underwy. M72/AS1E M72/AS1E is subunit vccine tht pirs two M. tuberculosis ntigens (32A nd 39A) with n djuvnt (AS1E). It is being tested in Phse IIb efficcy tril in HIVnegtive dults infected with M. tuberculosis in Keny, South Afric nd Zmbi. The primry end-point is the 1 Nemes et l Prevention of M. tuberculosis Infection with H4:IC31 Vccine or BCG Revccintion. N Engl J Med. 379: ( ncbi.nlm.nih.gov/pubmed/ , ccessed 18 July 218). number of incident cses of ctive pulmonry TB disese not ssocited with HIV infection. Secondry end-points include sfety nd immunogenicity. RUTI RUTI is non-live, polyntigenic vccine bsed on cellwll frgmented M. tuberculosis bcteri. It is intended s therpeutic vccine, to be used in conjunction with short, intensive ntibiotic tretment. A Phse I study in helthy volunteers nd Phse II study in people with LTBI hve demonstrted good sfety profile, nd found the vccine to be immunogenic t ll studied doses. The min trget for RUTI is MDR-TB, nd Phse II study in ptients with MDR-TB is being implemented. TB/FLU-4L TB/FLU-4L is mucosl-vectored vccine bsed on n ttenuted repliction-deficient influenz virus vector expressing ntigens Ag85A nd ESAT-6. It ws designed s prophylctic boost vccine for infnts, dolescents nd dults. A Phse II tril in people with LTBI is being implemented. Vcce Vcce vccine is specified lyste tht hs been licensed by the Chin Food nd Drug Administrtion s n immunotherpeutic gent to help shorten TB tretment for ptients with drug-susceptible TB. A Phse III tril to ssess its efficcy nd sfety in preventing TB disese in people with LTBI hs been completed, nd dt nlysis is underwy. It is the lrgest TB vccine tril undertken in the pst decde, involving 1 people ged yers. VPM2 VPM2 is live recombinnt vccine. A Phse II tril is being implemented in South Afric to ssess the sfety nd immunogenicity of the vccine in HIV-exposed nd unexposed neontes, nd the preprtions for subsequent Phse III tril re underwy. A Phse II/III tril for prevention of TB recurrence in dults is being implemented in Indi. 8.4 Reserch collbortions nd prtnerships to end TB Stkeholders with cler role to ply in dvncing TB reserch include ntionl nd locl governments, privte compnies, cdemi, civil society nd TB-ffected communities, reserch institutions, universities, nd funding gencies. The Globl Action Frmework for TB Reserch, published by WHO in 215, ws developed to fcilitte reserch collbortions nd prtnerships. 2 It hs two min components: promoting TB reserch t 2 World Helth Orgniztion. A globl ction frmework for TB reserch in support of the third pillr of WHO s End TB Strtegy. Genev: WHO; 215 ( en/, ccessed 8 August 217). 161

173 BOX 8.3 The BRICS TB Reserch Network In November 217, the governments of Brzil, the Russin Federtion, Indi, Chin nd South Afric nnounced the estblishment of collbortive TB reserch network, the im of which is to ccelerte TB reserch nd innovtion through coopertion mechnisms. The estblishment of the network follows previous BRICS commitments to coordinted ction relted to the TB response. In the 213 Delhi Communiqué, BRICS greed to collborte to develop cpcity nd infrstructure to reduce the prevlence nd incidence of TB through innovtion for new drugs, vccines, dignostics nd promotion of consorti of TB reserchers to collborte on clinicl trils of drugs nd vccines. When BRICS ministers of helth met in Brsili in 214, they greed to cooperte on TB reserch nd innovtion, nd they identified technology shring, mnufcturing cpcity nd TB finncing s key priorities. b In December 216, they greed to the setting up of BRICS network on TB reserch nd cretion of reserch nd development consortium on TB, HIV nd mlri, including the possibility of interntionl fund rising. c The new network will include coopertion on TB reserch nd innovtion relted to product development nd vlidtion, technology trnsfer, delivery of TB cre nd services, nd cpcitybuilding, bsed on the use of existing expertise nd technologicl cpcity within BRICS. Priority ctivities include leverging domestic funds to support the development of common protocols nd ssocited implementtion of multicountry studies to ccelerte the development of TB dignostics, drugs nd vccines; nd evluting the epidemiologicl, clinicl nd economic impct of dopting innovtive interventions t ntionl level. country level to find wys to ddress locl brriers; nd ctlysing reserch t globl level through dvoccy, knowledge shring, reserch prioritiztion, collbortion nd support to interntionl networks for reserch nd cpcity-building. One component of promoting reserch t the globl level is the estblishment of multicountry reserch networks. These cn help to expedite innovtion by fostering collbortion, leverging resources nd fcilitting technology trnsfer, through public privte prtnerships, north south nd south south coopertion. Governments hve n importnt role to ply in strengthening such inititives by creting policy frmeworks tht enble nd promote reserch prtnerships. At G2 summit 1 in 217, heds of stte clled for the estblishment of collbortive hub for reserch nd development to mximize the impct of new nd existing nti-microbil bsic nd clinicl reserch inititives s well s product development for drug-resistnt infections, including TB. A recent nlysis of the uthorship of reserch publictions on TB between 27 nd 216 suggested tht north south collbortions incresed stedily during this period, while south south collbortions were much less common. 2 With growing scientific nd economic cpcity in low- nd middle-income countries, the cpcity of countries with high burden of TB to contribute to reserch is expected to increse. This is prticulrly so for the BRICS countries (Brzil, Russin Federtion, Indi, Chin nd South Afric), which ccount for more thn 4% of the globl TB disese burden in terms of both TB incidence nd TB deths, nd bout % of the globl burden of drug-resistnt TB (Chpter 3). During the Globl Ministeril Conference on TB in November 217, the estblishment of BRICS TB reserch network ws nnounced; further detils re provided in Box 8.3. b c Government of Indi Ministry of Helth nd Fmily Welfre. Delhi communiqué. Delhi: Government of Indi; 213 ( spx?relid=91533, ccessed 11 June 218). BRICS Ministry of Externl Reltions. Communiqué of the IV meeting of BRICS helth ministers. Brsili: BRICS Ministry of Externl Reltions; 214 ( utoronto.c/docs/14125-helth.html, ccessed 11 June 218). Ministry of Helth nd Fmily Welfre, Government of Indi. 6th BRICS Helth Ministers Meeting Delhi Communiqué. Delhi: Government of Indi Ministry of Helth nd Fmily Welfre; 216 ( newsite/printrelese.spx?relid=155596, ccessed 11 June 218). 1 G2 Ntions. G2 Leders Declrtion: Shping n interconnected world. Hmburg: G2 Ntions; 217 ( c/217/217-g2-leders-declrtion.html, ccessed 11 June 218). 2 World Helth Orgniztion. Globl investments in tuberculosis reserch nd development pst, present, nd future. Genev: WHO; 217 ( pps.who.int/iris/bitstrem/hndle/1665/259412/ eng.pdf, ccessed 28 June 218). 162

174

175 An MDR-TB ptient in Krchi, Pkistn Hmd Drwish / WHO 164

176 ANNEX 1 The WHO globl TB dtbse

177 A.1 Dtbse contents The 218 globl TB report is bsed on dt collected nnully from 216 countries nd territories, including ll 194 WHO Member Sttes. These dt re stored in globl TB dtbse tht is mnged by the TB monitoring nd evlution unit of the Globl TB Progrmme, t WHO hedqurters. In 218, 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; pllitive cre; enggement of ll public nd privte cre providers in TB prevention nd cre; community enggement; the budgets of ntionl TB control progrmmes (NTPs); utiliztion of generl helth services (hospitliztion nd outptient visits) during tretment; nd NTP expenditures. A shortened version of the online questionnire ws used for high-income countries (tht is, countries with gross ntionl income per cpit of US$ in 216, s defined by the World Bnk) 1 nd/or low-incidence countries (defined s countries with n incidence rte of <2 cses per popultion or <1 cses in totl in 216). Countries reported dt using dedicted website ( which ws opened for reporting in April 218. Switzerlnd nd countries in the Europen Union submitted dt on notifictions nd tretment outcomes to the TESSy system mnged by the Europen Centre for Disese Prevention nd Control (ECDC). Dt from TESSy were uploded into the globl TB dtbse. Additionl dt bout the provision of tretment for ltent TB infection to people newly enrolled in HIV cre nd ntiretrovirl therpy for HIV-positive TB ptients were collected by the Joint United Ntions Progrmme on HIV/AIDS (UNAIDS). 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 6 August 218. Tble A1.1 shows the number of countries nd territories tht hd reported dt by 6 August 218. TABLE A1.1 Reporting of dt in the 218 round of globl TB dt collection COUNTRIES AND TERRITORIES WHO MEMBER STATES 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 Indictors in the Sustinble Development Gols ssocited with TB incidence were imported into the globl TB dtbse on 3 July 218. Tble A1.2 shows the dt sources used. A.2 Accessing TB dt using the WHO Globl TB Progrmme website Most of the dt held in the globl TB dtbse cn be found by going to This web pge provides ccess to country profiles, comm-seprted vlue (CSV) dt files nd dt visulistions. A2.1 Country profiles Profiles cn be viewed nd downloded for ll 216 countries nd territories tht report TB dt to WHO ech yer, nd not just the 3 high burden countries shown in the printed version of the globl TB report. The profiles cn be generted on-demnd directly from the globl TB dtbse nd therefore my include updtes received fter publiction of the globl TB report. TB finncil profiles cn be viewed nd downloded for over countries nd territories tht report detiled TB finncil dt to WHO. 1 clssifictions 166

178 TABLE A1.2 Dt sources for indictors in the Sustinble Development Gols ssocited with TB incidence SDG INDICATOR DISPLAY NAME IN PROFILE DATA SOURCE NAME AT SOURCE SOURCE URL Popultion living below the interntionl poverty line (% of popultion) UN SDG dtbse Proportion of popultion below the interntionl poverty line dtbse/?indictor= Popultion covered by socil protection floors/systems (% of popultion) World Bnk Coverge All Socil Protection nd Lbour (% of popultion) Prevlence of undernourishment (% of popultion) World Bnk Prevlence of undernourishment (% of popultion) (lterntive) HIV prevlence (% of popultion ged yers) World Bnk Prevlence of HIV, totl (% of popultion ged 15 49) (lterntive) Dibetes prevlence (% of popultion ged 18 yers) WHO-GHO Rised fsting blood glucose ( 7. mmol/l or on mediction) (ge-stndrdized estimte) Direct links to CSV files: dt coded.csv?trget=gho/ncd_ GLUC_4&filter=AGEGROUP:*;COUNTRY:*;SEX:FMLE nd dt coded.csv?trget=gho/ncd_ GLUC_4&filter=AGEGROUP:*;COUNTRY:*;SEX:MLE (lterntive) Alcohol use disorders, 12 month prevlence (% in popultion ged 15 yers) WHO-GHO Alcohol use disorders (15+), 12 month prevlence (%) Direct links to CSV files: dt/dt coded.csv?trget=gho/ SA_1462&filter=COUNTRY:*;SEX:FMLE nd dt/dt coded.csv?trget=gho/ SA_1462&filter=COUNTRY:*;SEX:MLE 3..1 (lterntive) Smoking prevlence (% ged 15 yers) World Bnk Smoking prevlence, femles (% of dults) nd Smoking prevlence, mles (% of dults) nd (lterntive) Helth expenditure per cpit, PPP (current interntionl $) World Bnk Helth expenditure per cpit, PPP (current interntionl $) (lterntive) Out-of-pocket helth expenditure (% of current helth expenditure) World Bnk Out-of-pocket helth expenditure (% of current helth expenditure) UHC Index of essentil service coverge (%, bsed on 16 trcer indictors including TB tretment) Access to clen fuels nd technologies for cooking (% of popultion) (lterntive) (lterntive) GDP per cpit, PPP (constnt 211 interntionl $) GINI index (=perfect equlity, =perfect inequlity) Popultion living in slums (% of urbn popultion) WHO-GHO World Bnk World Bnk World Bnk World Bnk UHC Index of essentil service coverge (%) Access to clen fuels nd technologies for cooking (% of popultion) GDP per cpit, PPP (constnt 211 interntionl $) GINI index (World Bnk estimte) Popultion living in slums (% of urbn popultion) INDEXOFESSENTIALSERVICECOVERAGE Direct links to CSV file: dt coded.csv?trget=gho/uhc_index_ REPORTED&filter=COUNTRY:*

179 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. A dt dictionry tht defines ech of the vribles vilble in the CSV files is lso vilble nd cn be downloded. The CSV files re generted on-demnd directly from the globl TB dtbse, nd therefore my include updtes received fter publiction of the globl TB report. A2.3 Dt visulistions There re severl interctive web pges tht cn be used to view mps, grphs nd underlying dt on TB cse notifictions, drug-resistnt TB cses, tretment outcomes nd WHO estimtes of TB incidence nd mortlity. A.3 Accessing TB dt using the WHO Globl Helth Observtory The WHO Globl Helth Observtory (GHO) t is WHO s portl, providing ccess to dt nd nlyses for monitoring the globl helth sitution. It includes dt repository. Dt from WHO s globl TB dtbse cn be viewed, filtered, ggregted nd downloded from within the GHO Dt Repository t The GHO dt tble heders include links to vrible nd indictor definitions. The dt cn be downloded in mny formts, including s CSV nd Excel files. There is lso n Appliction Progrmme Interfce (API) for nlysts nd progrmmers to use GHO dt directly in their softwre pplictions. See 168

180

181 A busy mrket ner Surulere in Lgos, Nigeri Ynn Arthus-Bertrnd / Getty imges 17

182 ANNEX 2 Country profiles FOR 3 HIGH TB 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) 171

183 Angol ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 2 (12 31) 67 (39 13) Mortlity (HIV+TB only) 7.8 (3.9 13) 26 (13 44) Incidence (includes HIV+TB) 17 (69 153) 359 ( ) Incidence (HIV+TB only) 18 (9.1 3) 61 (31 12) Incidence (MDR/RR-TB) b 3.9 ( ) 13 (5.5 24) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 5.2 ( ) 35 (27 43) 4 (31 ) Mles 5.7 ( ) 61 (43 79) 67 (46 87) Totl 11 (9.5 12) 96 (6 131) 17 (69 153) Mortlity (excludes HIV+TB) Rte per popultion per yer POPULATION MILLION TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 59% % pulmonry 94% % bcteriologiclly confirmed mong pulmonry 53% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (36 79) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted.27 (.14.42) incidence), 217 Incidence Rte per popultion per yer Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 2 mong notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 2.5% ( ) 14% (1 18) % notified tested for rifmpicin resistnce <1% 6% 534 MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 534, XDR-TB: Ptients strted on tretment d MDR/RR-TB: 534, XDR-TB: Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New cses registered in % Previously treted cses registered in % 7 69 HIV-positive TB cses registered in 216 % MDR/RR-TB cses strted on second-line tretment in % 227 XDR-TB cses strted on second-line tretment in 215 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % of HIV-positive people (newly enrolled in cre) on preventive tretment 13% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment TB FINANCING, 218 Ntionl TB budget (US$ millions) 46 Funding source: 7% domestic, 12% interntionl, 8% 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 217 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) New cses Previously treted cses HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 172 Dt for ll countries nd yers cn be downloded from

184 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 173

185 Bngldesh ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 59 (38 85) 36 (23 52) Mortlity (HIV+TB only).17 (.85.29).11 (.5.18) Incidence (includes HIV+TB) 364 ( ) 221 ( ) Incidence (HIV+TB only).55 (.27.92).33 (.17.56) Incidence (MDR/RR-TB) b 8.4 (3.8 15) 5.1 (2.3 9) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS)*, YEARS > 14 YEARS TOTAL Femles 17 (16 18) 118 (98 137) 134 (11 158) Mles 18 (17 19) 212 ( ) 23 ( ) Totl 35 (32 38) 329 ( ) 364 ( ) TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis <1% % with known HIV sttus 2% % pulmonry 81% % bcteriologiclly confirmed mong pulmonry 74% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (51 92) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted.17 (.1.26) incidence), 217 Mortlity (excludes HIV+TB) Rte per popultion per yer Incidence Rte per popultion per yer POPULATION MILLION Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive 89 2% on ntiretrovirl therpy 84 94% DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 5 8 mong notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 1.6% ( ) 29% (24 35) % notified tested for rifmpicin resistnce 18% 63% MDR/RR-TB cses tested for resistnce to second-line drugs 362 Lbortory-confirmed cses MDR/RR-TB: 944, XDR-TB: 6 Ptients strted on tretment d MDR/RR-TB: 92, XDR-TB: 6 Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses registered in % 87 MDR/RR-TB cses strted on second-line tretment in % 88 XDR-TB cses strted on second-line tretment in 215 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % of HIV-positive people (newly enrolled in cre) on preventive tretment % of children (ged < 5) household contcts of 21% (19 23) bcteriologiclly-confirmed TB cses on preventive tretment TB FINANCING, 218 Ntionl TB budget (US$ millions) 66 Funding source: 14% domestic, 55% interntionl, 31% 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 217 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 174 Dt for ll countries nd yers cn be downloded from

186 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 175

187 Brzil POPULATION MILLION ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 5.1 ( ) 2.4 ( ) Mortlity (HIV+TB only) 1.9 ( ).91 ( ) Incidence (includes HIV+TB) 91 (78 15) 44 (37 ) Incidence (HIV+TB only) 11 (9.3 13) 5.3 ( ) Incidence (MDR/RR-TB) b 2.4 ( ) 1.2 ( ) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 5.2 (5 5.4) 24 (22 26) 29 (27 32) Mles 5.7 ( ) 56 ( 63) 62 (54 7) Totl 11 (1 11) 8 (69 92) 91 (78 15) Mortlity (excludes HIV+TB) Rte per popultion per yer TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 26% % with known HIV sttus 78% % pulmonry 87% % bcteriologiclly confirmed mong pulmonry 72% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (75 ) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted.8 (.6.9) incidence), 217 Incidence Rte per popultion per yer Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 2 mong notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 1.5% (1.1 2) 8% (6 1) % notified tested for rifmpicin resistnce 3% 39% MDR/RR-TB cses tested for resistnce to second-line drugs 173 Lbortory-confirmed cses MDR/RR-TB: 1 11, XDR-TB: 16 Ptients strted on tretment d MDR/RR-TB: 964, XDR-TB: 16 Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses registered in % MDR/RR-TB cses strted on second-line tretment in 215 6% 954 XDR-TB cses strted on second-line tretment in % 27 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % 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 FINANCING, 218 Ntionl TB budget (US$ millions) 57 Funding source: 85% domestic, % interntionl, 15% unfunded Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. 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 217 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 176 Dt for ll countries nd yers cn be downloded from

188 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 177

189 Chin POPULATION MILLION ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 37 (33 41) 2.6 ( ) Mortlity (HIV+TB only) 1.8 ( ).13 (.6.22) Incidence (includes HIV+TB) 889 ( ) 63 (54 73) Incidence (HIV+TB only) 12 (6.3 18).82 ( ) Incidence (MDR/RR-TB) b 73 (55 94) 5.2 ( ) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 47 (46 49) 241 (223 26) 289 ( ) Mles 52 ( 54) 548 ( ) 6 ( ) Totl 99 (94 14) 79 (678 91) 889 ( ) Mortlity (excludes HIV+TB) Rte per popultion per yer TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 55% % pulmonry 95% % bcteriologiclly confirmed mong pulmonry 32% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (75 ) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.4.5) Incidence Rte per popultion per yer Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 58 mong notified pulmonry TB cses d (46 69 ) Estimted % of TB cses with MDR/RR-TB 7.1% ( ) 24% (2 28) % notified tested for rifmpicin resistnce 12% 69% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 13 69, XDR-TB: Ptients strted on tretment e MDR/RR-TB: 5 943, XDR-TB: Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses registered in % MDR/RR-TB cses strted on second-line tretment in % XDR-TB cses strted on second-line tretment in 215 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % 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 FINANCING, 218 Ntionl TB budget (US$ millions) 69 Funding source: 87% domestic, 2% interntionl, 11% 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 The estimted number of MDR/RR-TB cses mong bcteriologiclly confirmed pulmonry cses is 21 (17 25 ). e Includes ptients dignosed before 217 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 178 Dt for ll countries nd yers cn be downloded from

190 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 179

191 Democrtic People s Republic of Kore POPULATION MILLION ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 16 (11 22) 63 (43 86) Mortlity (HIV+TB only).44 (.22.72).17 (.9.28) Incidence (includes HIV+TB) 131 ( ) 513 ( ) Incidence (HIV+TB only).17 (.94.28).69 ( ) Incidence (MDR/RR-TB) b 5.2 ( ) 2 (1 34) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 6.2 (6 6.4) 43 (4 47) (45 54) Mles 8.4 ( ) 73 (66 8) 81 (73 9) Totl 15 (14 15) 116 (11 131) 131 ( ) TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse 553 % tested with rpid dignostics t time of dignosis % with known HIV sttus % pulmonry 81% % bcteriologiclly confirmed mong pulmonry % UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (68 88) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.8.17) Mortlity (excludes HIV+TB) Rte per popultion per yer Incidence Rte per popultion per yer Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 Ptients with known HIV-sttus who re HIV-positive on ntiretrovirl therpy DRUG-RESISTANT TB CARE, 217 NUMBER (%) NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 4 mong notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 2.2% ( ) 16% (9.1 25) % notified tested for rifmpicin resistnce 14% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 1 515, XDR-TB: Ptients strted on tretment d MDR/RR-TB: 1 732, XDR-TB: 19 Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New cses registered in 216 Previously treted cses registered in 216 HIV-positive TB cses registered in 216 MDR/RR-TB cses strted on second-line tretment in % 325 XDR-TB cses strted on second-line tretment in 215 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % 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 e > % TB FINANCING, 218 Ntionl TB budget (US$ millions) 84 Funding source: 7% domestic, 1% interntionl, 92% 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 217 nd ptients who were not lbortory-confirmed. e Resons for higher thn expected coverge might be tht the numertor did not exclude nonhousehold contcts or children of five yers nd older. Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 18 Dt for ll countries nd yers cn be downloded from

192 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 181

193 Democrtic Republic of the Congo ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 49 (29 74) 6 (35 9) Mortlity (HIV+TB only) 7.5 (3.5 13) 9.2 (4.3 16) Incidence (includes HIV+TB) 262 ( ) 322 (28 46) Incidence (HIV+TB only) 2 (13 29) 25 (16 35) Incidence (MDR/RR-TB)** 7.5 (3.3 13) 9.2 (4 17) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 16 (14 17) 84 (65 12) 99 (76 123) Mles 17 (16 19) 145 (13 187) 162 ( ) Totl 33 (28 37) 229 ( ) 262 ( ) Mortlity (excludes HIV+TB) Rte per popultion per yer POPULATION MILLION TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse 1 85 % tested with rpid dignostics t time of dignosis % with known HIV sttus 64% % pulmonry 83% % bcteriologiclly confirmed mong pulmonry 8% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (4 89) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.11.35) Incidence Rte per popultion per yer Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 3 4 mong notified pulmonry TB cses (2 4 9) Estimted % of TB cses with MDR/RR-TB 2.2% (1 3.5) 9.5% (8.8 1) % notified tested for rifmpicin resistnce 3% 57% MDR/RR-TB cses tested for resistnce to second-line drugs 147 Lbortory-confirmed cses MDR/RR-TB: 893, XDR-TB: 19 Ptients strted on tretment d MDR/RR-TB: 839, XDR-TB: 15 Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in 216 6% 789 HIV-positive TB cses registered in 216 MDR/RR-TB cses strted on second-line tretment in 215 9% 463 XDR-TB cses strted on second-line tretment in 215 1% 21 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % 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 15% (14 17) TB FINANCING, 218 Ntionl TB budget (US$ millions) 74 Funding source: 2% domestic, 48% interntionl, 49% 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 217 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 182 Dt for ll countries nd yers cn be downloded from

194 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence 2 Prevlence of undernourishment (% of popultion) (% of popultion ged 15 yers) femles mles Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 183

195 Ethiopi ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 25 (16 37) 24 (15 35) Mortlity (HIV+TB only) 3.6 (2.5 5) 3.5 ( ) Incidence (includes HIV+TB) 172 ( ) 164 ( ) Incidence (HIV+TB only) 12 (8.6 17) 12 (8.2 16) Incidence (MDR/RR-TB)** 5.5 ( ) 5.2 ( ) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 9.5 (8.7 1) 69 (55 83) 78 (61 95) Mles 1 (9.6 11) 83 (65 12) 94 (71 116) Totl 2 (18 22) 152 (16 198) 172 ( ) TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 86% % pulmonry 69% % bcteriologiclly confirmed mong pulmonry 58% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % ( 96) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.1.26) Mortlity (excludes HIV+TB) Rte per popultion per yer Incidence Rte per popultion per yer POPULATION MILLION Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 2 7 mong notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 2.7% ( ) 14% (6.7 25) % notified tested for rifmpicin resistnce 38 1 MDR/RR-TB cses tested for resistnce to second-line drugs 25 Lbortory-confirmed cses MDR/RR-TB: 68, XDR-TB: 4 Ptients strted on tretment d MDR/RR-TB: 68, XDR-TB: 4 Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New cses registered in 216 9% Previously treted cses registered in 216 HIV-positive TB cses registered in 216 MDR/RR-TB cses strted on second-line tretment in % 66 XDR-TB cses strted on second-line tretment in 215 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % 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 11% (9.9 12) TB FINANCING, 218 Ntionl TB budget (US$ millions) 93 Funding source: 11% domestic, 33% interntionl, 56% 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 217 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) New cses Previously treted cses HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 184 Dt for ll countries nd yers cn be downloded from

196 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 185

197 Indi POPULATION MILLION ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 41 ( ) 31 (28 33) Mortlity (HIV+TB only) 11 (6.5 16).79 ( ) Incidence (includes HIV+TB) 2 74 ( ) 24 (14 281) Incidence (HIV+TB only) 86 (57 12) 6.4 (4.3 9) Incidence (MDR/RR-TB)** 135 (78 28) 1 (5.8 16) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 17 ( 114) 847 ( ) 954 ( ) Mles 117 (19 126) 1 67 ( ) 1 78 ( ) Totl 224 (22 247) 2 51 ( ) 2 74 ( ) Mortlity (excludes HIV+TB) Rte per popultion per yer TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 4% % with known HIV sttus 64% % pulmonry 85% % bcteriologiclly confirmed mong pulmonry 6% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (47 96) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.11.22) Incidence Rte per popultion per yer Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 65 mong notified pulmonry TB cses (54 76 ) Estimted % of TB cses with MDR/RR-TB 2.8% (2 3.5) 12% (1 13) % notified tested for rifmpicin resistnce 32% 82% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 39 9, XDR-TB: 2 6 Ptients strted on tretment d MDR/RR-TB: 35 9, XDR-TB: Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in 216 7% HIV-positive TB cses registered in % MDR/RR-TB cses strted on second-line tretment in % XDR-TB cses strted on second-line tretment in % 2 13 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % 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 11% (1 12) TB FINANCING, 218 Ntionl TB budget (US$ millions) 58 Funding source: 79% domestic, 21% interntionl, % unfunded Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. Estimtes of TB incidence nd mortlity for Indi re interim in nture, pending results from the ntionl TB prevlence survey plnned for 219/22. 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 217 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 186 Dt for ll countries nd yers cn be downloded from

198 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 187

199 Indonesi ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 17 ( 114) 4 (38 43) Mortlity (HIV+TB only) 9.4 (5 15) 3.6 ( ) Incidence (includes HIV+TB) 842 ( ) 319 ( ) Incidence (HIV+TB only) 36 (2 57) 14 (7.7 21) Incidence (MDR/RR-TB) b 23 (16 31) 8.8 (6.2 12) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 23 (23 23) 326 (38 345) 349 (329 37) Mles 26 (26 27) 466 ( ) 492 ( ) Totl 49 (48 ) 792 ( ) 842 ( ) TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 2% % with known HIV sttus 29% % pulmonry 9% % bcteriologiclly confirmed mong pulmonry 54% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (48 58) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.12.15) Mortlity (excludes HIV+TB) Rte per popultion per yer Incidence Rte per popultion per yer POPULATION MILLION Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 12 mong notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 2.4% ( ) 13% (9 18) % notified tested for rifmpicin resistnce 16% 223% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 5 7, XDR-TB: 51 Ptients strted on tretment d MDR/RR-TB: 3 42, XDR-TB: Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % 2 2 HIV-positive TB cses registered in % 4 47 MDR/RR-TB cses strted on second-line tretment in % XDR-TB cses strted on second-line tretment in % 32 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % of HIV-positive people (newly enrolled in cre) on preventive tretment 16% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 8.5% ( ) TB FINANCING, 218 Ntionl TB budget (US$ millions) 294 Funding source: 34% domestic, 16% interntionl, 49% 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 217 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 188 Dt for ll countries nd yers cn be downloded from

200 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence 5 Prevlence of undernourishment (% of popultion) 3 (% of popultion ged 15 yers) femles mles Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 189

201 Keny ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 25 (14 39) (28 78) Mortlity (HIV+TB only) 18 (11 27) 37 (22 55) Incidence (includes HIV+TB) 158 (97 235) 319 ( ) Incidence (HIV+TB only) 45 (27 68) 91 (55 137) Incidence (MDR/RR-TB) b 2.8 ( ) 5.6 ( ) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 9.9 (8.8 11) 43 (33 53) 53 (39 66) Mles 11 (9.7 12) 95 (63 127) 16 (68 143) Totl 21 (18 24) 138 (82 193) 158 (97 235) TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 47% % with known HIV sttus 96% % pulmonry 84% % bcteriologiclly confirmed mong pulmonry 67% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (36 86) TB ptients fcing ctstrophic totl costs, % (21 32) TB cse ftlity rtio (estimted mortlity/estimted incidence), (.15.45) Mortlity (excludes HIV+TB) Rte per popultion per yer Incidence Rte per popultion per yer POPULATION 217 MILLION Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 1 mong notified pulmonry TB cses (67 1 ) Estimted % of TB cses with MDR/RR-TB 1.3% (.74 2) 4.4% ( ) % notified tested for rifmpicin resistnce 46% 52% MDR/RR-TB cses tested for resistnce to second-line drugs 198 Lbortory-confirmed cses MDR/RR-TB: 39, XDR-TB: 1 Ptients strted on tretment d MDR/RR-TB: 394, XDR-TB: 1 Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in 216 7% 1 48 HIV-positive TB cses registered in % 22 2 MDR/RR-TB cses strted on second-line tretment in % 33 XDR-TB cses strted on second-line tretment in 215 % 1 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % of HIV-positive people (newly enrolled in cre) on preventive tretment % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 26% (24 29) TB FINANCING, 218 Ntionl TB budget (US$ millions) 42 Funding source: 33% domestic, 31% interntionl, 36% 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 217 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 19 Dt for ll countries nd yers cn be downloded from

202 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 191

203 Mozmbique ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 22 (13 33) 73 (43 111) Mortlity (HIV+TB only) 27 (17 39) 9 (56 131) Incidence (includes HIV+TB) 163 (16 233) 551 ( ) Incidence (HIV+TB only) 66 (42 95) 221 ( ) Incidence (MDR/RR-TB)** 8.8 (4.6 14) 3 (15 48) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 11 (9.6 12) 51 (4 63) 62 (47 77) Mles 12 (11 13) 9 (64 115) 11 (7 133) Totl 23 (19 26) 141 (9 192) 163 (16 233) TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 96% % pulmonry 93% % bcteriologiclly confirmed mong pulmonry 4% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (37 81) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.17.46) Mortlity (excludes HIV+TB) Rte per popultion per yer Incidence Rte per popultion per yer POPULATION MILLION Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 4 mong notified pulmonry TB cses (2 5 7) Estimted % of TB cses with MDR/RR-TB 3.7% ( ) 2% (5.2 4) % notified tested for rifmpicin resistnce MDR/RR-TB cses tested for resistnce to second-line drugs 29 Lbortory-confirmed cses MDR/RR-TB: 861, XDR-TB: 31 Ptients strted on tretment **** MDR/RR-TB: 97, XDR-TB: 31 Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New nd relpse cses registered in 216 9% 7 51 Previously treted cses, excluding relpse, registered in % HIV-positive TB cses registered in % MDR/RR-TB cses strted on second-line tretment in % 646 XDR-TB cses strted on second-line tretment in % 16 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % 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 e > % TB FINANCING, 218 Ntionl TB budget (US$ millions) 3 Funding source: 5% domestic, 95% interntionl, % unfunded Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. Estimtes of TB incidence nd mortlity for Mozmbique will be reviewed fter finl results from their ntionl TB prevlence survey re vilble in 219. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 217 nd ptients who were not lbortory-confirmed. e Resons for higher thn expected coverge might be tht the numertor did not exclude nonhousehold contcts or children of five yers nd older. Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 192 Dt for ll countries nd yers cn be downloded from

204 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence 1 Prevlence of undernourishment (% of popultion) (% of popultion ged 15 yers) femles mles Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 193

205 Mynmr ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 27 (18 39) 51 (33 73) Mortlity (HIV+TB only) 4.9 ( ) 9.2 (6.6 12) Incidence (includes HIV+TB) 191 ( ) 358 ( ) Incidence (HIV+TB only) 17 (12 22) 31 (23 41) Incidence (MDR/RR-TB) b 14 (8 21) 26 (15 39) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 11 (1 12) 57 (48 66) 68 (57 8) Mles 12 (11 13) 11 (87 134) 123 (95 1) Totl 23 (21 26) 168 ( ) 191 ( ) TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 9% % pulmonry 9% % bcteriologiclly confirmed mong pulmonry 41% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (52 93) TB ptients fcing ctstrophic totl costs, 215 6% (57 63) TB cse ftlity rtio (estimted mortlity/estimted incidence), (.11.25) Mortlity (excludes HIV+TB) Rte per popultion per yer Incidence Rte per popultion per yer POPULATION MILLION Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 8 7 mong notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 5.1% ( ) 27% (16 4) % notified tested for rifmpicin resistnce 29% 63% MDR/RR-TB cses tested for resistnce to second-line drugs 165 Lbortory-confirmed cses MDR/RR-TB: 3 281, XDR-TB: 28 Ptients strted on tretment d MDR/RR-TB: 2 666, XDR-TB: 9 Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % 2 51 HIV-positive TB cses registered in % MDR/RR-TB cses strted on second-line tretment in 215 8% 2 18 XDR-TB cses strted on second-line tretment in % 7 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % of HIV-positive people (newly enrolled in cre) on preventive tretment 17% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 2.1% ( ) TB FINANCING, 218 Ntionl TB budget (US$ millions) 58 Funding source: 4% domestic, 52% interntionl, 45% unfunded Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. Estimtes of TB incidence nd mortlity for Mynmr will be reviewed fter finl results from their ntionl TB prevlence survey re vilble in 219. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 217 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 194 Dt for ll countries nd yers cn be downloded from

206 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 195

207 Nigeri ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 12 (7 183) 63 (36 96) Mortlity (HIV+TB only) 35 (21 52) 18 (11 27) Incidence (includes HIV+TB) 418 ( ) 219 ( ) Incidence (HIV+TB only) 58 (37 85) 3 (19 44) Incidence (MDR/RR-TB) b 24 (14 36) 12 (7.3 19) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 27 (24 3) 123 (97 148) 1 ( ) Mles 3 (27 33) 238 (169 37) 268 ( ) Totl 57 (49 65) 361 (232 49) 418 ( ) Mortlity (excludes HIV+TB) Rte per popultion per yer POPULATION MILLION TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 41% % with known HIV sttus 95% % pulmonry 96% % bcteriologiclly confirmed mong pulmonry 78% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (17 38) TB ptients fcing ctstrophic totl costs, % (68 73) TB cse ftlity rtio (estimted mortlity/estimted incidence), (.2.59) Incidence Rte per popultion per yer Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 5 4 mong notified pulmonry TB cses (4 2 6 ) Estimted % of TB cses with MDR/RR-TB 4.3% ( ) 25% (19 31) % notified tested for rifmpicin resistnce 41% 61% MDR/RR-TB cses tested for resistnce to second-line drugs 691 Lbortory-confirmed cses MDR/RR-TB: 2 286, XDR-TB: 14 Ptients strted on tretment d MDR/RR-TB: 1 786, XDR-TB: 1 Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses registered in % MDR/RR-TB cses strted on second-line tretment in % 656 XDR-TB cses strted on second-line tretment in 215 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % 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 2% (18 21) TB FINANCING, 218 Ntionl TB budget (US$ millions) 49 Funding source: 8% domestic, 16% interntionl, 76% 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 217 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 196 Dt for ll countries nd yers cn be downloded from

208 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 197

209 Pkistn ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 54 (42 67) 27 (21 34) Mortlity (HIV+TB only) 2.2 ( ) 1.1 ( ) Incidence (includes HIV+TB) 525 (373 74) 267 ( ) Incidence (HIV+TB only) 7.3 (3.6 12) 3.7 ( ) Incidence (MDR/RR-TB) b 27 (17 39) 14 (8.8 2) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 27 (25 29) 27 ( ) 235 ( ) Mles 3 (28 32) 261 (23 319) 291 ( ) Totl 57 (51 63) 468 (329 67) 525 (373 74) TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 3% % with known HIV sttus 7% % pulmonry 8% % bcteriologiclly confirmed mong pulmonry 48% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (51 96) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.7.15) Mortlity (excludes HIV+TB) Rte per popultion per yer Incidence Rte per popultion per yer POPULATION MILLION Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive 121 <1% on ntiretrovirl therpy 97 8% DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 15 mong notified pulmonry TB cses (12 18 ) Estimted % of TB cses with MDR/RR-TB 4.2% ( ) 16% (15 17) % notified tested for rifmpicin resistnce 11% 47% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 3 475, XDR-TB: 128 Ptients strted on tretment d MDR/RR-TB: 3 16, XDR-TB: 65 Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND COHORT SIZE Success Cohort New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses registered in 216 MDR/RR-TB cses strted on second-line tretment in % XDR-TB cses strted on second-line tretment in % 77 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % 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 FINANCING, 218 Ntionl TB budget (US$ millions) 118 Funding source: 3% domestic, 54% interntionl, 43% 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 217 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 198 Dt for ll countries nd yers cn be downloded from

210 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 199

211 Philippines POPULATION MILLION ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 26 (23 31) 25 (22 29) Mortlity (HIV+TB only).38 ( 3.3).36 ( 3.1) Incidence (includes HIV+TB) 581 (326 99) 554 ( ) Incidence (HIV+TB only) 7.1 (2.9 13) 6.7 (2.8 12) Incidence (MDR/RR-TB) b 27 (12 47) 26 (12 45) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 34 (3 38) 139 (15 173) 173 (126 22) Mles 37 (33 42) 371 ( ) 48 (237 58) Totl 71 (59 84) 51 ( ) 581 (326 99) Mortlity (excludes HIV+TB) Rte per popultion per yer TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 26% % with known HIV sttus 24% % pulmonry 98% % bcteriologiclly confirmed mong pulmonry 39% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (35 97) TB ptients fcing ctstrophic totl costs, % TB cse ftlity rtio (estimted mortlity/estimted incidence), (.3.8) Incidence Rte per popultion per yer Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 2 mong notified pulmonry TB cses (18 22 ) Estimted % of TB cses with MDR/RR-TB 2.6% ( ) 28% (27 28) % notified tested for rifmpicin resistnce 19% 83% MDR/RR-TB cses tested for resistnce to second-line drugs 2 41 Lbortory-confirmed cses MDR/RR-TB: 6 438, XDR-TB: 15 Ptients strted on tretment d MDR/RR-TB: 5 623, XDR-TB: 16 Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in 216 8% 1 97 HIV-positive TB cses registered in % 989 MDR/RR-TB cses strted on second-line tretment in % XDR-TB cses strted on second-line tretment in % 9 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % of HIV-positive people (newly enrolled in cre) on preventive tretment 57% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 12% (11 13) TB FINANCING, 218 Ntionl TB budget (US$ millions) 16 Funding source: 37% domestic, 21% interntionl, 42% 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 217 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 2 Dt for ll countries nd yers cn be downloded from

212 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 21

213 Russin Federtion POPULATION MILLION ESTIMATES OF TB BURDEN, b 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 1 (9.4 12) 7.3 (6.6 8) Mortlity (HIV+TB only) 1.7 ( ) 1.2 ( ) Incidence (includes HIV+TB) 86 (56 123) 6 (39 85) Incidence (HIV+TB only) 18 (12 26) 13 (8.3 18) Incidence (MDR/RR-TB) c 56 (36 82) 39 (25 57) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), b YEARS > 14 YEARS TOTAL Femles 1.4 ( ) 25 (2 3) 26 (21 32) Mles 1.2 ( ) 59 (4 78) 6 (4 79) Totl 2.6 ( ) 84 (51 116) 86 (56 123) Mortlity (excludes HIV+TB) Rte per popultion per yer TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 78% % with known HIV sttus 96% % pulmonry 92% % bcteriologiclly confirmed mong pulmonry 52% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (69 1) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.9.21) Incidence Rte per popultion per yer Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER d Estimted MDR/RR-TB cses 49 mong notified pulmonry TB cses (49 ) Estimted % of TB cses with MDR/RR-TB 32% (31 33) 67% (66 67) % notified tested for rifmpicin resistnce 42% 58% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 26 62, XDR-TB: Ptients strted on tretment e MDR/RR-TB: , XDR-TB: 2 77 Notified cses by ge group nd sex, Femles Mles Incidence 2 TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses registered in % MDR/RR-TB cses strted on second-line tretment in % XDR-TB cses strted on second-line tretment in % Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % of HIV-positive people (newly enrolled in cre) on preventive tretment 97% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment f > % TB FINANCING, 218 Ntionl TB budget (US$ millions) Funding source: % domestic, % interntionl, % unfunded Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. UN Popultion Division estimtes re lower thn the popultion registered by the Federl Stte Sttistics Service of the Russin Federtion. b Rnges represent uncertinty intervls. c MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. d Includes cses with unknown previous TB tretment history. e Includes ptients dignosed before 217 nd ptients who were not lbortory-confirmed. f Resons for higher thn expected coverge might be tht the numertor did not exclude nonhousehold contcts or children of five yers nd older. Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 22 Dt for ll countries nd yers cn be downloded from

214 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 23

215 South Afric POPULATION MILLION ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 22 (2 24) 39 (35 43) Mortlity (HIV+TB only) 56 (39 77) 99 (68 135) Incidence (includes HIV+TB) 322 (23 428) 567 (46 754) Incidence (HIV+TB only) 193 ( ) 34 ( ) Incidence (MDR/RR-TB) b 14 (8.9 2) 25 (16 36) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 18 (17 19) 117 (95 138) 135 (18 161) Mles 2 (18 21) 167 (13 24) 187 ( ) Totl 38 (34 42) 284 (22 366) 322 (23 428) Mortlity (excludes HIV+TB) Rte per popultion per yer TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 66% % with known HIV sttus 94% % pulmonry 89% % bcteriologiclly confirmed mong pulmonry 65% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (51 96) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.16.35) Incidence Rte per popultion per yer Notified, new nd relpse Incidence (HIV+TB only) Incidence TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 7 7 mong notified pulmonry TB cses (6 9 4) Estimted % of TB cses with MDR/RR-TB 3.4% ( ) 7.1% ( ) % notified tested for rifmpicin resistnce 64% 68% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: , XDR-TB: 747 Ptients strted on tretment d MDR/RR-TB: 1 259, XDR-TB: 463 Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses registered in 216 8% MDR/RR-TB cses strted on second-line tretment in % 9 7 XDR-TB cses strted on second-line tretment in % 427 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % of HIV-positive people (newly enrolled in cre) on preventive tretment 53% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 79% (72 86) TB FINANCING, 218 Ntionl TB budget (US$ millions) 271 Funding source: 91% domestic, 8% interntionl, <1% unfunded Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. Estimtes of TB incidence nd mortlity for South Afric will be reviewed fter finl results from their ntionl TB prevlence survey re vilble in 219. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 217 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 24 Dt for ll countries nd yers cn be downloded from

216 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence 2 Prevlence of undernourishment (% of popultion) 1 (% of popultion ged 15 yers) femles mles Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 25

217 Thilnd ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 9.3 (7 12) 13 (1 17) Mortlity (HIV+TB only) 2.9 ( ) 4.2 ( ) Incidence (includes HIV+TB) 18 (82 138) 156 ( ) Incidence (HIV+TB only) 11 (8.5 15) 16 (12 21) Incidence (MDR/RR-TB)** 3.9 ( ) 5.7 ( ) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 4.1 ( ) 33 (28 37) 37 (31 42) Mles 4.4 ( ) 67 (53 81) 71 (56 86) Totl 8.5 ( ) (75 124) 18 (82 138) TB CASE NOTIFICATIONS, 217 Totl cses notified 82 8 Totl new nd relpse 8 16 % tested with rpid dignostics t time of dignosis 12% % with known HIV sttus 82% % pulmonry 83% % bcteriologiclly confirmed mong pulmonry 55% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (58 98) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.8.16) Mortlity (excludes HIV+TB) Rte per popultion per yer Incidence Rte per popultion per yer POPULATION MILLION Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 2 7 mong notified pulmonry TB cses (2 3 3) Estimted % of TB cses with MDR/RR-TB 2.2% (1.5 3) 24% (18 31) % notified tested for rifmpicin resistnce 24% 37% MDR/RR-TB cses tested for resistnce to second-line drugs 272 Lbortory-confirmed cses MDR/RR-TB: 1 339, XDR-TB: 7 Ptients strted on tretment d MDR/RR-TB: 851, XDR-TB: 8 Notified cses by ge group nd sex, Femles Mles Incidence 1 TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % 3 86 HIV-positive TB cses registered in % MDR/RR-TB cses strted on second-line tretment in 215 6% 352 XDR-TB cses strted on second-line tretment in 215 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % 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 5% ( ) TB FINANCING, 218 Ntionl TB budget (US$ millions) 26 Funding source: 87% domestic, 13% interntionl, % unfunded Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 217 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 26 Dt for ll countries nd yers cn be downloded from

218 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence 2 Prevlence of undernourishment (% of popultion) 3 (% of popultion ged 15 yers) femles mles Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 27

219 United Republic of Tnzni ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 27 (12 48) 47 (21 83) Mortlity (HIV+TB only) 22 (1 38) 39 (18 67) Incidence (includes HIV+TB) 154 (73 266) 269 ( ) Incidence (HIV+TB only) 48 (31 69) 84 (54 12) Incidence (MDR/RR-TB)** 1.7 ( ) 2.9 (.91 6) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 4.1 ( ) 46 (3 62) (32 68) Mles 4.6 (4.1 5) ( 1) 14 (51 158) Totl 8.7 ( ) 146 (57 234) 154 (73 266) TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 14% % with known HIV sttus 98% % pulmonry 8% % bcteriologiclly confirmed mong pulmonry 52% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (26 94) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.13.62) Mortlity (excludes HIV+TB) Rte per popultion per yer Incidence Rte per popultion per yer POPULATION MILLION Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 64 mong notified pulmonry TB cses (29 98) Estimted % of TB cses with MDR/RR-TB.9% (.3 1.5) 4.7% (.7 8.6) % notified tested for rifmpicin resistnce 14% 56% MDR/RR-TB cses tested for resistnce to second-line drugs 44 Lbortory-confirmed cses MDR/RR-TB: 2, XDR-TB: Ptients strted on tretment d MDR/RR-TB: 167, XDR-TB: Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New nd relpse cses registered in 216 9% Previously treted cses, excluding relpse, registered in % HIV-positive TB cses registered in % MDR/RR-TB cses strted on second-line tretment in % 119 XDR-TB cses strted on second-line tretment in 215 % 1 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % 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 35% (32 38) TB FINANCING, 218 Ntionl TB budget (US$ millions) 64 Funding source: 3% domestic, 46% interntionl, 52% 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 217 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 28 Dt for ll countries nd yers cn be downloded from

220 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 29

221 Viet Nm POPULATION MILLION ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 12 (7.5 17) 12 (7.8 17) Mortlity (HIV+TB only).84 ( ).88 ( ) Incidence (includes HIV+TB) 124 (11 148) 129 (16 155) Incidence (HIV+TB only) 4.5 ( ) 4.7 ( ) Incidence (MDR/RR-TB)** 7.1 (4.6 1) 7.4 (4.8 11) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 6.6 ( ) 3 (27 33) 37 (33 4) Mles 8.5 ( ) 79 (67 9) 87 (73 11) Totl 15 (14 16) 19 (89 128) 124 (11 148) Mortlity (excludes HIV+TB) Rte per popultion per yer TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 26% % with known HIV sttus 85% % pulmonry 8% % bcteriologiclly confirmed mong pulmonry 7% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (69 ) TB ptients fcing ctstrophic totl costs, % (58 67) TB cse ftlity rtio (estimted mortlity/estimted incidence), (.6.15) Incidence Rte per popultion per yer Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 4 9 mong notified pulmonry TB cses (3 8 6 ) Estimted % of TB cses with MDR/RR-TB 4.1% ( ) 17% (17 18) % notified tested for rifmpicin resistnce 32% 67% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 3 71, XDR-TB: Ptients strted on tretment d MDR/RR-TB: 2 694, XDR-TB: 12 Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % 4 43 HIV-positive TB cses registered in % MDR/RR-TB cses strted on second-line tretment in % 2 45 XDR-TB cses strted on second-line tretment in 215 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % 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 26% (24 29) TB FINANCING, 218 Ntionl TB budget (US$ millions) 7 Funding source: 11% domestic, 28% interntionl, 61% unfunded Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. Estimtes of TB incidence nd mortlity for Viet Nm will be reviewed fter finl results from their ntionl TB prevlence survey re vilble in 219. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 217 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 21 Dt for ll countries nd yers cn be downloded from

222 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge 6 Dt for ll countries nd yers cn be downloded from 211

223 Cmbodi ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 3.1 (2 4.3) 19 (13 27) Mortlity (HIV+TB only).41 (.27.57) 2.6 ( ) Incidence (includes HIV+TB) 52 (36 72) 326 ( ) Incidence (HIV+TB only) 1.3 ( ) 8.2 (5.6 11) Incidence (MDR/RR-TB)** 1.2 ( ) 7.2 (3.2 13) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 3.1 ( ) 19 (15 22) 22 (17 27) Mles 3.4 ( ) 27 (2 34) 3 (22 38) Totl 6.6 ( ) 46 (31 6) 52 (36 72) TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 87% % pulmonry 66% % bcteriologiclly confirmed mong pulmonry 54% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (48 96) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.4.1) Mortlity (excludes HIV+TB) Rte per popultion per yer Incidence Rte per popultion per yer POPULATION MILLION Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive 748 3% on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 56 mong notified pulmonry TB cses (29 84) Estimted % of TB cses with MDR/RR-TB 1.8% (.9 3) 11% (3.2 22) % notified tested for rifmpicin resistnce 33% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 136, XDR-TB: 1 Ptients strted on tretment d MDR/RR-TB: 143, XDR-TB: 1 Notified cses by ge group nd sex, Femles Mles Incidence 5 TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % 38 HIV-positive TB cses registered in 216 MDR/RR-TB cses strted on second-line tretment in % 75 XDR-TB cses strted on second-line tretment in 215 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % of HIV-positive people (newly enrolled in cre) on preventive tretment 21% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 44% (4 48) TB FINANCING, 218 Ntionl TB budget (US$ millions) 37 Funding source: 12% domestic, 24% interntionl, 64% 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 217 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 212 Dt for ll countries nd yers cn be downloded from

224 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 213

225 Centrl Africn Republic ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 3.2 ( ) 68 (38 15) Mortlity (HIV+TB only) 2.7 ( ) 58 (31 94) Incidence (includes HIV+TB) 2 (13 28) 423 (274 64) Incidence (HIV+TB only) 6.2 (3.3 1) 134 (72 214) Incidence (MDR/RR-TB) b.15 (.84.23) 3.2 ( ) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 1.3 ( ) 6.3 ( ) 7.5 ( ) Mles 1.4 ( ) 11 (7.6 14) 12 (8.4 16) Totl 2.7 ( ) 17 (11 23) 2 (13 28) TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 3% % with known HIV sttus 77% % pulmonry 81% % bcteriologiclly confirmed mong pulmonry 66% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (34 76) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.16.48) Mortlity (excludes HIV+TB) Rte per popultion per yer Incidence Rte per popultion per yer POPULATION MILLION Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 91 mong notified pulmonry TB cses ( 19) Estimted % of TB cses with MDR/RR-TB.4% ( 2.2) 14% (1 18) % notified tested for rifmpicin resistnce % 62% 268 MDR/RR-TB cses tested for resistnce to second-line drugs 2 Lbortory-confirmed cses MDR/RR-TB: 93, XDR-TB: 2 Ptients strted on tretment d MDR/RR-TB: 86, XDR-TB: Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % 186 HIV-positive TB cses registered in % 2 53 MDR/RR-TB cses strted on second-line tretment in % 41 XDR-TB cses strted on second-line tretment in 215 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % 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 FINANCING, 218 Ntionl TB budget (US$ millions) 1.9 Funding source: 14% domestic, 53% interntionl, 32% 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 217 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 214 Dt for ll countries nd yers cn be downloded from

226 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 215

227 Congo ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 3.3 ( ) 63 (36 98) Mortlity (HIV+TB only) 2.3 ( ) 43 (22 71) Incidence (includes HIV+TB) 2 (13 29) 376 ( ) Incidence (HIV+TB only) 5.3 ( ) (52 164) Incidence (MDR/RR-TB) b.61 ( ) 12 (4.8 21) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 1.3 ( ) 6.3 ( ) 7.6 ( ) Mles 1.5 ( ) 11 (7.6 14) 12 (8.3 16) Totl 2.8 ( ) 17 (11 23) 2 (13 29) TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse 1 5 % tested with rpid dignostics t time of dignosis 5% % with known HIV sttus 13% % pulmonry 78% % bcteriologiclly confirmed mong pulmonry 51% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (35 8) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.15.46) Mortlity (excludes HIV+TB) Rte per popultion per yer Incidence Rte per popultion per yer POPULATION MILLION Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive 374 3% on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 29 mong notified pulmonry TB cses (17 42) Estimted % of TB cses with MDR/RR-TB 2.5% ( ) 21% (16 27) % notified tested for rifmpicin resistnce <1% 89% 532 MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 58, XDR-TB: Ptients strted on tretment d MDR/RR-TB: 28, XDR-TB: Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % 232 HIV-positive TB cses registered in 216 MDR/RR-TB cses strted on second-line tretment in % 13 XDR-TB cses strted on second-line tretment in 215 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % 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 4.1% ( ) TB FINANCING, 218 Ntionl TB budget (US$ millions) 1.5 Funding source: 72% domestic, 28% interntionl, % unfunded Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 217 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 216 Dt for ll countries nd yers cn be downloded from

228 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 217

229 Lesotho ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 1 ( ) 46 (25 75) Mortlity (HIV+TB only) 4.6 ( ) 26 (128 32) Incidence (includes HIV+TB) 15 (9.6 21) 665 (43 949) Incidence (HIV+TB only) 11 (6.7 15) 47 (298 68) Incidence (MDR/RR-TB) b 1.1 ( ) (27 78) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 1 ( ) 4.6 ( ) 5.7 ( ) Mles 1.1 (1 1.3) 8 (5.7 1) 9.2 (6.4 12) Totl 2.2 ( ) 13 (8.1 17) 15 (9.6 21) Mortlity (excludes HIV+TB) Rte per popultion per yer 1 POPULATION MILLION TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 92% % pulmonry 89% % bcteriologiclly confirmed mong pulmonry 58% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (34 74) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.2.6) Incidence Rte per popultion per yer Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 41 mong notified pulmonry TB cses (33 49) Estimted % of TB cses with MDR/RR-TB 4.8% (3.7 6) 14% (9.5 18) % notified tested for rifmpicin resistnce 63% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 351, XDR-TB: Ptients strted on tretment d MDR/RR-TB: 151, XDR-TB: Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % 228 HIV-positive TB cses registered in % 5 85 MDR/RR-TB cses strted on second-line tretment in % 21 XDR-TB cses strted on second-line tretment in 215 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % 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 FINANCING, 218 Ntionl TB budget (US$ millions) 3.3 Funding source: 3% domestic, 55% interntionl, 15% unfunded Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. 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 217 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 218 Dt for ll countries nd yers cn be downloded from

230 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 219

231 Liberi ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 2.7 ( ) 57 (34 86) Mortlity (HIV+TB only).91 ( ) 19 (12 28) Incidence (includes HIV+TB) 15 (9.4 21) 38 (199 44) Incidence (HIV+TB only) 2.2 ( ) 47 (3 68) Incidence (MDR/RR-TB)**.39 (.15.74) 8.3 (3.2 16) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles.91 (.82.99) 4.6 ( ) 5.5 ( ) Mles 1 (.9 1.1) 8 (5.7 1) 9 (6.3 12) Totl 1.9 ( ) 13 (8.1 17) 15 (9.4 21) Mortlity (excludes HIV+TB) Rte per popultion per yer 1 POPULATION MILLION TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 17% % with known HIV sttus 7% % pulmonry 68% % bcteriologiclly confirmed mong pulmonry 64% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (37 82) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.14.4) Incidence Rte per popultion per yer Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 1 mong notified pulmonry TB cses (65 23) Estimted % of TB cses with MDR/RR-TB 2.5% ( ) 14% (1 18) % notified tested for rifmpicin resistnce 43% % MDR/RR-TB cses tested for resistnce to second-line drugs 19 Lbortory-confirmed cses MDR/RR-TB: 88, XDR-TB: Ptients strted on tretment d MDR/RR-TB: 55, XDR-TB: Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in 216 % 127 HIV-positive TB cses registered in 216 MDR/RR-TB cses strted on second-line tretment in 215 XDR-TB cses strted on second-line tretment in 215 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % 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 5.8% ( ) TB FINANCING, 218 Ntionl TB budget (US$ millions) 6.4 Funding source: 2% domestic, 98% interntionl, % unfunded Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 217 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 22 Dt for ll countries nd yers cn be downloded from

232 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 221

233 Nmibi ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB).75 ( ) 3 (19 43) Mortlity (HIV+TB only).8 ( ) 31 (22 43) Incidence (includes HIV+TB) 11 (8.2 14) 423 ( ) Incidence (HIV+TB only) 3.9 ( ) 153 (99 219) Incidence (MDR/RR-TB)**.95 ( ) 37 (26 51) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles.88 (.81.94) 3.6 ( ) 4.4 ( ) Mles.92 (.85.99) 5.4 ( ) 6.3 ( ) Totl 1.8 (1.6 2) 8.9 (6.9 11) 11 (8.2 14) TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % % with known HIV sttus 98% % pulmonry 82% % bcteriologiclly confirmed mong pulmonry 83% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), 217 8% (63 ) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.1.2) Mortlity (excludes HIV+TB) Rte per popultion per yer Incidence Rte per popultion per yer POPULATION MILLION Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 47 mong notified pulmonry TB cses (41 54) Estimted % of TB cses with MDR/RR-TB 5% ( ) 12% (9.4 14) % notified tested for rifmpicin resistnce MDR/RR-TB cses tested for resistnce to second-line drugs 78 Lbortory-confirmed cses MDR/RR-TB: 49, XDR-TB: 14 Ptients strted on tretment d MDR/RR-TB: 41, XDR-TB: 13 Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % 297 HIV-positive TB cses registered in 216 8% 3 41 MDR/RR-TB cses strted on second-line tretment in % 288 XDR-TB cses strted on second-line tretment in 215 % 2 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % of HIV-positive people (newly enrolled in cre) on preventive tretment 15% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 34% (31 37) TB FINANCING, 218 Ntionl TB budget (US$ millions) 49 Funding source: 57% domestic, 3% interntionl, 4% unfunded Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. Estimtes re rounded nd totls re computed prior to rounding. Rnges represent uncertinty intervls. Estimtes of TB incidence nd mortlity for Nmibi will be reviewed fter finl results from their ntionl TB prevlence survey re vilble in 219. b MDR is TB resistnt to rifmpicin nd isonizid; RR is TB resistnt to rifmpicin. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 217 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 222 Dt for ll countries nd yers cn be downloded from

234 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence 2 Prevlence of undernourishment (% of popultion) (% of popultion ged 15 yers) femles mles Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 223

235 Ppu New Guine ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 4.3 (2.9 6) 53 (36 73) Mortlity (HIV+TB only).93 ( ) 11 (6.2 18) Incidence (includes HIV+TB) 36 (29 43) 432 ( ) Incidence (HIV+TB only) 3.5 (2 5.5) 43 (24 66) Incidence (MDR/RR-TB)** 1.9 ( ) 23 (15 34) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 1.8 ( ) 11 (9.7 12) 13 (11 14) Mles 2 ( ) 21 (18 24) 23 (19 27) Totl 3.9 ( ) 32 (26 38) 36 (29 43) TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus 45% % pulmonry 57% % bcteriologiclly confirmed mong pulmonry 26% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (61 91) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.1.21) Mortlity (excludes HIV+TB) Rte per popultion per yer Incidence Rte per popultion per yer POPULATION MILLION Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive 791 7% on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 96 mong notified pulmonry TB cses (6 1 3) Estimted % of TB cses with MDR/RR-TB 3.4% (1.7 5) 26% (15 36) % notified tested for rifmpicin resistnce 11% 56% 15 9 MDR/RR-TB cses tested for resistnce to second-line drugs 161 Lbortory-confirmed cses MDR/RR-TB: 356, XDR-TB: 13 Ptients strted on tretment d MDR/RR-TB: 356, XDR-TB: 15 Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New cses registered in % Previously treted cses registered in % HIV-positive TB cses registered in 216 MDR/RR-TB cses strted on second-line tretment in % 149 XDR-TB cses strted on second-line tretment in % 11 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % of HIV-positive people (newly enrolled in cre) on preventive tretment 16% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment TB FINANCING, 218 Ntionl TB budget (US$ millions) 28 Funding source: % domestic, 21% 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 217 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) New cses Previously treted cses HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 224 Dt for ll countries nd yers cn be downloded from

236 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence 2 Prevlence of undernourishment (% of popultion) (% of popultion ged 15 yers) femles mles Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 225

237 Sierr Leone ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 3 ( ) 39 (23 59) Mortlity (HIV+TB only).78 ( ) 1 (6.5 15) Incidence (includes HIV+TB) 23 (15 33) 31 ( ) Incidence (HIV+TB only) 2.8 (1.8 4) 37 (24 53) Incidence (MDR/RR-TB)**.66 ( ) 8.8 (3.6 16) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 1.2 ( ) 8.1 (6.2 1) 9.3 (6.9 12) Mles 1.3 ( ) 12 (8.6 16) 13 (9.3 17) Totl 2.5 ( ) 2 (13 28) 23 (15 33) Mortlity (excludes HIV+TB) Rte per popultion per yer 1 POPULATION MILLION TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis 3% % with known HIV sttus 98% % pulmonry 93% % bcteriologiclly confirmed mong pulmonry 65% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), 217 7% (49 11) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.9.27) Incidence Rte per popultion per yer Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 43 mong notified pulmonry TB cses (2 66) Estimted % of TB cses with MDR/RR-TB 2.5% ( ) 14% (1 18) % notified tested for rifmpicin resistnce 456 MDR/RR-TB cses tested for resistnce to second-line drugs 19 Lbortory-confirmed cses MDR/RR-TB: 174, XDR-TB: Ptients strted on tretment d MDR/RR-TB: 14, XDR-TB: Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % 239 HIV-positive TB cses registered in 216 MDR/RR-TB cses strted on second-line tretment in 215 XDR-TB cses strted on second-line tretment in 215 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % of HIV-positive people (newly enrolled in cre) on preventive tretment 22% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment TB FINANCING, 218 Ntionl TB budget (US$ millions) 16 Funding source: 2% domestic, 76% interntionl, 23% 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 217 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 226 Dt for ll countries nd yers cn be downloded from

238 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 227

239 Zmbi POPULATION MILLION ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 5 ( ) 3 (17 45) Mortlity (HIV+TB only) 13 (8.2 19) 76 (48 11) Incidence (includes HIV+TB) 62 (4 88) 361 ( ) Incidence (HIV+TB only) 36 (23 52) 21 (135 32) Incidence (MDR/RR-TB) b 1.9 ( ) 11 (3.9 22) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 3.6 ( ) 2 (16 25) 24 (18 3) Mles 4 ( ) 34 (24 44) 38 (26 49) Totl 7.5 ( ) 54 (34 74) 62 (4 88) Mortlity (excludes HIV+TB) Rte per popultion per yer TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse 36 1 % tested with rpid dignostics t time of dignosis 28% % with known HIV sttus 93% % pulmonry 84% % bcteriologiclly confirmed mong pulmonry 53% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (41 9) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.17.46) Incidence Rte per popultion per yer Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 1 3 mong notified pulmonry TB cses (8 1 8) Estimted % of TB cses with MDR/RR-TB 1.1% ( ) 18% (12 26) % notified tested for rifmpicin resistnce 23% 9% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 546, XDR-TB: Ptients strted on tretment d MDR/RR-TB: 27, XDR-TB: Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in % HIV-positive TB cses registered in % MDR/RR-TB cses strted on second-line tretment in 215 6% 99 XDR-TB cses strted on second-line tretment in 215 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % of HIV-positive people (newly enrolled in cre) on preventive tretment 18% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 3.8% ( ) TB FINANCING, 218 Ntionl TB budget (US$ millions) 38 Funding source: 28% domestic, 52% 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 217 nd ptients who were not lbortory-confirmed. Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 228 Dt for ll countries nd yers cn be downloded from

240 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 229

241 Zimbbwe POPULATION MILLION ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 2 ( ) 12 (7.7 17) Mortlity (HIV+TB only) 6.3 ( ) 38 (27 51) Incidence (includes HIV+TB) 37 (27 47) 221 ( ) Incidence (HIV+TB only) 23 (15 33) 14 (9 199) Incidence (MDR/RR-TB) b 2.3 ( ) 14 (8.5 21) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 2.6 ( ) 13 (11 15) 15 (12 18) Mles 2.9 ( ) 18 (15 22) 21 (17 26) Totl 5.6 ( ) 31 (23 39) 37 (27 47) Mortlity (excludes HIV+TB) Rte per popultion per yer TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % tested with rpid dignostics t time of dignosis % with known HIV sttus % % pulmonry 89% % bcteriologiclly confirmed mong pulmonry 58% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (55 96) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.15.32) Incidence Rte per popultion per yer Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER (%) Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 1 3 mong notified pulmonry TB cses (92 1 6) Estimted % of TB cses with MDR/RR-TB 4.6% (3 6.2) 14% (8.9 2) % notified tested for rifmpicin resistnce MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 474, XDR-TB: 4 Ptients strted on tretment d MDR/RR-TB: 439, XDR-TB: 3 Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New nd relpse cses registered in % Previously treted cses, excluding relpse, registered in 216 7% 735 HIV-positive TB cses registered in % MDR/RR-TB cses strted on second-line tretment in % 433 XDR-TB cses strted on second-line tretment in 215 8% 5 Tretment success rte (%) TB PREVENTIVE TREATMENT, 217 % of HIV-positive people (newly enrolled in cre) on preventive tretment e 11% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 24% (22 26) TB FINANCING, 218 Ntionl TB budget (US$ millions) 3 Funding source: domestic, 43% interntionl, 57% 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 217 nd ptients who were not lbortory-confirmed. e The number on preventive tretment ws provided for the period July December 217 only. Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 23 Dt for ll countries nd yers cn be downloded from

242 INDICATORS IN THE SUSTAINABLE DEVELOPMENT GOALS ASSOCIATED WITH TB INCIDENCE HIV prevlence (% of popultion ged yers) Popultion living below the interntionl poverty line (% of popultion) Dibetes prevlence (% of popultion ged 18 yers) femles mles Popultion covered by socil protection floors/ systems (% of popultion) Alcohol use disorders, 12 month prevlence (% of popultion ged 15 yers) femles mles Prevlence of undernourishment (% of popultion) Smoking prevlence (% of popultion ged 15 yers) femles mles Access to clen fuels nd technologies for cooking (% of popultion) Helth expenditure per cpit, PPP b (current interntionl $) GDP per cpit, PPP b (constnt 211 interntionl $) Out-of-pocket helth expenditure (% of current helth expenditure) GINI index ( = perfect equlity, = perfect inequlity) b UHC index of essentil service coverge b (bsed on 16 trcer indictors including TB tretment) Popultion living in slums (% of urbn popultion) Trgets for reductions in TB incidence nd TB deths set in WHO s End TB Strtegy nd the United Ntions Sustinble Development Gols (SDGs) re mbitious. Achieving them requires progress in reducing helth-relted risk fctors for TB infection nd disese, s well s broder socil nd economic determinnts of TB infection nd disese. WHO hs developed TB-SDG monitoring frmework tht comprises 14 indictors under seven SDGs for which there is evidence of n ssocition with TB incidence. Further detils re provided in Chpter 2. Dt sources: SDG indictors dtbse, The World Bnk, World Helth Orgniztion. Missing vlues nd empty boxes indicte dt not vilble in these dt sources. GDP = gross domestic product; PPP = purchsing power prity; UHC = universl helth coverge Dt for ll countries nd yers cn be downloded from 231

243 A frmer in Zmbi. Zoonotic TB cn be trnsmitted to people through the consumption of unpsteurized milk nd diry products Ulrich Doering / Almy Stock Photo 232

244 ANNEX 3 Regionl nd globl profiles

245 WHO Africn Region WHO Member Sttes 47 ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 413 ( ) 39 (33 46) Mortlity (HIV+TB only) 252 ( ) 24 (21 27) Incidence (includes HIV+TB) 2 48 ( ) 237 ( ) Incidence (HIV+TB only) 663 ( ) 63 (56 71) Incidence (MDR/RR-TB) b 9 (76 16) 8.6 (7.2 1) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 141 ( ) 8 ( ) 941 ( ) Mles 156 ( ) 1 38 ( ) 1 54 ( ) Totl 296 (26 333) 2 18 ( ) 2 48 ( ) TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % with known HIV sttus 86% % pulmonry 84% % bcteriologiclly confirmed mong pulmonry 66% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (47 58) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.23.31) Mortlity (excludes HIV+TB) Rte per popultion per yer Incidence Rte per popultion per yer POPULATION MILLION Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 (%) f NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 39 mong notified pulmonry TB cses (35 42 ) Estimted % of TB cses with MDR/RR-TB 2.7% (1.7 4) 14% (.49 43) % notified tested for rifmpicin resistnce 23% 43% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: , XDR-TB: 867 Ptients strted on tretment d MDR/RR-TB: 19 21, XDR-TB: 568 Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND 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 216 8% MDR/RR-TB cses strted on second-line tretment in % XDR-TB cses strted on second-line tretment in % 483 TB PREVENTIVE TREATMENT, 217 % of HIV-positive people (newly enrolled in cre) on preventive tretment 32% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 29% (28 3) TB FINANCING (LOW- AND MIDDLE-INCOME COUNTRIES), g,h 218 Ntionl TB budget (US$ millions) Funding source: 27% domestic, 27% interntionl, 46% 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 217 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. Tretment success rte (%) Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 234 Dt for ll countries nd yers cn be downloded from

246 WHO/PAHO Region of the Americs POPULATION MILLION WHO Member Sttes 35 Other countries nd territories 11 ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 18 (17 19) 1.8 ( ) Mortlity (HIV+TB only) 6 (5 7).6 (.53.67) Incidence (includes HIV+TB) 282 (262 32) 28 (26 3) Incidence (HIV+TB only) 3 (28 33) 3 ( ) Incidence (MDR/RR-TB) b 11 (1 13) 1.1 ( ) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 16 (14 18) 86 (77 96) 12 (92 112) Mles 17 (15 19) 162 (144 18) 179 ( ) Totl 33 (3 36) 249 ( ) 282 (262 32) TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % with known HIV sttus 81% % pulmonry 85% % bcteriologiclly confirmed mong pulmonry 78% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (76 87) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.8.9) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 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 217 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 CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 8 mong notified pulmonry TB cses (7 8 7) Estimted % of TB cses with MDR/RR-TB 2.7% (1.6 4) 12% (3.8 24) % notified tested for rifmpicin resistnce 31% 46% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 4 84, XDR-TB: 121 Ptients strted on tretment d MDR/RR-TB: 4 13, XDR-TB: 115 TREATMENT SUCCESS RATE AND 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 215 % 11 TB PREVENTIVE TREATMENT, 217 % of HIV-positive people (newly enrolled in cre) on preventive tretment 16% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 63% (6 67) TB FINANCING (LOW- AND MIDDLE-INCOME COUNTRIES), g,h 218 Ntionl TB budget (US$ millions) 337 Funding source: 66% domestic, 12% interntionl, 22% unfunded Mortlity (excludes HIV+TB) Rte per popultion per yer Incidence Rte per popultion per yer Notified cses by ge group nd sex, 217 Tretment success rte (%) Totl budget (US$ millions) Notified, new nd relpse Incidence (HIV+TB only) Incidence Femles Mles Incidence New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded Dt for ll countries nd yers cn be downloded from 235

247 WHO Estern Mediterrnen Region POPULATION MILLION WHO Member Sttes 21 Other countries nd territories 1 ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 89 (75 14) 13 (11 15) Mortlity (HIV+TB only) 3 (2 5).43 (.26.66) Incidence (includes HIV+TB) 771 (611 9) 113 (9 139) Incidence (HIV+TB only) 1 (6 15) 1.4 ( ) Incidence (MDR/RR-TB) b 41 (31 53) 6 ( ) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 41 (27 55) 35 (2 41) 346 ( ) Mles 45 (3 61) 38 ( ) 425 ( ) Totl 87 (65 18) 685 ( ) 771 (611 9) TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % with known HIV sttus 21% % pulmonry 76% % bcteriologiclly confirmed mong pulmonry 53% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (55 86) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.9.16) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 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 217 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 CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 21 mong notified pulmonry TB cses (18 24 ) Estimted % of TB cses with MDR/RR-TB 4.3% (3 5.8) 18% (2.9 42) % notified tested for rifmpicin resistnce 14% 53% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: 4 969, XDR-TB: 168 Ptients strted on tretment d MDR/RR-TB: 4 253, XDR-TB: TREATMENT SUCCESS RATE AND 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 % 858 MDR/RR-TB cses strted on second-line tretment in % XDR-TB cses strted on second-line tretment in % 77 TB PREVENTIVE TREATMENT, 217 % of HIV-positive people (newly enrolled in cre) on preventive tretment 16% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 2% (19 22) TB FINANCING (LOW- AND MIDDLE-INCOME COUNTRIES), g,h 218 Ntionl TB budget (US$ millions) 217 Funding source: 21% domestic, 43% interntionl, 36% unfunded Mortlity (excludes HIV+TB) Rte per popultion per yer Incidence Rte per popultion per yer Notified cses by ge group nd sex, 217 Tretment success rte (%) Totl budget (US$ millions) Notified, new nd relpse Incidence (HIV+TB only) Incidence 4 4 Femles Mles Incidence New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 236 Dt for ll countries nd yers cn be downloded from

248 WHO Europen Region POPULATION MILLION WHO Member Sttes 53 Other countries nd territories 1 ESTIMATES OF TB BURDEN, A 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 24 (23 25) 2.6 ( ) Mortlity (HIV+TB only) 5 (4 6).54 (.41.69) Incidence (includes HIV+TB) 273 ( ) 3 (26 34) Incidence (HIV+TB only) 33 (26 42) 3.6 ( ) Incidence (MDR/RR-TB) b 19 (86 136) 12 (9.4 15) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 1 (8 12) 86 (68 13) 96 (78 114) Mles 11 (9 13) 166 (133 2) 177 ( ) Totl 21 (18 24) 252 (214 29) 273 ( ) TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % with known HIV sttus 91% % pulmonry 84% % bcteriologiclly confirmed mong pulmonry 64% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (71 93) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.9.12) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 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 217 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 CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 76 mong notified pulmonry TB cses (76 77 ) Estimted % of TB cses with MDR/RR-TB 17% (16 18) 53% (46 61) % notified tested for rifmpicin resistnce 56% 65% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: , XDR-TB: Ptients strted on tretment d MDR/RR-TB: 49 79, XDR-TB: 6 2 TREATMENT SUCCESS RATE AND COHORT SIZE SUCCESS COHORT New nd relpse e cses registered in % 193 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 % TB PREVENTIVE TREATMENT, 217 % of HIV-positive people (newly enrolled in cre) on preventive tretment 72% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 157% ( ) TB FINANCING (LOW- AND MIDDLE-INCOME COUNTRIES), g,h 218 Ntionl TB budget (US$ millions) 1 88 Funding source: 95% domestic, 3.9% interntionl, 1.% unfunded Mortlity (excludes HIV+TB) Rte per popultion per yer Incidence Rte per popultion per yer Notified cses by ge group nd sex, 217 Tretment success rte (%) Totl budget (US$ millions) Notified, new nd relpse Incidence (HIV+TB only) Incidence Femles Mles Incidence New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded Dt for ll countries nd yers cn be downloded from 237

249 WHO South-Est Asi Region WHO Member Sttes 11 ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 638 ( ) 32 (3 35) Mortlity (HIV+TB only) 28 (22 36) 1.4 ( ) Incidence (includes HIV+TB) 4 44 ( ) 226 ( ) Incidence (HIV+TB only) 152 ( ) 7.7 ( ) Incidence (MDR/RR-TB) b 192 ( ) 9.7 (6.7 13) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 171 ( ) 1 44 ( ) 1 62 ( ) Mles 19 (13 251) 2 63 ( ) 2 82 ( ) Totl 362 ( ) 4 8 ( ) 4 44 ( ) TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % with known HIV sttus 55% % pulmonry 85% % bcteriologiclly confirmed mong pulmonry 59% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (52 8) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.12.19) Mortlity (excludes HIV+TB) Rte per popultion per yer Incidence Rte per popultion per yer POPULATION MILLION Notified, new nd relpse Incidence Incidence (HIV+TB only) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 (%) f NEW CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 99 mong notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 2.7% ( ) 13% (4.3 25) % notified tested for rifmpicin resistnce 27% 85% 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: Notified cses by ge group nd sex, Femles Mles Incidence TREATMENT SUCCESS RATE AND 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 % 6 89 MDR/RR-TB cses strted on second-line tretment in 215 % XDR-TB cses strted on second-line tretment in % TB PREVENTIVE TREATMENT, 217 % of HIV-positive people (newly enrolled in cre) on preventive tretment 12% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 14% (13 15) TB FINANCING (LOW- AND MIDDLE-INCOME COUNTRIES), g,h 218 Ntionl TB budget (US$ millions) Funding source: 54% domestic, 22% interntionl, 24% unfunded Dt re s reported to WHO. Estimtes of TB nd MDR/RR-TB burden re produced by WHO in consulttion with countries. 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 217 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. Tretment success rte (%) Totl budget (US$ millions) New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 238 Dt for ll countries nd yers cn be downloded from

250 WHO Western Pcific Region POPULATION MILLION WHO Member Sttes 27 Other countries nd territories 9 ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 92 (85 ) 4.9 ( ) Mortlity (HIV+TB only) 5 (4 6).26 (.2.34) Incidence (includes HIV+TB) 1 8 ( ) 94 (78 112) Incidence (HIV+TB only) 31 (24 4) 1.6 ( ) Incidence (MDR/RR-TB) b 114 (89 142) 6 ( ) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 98 (72 124) 479 (352 66) 577 ( ) Mles 19 (8 138) 1 11 ( ) 1 22 ( ) Totl 27 ( ) 1 59 ( ) 1 8 ( ) TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % with known HIV sttus 51% % pulmonry 92% % bcteriologiclly confirmed mong pulmonry 39% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (63 91) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.4.7) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 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 217 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 CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 87 mong notified pulmonry TB cses (75 98 ) Estimted % of TB cses with MDR/RR-TB 5% ( ) 24% (12 38) % notified tested for rifmpicin resistnce 17% 73% MDR/RR-TB cses tested for resistnce to second-line drugs 5 1 Lbortory-confirmed cses MDR/RR-TB: , XDR-TB: 131 Ptients strted on tretment d MDR/RR-TB: 16 54, XDR-TB: 94 TREATMENT SUCCESS RATE AND 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 % 1 58 MDR/RR-TB cses strted on second-line tretment in % XDR-TB cses strted on second-line tretment in % 87 TB PREVENTIVE TREATMENT, 217 % 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 17% (16 18) TB FINANCING (LOW- AND MIDDLE-INCOME COUNTRIES), g,h 218 Ntionl TB budget (US$ millions) 933 Funding source: 68% domestic, 9.6% interntionl, 22% unfunded Mortlity (excludes HIV+TB) Rte per popultion per yer Incidence Rte per popultion per yer Notified cses by ge group nd sex, 217 Tretment success rte (%) Totl budget (US$ millions) Notified, new nd relpse Incidence (HIV+TB only) Incidence 2 Femles Mles Incidence New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded Dt for ll countries nd yers cn be downloded from 239

251 Globl POPULATION MILLION WHO Member Sttes 194 Other countries nd territories 22 ESTIMATES OF TB BURDEN, 217 NUMBER (THOUSANDS) RATE (PER POPULATION) Mortlity (excludes HIV+TB) 1 27 ( ) 17 (16 18) Mortlity (HIV+TB only) 3 ( ) 4 ( ) Incidence (includes HIV+TB) 1 (9 11 ) 133 (12 148) Incidence (HIV+TB only) 92 ( ) 12 (11 13) Incidence (MDR/RR-TB) b 558 ( ) 7.4 ( ) ESTIMATED TB INCIDENCE BY AGE AND SEX (THOUSANDS), YEARS > 14 YEARS TOTAL Femles 478 (41 554) 3 2 ( ) 3 68 ( ) Mles 529 ( ) 5 83 ( ) 6 36 ( ) Totl 1 1 ( ) 9 3 ( ) 1 (9 11 ) TB CASE NOTIFICATIONS, 217 Totl cses notified Totl new nd relpse % with known HIV sttus 6% % pulmonry 86% % bcteriologiclly confirmed mong pulmonry 56% UNIVERSAL HEALTH COVERAGE AND SOCIAL PROTECTION TB tretment coverge (notified/estimted incidence), % (58 72) TB ptients fcing ctstrophic totl costs TB cse ftlity rtio (estimted mortlity/estimted incidence), (.14.18) TB/HIV CARE IN NEW AND RELAPSE TB PATIENTS, 217 NUMBER Ptients with known HIV-sttus who re HIV-positive % on ntiretrovirl therpy % DRUG-RESISTANT TB CARE, 217 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 217 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 CASES PREVIOUSLY TREATED CASES TOTAL NUMBER c Estimted MDR/RR-TB cses 33 mong notified pulmonry TB cses ( ) Estimted % of TB cses with MDR/RR-TB 3.5% ( ) 18% (6.3 34) % notified tested for rifmpicin resistnce 24% 7% MDR/RR-TB cses tested for resistnce to second-line drugs Lbortory-confirmed cses MDR/RR-TB: , XDR-TB: 1 8 Ptients strted on tretment d MDR/RR-TB: , XDR-TB: TREATMENT SUCCESS RATE AND 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 % TB PREVENTIVE TREATMENT, 217 % of HIV-positive people (newly enrolled in cre) on preventive tretment 3% % of children (ged < 5) household contcts of bcteriologiclly-confirmed TB cses on preventive tretment 23% (22 24) TB FINANCING (LOW- AND MIDDLE-INCOME COUNTRIES),G,H 218 Ntionl TB budget (US$ millions) 5 87 Funding source: 62% domestic, 16% interntionl, 22% unfunded Mortlity (excludes HIV+TB) Rte per popultion per yer Incidence Rte per popultion per yer Notified cses by ge group nd sex, 217 Tretment success rte (%) Totl budget (US$ millions) Notified, new nd relpse Incidence (HIV+TB only) Incidence Femles Mles Incidence New nd relpse Retretment, excluding relpse HIV-positive MDR/RR-TB XDR-TB Funded domesticlly Funded interntionlly Unfunded 24 Dt for ll countries nd yers cn be downloded from

252

253 An XDR-TB ptient on new drug tretment in Armeni Mxim Dondyuk 242

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

255 Estimtes of incidence nd mortlity Estimted vlues re shown s best estimtes followed by lower nd upper bounds. The lower nd upper bounds re defined s the 2.5th nd 97.5th centiles of outcome distributions produced in simultions. For detils bout the methods used to produce these estimtes see the technicl ppendix t Estimtes re shown rounded to three significnt figures unless the displyed vlue is under, in which cse it is shown rounded to two significnt figures. Dt source Dt shown in this file were tken from the WHO globl TB dtbse on 5 October 218. Dt shown in the min prt of the report were tken from the dtbse on 6 August 218. As result, dt in this nnex my differ slightly from those in the min prt of the report. Downlodble dt This nnex is provided s reference for looking up figures when needed. It is not suitble for conducting nlyses or producing grphs nd tbles. Insted, downlod dt for ll countries nd ll yers s comm-seprted vlue (CSV) files from the WHO globl TB dtbse t See Annex 1 for more detils. Country notes Cribben Islnds Dt collection from Cribben Islnds tht re not Member Sttes of WHO ws resumed in 211 fter brek of few yers. This includes Arub, Curço, Puerto Rico nd Sint Mrten, which re Associte Members of the Pn Americn Helth Orgniztion, plus the territories of Anguill, Bermud, Bonire, Sint Eusttius nd Sb, British Virgin Islnds, Cymn Islnds, Montserrt nd Turks nd Cicos Islnds. 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. Eswtini, Mozmbique, Mynmr, Nmibi, Nepl, South Afric nd Viet Nm Estimtes of TB incidence nd mortlity for Eswtini, Mozmbique, Mynmr, Nmibi, Nepl, South Afric nd Viet Nm will be reviewed fter finl results from their respective ntionl TB prevlence surveys re vilble in 219. Frnce Dt from Frnce include dt from 5 overses deprtments (French Guin, Gudeloupe, Mrtinique, Myotte nd Réunion) nd exclude French territories of the Pcific. Indi Estimtes of TB incidence nd mortlity for Indi re interim, pending results from the ntionl TB prevlence survey plnned for 219/22. Russin Federtion UN Popultion Division estimtes re lower thn the popultion registered by the Federl Stte Sttistics Service of the Russin Federtion. United Sttes of Americ In ddition to the 51 reporting res, the USA includes territories tht report seprtely to WHO. The dt for these territories re not included in the dt reported by the USA. Definitions of cse types nd outcomes do not exctly mtch those used by WHO. 244 Dt for ll countries nd yers cn be downloded from

256 TABLE A4.1 TB incidence estimtes, 217 Incidence (including HIV) Incidence (HIV-positive) Incidence (MDR/RR-TB) Popultion (millions) Number (thousnds) Rte Number (thousnds) Rte Number (thousnds) Rte Afghnistn (43 96) 189 (122 27).21 (.14.3).6 (.39.86) 3.2 ( ) 9(4.3 15) Albni 3.58 (.49.67) 2 (17 23) <.1 (<.1 <.1).17 (.11.24).17 (<.1.36).58 ( ) Algeri (22 36) 7 (53 88).18 (.94.29).44 (.23.71).78 ( ) 1.9 ( ) Americn Smo < 1 <.1 (<.1 <.1) 1 (8.8 12) ( ) ( ) <.1(<.1 <.1).31(.13.57) Andorr < 1 <.1 (<.1 <.1) 1.5 ( ) <.1 (<.1 <.1) <.1 (<.1 <.1) Angol 3 17 (69 153) 359 ( ) 18 (9.1 3) 61 (31 12) 3.9 ( ) 13 (5.5 24) Anguill < 1 <.1 (<.1 <.1) 22 (14 31) <.1 (<.1 <.1) 2.2 ( ) Antigu nd Brbud < 1 <.1 (<.1 <.1) 1.1 ( ) ( ) ( ) <.1(<.1 <.1) <.1(<.1 <.1) Argentin (1 14) 26 (23 31) 1.5 ( ) 3.4 (2. 5.1).54 (.35.78) 1.2 ( ) Armeni (.8 1.3) 36 (27 45).75 (.49.11) 2.6 ( ).34 (.22.48) 12 (7.6 16) Arub < 1 <.1 (<.1.11) 8.7 (7.5 1) <.1 (<.1 <.1).29 (.12.53) Austrli ( ) 6.8 ( ).35 (.3.41).14 (.12.17).38 (.2.62).16 (<.1.25) Austri 9.64 (.55.74) 7.3 ( ).28 (.16.44).32 (.18.51).19 (<.1.35).22 (.1.4) Azerbijn (5. 8.3) 67 (51 84).11 (.71.16) 1.1 ( ) 2.1 ( ) 22 (16 28) Bhms < 1.59 (..68) 15 (13 17).23 (.2.27) 5.8 (5. 6.8) <.1 (<.1 <.1) <.1 (<.1.12) Bhrin 1.17 (.15.2) 12 (9.9 13) <.1 (<.1.1).55 (.46.64) <.1 (<.1 <.1).22 (<.1.64) Bngldesh ( ) 221 ( ).55 (.27.92).33 (.17.56) 8.4 (3.8 15) 5.1 (2.3 9.) Brbdos < 1 ( ) ( ) ( ) ( ) ( ) ( ) Belrus ( ) 37 (28 46).27 (.21.34) 2.9 ( ) 2.5( ) 26(19 35) Belgium ( ) 9.8 (8.4 11).87 (.72.1).76 (.63.91).29 (.13.).25 (.12.43) Belize < 1.13 (.12.16) 36 (31 41).32 (.21.46) 8.6 (5.6 12).15 (<.1.45) 4.1 (.42 12) Benin ( ) 58 (37 82).98 ( ) 8.8 (5.6 13).97 (.18.24).87 ( ) Bermud < 1 <.1 (<.1 <.1) 3.7 ( ) ( ) ( ) <.1(<.1 <.1).29 (.17.45) Bhutn < ( ) 134 (13 169) <.1 (<.1 <.1).77 (. 1.1).18 (.12.25) 22 (15 31) Bolivi (Plurintionl Stte of) (8. 17) 111 (73 158).56 (.36.8) 5 ( ).38 (.12.79) 3.4 ( ) Bonire, Sint Eusttius nd Sb < 1 <.1 (<.1 <.1) 3.1 ( ) <.1 (<.1 <.1).26 (.15.41) Bosni nd Herzegovin 4.96 ( ) 27 (21 35) <.1 (<.1 <.1) <.1 (<.1 <.1) ( ) ( ) Botswn ( ) 3 ( ) 3.3 ( ) 144 (93 26).4 (.23.61) 17 (1 27) Brzil (78 15) 44 (37 ) 11 (9.3 13) 5.3 ( ) 2.4 ( ) 1.2 ( ) British Virgin Islnds < 1 ( ) ( ) ( ) ( ) Brunei Drusslm < 1.27 (.23.32) 64 (55 74) <.1 (<.1 <.1).54 (.35.77) ( ) ( ) Bulgri ( ) 24 (18 3) <.1 (<.1 <.1) <.1 (<.1 <.1).37 (.15.69).53 (.22.98) Burkin Fso (6.1 14) 49 (32 71).86 ( ) 4.5 ( ).29 (.16.47) 1.5 ( ) Burundi (8. 18) 114 (74 163) 1.4 (.93 2.) 13 (8.5 19).37 (.15.69) 3.4 ( ) Cbo Verde < 1.73 (.47 1.) 134 (87 192).82 (.51.12) 15 (9.4 22).27 (.11.49) 4.9 (2. 9.) Cmbodi (36 72) 326 ( ) 1.3 ( ) 8.2 (5.6 11) 1.2 ( ) 7.2 (3.2 13) Cmeroon (3 67) 194 ( ) 14 (9.2 21) 6 (38 86) 1.5 (.6 2.7) 6.1 (2.5 11) Cnd 37 2 ( ) 5.5 ( ).16 (.13.19).44 (.36.52).24 (.11.42) <.1 (<.1.12) Cymn Islnds < 1 <.1 (<.1 <.1) 7.5 ( ) ( ) ( ) <.1(<.1 <.1).19(.11.3) Centrl Africn Republic 5 2 (13 28) 423 (274 64) 6.2 (3.3 1) 134 (72 214).15 (.84.23) 3.2 ( ) Chd (15 33) 154 ( 22) 4.6 ( ) 31 (19 44).76 ( ) 5.1 ( ) Chile ( ) 17 (15 2).51 (.31.77) 2.8 ( ).85 (.56.12).47 (.31.66) Chin ( ) 63 (54 73) 12 (6.3 18).82 ( ) 73 (55 94) 5.2 ( ) Chin, Hong Kong SAR 7 5 ( ) 67 (58 78).47 (.39.55).63 (.53.74).6 (.35.91).81 ( ) Chin, Mco SAR < 1.44 (.37.) 7 (6 81) <.1 (<.1 <.1).12 (<.1.15).14 (<.1.28) 2.3 ( ) Colombi (12 21) 33 (25 42) 2 ( ) 4.1 ( ).57 (.36.84) 1.2 ( ) Comoros < 1.28 (.18.4) 35 (22 ) <.1 (<.1.13) 1.1 ( ).25 (<.1.81) 3 ( ) Congo 5 2 (13 29) 376 ( ) 5.3 ( ) (52 164).61 ( ) 12 (4.8 21) Cook Islnds < 1 ( ) ( ) ( ) ( ) ( ) ( ) Cost Ric 5.47 (.36.6) 9.7 (7.4 12).42 (.32.53).86 ( ) <.1 (<.1.17).16 (<.1.36) Côte d'ivoire (23 51) 148 (95 212) 7.3 (4.6 1) 3 (19 43) 2.1 (1. 3.6) 8.8 (4.3 15) Croti 4.42 (.36.49) 1 (8.7 12) <.1 (<.1.13).19 (.11.31) ( ) ( ) Cub (.7.95) 7.1 ( ).98 (.63.14).85 ( ).25 (<.1.48).22 (<.1.41) Curço < 1.1 (<.1.12) 6.4 ( ) ( ) <.1 ( <.1) <.1 (<.1 <.1) <.1 (<.1 <.1) Cyprus 1.66 (.56.76) 5.6 ( ) <.1 (<.1 <.1).22 (.12.34) <.1 (<.1 <.1) <.1 (<.1 <.1) Czechi (.49.66) 5.4 ( ) <.1 (<.1.13) <.1 (<.1.12).17 (<.1.31).16 (<.1.29) Democrtic People's Republic of Kore ( ) 513 ( ).17 (.94.28).69 ( ) 5.2 ( ) 2 (1 34) Democrtic Republic of the Congo ( ) 322 (28 46) 2 (13 29) 25 (16 35) 7.5 (3.3 13) 9.2 (4. 17) Denmrk 6.29 (.25.34) 5.1 ( ) <.1 (<.1.11).15 (.12.19) <.1 (<.1 <.1) <.1 (<.1 <.1) Djibouti < (2. 3.3) 269 (26 34).12 (.94.16) 13 (9.8 17).14 (.69.24) 15 (7.2 26) Dominic < 1 <.1 (<.1 <.1) 1.6 ( ) ( ) ( ) <.1(<.1 <.1) <.1 (<.1 <.1) Dominicn Republic ( ) 45 (34 57) 1.2 ( ) 11 (8.1 14).23 (.11.39) 2.1 (1. 3.6) Ecudor (5.5 9.) 43 (33 54).95 ( ) 5.7 ( ).65 (.43.92) 3.9 ( ) Egypt (11 14) 13 (12 14).53 (.34.76) <.1 (<.1 <.1) 2.2 ( ) 2.3 ( ) El Slvdor ( ) 72 (55 91).22 (.14.31) 3.4 ( ).14 (.44.28) 2.1 ( ) Equtoril Guine ( ) 191 ( ).95 ( ) 75 (63 88).1 (.57.16) 8 (4.5 12) Rtes re per popultion. Dt for ll countries nd yers cn be downloded from 245

257 TABLE A4.1 TB incidence estimtes, 217 Incidence (including HIV) Incidence (HIV-positive) Incidence (MDR/RR-TB) Popultion (millions) Number (thousnds) Rte Number (thousnds) Rte Number (thousnds) Rte Eritre ( ) 67 (31 116).15 (.95.21) 2.9 ( ).97 (.29.2) 1.9 (.58 4.) Estoni 1.2 (.17.23) 15 (13 17).17 (.15.2) 1.3 ( ).71 (.46.1) 5.4 ( ) Eswtini ( ) 38 ( ) 2.9 ( ) 213 (138 34).42 (.28.58) 31 (2 43) Ethiopi ( ) 164 ( ) 12 (8.6 17) 12 (8.2 16) 5.5 ( ) 5.2 ( ) Fiji < 1.45 (.34.56) 49 (38 62).12 (<.1.16) 1.3 ( ) <.1 (<.1 <.1).5 (.28.77) Finlnd 6.27 (.23.31) 4.9 ( ) <.1 (<.1.13).15 (<.1.24).13 (<.1.25).23 (<.1.46) Frnce ( ) 8(7. 9.).74( ) 1.1( ).94 (.66.13).14 (.1.2) French Polynesi < 1.6 (.51.69) 21 (18 24) <.1 (<.1.11) 1.2 (<.1 3.9) Gbon 2 11 (6.9 15) 529 ( ) 2.2 ( ) 111 (69 162).44 (.2.77) 22 (9.7 38) Gmbi ( ) 174 ( ).7 (.53.9) 33 (25 43).11(.47.2) 5.2( ) Georgi ( ) 86 (72 11).59 (.49.7) 1.5 ( ).73 (.55.94) 19 (14 24) Germny ( ) 7.5 ( ).35 (.2.55).43 (.24.67).19 (.9.33).23 (.11.41) Ghn (21 74) 152 (73 258) 9.5 (4.5 16) 33 (16 56).99 (.4 1.8) 3.4 ( ) Greece (.39.52) 4.1 ( ).29 (.17.46).26 (.15.41).11 (<.1.33).1 (<.1.3) Greenlnd < 1.66 (.56.76) 116 (99 134) <.1 (<.1 <.1) 6.2 (3.3 1) Grend < 1 <.1 (<.1 <.1) 3.2 ( ) <.1 (<.1 <.1) 1.1 ( ) <.1 (<.1 <.1).2 (<.1.64) Gum < 1.98 (.84.11) 6 (51 69) <.1 (<.1 <.1).72 (.46 1.) <.1 (<.1.12) 3.5 ( ) Guteml ( ) 25 (19 32).33 (.25.41) 1.9 ( ).13 (.46.25).75 ( ) Guine (14 32) 176 ( ) 5.6 ( ) 44 (28 64).67 ( ) 5.2 ( ) Guine-Bissu 2 7 ( ) 374 ( ) 2.2 ( ) 119 (75 174).19 (.75.36) 1 (4. 19) Guyn < 1.67 (.51.85) 86 (66 19).18 (.14.23) 23 (18 3).35 (.16.6) 4.4 ( ) Hiti 11 2 (15 25) 181 ( ) 2.9 ( ) 27 (2 34).6 ( ) 5.4 (1.9 11) Hondurs ( ) 38 (29 48).24 (.16.35) 2.6 ( ).1(.41.19) 1.1( ) Hungry 1.72 (.62.83) 7.4 ( ).11 (<.1.17).11 (<.1.18).29 (.16.45).29 (.16.46) Icelnd < 1.15 (.13.17) 4.5 ( ) ( ) ( <.1) ( ) ( ) Indi ( ) 24 (14 281) 86 (57 12) 6.4 (4.3 9.) 135 (78 28) 1 (5.8 16) Indonesi ( ) 319 ( ) 36 (2 57) 14 (7.7 21) 23 (16 31) 8.8 (6.2 12) Irn (Islmic Republic of) (8.7 14) 14 (11 18).3 (.2.43).37 (.24.53).2 (.1.32).24 (.13.39) Irq (14 18) 42 (37 48).16 (.13.2) <.1 (<.1 <.1) 1.3 ( ) 3.5 ( ) Irelnd 5.35 (.3.4) 7.3 ( ).26 (.17.37).55 (.35.78) <.1 (<.1 <.1) <.1 (<.1.14) Isrel 8.27 (.23.31) 3.2 ( ).14 (<.1.2).17 (.11.24).21 (<.1.37).25 (.11.45) Itly ( ) 6.9 (5.9 8.).44 (.25.68).74 ( ).17 (.11.25).29 (.19.42) Jmic 3.15 (.11.19) 5.1 ( ).38 (.29.48) 1.3 (1. 1.7) <.1 (<.1 <.1) <.1 (<.1.15) Jpn (17 22) 15 (13 17).85 (.7.1) <.1 (<.1 <.1).57 ( ).45 (.18.83) Jordn 1.66 (..83) 6.8 ( ) ( ) ( ).48(.19.91).5 (.19.94) Kzkhstn (7.8 17) 66 (43 94).53 (.34.75) 2.9 ( ) 7.1 (4.2 11) 39 (23 59) Keny 158 (97 235) 319 ( ) 45 (27 68) 91 (55 137) 2.8 ( ) 5.6 ( ) Kiribti < 1.48 (.37.61) 413 ( ) <.1 (<.1 <.1) 1.7 ( ).14 (<.1.27) 12 (4.5 23) Kuwit ( ) 27 (23 32) <.1 (<.1 <.1).12 (<.1.17).23 (.11.41).57 (.26.98) Kyrgyzstn (7.2 1) 144 (12 17).31 (.25.37) 5.1 ( ) 4.1 (3. 5.4) 68 ( 89) Lo People's Democrtic Republic 7 12 (7.5 16) 168 (19 24).68 (.43.98) 9.9 (6.3 14).17 (.7.31) 2.5 (1. 4.5) Ltvi 2.62 (.53.72) 32 (27 37).63 (.53.73) 3.2 ( ).8 (.53.11) 4.1 ( ) Lebnon 6.71 (.61.82) 12 (1 14) <.1 (<.1 <.1) <.1 (<.1.1).15 (<.1.3).25 (<.1.49) Lesotho 2 15 (9.6 21) 665 (43 949) 11 (6.7 15) 47 (298 68) 1.1 ( ) (27 78) Liberi 5 15 (9.4 21) 38 (199 44) 2.2 ( ) 47 (3 68).39 (.15.74) 8.3 (3.2 16) Liby ( ) 4 (25 58).65 (.41.96) 1 ( ).12 (.57.2) 1.8 ( ) Lithuni ( ) (43 58).5 (.42.58) 1.7 (1.4 2.).36 (.28.45) 13 (9.8 16) Luxembourg < 1.37 (.31.43) 6.3 ( ) <.1 (<.1 <.1).57 (.33.88) <.1 (<.1 <.1).24 (.14.37) Mdgscr (39 87) 238 (154 34) 1.5 ( ) 6 (2.7 11).44 ( ) 1.7 ( ) Mlwi (14 39) 133 (75 27) 12 (7.9 17) 66 (43 94).33 (.95.71) 1.8 ( ) Mlysi (25 34) 93 (79 17) 1.8 ( ) 5.7 ( ).57 (.42.73) 1.8 ( ) Mldives < 1.17 (.13.22) 39 (3 49) ( ) ( ) <.1(<.1.12).91 (<.1 2.7) Mli 19 1 (6.6 14) 55 (36 77) 1.2 ( ) 6.2 (4. 8.9).34 (.15.6) 1.8 (.8 3.2) Mlt < 1.48 (.41.56) 11 (9.6 13) ( ) <.1 (<.1 <.1) <.1 (<.1 <.1) <.1 (<.1 <.1) Mrshll Islnds < 1.25 (.2.32) 48 (368 67) ( ).4 (.28.53) ( ) ( ) Muritni ( ) 97 (63 139).16 (.69.3) 3.7 ( ).13 (.51.24) 2.9 ( ) Muritius 1.15 (.11.19) 12 (8.9 15).27 (.18.39) 2.1 ( ) <.1 (<.1 <.1).24 (<.1.69) Mexico (22 36) 22 (17 28) 3.5 ( ) 2.7 ( ).97 ( ).75 (.56.98) Micronesi (Federted Sttes of) < 1.17 (.13.22) 165 (126 28) <.1 (<.1 <.1) 3 ( ) <.1 (<.1 <.1) 4 ( ) Monco < 1 ( ) ( ) ( ) ( ) Mongoli 3 13 (6.8 22) 428 (22 73).25 (.13.42).81 ( ).41 (.28.58) 13 (9. 19) Montenegro < 1.86 (.74.1) 14 (12 16) ( ) <.1 (<.1 <.1) <.1 (<.1 <.1) <.1 (<.1 <.1) Montserrt < 1 ( ) ( ) ( ) ( ) Morocco (3 41) 99 (85 115).38 (.25.54) 1.1 ( ).53 (.26.9) 1.5 ( ) Mozmbique (16 233) 551 ( ) 66 (42 95) 221 ( ) 8.8 (4.6 14) 3 (15 48) Mynmr ( ) 358 ( ) 17 (12 22) 31 (23 41) 14 (8. 21) 26 (15 39) Rtes re per popultion. 246 Dt for ll countries nd yers cn be downloded from

258 TABLE A4.1 TB incidence estimtes, 217 Incidence (including HIV) Incidence (HIV-positive) Incidence (MDR/RR-TB) Popultion (millions) Number (thousnds) Rte Number (thousnds) Rte Number (thousnds) Rte Nmibi 3 11 (8.2 14) 423 ( ) 3.9 ( ) 153 (99 219).95 ( ) 37 (26 51) Nuru < 1.1 (<.1.12) 91 (78 15) <.1 (<.1 <.1) 2.7 (1.1 5.) Nepl (39 ) 152 ( ).88 ( ) 3 ( ) 1.5 ( ) 5.2 ( ) Netherlnds (.76 1.) 5.2 ( ).36 (.3.42).21 (.17.25).18 (<.1.35).11 (<.1.21) New Cledoni < 1.39 (.33.45) 14 (12 16) <.1 (<.1 <.1).63 (.36.97) New Zelnd 5.35 (.3.41) 7.5 ( ) <.1 (<.1 <.1) <.1 (<.1 <.1).11 (<.1.22).23 (<.1.48) Nicrgu ( ) 45 (35 57).14 (.88.2) 2.2 ( ).42 (<.1.1).67 ( ) Niger (12 27) 9 (58 128).83 ( ) 3.9 ( ).6 ( ) 2.8 ( ) Nigeri ( ) 219 ( ) 58 (37 85) 3 (19 44) 24 (14 36) 12 (7.3 19) Niue < 1 <.1 (<.1 <.1) 71 (61 82) <.1 (<.1 <.1) 8.8 (5. 14) Northern Mrin Islnds < 1.47 (.4.54) 86 (73 99) ( ) ( ) <.1(<.1 <.1).26(.15.39) Norwy 5.27 (.23.31) 5.1 ( ).13 (<.1.21).25 (.14.39).14 (<.1.29).27 (<.1.54) Omn 5.31 (.27.36) 6.7 ( ) <.1 (<.1 <.1) <.1 (<.1.11) ( ) ( ) Pkistn (373 74) 267 ( ) 7.3 (3.6 12) 3.7 ( ) 27 (17 39) 14 (8.8 2) Plu < 1.23 (.2.27) 16 (91 122) ( ) ( ) <.1(<.1 <.1).32 (.18.49) Pnm ( ) 54 (42 69).4 (.31.51) 9.8 (7.5 12).84(.36.15) 2( ) Ppu New Guine 8 36 (29 43) 432 ( ) 3.5 (2. 5.5) 43(24 66) 1.9( ) 23(15 34) Prguy 7 3 ( ) 44 (37 ).26 (.22.3) 3.8 ( ).67(.22.14).99(.32 2.) Peru (29 47) 116 (89 147) 1.8 ( ) 5.7 ( ) 3.5 ( ) 11 (8.1 14) Philippines (326 99) 554 ( ) 7.1 (2.9 13) 6.7 (2.8 12) 27 (12 47) 26 (12 45) Polnd ( ) 17 (14 19).16 (.9.25).43 (.24.67).1 (.7.14).27 (.18.37) Portugl 1 2 ( ) 2 (17 23).25 (.21.29) 2.4 (2. 2.8).27 (.15.43).26 (.14.42) Puerto Rico 4.45 (.38.52) 1.2 (1. 1.4).1 (<.1.14).27(.18.39) ( ) ( ) Qtr 3.69 (.59.8) 26 (22 3) <.1 (<.1 <.1) <.1 (<.1 <.1).15 (<.1.27).57 (.24 1.) Republic of Kore (33 38) 7 (65 75).63 (.36.97) 1.2 (.7 1.9) 2.1 ( ) 4( ) Republic of Moldov ( ) 95 (82 11).33 (.28.39) 8.2 (7. 9.5) 2.2 ( ) 54 (43 66) Romni 2 14 (12 16) 72 (62 83).3 (.25.35) 1.5 ( ).73 (.58.9) 3.7 ( ) Russin Federtion (56 123) 6 (39 85) 18 (12 26) 13 (8.3 18) 56 (36 82) 39 (25 57) Rwnd 12 7 ( ) 57 (44 72) 1.5 ( ) 12 (8. 18).15 (.78.23) 1.2 ( ) Sint Kitts nd Nevis < 1 <.1 (<.1 <.1) 2.1 ( ) ( ) ( ) <.1(<.1 <.1).13(<.1.21) Sint Luci < 1.14 (.12.16) 7.7 ( ) ( ) ( ) <.1(<.1 <.1) <.1 (<.1 <.1) Sint Vincent nd the Grendines < 1 <.1 (<.1 <.1) 2.1 ( ) ( ) ( ) <.1(<.1 <.1) <.1(<.1 <.1) Smo < 1.34 (.3.4) 18 (15 2) <.1 (<.1 <.1) <.1 (<.1 <.1) Sn Mrino < 1 ( ) ( ) ( ) ( ) So Tome nd Principe < 1.24 (.96.45) 118 (47 222).37 (.24.52) 18 (12 26).23 (<.1.67) 11 (1.2 33) Sudi Arbi ( ) 1 (8.6 12).12 (.1.14).37 (.31.44).12 (.89.15).36 (.27.46) Senegl (14 26) 122 (87 163) 1.2 ( ) 7.4 (5.2 1).24 (.97.45) 1.5 ( ) Serbi ( ) 19 (16 22).1 (<.1.14).11 (<.1.16).25 (.11.46).29 (.12.52) Seychelles < 1.18 (.16.21) 19 (17 22) ( ) ( ) <.1(<.1 <.1) <.1 (<.1.11) Sierr Leone 8 23 (15 33) 31 ( ) 2.8 (1.8 4.) 37 (24 53).66 ( ) 8.8 (3.6 16) Singpore ( ) 47 (4 54).39 (.33.46).69 (.58.8).53 (.3.83).93 ( ) Sint Mrten (Dutch prt) < 1 <.1 (<.1 <.1) 14 (12 17) <.1 (<.1 <.1) 1.3 ( ) Slovki 5.26 (.22.3) 4.8 ( ) ( ) ( <.1).16(<.1.34).29 (<.1.62) Sloveni 2.12 (.1.14) 5.7 ( ) <.1 (<.1 <.1) <.1 (<.1 <.1) ( ) ( ) Solomon Islnds < 1.47 (.36.59) 76 (58 96).12 (<.1.23) 1.9 ( ) Somli (25 56) 266 (172 38).42 (.27.61) 2.9 ( ) 4.2 ( ) 28 (16 44) South Afric (23 428) 567 (46 754) 193 ( ) 34 ( ) 14 (8.9 2) 25(16 36) South Sudn (12 26) 146 (95 29) 2.3 ( ) 18 (12 26).64 ( ) 5.1 (2.3 9.) Spin (4. 5.4) 1 (8.6 12).34 (.28.4).73 (.61.86).27 (.18.37).58 (.4.8) Sri Lnk (9.9 17) 64 (47 84).49 (.35.64).23 (.17.31).88 (.34.17).42 (.16.8) Sudn (21 42) 77 (53 15).72 (.47 1.) 1.8 ( ) 1.2 ( ) 2.9 ( ) Surinme < 1.16 (.12.2) 29 (22 36).27 (.17.38) 4.7 ( ).11 (<.1.25) 2 ( ) Sweden 1.56 (.48.65) 5.7 ( ).24 (.14.38).25 (.14.38).2 (<.1.35).21 (.1.36) Switzerlnd 8.61 (.52.7) 7.2 ( ).55 (.32.85).65 (.38 1.).36 (.17.62).42 (.2.73) Syrin Arb Republic ( ) 19 (14 24) <.1 (<.1.15) <.1 (<.1 <.1).32 (.19.48) 1.8 ( ) Tjikistn ( ) 85 (65 16).28 (.18.4) 3.1 (2. 4.5) 2.3 ( ) 26 (18 35) Thilnd (82 138) 156 ( ) 11 (8.5 15) 16 (12 21) 3.9 ( ) 5.7 ( ) The Former Yugoslv Republic of Mcedoni Rtes re per popultion (.21.34) 13 (9.9 16) ( ) <.1 (<.1 <.1) ( ) ( ) Timor-Leste ( ) 498 ( ).59 (.37.85) 4.5 ( ).26 (.89.52) 2 (6.9 4) Togo ( ) 41 (33 49).58 (.38.83) 7.5 (4.8 11).64 (.32.11).82 ( ) Tokelu < 1 ( ) ( ) ( ) ( ) Tong < 1.13 (.11.15) 12 (1 14) ( ) ( ) <.1(<.1 <.1) <.1 (<.1 <.1) Trinidd nd Tobgo 1.23 (.2.27) 17 (14 19).31 (.26.36) 2.3 ( ) <.1 (<.1.15).65 ( ) Tunisi (3. 4.9) 34 (26 43).18 (.14.23).16 (.12.2).5 (.24.86).44 (.21.75) Turkey (12 16) 17 (14 19).1 (.88.12).13 (.11.15).6 (.48.74).74 (.59.91) Turkmenistn ( ) 43 (33 54).13 (.61.23) 2.3 ( ).54 (.37.73) 9.4 (6.5 13) Dt for ll countries nd yers cn be downloded from 247

259 TABLE A4.1 TB incidence estimtes, 217 Incidence (including HIV) Incidence (HIV-positive) Incidence (MDR/RR-TB) Popultion (millions) Number (thousnds) Rte Number (thousnds) Rte Number (thousnds) Rte Turks nd Cicos Islnds < 1 <.1 (<.1 <.1) 6.1 (5.2 7.) <.1 (<.1 <.1) 3 ( ) <.1 (<.1 <.1).33 (<.1 1.2) Tuvlu < 1.26 (.23.31) 236 (22 273) ( ) ( ) <.1(<.1 <.1) 6.8 (2.5 13) Ugnd (51 131) 21 (118 35) 34 (22 49) 8 (52 114) 2( ) 4.8 ( ) Ukrine (24 53) 84 (54 119) 8 (5.2 11) 18 (12 26) 2 (13 3) 46 (29 67) United Arb Emirtes 9.76 (.65.88).81 (.69.93) <.1 (<.1 <.1) <.1 (<.1 <.1) <.1 (<.1 <.1) <.1 (<.1 <.1) United Kingdom of Gret Britin nd Northern Irelnd ( ) 8.9 ( ).41 (.23.62).61 (.35.94).12 (.78.16).17 (.12.24) United Republic of Tnzni (73 266) 269 ( ) 48 (31 69) 84 (54 12) 1.7 ( ) 2.9 (.91 6.) United Sttes of Americ (8.5 12) 3.1 ( ).55 (.47.64).17 (.14.2).29 (.23.37) <.1 (<.1.11) Uruguy ( ) 31 (27 36).17 (.14.19) 4.9 ( ) <.1 (<.1.17).19 (<.1.) Uzbekistn (16 32) 73 (51 99) 1.2 ( ) 3.6 ( ) 7.5 (4.7 11) 24 (15 34) Vnutu < 1.14 (.11.18) 51 (38 65) ( ) <.1 (<.1 <.1) <.1 (<.1.12) 1.2 (<.1 4.3) Venezuel (Bolivrin Republic of) (1 17) 42 (32 53) 1.2 ( ) 3.7 ( ).42 (.16.79) 1.3 (. 2.5) Viet Nm (11 148) 129 (16 155) 4.5 ( ) 4.7 ( ) 7.1 (4.6 1) 7.4 (4.8 11) Wllis nd Futun Islnds < 1 ( ) <.1 (<.1.1) <.1 (<.1 <.1) <.1 (<.1 <.1) West Bnk nd Gz Strip 5.47 (.36.6).96 ( ) ( ) ( ) <.1(<.1 <.1) <.1(<.1 <.1) Yemen (12 15) 48 (42 54).96 (.33.19).34 (.12.68).36 (.18.6) 1.3 ( ) Zmbi (4 88) 361 ( ) 36 (23 52) 21 (135 32) 1.9 ( ) 11 (3.9 22) Zimbbwe (27 47) 221 ( ) 23 (15 33) 14 (9 199) 2.3 ( ) 14 (8.5 21) WHO regions Africn Region ( ) 237 ( ) 663 ( ) 63(56 71) 9 (76 16) 8.6 (7.2 1) Region of the Americs (262 32) 28 (26 3) 3 (28 33) 3( ) 11(9.9 13) 1.1( ) Estern Mediterrnen Region (611 9) 113 (9 139) 9.8 (6. 15) 1.4 ( ) 41 (31 53) 6( ) Europen Region ( ) 3 (26 34) 33 (26 42) 3.6 ( ) 19 (86 136) 12 (9.4 15) South-Est Asi Region ( ) 226 ( ) 152 ( ) 7.7 ( ) 192 ( ) 9.7 (6.7 13) Western Pcific Region ( ) 94 (78 112) 31 (24 4) 1.6 ( ) 114 (89 142) 6( ) Globl (9 11 ) 133 (12 148) 92 ( ) 12 (11 13) 558 ( ) 7.4( ) Rtes re per popultion. 248 Dt for ll countries nd yers cn be downloded from

260 TABLE A4.2 Estimtes of TB mortlity, 217. Deths from TB mong HIV-positive people re officilly clssified s deths cused by HIV/AIDS in the Interntionl clssifiction of diseses. b Popultion (millions) Number (thousnds) Rtes re per popultion. All clcultions re mde before numbers re rounded. Rte Number (thousnds) Rte Number (thousnds) Afghnistn 36 1 (6. 15) 29 (17 43).64 (.1.17).18 (<.1.47) 1 (6.1 15) 29 (17 43) Albni 3 <.1 (<.1.14).29 (.15.48) <.1 ( <.1) <.1 (<.1 <.1) <.1 (<.1.15).32 (.18.51) Algeri (2. 4.5) 7.6 (4.9 11).37 (.18.62) <.1 (<.1.15) 3.2 ( ) 7.7 (5. 11) Americn Smo < 1 ( <.1).85 ( ) ( ) ( ) ( <.1).85( ) Andorr < 1 ( ) ( ) ( ) ( ) ( ) ( ) Angol 3 2 (12 31) 67 (39 13) 7.8 (3.9 13) 26 (13 44) 28 (18 39) 93 (61 132) Anguill < 1 <.1 (<.1 <.1) 8.4 (4.8 13) ( ) ( ) <.1(<.1 <.1) 8.4(4.8 13) Antigu nd Brbud < 1 ( ) ( ) ( ) ( ) ( ) ( ) Argentin (.62.66) 1.4 ( ).27 (.14.43).6 (.32.97).91 ( ) 2 ( ) Armeni 3.36 (.35.36) 1.2 ( ).16 (.11.21).54 (.38.72).52 (.47.57) 1.8 ( ) Arub < 1 <.1 ( <.1).72 ( ) ( ) ( ) <.1( <.1).72 ( ) Austrli (.53.53).22 (.22.22) <.1 (<.1 <.1) <.1 (<.1 <.1).59 (.56.61).24 (.23.25) Austri 9.38 (.38.39).44 (.43.44) <.1 (<.1 <.1) <.1 (<.1 <.1).43 (.4.45).49 (.46.52) Azerbijn 1.86 (.81.9) 8.7 ( ).23 (.17.31).24 (.17.31).88 (.83.93) 8.9 ( ) Bhms < 1 ( <.1).11 (<.1.14) <.1 (<.1 <.1).96 ( ) <.1 (<.1 <.1) 1.1 ( ) Bhrin 1 <.1 (<.1 <.1).51 (.48.54) <.1 (<.1 <.1) <.1 (<.1.12) <.1 (<.1.1).6 (.56.65) Bngldesh (38 85) 36 (23 52).17 (.85.29).11 (<.1.18) 6 (39 85) 36 (23 52) Brbdos < 1 <.1 (<.1 <.1).91 (.79 1.) ( ) ( ) <.1(<.1 <.1).91(.79 1.) Belrus 9.76 (.44.12).81 ( ).58 (.42.76).61 (.44.8).13 (.97.18) 1.4 (1. 1.9) Belgium (.59.63).54 (.52.55).13 (<.1.19).12 (<.1.17).75 (.69.81).65 (.61.71) Belize < 1.1 (<.1.1) 2.6 ( ) <.1 (<.1 <.1) 1.3 ( ).15 (.13.17) 3.9 ( ) Benin ( ) 1 (6. 15).38 (.24.55) 3.4 ( ) 1.5 (1. 2.1) 14 (9.1 19) Bermud < 1 ( ).31 (.19.46) ( ) ( ) ( ).31 (.19.46) Bhutn < 1.12 (.76.17) 15 (9.4 21) <.1 (<.1 <.1).16 (.11.22).12 (.77.17) 15 (9.5 21) Bolivi (Plurintionl Stte of) ( ) 9.8 (7. 13).19 (.12.27) 1.7 ( ) 1.3 ( ) 12 (8.6 15) Bonire, Sint Eusttius nd Sb < 1 ( ).25 (.15.37) ( ) ( ) ( ).25 (.15.37) Bosni nd Herzegovin 4.13 (.12.14) 3.7 (3.4 4.) ( ) <.1 ( <.1).13 (.12.14) 3.7 (3.4 4.) Botswn 2.44 (.29.62) 19 (12 27).8 (.59 1.) 35 (26 45) 1.2 ( ) 54 (42 67) Brzil ( ) 2.4 ( ) 1.9 ( ).91 ( ) 7 ( ) 3.3 ( ) British Virgin Islnds < 1 ( ) ( ) ( ) ( ) ( ) ( ) Brunei Drusslm < 1.21 (.2.21) 4.8 (4.7 5.) ( ) ( <.1).21(.2.21) 4.8(4.7 5.) Bulgri 7.91 (.89.93) 1.3 ( ) ( ) ( <.1).91(.89.93) 1.3 ( ) Burkin Fso ( ) 8.7 (5.2 13).31 (.2.45) 1.6 (1. 2.3) 2 ( ) 1 (6.7 15) Burundi 11 2 (1.2 3.) 18 (11 27).47 (.3.69) 4.4 ( ) 2.4 ( ) 23 (15 32) Cbo Verde < 1.22 (.2.24) 4 ( ).44 (.27.65) 8 (4.9 12).66 (.48.86) 12 (8.7 16) Cmbodi (2. 4.3) 19 (13 27).41 (.27.57) 2.6 ( ) 3.5 ( ) 22 (15 3) Cmeroon (4.2 11) 3 (17 45) 6( ) 25(16 36) 13(9.3 18) 55 (39 73) Cnd (.11.11).3 (.3.3).25 (.16.35) <.1 (<.1.1).13 (.13.14).37 (.34.39) Cymn Islnds < 1 ( ) ( ) ( ) ( ) ( ) ( ) Centrl Africn Republic ( ) 68 (38 15) 2.7 ( ) 58 (31 94) 5.9 ( ) 126 (84 176) Chd ( ) 28 (16 42) 1.9 ( ) 13 (8.2 19) 6.1 ( ) 41 (28 56) Chile (.41.44) 2.4 ( ).79 (.4.13).44 (.22.73).51 (.46.55) 2.8 ( ) Chin (33 41) 2.6 ( ) 1.8 ( ).13 (<.1.22) 39 (35 43) 2.7 (2.5 3.) Chin, Hong Kong SAR 7.16 (.16.17) 2.2 ( ) <.1 (<.1.11).11 (<.1.14).17 (.17.18) 2.3 ( ) Chin, Mco SAR < 1.36 (.22.53) 5.7 ( ) ( ) <.1 (<.1 <.1).36 (.22.53) 5.8 ( ) Colombi ( ) 2.6 (2.3 3.).43 (.32.57).88 ( ) 1.7(1.5 2.) 3.5(3.1 4.) Comoros < 1.53 (.32.8) 6.5 ( ) <.1 (<.1 <.1).42 (.26.6).57 (.35.84) 6.9 (4.3 1) Congo ( ) 63 (36 98) 2.3 ( ) 43 (22 71) 5.6 ( ) 16 (7 149) Cook Islnds < 1 ( ) ( ) ( ) ( ) Cost Ric 5.42 (.38.46).86 (.77.94) <.1 (<.1.12).18 (.13.24).51 (.46.56) 1 ( ) Côte d'ivoire ( ) 23 (14 35) 2.6 ( ) 11 (6.8 16) 8.3 (5.7 11) 34 (23 47) Croti 4.41 (.4.41).97 (.97.98) <.1 (<.1 <.1) <.1 (<.1 <.1).42 (.41.43) 1 (.98 1.) Cub (.48.49).42 (.42.42).12 (<.1.17).1 (<.1.14).6 (.56.65).52 (.49.56) Curço < 1 <.1 (<.1 <.1).53 (.32.78) ( ) ( ) <.1(<.1 <.1).53(.33.78) Cyprus 1 <.1 (<.1 <.1).26 (.2.33) ( <.1) <.1 (<.1 <.1) <.1 (<.1 <.1).29 (.23.37) Czechi (.42.43).4 (.4.4) <.1 (<.1 <.1) <.1 (<.1 <.1).44 (.43.45).41 (.41.42) Democrtic People's Republic of Kore Mortlity (HIV-negtive people) Mortlity (HIV-positive people) Mortlity (HIV-negtive nd HIV-positive people) b (11 22) 63 (43 86).44 (.22.72).17 (<.1.28) 16 (11 22) 63 (43 86) Democrtic Republic of the Congo (29 74) 6 (35 9) 7.5 (3.5 13) 9.2 (4.3 16) 56 (35 81) 69 (44 ) Denmrk 6.18 (.17.18).31 (.29.32) <.1 (<.1 <.1) <.1 (<.1 <.1).19 (.18.2).33 (.31.35) Djibouti < 1.27 (.17.39) 28 (18 4).27 (.2.35) 2.8 (2. 3.7).3 (.2.41) 31 (21 43) Dominic < 1 ( ).6 (.56.64) ( ) ( ) ( ).6 (.56.64) Dominicn Republic 11.3 (.15.) 2.8 ( ).25 (.18.33) 2.3 ( ).55 (.37.76) 5.1 ( ) Rte Dt for ll countries nd yers cn be downloded from 249

261 TABLE A4.2 Estimtes of TB mortlity, 217. Deths from TB mong HIV-positive people re officilly clssified s deths cused by HIV/AIDS in the Interntionl clssifiction of diseses. b Popultion (millions) Rtes re per popultion. All clcultions re mde before numbers re rounded. 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 (.37.61) 2.9 ( ).2 (.14.27) 1.2 ( ).68 (.55.82) 4.1 ( ) Egypt (.37.46).42 (.38.47).13 (<.1.21) <.1 (<.1 <.1).43 (.38.47).44 (.39.48) El Slvdor 6.79 (.63.98) 1.2 ( ).44 (.3.6).69 (.48.94).12 (.1.15) 1.9 ( ) Equtoril Guine 1.28 (.2.38) 22 (16 3).34 (.26.43) 27 (21 34).62 (.51.75) 49 (4 59) Eritre 5.61 ( ) 12 (5.4 21).51 (.24.87) 1 ( ).66 ( ) 13 (6.3 22) Estoni 1.12 (.12.12).93 (.91.95) <.1 (<.1 <.1).21 (.15.28).15 (.14.16) 1.1 ( ) Eswtini 1.14 (.9.21) 1 (6.6 15).6 (.43.81) 44 (31 59).75 (.56.96) 55 (41 7) Ethiopi (16 37) 24 (15 35) 3.6 (2.5 5.) 3.5 ( ) 29 (19 4) 28 (19 38) Fiji < 1.37 (.36.38) 4.1 (4. 4.2) <.1 (<.1 <.1).26 (.18.36).39 (.38.4) 4.4 ( ) Finlnd 6.26 (.26.26).47 (.47.48) <.1 (<.1 <.1) <.1 (<.1 <.1).27 (.27.28).5 (.48.51) Frnce (.33.38).55 (.51.58).14 (.72.22).21 (.11.34).49(.42.57).76(.64.88) French Polynesi < 1 <.1 (<.1 <.1) 1.7 ( ) ( ) ( ) <.1(<.1 <.1) 1.7( ) Gbon 2 2 (1.2 3.) 98 (58 1).98 ( ) 48 (3 71) 3(2. 4.1) 147 (11 22) Gmbi 2.47 (.31.65) 22 (15 31).21 (.15.28) 1 (7.3 13).68 (..87) 32 (24 42) Georgi 4.21 (.16.27) 5.3 ( ).13 (.1.17).34 (.25.44).22 (.17.28) 5.7 ( ) Germny (.32.33).39 (.39.4).54 (.26.92) <.1 (<.1.11).38 (.34.41).46 (.42.) Ghn 29 1 (4.6 18) 36 (16 63) 5.2 (2.5 9.) 18 (8.5 31) 16 (8.9 24) 54 (31 83) Greece (.43.46).4 (.39.41) <.1 (<.1 <.1) <.1 (<.1 <.1).49 (.46.52).44 (.41.47) Greenlnd < 1 <.1 (<.1 <.1) 9.5 (5.8 14) ( ) ( ) <.1(<.1 <.1) 9.5(5.8 14) Grend < 1 ( ) ( ) ( ).16(.11.23) ( ).16 (.11.23) Gum < 1 <.1 (<.1.12) 4.8 (3. 7.2) ( ).11 (<.1.16) <.1 (<.1.12) 4.9 ( ) Guteml 17.3 (.29.32) 1.8 ( ).69 (..91).41 (.29.54).37 (.34.4) 2.2 (2. 2.4) Guine ( ) 24 (14 37) 1.9 ( ) 15 (9.6 22) 5( ) 39 (28 53) Guine-Bissu ( ) 77 (44 118) 1.2 ( ) 66(4 99) 2.7( ) 143( 194) Guyn < 1.14 (.13.15) 18 (17 2).39 (.28.51) 5( ).18(.17.2) 23(21 25) Hiti ( ) 12 (8.3 16).71 (.51.94) 6.5 ( ) 2 ( ) 18 (14 22) Hondurs 9.41 (.31.53) 4.5 ( ).5 (.35.68).54 (.38.73).46 (.36.58) 5 ( ) Hungry 1.54 (.54.54).55 (.55.55) <.1 (<.1 <.1) <.1 (<.1 <.1).55 (.54.56).57 (.56.58) Icelnd < 1 ( ) ( ) ( ) ( ) ( ) ( ) Indi ( ) 31 (28 33) 11 (6.5 16).79 ( ) 421 ( ) 31 (29 34) Indonesi ( 114) 4 (38 43) 9.4 (5. 15) 3.6 ( ) 116 (18 125) 44 (41 47) Irn (Islmic Republic of) (.76.94) 1 ( ).32 (<.1.67) <.1 (<.1 <.1).88 (.79.97) 1.1 ( ) Irq ( ) 2.9 ( ) <.1 (<.1 <.1) <.1 (<.1 <.1) 1.1 ( ) 2.9 ( ) Irelnd 5.24 (.24.25).51 (.51.52) <.1 (<.1 <.1) <.1 (<.1.15).29 (.27.31).61 (.56.66) Isrel 8.15 (.15.16).18 (.18.19) <.1 (<.1 <.1) <.1 (<.1 <.1).18 (.17.18).21 (.2.22) Itly (.33.34).57 (.56.58).68 (.33.11).11 (<.1.19).41 (.37.45).68 (.62.75) Jmic 3 <.1 (<.1 <.1).28 (.26.3) <.1 (<.1.11).29 (.21.38).16 (.14.19).57 (.49.66) Jpn ( ) 2.2 ( ).13 (<.1.19) <.1 (<.1 <.1) 2.8 ( ) 2.2 ( ) Jordn 1.26 (.17.38).27 (.17.39) ( ) ( ).26(.17.38).27(.17.39) Kzkhstn (.91.25).89 (. 1.4).37 (.14.72).2 (<.1.4).2 (.12.29) 1.1 ( ) Keny 25 (14 39) (28 78) 18 (11 27) 37 (22 55) 43 (29 59) 86 (59 119) Kiribti < 1.32 (.26.38) 27 (23 33) ( <.1).4(.28.54).32 (.27.39) 28 (23 33) Kuwit 4.14 (.1.19).35 (.25.47) <.1 ( <.1) <.1(<.1 <.1).15(.11.2).36(.26.48) Kyrgyzstn 6.4 (.39.42) 6.7 ( ).73 (.56.93) 1.2 ( ).48 (.45.) 7.9 ( ) Lo People's Democrtic Republic ( ) 37 (22 56).3 (.19.43) 4.3 ( ) 2.8 ( ) 41 (26 6) Ltvi 2.62 (.61.62) 3.2 ( ).1 (<.1.13).52 (.38.69).72 (.69.75) 3.7 ( ) Lebnon 6.58 (.36.86).95 ( ) <.1 (<.1 <.1) <.1 (<.1 <.1).59 (.36.87).97 (.6 1.4) Lesotho 2 1 ( ) 46 (25 75) 4.6 ( ) 26 (128 32) 5.6 ( ) 252 ( ) Liberi ( ) 57 (34 86).91 ( ) 19 (12 28) 3.6 (2.4 5.) 76 (51 16) Liby 6.54 (.31.82) 8.4 (4.9 13).26 (.16.38).4 (.25.6).56 (.33.85) 8.8 (5.2 13) Lithuni 3.17 (.17.17) 5.8 ( ) <.1 (<.1.11).27 (.17.38).18 (.17.18) 6.1 (6. 6.2) Luxembourg < 1 <.1 (<.1 <.1).18 (.18.18) <.1 ( <.1) <.1 (<.1.15) <.1 (<.1 <.1).27 (.22.32) Mdgscr (7.8 2) 52 (31 79).65 ( ) 2.6 ( ) 14 (8.4 21) 54 (33 81) Mlwi 19 2 ( ) 11 (5.9 18) 3.7 ( ) 2 (11 31) 5.7 (3.8 8.) 31(2 43) Mlysi ( ) 4 ( ).3 (.22.38).93 ( ) 1.6 ( ) 4.9 ( ) Mldives < 1.16 (.15.18) 3.7 ( ) ( ) ( ).16 (.15.18) 3.7 ( ) Mli ( ) 8.6 (5.2 13).39 (.25.55) 2.1 (1.3 3.) 2 ( ) 11 (7.1 15) Mlt < 1 <.1 (<.1 <.1).46 (.46.46) ( ) <.1 (<.1 <.1) <.1 (<.1 <.1).47 (.47.48) Mrshll Islnds < 1.28 (.18.4) 53 (34 76) ( ) <.1 (<.1.13).28 (.18.4) 53 (34 76) Muritni 4.84 ( ) 19 (11 29).63 (.27.12) 1.4 (.6 2.6).9 ( ) 2 (12 3) Muritius 1.19 (.19.19) 1.5 ( ) <.1 (<.1 <.1).44 (.3.6).25 (.23.26) 1.9 ( ) Mexico (2. 2.1) 1.6 ( ).77 (.56 1.).6 (.44.78) 2.8 (2.6 3.) 2.2 (2. 2.3) Rte 2 Dt for ll countries nd yers cn be downloded from

262 TABLE A4.2 Estimtes of TB mortlity, 217. Deths from TB mong HIV-positive people re officilly clssified s deths cused by HIV/AIDS in the Interntionl clssifiction of diseses. b Popultion (millions) Rtes re per popultion. All clcultions re mde before numbers re rounded. Mortlity (HIV-negtive people) Number (thousnds) Rte Mortlity (HIV-positive people) Number (thousnds) Rte Mortlity (HIV-negtive nd HIV-positive people) b Number (thousnds) Micronesi (Federted Sttes of) < 1.19 (.12.27) 18 (11 26) <.1 (<.1 <.1).68 (.48.91).19 (.13.28) 18 (12 26) Monco < 1 ( ) ( ) ( ) ( ) Mongoli 3.33 (.3.35) 11 (9.7 11) <.1 (<.1 <.1) <.1 (<.1 <.1).33 (.3.35) 11 (9.8 12) Montenegro < 1 <.1 (<.1 <.1).2 (.18.22) ( ) ( ) <.1(<.1 <.1).2(.18.23) Montserrt < 1 ( ).57 (.57.57) ( ) ( ) ( ).57 (.57.57) Morocco ( ) 8.1 (4.9 12).65 (.31.11).18 (<.1.31) 3 ( ) 8.3 (5.1 12) Mozmbique 3 22 (13 33) 73 (43 111) 27 (17 39) 9 (56 131) 48 (34 64) 163 ( ) Mynmr (18 39) 51 (33 73) 4.9 ( ) 9.2 (6.6 12) 32 (22 44) 6 (42 82) Nmibi 3.75 ( ) 3 (19 43).8 ( ) 31 (22 43) 1.5 (1.2 2.) 61 (46 78) Nuru < 1 <.1 (<.1 <.1) 7.5 (4.6 11) ( ) ( ) <.1(<.1 <.1) 7.5(4.6 11) Nepl ( ) 23 (16 3).26 (.14.42).88 ( ) 6.9 (5. 9.2) 24 (17 31) Netherlnds 17.3 (.3.31).18 (.17.18) <.1 (<.1 <.1) <.1 (<.1 <.1).36 (.35.38).21 (.2.22) New Cledoni < 1 <.1 (<.1 <.1) 1.2 ( ) ( ) ( ) <.1(<.1 <.1) 1.2( ) New Zelnd 5.13 (.13.13).27 (.27.27) ( ) ( <.1).13(.13.13).27(.27.27) Nicrgu 6.99 (.74.13) 1.6 ( ).29 (.21.38).46 (.33.61).13 (.1.16) 2.1 ( ) Niger (2.3 6.) 18 (11 28).33 (.21.48) 1.5 ( ) 4.3 ( ) 2 (12 29) Nigeri (7 183) 63 (36 96) 35 (21 52) 18 (11 27) 155 (11 219) 81 (53 115) Niue < 1 ( ) 5.8 ( ) ( ) ( ) ( ) 5.8 ( ) Northern Mrin Islnds < 1 <.1 (<.1 <.1) 7(4.3 1) ( ) ( ) <.1(<.1 <.1) 7(4.3 1) Norwy 5.12 (.12.12).22 (.22.23) <.1 (<.1 <.1) <.1 (<.1 <.1).14 (.13.15).26 (.24.29) Omn 5.23 (.18.27).49 (.4.59) <.1 ( <.1) <.1(<.1 <.1).23(.19.28).5(.41.6) Pkistn (42 67) 27 (21 34) 2.2 ( ) 1.1 ( ) 56 (44 69) 28 (22 35) Plu < 1 <.1 (<.1 <.1) 8.7 (5.3 13) ( ) ( ) <.1(<.1 <.1) 8.7(5.3 13) Pnm 4.23 (.21.25) 5.6 (5.1 6.).83 (.59.11) 2 ( ).31 (.28.34) 7.6 ( ) Ppu New Guine (2.9 6.) 53 (36 73).93 ( ) 11 (6.2 18) 5.3 (3.8 7.) 64 (46 85) Prguy 7.27 (.21.34) 3.9 ( ).41 (.3.55).61 (.44.8).31 (.25.38) 4.5 ( ) Peru ( ) 6.8 ( ).39 (.28.51) 1.2 ( ) 2.6 ( ) 8(5.3 11) Philippines (23 31) 25 (22 29).38 ( 3.3).36 ( 3.1) 27 (23 31) 26 (22 29) Polnd (.43.47) 1.2 ( ).25 (.12.43) <.1 (<.1.11).48 (.45.) 1.3 ( ) Portugl 1.21 (.2.22) 2 (2. 2.1).38 (.25.54).37 (.24.52).25 (.23.26) 2.4 ( ) Puerto Rico 4 <.1 (<.1 <.1).17 (.17.17) <.1 (<.1 <.1) <.1 (<.1 <.1) <.1 (<.1 <.1).21 (.19.22) Qtr 3 <.1 (<.1.12).33 (.21.47) ( ) ( ) <.1(<.1.12).33(.21.47) Republic of Kore ( ) 4.9 ( ).67 (.27.12).13 (<.1.24) 2.5 ( ) 5( ) Republic of Moldov 4.25 (.22.28) 6.1 (5.4 7.).55(.41.71) 1.4(1. 1.8).3(.27.34) 7.5( ) Romni 2.92 (.91.92) 4.7 ( ).49 (.36.65).25 (.18.33).97 (.95.98) 4.9 (4.8 5.) Russin Federtion (9.4 12) 7.3 (6.6 8.) 1.7 ( ) 1.2 ( ) 12 (11 14) 8.4 ( ) Rwnd 12.6 (.39.87) 4.9 ( ).32 (.22.42) 2.6 ( ).92( ) 7.5( ) Sint Kitts nd Nevis < 1 ( ) <.1 (<.1 <.1) ( ) ( ) ( ) <.1 (<.1 <.1) Sint Luci < 1 <.1 (<.1 <.1) 1.9 (1.9 2.) ( ) ( ) <.1(<.1 <.1) 1.9(1.9 2.) Sint Vincent nd the Grendines < 1 <.1 (<.1 <.1) 1.9 ( ) ( ) ( ) <.1(<.1 <.1) 1.9( ) Smo < 1 <.1 (<.1 <.1) 1.4 ( ) ( ) ( ) <.1(<.1 <.1) 1.4( ) Sn Mrino < 1 ( ) ( ) ( ) ( ) ( ) ( ) So Tome nd Principe < 1.41 (.16.78) 2 (8. 38).14 (<.1.25) 6.6 (2.8 12).55 (.27.92) 27 (13 45) Sudi Arbi 33 1 ( ) 3.2 ( ).2 (.14.26) <.1 (<.1 <.1) 1.1 ( ) 3.2 ( ) Senegl ( ) 18 (11 26).34 (.24.47) 2.2 (1.5 3.) 3.2 ( ) 2 (13 28) Serbi 9.66 (.62.71).75 (.71.8) <.1 (<.1 <.1) <.1 (<.1 <.1).68 (.63.72).77 (.72.82) Seychelles < 1 ( ).28 (.21.36) ( ) ( ) ( ).28 (.21.36) Sierr Leone 8 3 ( ) 39 (23 59).78 ( ) 1 (6.5 15) 3.7 ( ) (33 7) Singpore 6.51 (.38.66).89 ( ) <.1 (<.1 <.1).11 (<.1.15).57 (.43.72).99 ( ) Sint Mrten (Dutch prt) < 1 ( <.1) 1.2 ( ) ( ) ( ) ( <.1) 1.2( ) Slovki 5.35 (.34.35).64 (.63.65) ( ) ( ).35(.35.35).64 (.63.65) Sloveni 2.12 (.12.12).59 (.58.59) ( ) <.1 ( <.1).12 (.12.13).6 (.59.6) Solomon Islnds < 1.51 (.33.74) 8.4 (5.4 12) ( ) ( ).51(.33.74) 8.4(5.4 12) Somli 15 1 (5.9 15) 69 (4 15).2 (.13.3) 1.4 (.86 2.) 1 (6.1 16) 7 (42 16) South Afric (2 24) 39 (35 43) 56 (39 77) 99 (68 135) 78 (6 98) 138 (16 174) South Sudn (2. 5.1) 27 (16 4).87 ( ) 6.9 (4.4 1) 4.2 ( ) 33 (22 47) Spin (.25.25).54 (.53.54).52 (.34.74).11 (<.1.16).3 (.28.32).65 (.61.7) Sri Lnk (.48.88) 3.2 ( ).16 (.11.22) <.1 (<.1.11).68 (.49.9) 3.2 ( ) Sudn 41 5 ( ) 12 (7.7 18).23 (.81.45).56 (.2 1.1) 5.3 ( ) 13 (8.3 19) Surinme < 1.15 (.13.18) 2.7 ( ) <.1 (<.1 <.1) 1( ).21(.18.24) 3.7( ) Sweden 1.26 (.26.27).26 (.26.27) <.1 (<.1 <.1) <.1 (<.1 <.1).3 (.28.32).3 (.28.33) Switzerlnd 8.17 (.17.17).2 (.2.21) <.1 (<.1.14).1 (<.1.17).26 (.21.31).3 (.24.36) Rte Dt for ll countries nd yers cn be downloded from 251

263 TABLE A4.2 Estimtes of TB mortlity, 217. 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 (.39.56).26 (.21.31) <.1 (<.1 <.1) <.1 (<.1 <.1).49 (.41.58).27 (.22.32) Tjikistn 9.46 (.35.6) 5.2 ( ).64 (.47.84).72 (.53.94).53 (.41.66) 5.9 ( ) Thilnd (7. 12) 13 (1 17) 2.9 ( ) 4.2 ( ) 12 (9.7 15) 18 (14 22) The Former Yugoslv Republic of Mcedoni 2.2 (.2.21).98 (.94 1.) ( ) ( ).2 (.2.21).98 (.95 1.) Timor-Leste ( ) 16 (63 161) <.1 (.19).46 (<.1 1.5) 1.4 ( ) 17 (63 161) Togo 8.28 (.19.4) 3.6 ( ).12 (.85.16) 1.5 (1.1 2.).4 (.3.52) 5.2 ( ) Tokelu < 1 ( ) ( ) ( ) ( ) Tong < 1 <.1 (<.1 <.1).96 ( ) ( ) ( ) <.1(<.1 <.1).96( ) Trinidd nd Tobgo 1.22 (.2.25) 1.6 ( ) <.1 (<.1 <.1).39 (.29.51).28 (.25.31) 2 ( ) Tunisi (.24.45) 2.9 ( ) <.1 (<.1 <.1) <.1 (<.1 <.1).34 (.24.46) 2.9 (2.1 4.) Turkey (.37.46).51 (.45.57).17 (.13.23) <.1 (<.1 <.1).43 (.38.48).53 (.48.59) Turkmenistn 6.57 (..65) 9.9 (8.6 11).27 (.12.49).47 (.2.85).6 (.52.68) 1 (9. 12) Turks nd Cicos Islnds < 1 ( ).25 (.15.37) ( ).47 (.31.66) ( ).72 (.52.94) Tuvlu < 1 <.1 (<.1 <.1) 19 (12 29) ( ) ( ) <.1(<.1 <.1) 19(12 29) Ugnd (6.1 18) 26 (14 42) 14 (7.9 21) 32 (18 49) 25 (17 34) 58 (39 8) Ukrine ( ) 8.7 ( ) 2.1 (1.4 3.) 4.7 ( ) 5.9 ( ) 13 (12 15) United Arb Emirtes 9.65 (.38.1).69 (.4 1.1) <.1 (<.1 <.1) <.1 (<.1 <.1).66 (.39.1).71 ( ) United Kingdom of Gret Britin nd Northern Irelnd (.35.35).53 (.52.53).57 (.27.98) <.1 (<.1.15).41 (.37.44).61 (.56.67) United Republic of Tnzni (12 48) 47 (21 83) 22 (1 38) 39 (18 67) 49 (29 74) 86 ( 13) United Sttes of Americ (.52.53).16 (.16.16).84 (.55.12) <.1 (<.1 <.1).61 (.58.64).19 (.18.2) Uruguy 3.82 (.78.86) 2.4 ( ).28 (.21.36).81 (.6 1.).11 (.1.12) 3.2 ( ) Uzbekistn ( ) 5.4 ( ).3 (.2.42).95 ( ) 2 ( ) 6.3 ( ) Vnutu < 1.24 (.16.34) 8.7 (5.8 12) ( ) <.1(<.1 <.1).24 (.16.34) 8.7 (5.8 12) Venezuel (Bolivrin Republic of) 32.8 (.75.84) 2.5 ( ).26 (.19.35).82 ( ) 1.1 ( ) 3.3 (3. 3.6) Viet Nm (7.5 17) 12 (7.8 17).84 ( ).88 ( ) 12 (8.3 18) 13 (8.6 18) Wllis nd Futun Islnds < 1 ( ) <.1 ( <.1) ( ) ( ) ( ) <.1 ( <.1) West Bnk nd Gz Strip 5 <.1 (<.1 <.1).11 (<.1.15) ( ) ( ) <.1(<.1 <.1).11(<.1.15) Yemen ( ) 6.8 ( ).27 (<.1.56).1 (<.1.2) 2 ( ) 6.9 ( ) Zmbi 17 5 ( ) 3 (17 45) 13 (8.2 19) 76 (48 11) 18 (13 24) 16 (74 143) Zimbbwe 17 2 ( ) 12 (7.7 17) 6.3 ( ) 38 (27 51) 8.3 (6.3 11) (38 64) WHO regions Africn Region ( ) 39 (33 46) 252 ( ) 24 (21 27) 666 ( ) 64 (56 71) Region of the Americs (17 19) 1.8 ( ) 6 ( ).6 (.53.67) 24 (23 25) 2.4 ( ) Estern Mediterrnen Region (75 14) 13 (11 15) 3 ( ).43 (.26.66) 92 (78 17) 13 (11 16) Europen Region (23 25) 2.6 ( ) 5 ( ).54 (.41.69) 29 (27 3) 3.1 ( ) South-Est Asi Region ( ) 32 (3 35) 28 (22 36) 1.4 ( ) 667 (626 78) 34 (32 36) Western Pcific Region (85 ) 4.9 ( ) 5 ( ).26 (.2.34) 97 (9 15) 5.1 ( ) Globl ( ) 17 (16 18) 3 ( ) 4 ( ) 1 57 ( ) 21 (2 22) Rte b Rtes re per popultion. All clcultions re mde before numbers re rounded. 252 Dt for ll countries nd yers cn be downloded from

264 TABLE A4.3 Mesured percentge of TB cses with MDR/RR-TB, most recent yer vilble New TB cses Previously treted TB cses Afghnistn Yer Source Coverge Percentge Yer Source Coverge Percentge Albni 212 Surveillnce Ntionl 2.3 ( ) 212 Surveillnce Ntionl 6.7 (.17 32) Algeri Americn Smo Andorr 217 Surveillnce Ntionl ( 98) 217 Surveillnce Ntionl 12 (8. 17) Angol Anguill Antigu nd Brbud Argentin 25 Survey Ntionl 2.3 ( ) 25 Survey Ntionl 18 (12 26) Armeni 217 Surveillnce Ntionl 16 (12 2) 217 Surveillnce Ntionl 44 (35 54) Arub Austrli 217 Surveillnce Ntionl 1.9 (1. 3.2) 217 Surveillnce Ntionl 23 (9. 44) Austri 215 Surveillnce Ntionl 2.3 ( ) 216 Surveillnce Ntionl 18 (3.8 43) Azerbijn 217 Surveillnce Ntionl 12 (11 14) 217 Surveillnce Ntionl 28 (27 3) Bhms 217 Surveillnce Ntionl ( 21) 217 Surveillnce Ntionl 13 (8.4 18) Bhrin 217 Surveillnce Ntionl 1.3 (<.1 6.8) 216 Surveillnce Ntionl 21 (15 27) Bngldesh 211 Survey Ntionl 1.6 ( ) 211 Survey Ntionl 29 (24 35) Brbdos 214 Surveillnce Ntionl ( 71) 214 Surveillnce Ntionl 13 (8.4 18) Belrus 217 Surveillnce Ntionl 38 (36 41) 217 Surveillnce Ntionl 67 (63 7) Belgium 215 Surveillnce Ntionl 1.6 ( ) 215 Surveillnce Ntionl 8.8 (1.9 24) Belize 213 Surveillnce Ntionl (29 ) Benin 21 Survey Ntionl 1.2 (.21 3.) 217 Surveillnce Ntionl 5.4 (3. 8.9) Bermud 217 Surveillnce Ntionl ( 98) 217 Surveillnce Ntionl 13 (8.4 18) Bhutn 217 Surveillnce Ntionl 13 (1 17) 217 Surveillnce Ntionl 33 (7.5 7) Bolivi (Plurintionl Stte of) 216 Surveillnce Ntionl 9.6 (7.2 12) Bonire, Sint Eusttius nd Sb 216 Surveillnce Ntionl ( 98) 216 Surveillnce Ntionl 13 (8.4 18) Bosni nd Herzegovin 217 Surveillnce Ntionl (.97) 217 Surveillnce Ntionl ( 8.2) Botswn 28 Survey Ntionl 3.6 ( ) 28 Survey Ntionl 13 (7.9 2) Brzil 28 Survey Sub-ntionl 1.5 (1.1 2.) 28 Survey Sub-ntionl 8 (6. 1) British Virgin Islnds Brunei Drusslm 217 Surveillnce Ntionl ( 2.1) 217 Surveillnce Ntionl ( 34) Bulgri 216 Surveillnce Ntionl 1.2 ( ) 216 Surveillnce Ntionl 19 (11 29) Burkin Fso 217 Survey Ntionl 2.1 (1.2 3.) 217 Survey Ntionl 14 (8.5 2) Burundi 217 Surveillnce Ntionl 16 (12 2) Cbo Verde Cmbodi 27 Survey Ntionl 1.8 (.9 3.) 27 Survey Ntionl 11 (3.2 22) Cmeroon Cnd 215 Surveillnce Ntionl.82 ( ) 215 Surveillnce Ntionl 6.3 (1.7 15) Cymn Islnds 217 Surveillnce Ntionl ( 71) 217 Surveillnce Ntionl 13 (8.4 18) Centrl Africn Republic 29 Survey Sub-ntionl.4 ( 2.2) Chd Chile 217 Surveillnce Ntionl 2 ( ) 217 Surveillnce Ntionl 5.9 (2.2 12) Chin 213 Survey Ntionl 7.1 ( ) 213 Survey Ntionl 24 (2 28) Chin, Hong Kong SAR 217 Surveillnce Ntionl.88 ( ) 217 Surveillnce Ntionl 4.6 ( ) Chin, Mco SAR 215 Surveillnce Ntionl 2.5 ( ) 217 Surveillnce Ntionl ( 14) Colombi 25 Survey Ntionl 2.4 ( ) 212 Surveillnce Ntionl 14 (11 18) Comoros Congo 217 Surveillnce Ntionl 21 (16 27) Cook Islnds 216 Surveillnce Ntionl ( 85) 216 Surveillnce Ntionl 12 (7.2 19) Cost Ric 217 Surveillnce Ntionl 1.4 ( ) 217 Surveillnce Ntionl ( 52) Côte d'ivoire 217 Survey Ntionl 4.6 ( ) 217 Surveillnce Ntionl 24 (22 27) Croti 215 Surveillnce Ntionl ( 1.4) 215 Surveillnce Ntionl ( 16) Cub 212 Surveillnce Ntionl 2.2 ( ) 214 Surveillnce Ntionl 4.2 (.51 14) Curço 217 Surveillnce Ntionl ( 37) 217 Surveillnce Ntionl 13 (8.4 18) Cyprus 215 Surveillnce Ntionl ( 1) 215 Surveillnce Ntionl 12 (8. 17) Czechi 215 Surveillnce Ntionl 2.2 (.9 4.6) 215 Surveillnce Ntionl 12 (2.4 3) Democrtic People's Republic of Kore 214 Survey Sub-ntionl 2.2 ( ) 214 Survey Sub-ntionl 16 (9.1 25) Democrtic Republic of the Congo 217 Survey Ntionl 2.2 (1. 3.5) 217 Surveillnce Ntionl 9.5 (8.8 1) Denmrk 217 Surveillnce Ntionl.65 (<.1 3.5) 217 Surveillnce Ntionl ( 21) Djibouti 215 Survey Ntionl 4.3 ( ) 215 Survey Ntionl 35 (25 47) Dominic 213 Surveillnce Ntionl ( 98) 213 Surveillnce Ntionl 13 (8.4 18) Dominicn Republic 216 Surveillnce Ntionl 34 (28 41) Ecudor 22 Survey Ntionl 7.3 ( ) 212 Surveillnce Ntionl 28 (25 31) Egypt 211 Survey Ntionl 14 (12 17) 217 Surveillnce Ntionl 3 (25 35) Empty rows indicte n bsence of high-qulity survey or surveillnce dt. In the bsence of high-qulity ntionl dt, high-qulity sub-ntionl dt re used. Dt for ll countries nd yers cn be downloded from 253

265 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 El Slvdor 214 Surveillnce Ntionl 4.1 ( ) Equtoril Guine 216 Surveillnce Ntionl 29 (21 39) Eritre 218 Survey Ntionl 2.2 ( ) 218 Survey Ntionl 7.4 (2.1 18) Estoni 217 Surveillnce Ntionl 21 (14 29) 217 Surveillnce Ntionl 52 (3 74) Eswtini 218 Survey Ntionl 6.8 ( ) 218 Survey Ntionl 16 (11 21) Ethiopi 25 Survey Ntionl 2.7 ( ) 25 Survey Ntionl 14 (6.7 25) Fiji 217 Surveillnce Ntionl ( 2.6) 217 Surveillnce Ntionl 33 (.84 91) Finlnd 217 Surveillnce Ntionl 3 ( ) 217 Surveillnce Ntionl 67 (9.4 99) Frnce 214 Surveillnce Ntionl 1 ( ) 214 Surveillnce Ntionl 1 (7.1 15) French Polynesi 217 Surveillnce Ntionl 3.3 (<.1 17) 217 Surveillnce Ntionl 14 (.36 58) Gbon Gmbi Georgi 217 Surveillnce Ntionl 11 (9.7 13) 217 Surveillnce Ntionl 3 (26 34) Germny 215 Surveillnce Ntionl 2.2 ( ) 215 Surveillnce Ntionl 23 (16 3) Ghn 217 Survey Ntionl 1.5 (.7 2.3) 217 Surveillnce Ntionl 17 (14 2) Greece 21 Surveillnce Ntionl 1.5 (<.1 8.) 21 Surveillnce Ntionl 9.1 (.23 41) Greenlnd Grend Gum 217 Surveillnce Ntionl 3.6 (.44 12) 217 Surveillnce Ntionl (2. ) Guteml Guine Guine-Bissu Guyn 217 Surveillnce Ntionl 2.5 ( ) 217 Surveillnce Ntionl 12 (5.8 22) Hiti Hondurs 24 Survey Ntionl 2.2 (.93 4.) 217 Surveillnce Ntionl 4 ( ) Hungry 21 Surveillnce Ntionl 2.9 ( ) 21 Surveillnce Ntionl 8.1 (3.3 16) Icelnd 217 Surveillnce Ntionl ( 41) 217 Surveillnce Ntionl ( 98) Indi 216 Survey Ntionl 2.8 (2. 3.5) 216 Survey Ntionl 12 (1 13) Indonesi 218 Survey Ntionl 2.4 ( ) 218 Survey Ntionl 13 (9. 18) Irn (Islmic Republic of) 214 Survey Ntionl 1.3 ( ) 216 Surveillnce Ntionl 8.3 (5.9 11) Irq 213 Survey Ntionl 6.1 (4.5 8.) 217 Surveillnce Ntionl 3 (25 35) Irelnd 215 Surveillnce Ntionl 1.1 (<.1 5.8) 215 Surveillnce Ntionl ( 31) Isrel 217 Surveillnce Ntionl 5.4 (2.2 11) 217 Surveillnce Ntionl (1.3 99) 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 13 (8.4 18) Jpn Jordn 29 Surveillnce Ntionl 6.3 (2.4 13) 29 Surveillnce Ntionl 29 (3.7 71) Kzkhstn 215 Surveillnce Ntionl 26 (25 28) 215 Surveillnce Ntionl 44 (42 46) Keny 214 Survey Ntionl 1.3 (.74 2.) 217 Surveillnce Ntionl 4.4 ( ) Kiribti Kuwit 217 Surveillnce Ntionl 1.6 ( ) 217 Surveillnce Ntionl 21 (15 27) Kyrgyzstn 217 Surveillnce Ntionl 26 (24 27) 217 Surveillnce Ntionl 61 (58 64) Lo People's Democrtic Republic 218 Survey Ntionl 1.2 (. 2.) 218 Survey Ntionl 4.1 ( 9.6) Ltvi 217 Surveillnce Ntionl 8 (5.4 11) 217 Surveillnce Ntionl 31 (19 44) Lebnon 217 Surveillnce Ntionl 1.7 (.57 4.) 217 Surveillnce Ntionl 2 (. 72) Lesotho 214 Survey Ntionl 4.8 (3.7 6.) 214 Survey Ntionl 14 (9.5 18) Liberi Liby Lithuni 217 Surveillnce Ntionl 14 (12 16) 217 Surveillnce Ntionl 54 (48 6) Luxembourg 214 Surveillnce Ntionl 2.7 ( ) 214 Surveillnce Ntionl 12 (8. 17) Mdgscr 27 Survey Ntionl.49 (<.1 1.2) 27 Survey Ntionl 5.9 (.59 17) Mlwi 211 Survey Ntionl.75 ( ) 211 Survey Ntionl 6.4 (4. 9.2) Mlysi 214 Surveillnce Ntionl 1.5 ( ) 214 Surveillnce Ntionl 3.1 ( ) Mldives 216 Surveillnce Ntionl 1.7 (<.1 9.1) 216 Surveillnce Ntionl 18 (11 26) Mli Mlt 217 Surveillnce Ntionl ( 15) 217 Surveillnce Ntionl 12 (8. 17) Mrshll Islnds 217 Surveillnce Ntionl ( 5.4) 217 Surveillnce Ntionl ( 6) Muritni Muritius 217 Surveillnce Ntionl 1.9 ( ) 217 Surveillnce Ntionl ( 52) Mexico 29 Survey Ntionl 2.6 (2.3 3.) 29 Survey Ntionl 11 (9.2 13) Micronesi (Federted Sttes of) Monco Mongoli 216 Survey Ntionl 5.5 ( ) 217 Surveillnce Ntionl 11 (8.2 14) Montenegro 217 Surveillnce Ntionl ( 7.3) 217 Surveillnce Ntionl 11 (.28 48) 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. 254 Dt for ll countries nd yers cn be downloded from

266 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 Montserrt Morocco 214 Survey Ntionl 1 ( ) 216 Surveillnce Ntionl 11 (9.5 12) Mozmbique 27 Survey Ntionl 3.7 ( ) 27 Survey Ntionl 2 (5.2 4) Mynmr 213 Survey Ntionl 5.1 ( ) 213 Survey Ntionl 27 (16 4) Nmibi 215 Survey Ntionl 5 ( ) 215 Survey Ntionl 12 (9.4 14) Nuru Nepl 211 Survey Ntionl 2.2 ( ) 211 Survey Ntionl 15 (9.6 22) Netherlnds 217 Surveillnce Ntionl 1.8 ( ) 217 Surveillnce Ntionl 7.1 (.18 34) New Cledoni 217 Surveillnce Ntionl 4 (.1 2) 216 Surveillnce Ntionl ( 98) New Zelnd 214 Surveillnce Ntionl 2.6 (.7 6.4) 214 Surveillnce Ntionl 2 (. 72) Nicrgu 26 Survey Ntionl.94 (<.1 2.7) 21 Surveillnce Ntionl 12 (7.3 18) Niger 217 Surveillnce Ntionl 14 (11 17) Nigeri 21 Survey Ntionl 4.3 ( ) 21 Survey Ntionl 25 (19 31) Niue Northern Mrin Islnds 217 Surveillnce Ntionl ( 15) 217 Surveillnce Ntionl 12 (7.2 19) Norwy 217 Surveillnce Ntionl 4.5 ( ) 217 Surveillnce Ntionl ( 34) Omn 217 Surveillnce Ntionl ( 1.9) 217 Surveillnce Ntionl ( 6) Pkistn 213 Survey Ntionl 4.2 ( ) 215 Surveillnce Ntionl 16 (15 17) Plu 217 Surveillnce Ntionl ( 18) 217 Surveillnce Ntionl 12 (7.2 19) Pnm 216 Surveillnce Ntionl 17 (8.9 29) Ppu New Guine 214 Survey Sub-ntionl 3.4 (1.7 5.) 214 Survey Sub-ntionl 26 (15 36) Prguy 28 Survey Ntionl.9 (<.1 2.7) 28 Survey Ntionl 15 (5.6 27) Peru 216 Surveillnce Ntionl 6.3 ( ) 217 Surveillnce Ntionl 2 (19 22) Philippines 212 Survey Ntionl 2.6 ( ) 217 Surveillnce Ntionl 28 (27 28) Polnd 217 Surveillnce Ntionl 1.1 ( ) 217 Surveillnce Ntionl 3.9 ( ) Portugl 212 Surveillnce Ntionl.98 ( ) 212 Surveillnce Ntionl 6.9 (2.8 14) Puerto Rico 217 Surveillnce Ntionl ( 12) 217 Surveillnce Ntionl ( 98) Qtr 217 Surveillnce Ntionl 1.5 ( ) 217 Surveillnce Ntionl 21 (15 27) Republic of Kore 217 Surveillnce Ntionl 3.2 (3. 3.6) 217 Surveillnce Ntionl 1 (9. 11) Republic of Moldov 217 Surveillnce Ntionl 28 (25 3) 217 Surveillnce Ntionl 55 (51 59) Romni 217 Surveillnce Ntionl 2.5 ( ) 217 Surveillnce Ntionl 15 (14 17) Russin Federtion 217 Surveillnce Ntionl 32 (31 33) 217 Surveillnce Ntionl 67 (66 67) Rwnd 215 Survey Ntionl 1.5 ( ) 216 Surveillnce Ntionl 5.1 ( ) Sint Kitts nd Nevis 217 Surveillnce Ntionl ( 98) Sint Luci 213 Surveillnce Ntionl ( 52) 213 Surveillnce Ntionl 13 (8.4 18) Sint Vincent nd the Grendines 214 Surveillnce Ntionl ( 98) Smo 217 Surveillnce Ntionl ( 25) 216 Surveillnce Ntionl 12 (7.2 19) Sn Mrino So Tome nd Principe 212 Surveillnce Ntionl 88 (47 ) Sudi Arbi 21 Survey Ntionl 2.6 (2. 3.2) 21 Survey Ntionl 2 (16 25) Senegl 214 Survey Ntionl.9 ( ) 217 Surveillnce Ntionl 6.2 ( ) Serbi 213 Surveillnce Ntionl 1.1 ( ) 213 Surveillnce Ntionl 4.7 (1.3 11) Seychelles 217 Surveillnce Ntionl ( 23) 217 Surveillnce Ntionl 14 (1 18) Sierr Leone Singpore 217 Surveillnce Ntionl 1.5 ( ) 217 Surveillnce Ntionl 3.6 (.74 1) Sint Mrten (Dutch prt) Slovki 217 Surveillnce Ntionl 4.1 (1.1 1) 217 Surveillnce Ntionl 7.7 (.95 25) Sloveni 216 Surveillnce Ntionl ( 3.9) 216 Surveillnce Ntionl ( 71) Solomon Islnds 213 Surveillnce Ntionl ( 41) Somli 211 Survey Ntionl 8.7 (6.1 12) 211 Survey Ntionl 47 (29 65) South Afric 214 Survey Ntionl 3.4 ( ) 214 Survey Ntionl 7.1 ( ) South Sudn Spin 215 Surveillnce Ntionl 4.2 ( ) 215 Surveillnce Ntionl 18 (9.4 3) Sri Lnk 218 Survey Ntionl.5 (.2 1.) 218 Survey Ntionl 4.1 (1.1 1) Sudn 217 Survey Ntionl 2.9 ( ) 217 Survey Ntionl 13 (8.6 17) Surinme 216 Surveillnce Ntionl 6.1 (1.7 15) 216 Surveillnce Ntionl ( 41) Sweden 217 Surveillnce Ntionl 3.2 ( ) 217 Surveillnce Ntionl 9.5 (1.2 3) Switzerlnd 215 Surveillnce Ntionl 3.2 ( ) 215 Surveillnce Ntionl 26 (9.1 51) Syrin Arb Republic 23 Survey Ntionl 8 (5.1 11) 216 Surveillnce Ntionl 24 (16 35) Tjikistn 217 Surveillnce Ntionl 2 (19 22) 217 Surveillnce Ntionl 23 (2 27) Thilnd 212 Survey Ntionl 2.2 (1.5 3.) 212 Survey Ntionl 24 (18 31) The Former Yugoslv Republic of Mcedoni Timor-Leste 217 Surveillnce Ntionl ( 2.7) 217 Surveillnce Ntionl ( 18) Togo 218 Survey Ntionl 1.5 (.8 2.6) 218 Survey Ntionl 9.7 (4.5 18) Empty rows indicte n bsence of high-qulity survey or surveillnce dt. In the bsence of high-qulity ntionl dt, high-qulity sub-ntionl dt re used. Dt for ll countries nd yers cn be downloded from 255

267 TABLE A4.3 Mesured percentge of TB cses with MDR/RR-TB, most recent yer vilble New TB cses Previously treted TB cses Tokelu Yer Source Coverge Percentge Yer Source Coverge Percentge Tong 217 Surveillnce Ntionl ( 41) 217 Surveillnce Ntionl 12 (7.2 19) Trinidd nd Tobgo Tunisi 217 Surveillnce Ntionl 1.1 (.53 2.) 217 Surveillnce Ntionl 13 (6.1 23) Turkey 217 Surveillnce Ntionl 3.3 ( ) 217 Surveillnce Ntionl 14 (11 17) Turkmenistn 213 Survey Ntionl 14 (11 18) 213 Survey Ntionl 38 (31 46) Turks nd Cicos Islnds Tuvlu Ugnd 211 Survey Ntionl 1.6 ( ) 211 Survey Ntionl 12 (6.5 19) Ukrine 217 Surveillnce Ntionl 28 (27 29) 217 Surveillnce Ntionl 48 (47 49) United Arb Emirtes 217 Surveillnce Ntionl 25 (.63 81) United Kingdom of Gret Britin nd Northern Irelnd 217 Surveillnce Ntionl 1.4 (.93 2.) 217 Surveillnce Ntionl 4.7 ( ) United Republic of Tnzni 218 Survey Ntionl.9 (.3 1.5) 218 Survey Ntionl 4.7 (.7 8.6) United Sttes of Americ 217 Surveillnce Ntionl 2 ( ) 217 Surveillnce Ntionl 1 (6.6 15) Uruguy 217 Surveillnce Ntionl.42 (<.1 1.5) 217 Surveillnce Ntionl 4.9 (.6 17) Uzbekistn 217 Surveillnce Ntionl 15 (14 16) 217 Surveillnce Ntionl 57 (55 6) Vnutu 217 Surveillnce Ntionl 2.2 (<.1 12) 217 Surveillnce Ntionl 12 (7.2 19) Venezuel (Bolivrin Republic of) Viet Nm 212 Survey Ntionl 4.1 ( ) 217 Surveillnce Ntionl 17 (17 18) Wllis nd Futun Islnds West Bnk nd Gz Strip Yemen 211 Survey Ntionl 2.3 ( ) 211 Survey Ntionl 18 (11 26) Zmbi 28 Survey Ntionl 1.1 ( ) 28 Survey Ntionl 18 (12 26) Zimbbwe 216 Survey Ntionl 4.6 (3. 6.2) 216 Survey Ntionl 14 (8.9 2) Empty rows indicte n bsence of high-qulity survey or surveillnce dt. In the bsence of high-qulity ntionl dt, high-qulity sub-ntionl dt re used. 256 Dt for ll countries nd yers cn be downloded from

268 TABLE A4.4 TB cse notifictions, 217 New nd relpse cses * Totl cses notified Includes cses for which the tretment history is unknown. Among ll notified cses, not just new nd relpse cses. Notified % tested with rpid dignostics t time of dignosis % with known HIV sttus % pulmonry % bcteriologiclly confirmed mong pulmonry Afghnistn Albni Algeri * Americn Smo 5 5 * 8 75 Andorr 1 1 Angol Anguill Antigu nd Brbud 1 1 Argentin Armeni Arub 8 8 * 25 Austrli Austri Azerbijn * 8 74 Bhms Bhrin Bngldesh * Brbdos Belrus Belgium Belize Benin * Bermud 2 2 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 * 8 86 Croti Cub Curço Cyprus * Czechi * Democrtic People's Republic of Kore Democrtic Republic of the Congo * 83 8 Dt for ll countries nd yers cn be downloded from 257

269 TABLE A4.4 TB cse notifictions, 217 New nd relpse cses * Totl cses notified Includes cses for which the tretment history is unknown. Among ll notified cses, not just new nd relpse cses. Notified % tested with rpid dignostics t time of dignosis % with known HIV sttus % pulmonry % bcteriologiclly confirmed mong pulmonry Denmrk Djibouti * 65 8 Dominic 1 1 * Dominicn Republic Ecudor Egypt El Slvdor Equtoril Guine Eritre Estoni Eswtini Ethiopi * Fiji Finlnd * Frnce * French Polynesi Gbon Gmbi Georgi Germny Ghn Greece Greenlnd Grend 3 3 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 * 8 87 Mlwi Dt for ll countries nd yers cn be downloded from

270 TABLE A4.4 TB cse notifictions, 217 New nd relpse cses * Totl cses notified Includes cses for which the tretment history is unknown. Among ll notified cses, not just new nd relpse cses. Notified % tested with rpid dignostics t time of dignosis % with known HIV sttus % pulmonry % bcteriologiclly confirmed mong pulmonry Mlysi Mldives Mli * Mlt Mrshll Islnds * Muritni Muritius Mexico Micronesi (Federted Sttes of) Monco Mongoli Montenegro Montserrt Morocco Mozmbique * 93 4 Mynmr Nmibi * Nuru Nepl * Netherlnds New Cledoni New Zelnd Nicrgu Niger * Nigeri Niue 2 1 * Northern Mrin Islnds > 9 63 Norwy Omn Pkistn * 8 48 Plu Pnm Ppu New Guine Prguy Peru * Philippines Polnd Portugl * Puerto Rico Qtr Republic of Kore Republic of Moldov Romni Russin Federtion Rwnd Sint Kitts nd Nevis 1 1 Sint Luci Sint Vincent nd the Grendines 3 2 Smo Sn Mrino So Tome nd Principe Sudi Arbi Senegl Serbi * Serbi (without Kosovo) Kosovo Seychelles Sierr Leone * Dt for ll countries nd yers cn be downloded from 259

271 TABLE A4.4 TB cse notifictions, 217 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 Singpore * Sint Mrten (Dutch prt) Slovki Sloveni Solomon Islnds Somli * South Afric South Sudn Spin Sri Lnk * 73 7 Sudn Surinme * 88 8 Sweden Switzerlnd Syrin Arb Republic Tjikistn * 7 68 Thilnd The Former Yugoslv Republic of Mcedoni Timor-Leste * Togo * Tokelu 2 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 * 8 52 United Sttes of Americ Uruguy 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. Among ll notified cses, not just new nd relpse cses. 26 Dt for ll countries nd yers cn be downloded from

272 TABLE A4.5 Tretment outcomes by TB cse type, 216 nd tretment outcomes for MDR/RR-TB nd XDR-TB cses, 215 New nd relpse, 216 cohort Previously treted, excluding relpse, 216 cohort HIV-positive TB, 216 cohort MDR/RR-TB, 215 cohort XDR-TB, 215 cohort * Relpses included in the previously treted cohort. Cohort (Number) Success (%) Afghnistn Albni Algeri Americn Smo* 3 3 Andorr 4 75 Angol* Anguill Antigu nd Brbud Argentin Armeni Arub* Austrli Austri Azerbijn* Bhms Bhrin Bngldesh Brbdos 3 Belrus Belgium Belize Benin Bermud 2 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 3 Centrl Africn Republic Chd Chile Chin Chin, Hong Kong SAR Chin, Mco SAR Colombi Comoros Cohort (Number) Success (%) Cohort (Number) Success (%) Cohort (Number) Congo Cook Islnds 2 Cost Ric Côte d'ivoire Croti Cub Curço 4 Cyprus Success (%) Cohort (Number) Czechi Democrtic People's Republic of Kore Success (%) Democrtic Republic of the Congo Dt for ll countries nd yers cn be downloded from 261

273 TABLE A4.5 Tretment outcomes by TB cse type, 216 nd tretment outcomes for MDR/RR-TB nd XDR-TB cses, 215 New nd relpse, 216 cohort Previously treted, excluding relpse, 216 cohort HIV-positive TB, 216 cohort MDR/RR-TB, 215 cohort XDR-TB, 215 cohort * Cohort (Number) Relpses included in the previously treted cohort. Success (%) Cohort (Number) Success (%) Cohort (Number) Success (%) Cohort (Number) Success (%) Cohort (Number) Denmrk Djibouti* Dominic 5 1 Success (%) Dominicn Republic Ecudor Egypt El Slvdor Equtoril Guine Eritre Estoni Eswtini Ethiopi* Fiji Finlnd Frnce French Polynesi Gbon Gmbi Georgi Germny Ghn Greece Greenlnd Grend 6 Gum Guteml Guine Guine-Bissu Guyn Hiti Hondurs Hungry Icelnd 6 83 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 Dt for ll countries nd yers cn be downloded from

274 TABLE A4.5 Tretment outcomes by TB cse type, 216 nd tretment outcomes for MDR/RR-TB nd XDR-TB cses, 215 New nd relpse, 216 cohort Previously treted, excluding relpse, 216 cohort HIV-positive TB, 216 cohort MDR/RR-TB, 215 cohort XDR-TB, 215 cohort * Cohort (Number) Relpses included in the previously treted cohort. Success (%) Cohort (Number) Success (%) Cohort (Number) Success (%) Cohort (Number) Success (%) Cohort (Number) Mlysi Mldives Mli Mlt Mrshll Islnds Muritni Muritius Success (%) 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 Seychelles Sierr Leone Singpore Sint Mrten (Dutch prt) Dt for ll countries nd yers cn be downloded from 263

275 TABLE A4.5 Tretment outcomes by TB cse type, 216 nd tretment outcomes for MDR/RR-TB nd XDR-TB cses, 215 New nd relpse, 216 cohort Previously treted, excluding relpse, 216 cohort HIV-positive TB, 216 cohort MDR/RR-TB, 215 cohort XDR-TB, 215 cohort Cohort (Number) Success (%) Cohort (Number) Success (%) Cohort (Number) Success (%) Cohort (Number) Success (%) Cohort (Number) Slovki Sloveni Solomon Islnds Somli Success (%) South Afric South Sudn Spin Sri Lnk Sudn* Surinme Sweden Switzerlnd Syrin Arb Republic Tjikistn Thilnd The Former Yugoslv Republic of Mcedoni Timor-Leste Togo* Tokelu 2 Tong 8 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 Uzbekistn Vnutu 88 Venezuel (Bolivrin Republic of) Viet Nm Wllis nd Futun Islnds West Bnk nd Gz Strip Yemen Zmbi Zimbbwe WHO regions Africn Region Region of the Americs Estern Mediterrnen Region Europen Region South-Est Asi Region Western Pcific Region Globl * Relpses included in the previously treted cohort. 264 Dt for ll countries nd yers cn be downloded from

276 TABLE A4.6 Collbortive TB/HIV ctivities in 3 high TB/HIV burden countries, for WHO regions nd globlly, 217 Number % s % of notified TB ptients with known HIV sttus s % of notified HIVpositive TB ptients % provided with TB preventive tretment Angol 18 (9.1 3) (12 4) (4.6 15) Botswn 3.3 ( ) (57 >) (52 >) Brzil 11 (9.3 13) (6 84) (29 4) Cmeroon 14 (9.2 21) (35 8) Centrl Africn Republic 6.2 (3.3 1) (21 63) (15 46) 33 Chd 4.6 ( ) (25 59) Chin 12 (6.3 18) (23 67) Congo 5.3 ( ) (4.3 14) ( ) 2.5 Democrtic Republic of the Congo 2 (13 29) (34 75) 82 4 (28 62) Eswtini 2.9 ( ) (53 >) ( >) 1 1 Ethiopi 12 (8.6 17) (43 85) (4 78) Ghn 9.5 (4.5 16) (17 62) (8.9 33) 4.7 Guine-Bissu 2.2 ( ) (16 38) (7.2 17) 23 Indi 86 (57 12) (3 64) (24 ) 1 11 Indonesi 36 (2 57) (14 38) (4. 11) Keny 45 (27 68) (34 84) (32 79) 5.2 Lesotho 11 (6.7 15) (31 7) (28 65) Liberi 2.2 ( ) (26 59) (11 25) Mlwi 12 (7.9 17) (46 >) (45 >).76 Mozmbique 66 (42 95) (35 8) (34 76) Mynmr 17 (12 22) (47 84) (29 53) Nmibi 3.9 ( ) (57 >) (54 >) Nigeri 58 (37 85) (16 37) 85 2 (14 31) Ppu New Guine 3.5 (2. 5.5) (14 4) (14 38) South Afric 193 ( ) (48 9) (43 8) 53 Thilnd 11 (8.5 15) (49 84) 64 4 (31 54) 13 Ugnd 34 (22 49) (38 83) (35 78) United Republic of Tnzni 48 (31 69) (31 69) (29 65) Zmbi 36 (23 52) (39 88) 9 51 (36 8) 18 1 Zimbbwe 23 (15 33) ( >) (43 96) 11.5 WHO regions Estimted HIVpositive incident TB cses Number (thousnds) Notified TB ptients with known HIV sttus HIV-positve TB ptients s % of estimted HIV-positive incident TB cses HIV-positive TB ptients on ntiretrovirl therpy (ART) s % of estimted HIV-positive incident TB cses Of people newly enrolled in HIV cre Africn Region 663 ( ) (46 59) 9 45 (4 51) 32 6 Region of the Americs 3 (28 33) (63 74) 6 39 (36 43) Estern Mediterrnen Region 9.8 (6. 15) (9.1 22) 77 1 (6.8 17) 16 9 Europen Region 33 (26 42) (6 96) 68 (4 65) South-Est Asi Region 152 ( ) (32 53) (22 36) Western Pcific Region 31 (24 4) (31 51) (17 28) Globl 92 ( ) (46 56) (37 46) % notified s TB cse For new nd relpse cses only, lthough some countries report on ll cses. Dt for ll countries nd yers cn be downloded from 265

277 TRUMP END TB I ISBN Leve no one behind

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