SEA-TB-315 Distribution: General. Tuberculosis. in the South-East Asia Region

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2 SEA-TB-315 Distribution: General Tuberculosis in the South-East Asia Region Annual Report: 29

3 World Health Organization 29 All rights reserved. Requests for publications, or for permission to reproduce or translate WHO publications whether for sale or for noncommercial distribution can be obtained from Publishing and Sales, World Health Organization, Regional Office for South- East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 11 2, India (fax: ; The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. This publication does not necessarily represent the decisions or policies of the World Health Organization. Printed in India

4 Contents Abbreviations...v Preface...ix 1. Introduction Epidemiology of TB in the Region TB disease incidence, prevalence and mortality TB infection TB disease incidence, prevalence and mortality Impact of HIV on TB in the Region Drug-resistant TB Achievements DOTS coverage Case notifications Treatment outcomes Case detection and treatment success rates Key Milestones achieved in DOTS Strengthening national laboratory networks Addressing TB/HIV, MDR-TB, and other challenges Public and private partnerships Surveillance, monitoring and evaluation Resources Operational Research iii

5 5. WHO support in the Region Technical assistance Strengthening national laboratory networks Capacity building, information exchange Resource mobilization Ensuring regular supplies of drugs and improving procurement and supply management Operational research Coordination, collaboration and partnerships Advocacy, communication and social mobilization Monitoring and evaluation Country Profiles Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste... 8 Definitions iv

6 Abbreviations ACSM ADB AFB AIDS ART ARTI AusAID BRAC CHC CIDA CPT DFID DOT DOTS DPR Korea DRS DST DTC EC EP EQA ERD FDC FHI Fidelis Advocacy, Communication and Social Mobilization Asian Development Bank Acid-fast bacilli Acquired immunodeficiency syndrome Antiretroviral treatment Annual risk for tuberculosis infection Australian agency for international development Bangladesh Rural Advancement Committee Community Health Centre Canadian International Development Agency Cotrimoxazole Preventive Therapy United Kingdom Department for International Development Directly observed treatment Directly observed treatment short course Democratic People s Republic of Korea Drug-resistance survey/surveillance Drug-susceptibility testing District TB Coordinator European Commission Extra-pulmonary External quality assessment External Resource Division Fixed Dose Combination Family Health International Fund for Innovative DOTS Expansion through Local Initiatives to Stop TB v

7 FIND GDF GF GLC HIV HNPNP HRD ICDDR,B ICTC IDU IEC IMA IMPACT INGO IPT ISAC ISTC IVMS JATA JICA KNCV MDG MDR-TB MIFA MO MoF MoU NAP Foundation for Innovative New Diagnostics Global TB Drug Facility Global Fund to fight AIDS, Tuberculosis and Malaria Green Light Committee Human immunodeficiency virus Health, Nutrition and Population Sector Programme Human resources development International Centre for Diarrhoeal Disease Research, Bangladesh Integrated Counselling and Testing Centre Intravenous drug use/r Information, Education, Communication Indian Medical Association Indian Medical Professional Associations Coalition against TB International nongovernmental organization Isoniazid Preventive Treatment Intensified Support and Action Countries International standard for tuberculosis care International Centre for Veterinary and Medical Sciences, Australia Japan anti-tb association Japan International cooperation agency Royal Dutch Tuberculosis Association Millennium Development Goal Multidrug-resistant tuberculosis Managing Information for Action Medical officer Ministry of Finance Memorandum of Understanding National AIDS Programme vi

8 NGO NRL NSP NTI NPO NTP OGAC OSE PAL PLHIV PPM PPP PSI QA RBRC RHC RNTCP SAARC SEA Region SNRL SOP STD SSA TBCTA TB TB/HIV TBTEAM TDR TRC Nongovernmental organization National Reference Laboratory New smear-positive (TB cases) National Tuberculosis Institute, Bangalore, India National professional officer National Tuberculosis Programme Office of Global AIDS Control On-site evaluation Practical approach to lung health People living with HIV Public-private, public-public or private-private mix Public-private partnership Population Services International Quality Assurance Random blinded re-checking Rural Health Centre Revised National Tuberculosis Control Programme (India) South-Asian Association for Regional Cooperation WHO South-East Asia Region Supra-national reference laboratory Standard Operating Procedures Sexually transmitted disease Special Services Agreement TB Coalition for Technical Assistance Tuberculosis Tuberculosis and human immunodeficiency virus TB technical assistance mechanism UNICEF-UNDP-World Bank-WHO Special Programme for Research and Training in Tropical Diseases TB Research Centre, Chennai, India vii

9 TSG UNICEF UNICERF UNITAID UNDP Union USAID US$ VCTC WHO XDR-TB 3DF Technical Strategic Group United Nations Children s Fund UN Common Emergency Relief Fund International facility for the purchase of drugs against HIV/ AIDS, Malaria and Tuberculosis United Nations Development Programme International Union Against Tuberculosis and Lung Disease United States Agency for International Development United States dollar Voluntary counselling and testing centre World Health Organization Extensively drug-resistant tuberculosis Three disease fund viii

10 Preface Good progress continues to be made towards reaching the targets set for TB control in Member States of the South- East Asia Region. The indicators set under the Millennium Development Goals to measure progress in TB control are the case detection and treatment success rates among the new smear-positive TB cases and the rate of fall in the incidence, prevalence and mortality due to the disease. The overall rates for the first two indicators in the Region now stand at 69% and 87%, respectively. In terms of the impact indicators, the Region is witnessing a small but steady decline in TB incidence, prevalence, and mortality rates. Countries of the Region are also increasingly addressing the dual challenge of drug-resistant and HIV-associated TB. Interventions to diagnose and treat multidrug resistant TB (MDR-TB) are in place in 7 out of the 11 Member States of the Region. In response to the overlapping epidemics of TB and HIV, national HIV/AIDS and TB programmes within Ministries of Health have developed and established national policies and strategies and are expanding interventions to detect and care for people with HIV and active TB. Recognizing that national programmes and public health systems alone will not reach all those who require diagnosis and treatment for TB, over 25 medical colleges and large public and private hospitals, several thousand private practitioners and nongovernmental organizations, and over 1 corporate institutions have been involved in working with national TB control programmes. India and Indonesia have formally established widely inclusive partnerships to support TB control efforts at the national level. Many national TB programmes have established links with professional societies as a means of disseminating the principles and practices of the international standards for TB care to all care providers. A number of community-based TB care projects are also in place in countries of the Region. All 11 Member States continue to benefit from funding ix

11 support through many development partners, international initiatives such as the Global Fund, the Global Drug Facility, UNITAID and others, including the 3-Disease Fund in Myanmar. However, sustaining this progress by pursuing quality DOTS and implementing the five other equally important components of the Stop TB strategy is becoming increasingly challenging. While many national TB programmes in the Region are being acknowledged globally for establishing broad partnerships with private and public sector healthcare providers, there is still a long way to go in effectively expanding the reach of services through these partnerships. A lot of work remains to be done in mobilizing people and communities so that they use available services in a timely manner. Health systems and service delivery need to be improved through a strengthened and inclusive primary health care approach. At the same time, we must recognize that the health systems alone cannot succeed in isolation, and we must therefore address social, cultural and economic factors that impact the continuing epidemic of tuberculosis in this Region. These annual reports document the progress, present the challenges, constraints and plans for the effective implementation of interventions to combat TB in the Region. WHO will continue to provide technical support to catalyse and accelerate the implementation of TB control services in Member States through a range of activities as detailed in this report. There is much in this report that is very encouraging and I am confident that our collective efforts will lead us to achieve the goals set for reducing tuberculosis by 215. Dr Samlee Plianbangchang Regional Director x

12 1 Introduction Tuberculosis continues to remain one of the most serious health and developmental problems in the WHO South-East Asia Region. The Region still accounts for the highest numbers of TB patients globally, carrying over 3% of the world s TB burden. In the 11 Member countries of the Region, an estimated three million people contact TB, and 5 die of the disease every year. The Region is also home to the second-highest number of people living with HIV/AIDS, following Africa. However, the HIV epidemic in South-East Asia is at different stages both across the Region and within countries. India, Indonesia, Myanmar and Thailand are among the 41 countries globally that carry a high burden of both HIV and TB. Countries are responding to these challenges and expanding the implementation of the new Stop TB Strategy. Over two million TB patients are being registered for treatment by national programmes every year, of whom over 85% are successfully treated, averting at least 3 deaths from TB every year. As a result, the Region is already demonstrating a slow but steady decline in TB incidence rates. TB/HIV interventions to address the needs of those dually affected with TB and HIV are widely available in Thailand and are being expanded in India and Myanmar. Indonesia, with a concentrated HIV epidemic, has established interventions in Papua and Java Bali, two HIV highprevalence areas in the country. Countries are also slowly expanding diagnostic and treatment facilities for MDR-TB. This progress in TB control needs to be sustained and built upon to enable individual countries to achieve the targets set under the Millennium 1

13 Development Goals. While it costs less than US$ 2 to treat a patient diagnosed for the first time with drug susceptible TB, the cost of treating a patient with MDR-TB is a hundred fold. Reaching and curing each newly diagnosed case of TB through the application of DOTS by both public and the large and evergrowing private sector therefore has to remain the foremost priority. In addition, national programmes are now aiming to achieve universal case detection, further shorten diagnostic and treatment delays in order to cut transmission and prevent complications and deaths. At the same time, major efforts are being made to address TB-HIV through effective interventions together with HIV programmes; ensuring quality assured laboratory networks for microscopy, culture and drug susceptibility testing; rapidly scaling up capacity to treat existing multi-drug resistant cases and focusing on difficult areas such as TB control among high risk populations and in cross-border areas. Sustaining these efforts will require continued commitment and adequate resources for national TB control programmes for several more years. This is because an irreversible decline in TB incidence can only be achieved after several years of reduced transmission in the community. 2

14 2 Epidemiology of TB in the Region The South-East Asia Region, with an estimated 4.88 million prevalent cases and an annual incidence of 3.17 million TB cases, carries one-third of the global burden of TB (Figure 1). Five of the 11 Member countries in the Region are among the 22 high-burden countries, with India accounting for over 2% of the world s cases. Most cases occur in the age group of years, with males being disproportionately affected. The male/female ratio among newly detected cases is 2:1. Though deaths due to TB have declined after introduction of DOTS in the Region, the disease still claims more than 5 lives each year. Figure 1: Estimated incidence of all forms of TB, by WHO Region, 28. 4% 5% 34% 6% 21% Americas Europe Eastern Mediterrenean Western Pacific Africa South-East Asia 3% Source: Global Tuberculosis Control Surveillance, Planning, Financing, WHO, Geneva, 29 3

15 2.1 TB disease incidence, prevalence and mortality The control of tuberculosis in the Region is affected by variations in the quality and coverage of various TB control interventions, population demographics, urbanization, changes in socio-economic standards, HIV and, more recently, emerging drug resistance. Table 1 shows the estimated TB incidence, prevalence and mortality rates for countries in the Region. Table 1: Estimates of TB disease incidence, prevalence and mortality in the South-East Asia Region, 28 Country Population* (in 1 s) Estimated Annual Incidence rate/1 population All cases SS+ cases Estimated Prevalence rate per 1 pop. all forms of TB Estimated death rate per 1 pop. all forms of TB Bangladesh 158, Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste SEAR * UN Population Division, World Population Reports, 27, New York (Rev.) Figure 2 shows the estimated TB prevalence rates in the 11 Member countries of the Region comparing the rates between 199, 24 and 27. These are indicative of a decrease in all countries of the Region. 4

16 Figure 2: Estimated prevalence rates for all forms of TB, SEA Region 199, 24, 27 Rate per 1 population 1, BAN BHU DPRK IND INO MAV MMR NEP SRL THA TLS Source: Global Tuberculosis Control, WHO Reports Figure 3 shows the estimated TB mortality rates for all forms of tuberculosis per 1 population, comparing the rates between 199, 24 and 27. With respect to 199, a significant decrease is observed in 27 in all countries of the Region. Figure 3: Estimated mortality rates for all forms of TB per 1 population SEA Region: 199, 24, 27 Rate per 1 population BAN BHU DPRK IND INO MAV MMR NEP SRL THA TLS Source: Global Tuberculosis Control, WHO Reports,

17 Figure 4 shows the overall trends in the estimated TB prevalence, incidence and mortality rates per 1 population in the Region as a whole, between 199 and 27. The estimated prevalence and mortality rates decreased slowly between 24 and 27. Figure 4: Trends in estimated prevalence, incidence and mortality: SEA Region, Rate per 1 population Estimated prevalence all forms Estimated incidence new smear+ Estimated incidence all forms Estimated TB mortality Source: Global Tuberculosis Control: WHO Reports, TB infection Annual Risk of TB Infection (ARTI) studies undertaken in countries have revealed widely disparate results. Studies in four zones in India carried out during 2-23 showed ARTI rates ranging from 1. % in the south zone to 1.9% in the north zone; repeat ARTI surveys are being undertaken, but the results are not yet available. In Indonesia, an ARTI study carried out in 26 in West Sumatra yielded an incidence rate of 1.3%. A limited ARTI survey undertaken in 28 in DPR Korea is indicative that the incidence rates for the country as estimated by WHO may need to be revised upwards by a factor of two. Nepal undertook an ARTI survey in three ecological zones and in the Kathmandu valley during 26-27, revealing a rate of.86%, substantially lower than the previous rate of 2.1%. Similar surveys are planned in Bhutan and Sri Lanka in TB disease incidence, prevalence and mortality While these surveys are indeed contributing to more accurate estimations of the burden of disease in countries, there are still uncertainties about the current 6

18 estimates for TB disease incidence, prevalence and mortality rates in individual countries in the Region. The use of routine notification data as a measure of disease incidence is certainly the way to go in the future. This however requires strengthening all aspects of the TB surveillance system, focusing on quality of data entry, compilation and reporting, and giving attention to precise analysis and interpretation of the data. As part of this effort, the WHO Regional Office for South-East Asia (SEARO) organized a series of trainings on managing information for action (MIFA) in four Member countries during Meanwhile there is clearly a need to continue to support well-designed population-based surveys in the Region, particularly in the higher TB burden countries, until such time as routine case notifications can begin to be used to correctly reflect actual trends. 2.4 Impact of HIV on TB in the Region The expanding HIV epidemic in the Region is a growing concern. Of the 31.6 million people estimated to be living with HIV in the world at the end of 27, more than 3.6 million are estimated to be in the South-East Asia Region. India alone is estimated to have 2.4 million people living with HIV (Figure 5). Figure 5: HIV Prevalence in the SEA Region: 27 Nepal 7 Myanmar 24 India 2 4 Thailand 61 Five countries account for the majority of HIV burden in the Region Indonesia 27 Source: Report on the Global AIDS Epidemic: UNAIDS, 28 7

19 Three countries in the Region (Thailand, Myanmar and a number of districts in nine states in India) have rates of HIV > 1% in the general population and the highest HIV/TB co-infection rates in the Region. Four countries have concentrated epidemics: Bangladesh, Nepal, Indonesia and some states of India. While Myanmar and Thailand have a more homogenous and high HIV prevalence, only some states in India and three provinces in Indonesia report high HIV rates. HIV does not appear to have fundamentally altered the epidemiology of TB in the Region to the extent observed in sub-saharan Africa. Available data suggest that the incidence of TB has been minimally affected by the HIV epidemic. The impact on TB mortality however, has been much more substantial. In India, Myanmar and Thailand, high TB case-fatality rates have been reported in areas with high HIV rates in the general population. 2.5 Drug-resistant TB Seven countries have reported data on drug resistance since 22, namely, Bangladesh, India, Indonesia, Myanmar, Nepal, Sri Lanka, and Thailand. India reported data from three districts and one state, while Indonesia reported data from one district only. Orissa in India, Sri Lanka, and Thailand reported less than 2.% MDR-TB among new cases. Districts surveyed in the states of Kerala, West Bengal and Gujarat in India as well as Mimika district of Papua province in Indonesia, and Nepal reported between 2.-3.% MDR-TB among new cases. Myanmar reported a higher level of 3.9% (2.6%-5.7%) MDR among new cases. While a few tertiary-care facilities have reported levels of multi-drug resistance as high as 6% among previously treated cases, these are not representative of the situation in the community. Resistance to first-line anti-tb drugs is equally a concern for national TB control programmes in countries of the Region. The population weighted mean of MDR-TB based on all the countries that have reported in the South-East Asian Region is 2.8% (1.9%-3.6%) among new cases and 18.8% (13.3%-24.3%) among previously treated cases. However, given the large numbers of TB cases in the Region, these figures translate into nearly 15 cases as a whole, with over 8% of these cases residing in Bangladesh, India, Indonesia, Myanmar and Thailand. While Myanmar and Thailand report relatively lower rates of MDR-TB among new cases, the two countries report 15.5% and 35.5 % MDR-TB rates respectively, among previously treated cases, which is a serous concern. 8

20 Extensively drug resistant tuberculosis (XDR-TB), has been isolated in samples from India, Indonesia, Bangladesh, and Thailand. Given the widespread availability and use of second-line drugs, and as laboratory capacity to conduct second-line drugs susceptibility testing increases, additional occurrences of XDR-TB are likely to be identified. The other concern is that unless well managed MDR-TB programmes are rapidly established under national programmes, MDR-TB cases will continue to be treated by the private sector through not necessarily well supervised or well designed second-line regimens, or through over-the-counter purchase of these drugs, given their widespread and easy availability, risking further increase in drug resistance. 9

21 3 Achievements 3.1 DOTS coverage DOTS coverage is defined as the population living in administrative areas where DOTS services are available. This indicator serves as a proxy for people with access to DOTS. Population access to DOTS steadily increased to 1 % in the whole region by the end of 27 (Figure 6). Figure 6: Population covered by DOTS services, SEA Region Percentage population covered Source: Tuberculosis control in the South-East Asia Region, Annual Reports , WHO/SEARO 1

22 3.2 Case notifications Table 2 shows the cases notified in 27 by type of TB, in each Member country. The 11 Member countries of the Region together notified cases of tuberculosis (all forms) which represents a case notification rate of 126 per 1 population. Of those, (44 %) were new smear-positive pulmonary cases. Five countries in the Region, Bangladesh, India, Indonesia, Myanmar and Thailand which belong to the global list of 22 countries with the highest burdens of TB, notified a total of cases, or 95% of all cases notified in the Region. Country Table 2: Estimated incidence and cases notified in the Member countries, SEA Region, 27 Estimated incidence New smearpositive cases All forms of TB New smearpositive cases New smearnegative cases TB cases notified New extrapulmonary cases Relapse Other retreatment Total notifications Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste SEA Region Percentage change 27 vs Figure 7 shows the trends in notifications of new smear-positive (NSP) and all forms of TB cases in the Region. The NSP notifications increased gradually until 1999, with a sharper increase thereafter until 26. There appears to be a leveling off since, suggesting that much more effort is now needed to further increase case detection. 11

23 Notifications of all forms of TB showed a rather unstable profile till 2, followed by a steady increase from 23 onwards. This is probably attributable to the increasing involvement of medical colleges and private practitioners, through whom increasing numbers of smear negative and extra-pulmonary cases are notified. Figure 7: All Forms of TB and NSP cases notified, SEA Region, Case Notifications: New ss+ and all forms of TB SEA Region, ,25, 2,, All cases NSP cases Numbers of cases notified 1,75, 1,5, 1,25, 1,, 75, 5, 25, YEARS Source: Tuberculosis control in the South-East Asia Region, Annual Reports , WHO/SEARO Figure 8 a, b and c, show three distinct patterns in trends of case notifications: Bangladesh, India, Indonesia, Myanmar and Thailand characterized by an increasing trend over time; Bhutan, DPRK, Maldives, Nepal and Sri Lanka characterized by more or less stable rates over time, with Sri Lanka and the Maldives presenting low rates, and DPRK, Bhutan and Nepal presenting much higher rates; and a third pattern represented by Timor-Leste, which shows a sharply declining trend till 26, followed by a slight increase in

24 Figure 8a: Annual NSP notification rates of selected countries, SEA Region, : Increasing trend 1 Rate per 1 population Bangladesh Myanmar Indonesia Thailand India Figure 8b: Annual NSP notification rates, selected countries, SEA Region, : Stable trend Rate per 1 population Sri Lanka Maldives Nepal Bhutan DPRK

25 Figure 8c: Annual NSP notification rates, Timor-Leste, Rate per 1 population Source: Tuberculosis control in the South-East Asia Region, Annual Reports , WHO/SEARO Figure 9: Proportion of S+ retreatment cases, out of all S+ cases, all SEA Member countries, Rate per 1 population Bangladesh Bhutan DPRK India Indonesia Madives Myanmar Nepal Sri lanka Thailand TLS SEAR Source: Global Tuberculosis control: WHO Reports

26 Figure 9 shows the proportions of re-treatment cases among all smearpositive cases in all countries of the Region. However, the true percentages could be slightly higher, given under-reporting by some countries. Of the smear-positive cases, the re-treatment cases represent 13-14%. At country level, India and DPR Korea present high proportions, up to 19 % in India. Five countries present less than 5%; while in four countries the proportion varies between 5% and 8 %. The trend over time does not show marked differences, with the exception of the Maldives and Thailand. The variability in the Maldives could be attributed to the small numbers whereas in Thailand this could be due to variations in reporting. Age-and sex-specific rates among new smear-positive (NSP) cases The male:female ratio among new smear-positive patients registered in the Region in 27 was 2:1. This ratio varies by country, as shown in Figure 1. The highest ratio was seen in Sri Lanka (2.8) and the lowest in Timor-Leste (1.2) The age-and sex-specific NSP notification rates for 27 are shown in Figure 11. The rate in adult males shows a steady increase starting at 63/1 pop. Figure 1: Ratio of male vs female NSP cases, SEAR Member countries, 27 Male to Female ratio among NSP cases Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste SEAR Source: Annual reports, National TB Control Programmes, SEAR Member countries, 28 15

27 Figure 11: Age and sex specific NSP notification rates SEA Region, 27 Rate per 1 population male female Age grous (yrs) Source: Annual reports, National TB Control Programmes, SEAR Member countries, December 28 reaching a peak at 17/1 pop in the years age groups, followed by a decline in the 65+ age group. The NSP rate in females shows a plateau between the ages of 15 to 64 years, followed by a decline in the 65+ years age group. The NSP rate in the 65+ old females decreased 4% vs. the previous age strata (55-54 years), while the decrease in the males of age 65+ years vs years was only 22%. 3.3 Treatment outcomes Table 3 shows the treatment success rates among new smear-positive cases enrolled for treatment in countries of the Region during 26. The treatment success rate is 87% in the Region as a whole and above 85% in eight of the 11 Member countries. The case fatality rate among new smear-positive cases was 4%, the default rate 5%, and the failure rate 2% for the cases registered in 26 (Table 3). 16

28 The success rate (72%) among re-treatment cases was substantially lower. Similarly, while the case fatality rate among new smear-positive cases was around 4%, it was much higher among the re-treatment cases (7%). The default rate (14%) was also substantially higher among retreatment cases, especially in India, Sri Lanka and Timor-Leste as was the failure rate (5%) which was 2.5 times higher among retreatment cases than among NSP cases. Table 3: Treatment outcomes among cases notified; SEA Region: 26 New smear-positive cases* Re-treatment Cases* Countries Notified Success rate Case fatality rate Failure rate Default rate Notified Success rate Case fatality rate Failure rate Default rate Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste SEAR *The group of Transferred out and Not evaluated have not been included in the table since both figures were very small. This implies that the sum of the outcomes of success, died, failed and default will not always add up to exactly 1%. Figure 12 shows the treatment outcomes disaggregated by sex in India. It is clear that females have more favourable treatment outcomes than males. In the cohort of patients registered in 26, the treatment success rates (88%) among female NSP patients was higher than among male patients (85%), while the default (5%) and death (4%) rates among female NSP patients were lower than among males (default 7%; deaths 5%). 17

29 Figure 12: Treatment outcomes among female and male NSP patients, India (cohort of patient registration, 26) RNTCP: Treatment outcome of male new Sm+ve TB patients registered in 26 (n=383,129) RNTCP: Treatment outcomes of female new S+ve TB cases registered in 26 (n=17,2) Died 5% Treat. Com. 2% Failure 2% Defaulted 7% Transferred 1% Died 4% Treat. Com. 2% Failure 2% Defaulted 5% Transferred 1% Cured 83% Cured 86% Source: RNTCP India Annual Report December Case detection and treatment success rates With further improvements in both case-detection and case holdings in almost all countries in the Region compared to previous years (see country profiles), the Region as a whole is showing steady progress towards reaching both 7% case detection and 85% treatment success targets, as shown in Figure 13. Figure 13: Case detection and treatment success rates SEA Region, 1997 to 27 Treatment success rate (%) Target zone Case detection rate (%) Source: Annual Reports on TB control, National TB Programmes, SEAR Member Countries, December 28 18

30 By the end of 27, five of the 11 Member countries in the Region had achieved or maintained the global target for case detection, and nine the global target for treatment success, resulting in four countries being in the target zone as shown in Figure 14. Figure 14: Case detection and treatment success rates, SEA Region, 28 Treatment success rate (26 cohort of NSP cases) BAN NEP SEAR IND MAV BHU SRL MMR DPRK 8 TLS THA Case detection rate (27 cohort of NSP TB cases) Source: Annual Reports on TB Control, National TB Programmes, SEAR Member countries, December 28 INO The case detection rates for Bangladesh, India, Indonesia and Nepal when calculated based on the UN population figures for these countries reflects them as not having achieved the case detection target of 7%. However, the case detection rates were 7% or above in these countries when the most recent national population census figures were applied. 19

31 4 Key Milestones achieved in DOTS The entire population in the Region now lives within access to DOTS facilities; The overall case detection rate reported in 27 was 68.5%, close to the global target of 7%, and the overall treatment success rate for the cohort of new smear-positive cases initiated on treatment in 26 was 87%. By the end of 28, five * countries Bhutan, DPR Korea, Maldives, Myanmar and Sri Lanka had achieved or maintained both global targets for case detection and treatment success under DOTS, based on UN population figures for the Member countries. 4.2 Strengthening national laboratory networks External quality assurance for smear microscopy is being strengthened in all Member countries through training of laboratory staff. Seven countries Bangladesh, India, Indonesia, Myanmar, Nepal, Sri Lanka, and Thailand have at least one national-level laboratory with facilities for mycobacterial culture and drug susceptibility testing for the detection of MDR-TB cases. Bangladesh, Nepal and Sri Lanka are in the process of having their national reference laboratories accredited for quality assurance of culture and drug susceptibility testing, while additional reference laboratories are being accredited in India, Indonesia, Myanmar and Thailand. * Based on national population figures, more countries join that list: Bangladesh, India, Indonesia and Nepal. 2

32 4.3 Addressing TB/HIV, MDR-TB, and other challenges Recognizing that TB-HIV co-infection must be addressed effectively, national HIV/AIDS and TB programmes in seven countries in the Region have developed national policies and strategies for TB-HIV. National level TB/HIV coordinating bodies have been established. The regional strategic framework for TB/HIV is also being revised and updated. TB/HIV activities are widely available in Thailand and are being expanded in India and Myanmar. India is implementing an intensified package of TB/HIV interventions in the nine states with a high HIV prevalence. There has been a more than 5 fold increase in referrals from HIV counselling and testing centres to the TB services and more than 3 fold increase in referrals from the TB to HIV services over the last 3 years. Indonesia, with a concentrated HIV epidemic, has established interventions in Papua and Java Bali, which are the country s HIV high-prevalence areas. Cross-referrals between the TB and HIV programmes have been strengthened, and the TB recording and reporting systems in these countries revised to include information on TB/HIV co-infection. Bangladesh, India, Nepal, and Timor-Leste have established MDR-TB case management under their national programmes. Nepal has recently expanded to all five regions in the country, while India is gradually expanding services to additional states. Indonesia and Myanmar are expected to begin enrolling MDR-TB patients in early 29. Two countries, Bhutan and Sri Lanka, have submitted applications to the Green Light Committee and plan to commence MDR-TB case management in 29. National guidelines for the management of childhood TB were finalized in Bangladesh, Indonesia and Myanmar. Myanmar and Nepal received their first grants for anti-tb paediatric formulations through the Global Drug Facility (GDF), supported through UNITAID, while paediatric grants were approved for DPR Korea and Sri Lanka. India is introducing infection control measures in health facilities while Indonesia, Myanmar and Thailand will undertake assessments and prepare infection control plans in 29. Countries have also included measures to address vulnerable populations at higher risk and cross-border issues in their national plans for TB control and Global Fund applications. 21

33 4.4 Public and private partnerships TB technical working groups and/or specific task forces and sub-working groups have been established both at the regional and at national levels in Bangladesh, DPR Korea, India, Indonesia, Myanmar, and Nepal. A major strategy towards improving case detection and treatment success rates has been the inclusion of public health care providers operating outside the Ministry of Health, such as the railways, military and prison health services, as well as private providers in all Member countries where patients seek services through the private health sector. The International Standards of TB Care were endorsed by professional bodies-- medical associations in India, Indonesia, Myanmar, and Nepal. Inter-sectoral collaboration and public-private partnerships for delivery of services were further scaled up in eight Member countries Bangladesh, India, Indonesia, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste. Over 35 medical colleges, 22 private practitioners, 1 5 large public and private hospitals, 15 corporate institutions, 2,5 nongovernmental organizations and 55 prisons are now working with national TB control programmes. Some recent initiatives in countries were formal inclusion of pre-service training on the principles and practices of TB control and establishing of referral mechanisms through providing lists of DOTS centres to teaching institutes, inclusion of private laboratories in diagnostic network and QA systems, and launching of IMPACT a coalition of professional associations for TB control, in India. In 28, India also formally established a widely inclusive national partnership, becoming the second country in the Region to establish such a partnership, in addition to Indonesia. Indonesia intensified training of private and public hospital and laboratory staff and introduced coordination meetings between community health facilities and hospitals to improve transfer mechanisms between lung clinics and puskesmas. In Myanmar, services have been resumed throughout the network of PSI Sun Quality Clinics and the NTP plans further expansion of public/private mix services through the Myanmar Medical Association. There are also very encouraging examples of community-based approaches in several countries, but these need to be systematically documented and the experiences used to more widely replicate successful models at the national level. 4.5 Surveillance, monitoring and evaluation Impact assessments in the form of prevalence or ARTI surveys are on-going in Bangladesh, India, Indonesia, and Myanmar. ARTI surveys are expected to commence in Bhutan, India and Sri Lanka in 29. The estimates for TB 22

34 prevalence and incidence were revised for Timor-Leste based on a review of more recent data and trends in cases notified and for DPR Korea based on an ARTI survey completed in 27. Annual reports were received from all countries and are being used to finalize the Regional and WHO Global reports for 29. In five countries in the Region, drug resistance surveys were conducted or will continue through 28-29, to assess the extent of anti-tb drug resistance among TB patients. The overall rates of multi-drug resistant TB (MDR-TB) in the Region is 2.8% among new smear-positive patients and 18.8% among previously treated patients. Surveillance for HIV prevalence among TB patients is undertaken routinely in Thailand and in nine states in India. In Myanmar, Nepal, Sri Lanka and in the remaining states and union territories in India, data from sentinel surveys are used to follow trends in HIV prevalence among TB patients. These surveys are contributing to more accurate estimations of the burden of disease. At the same time, countries are beginning to focus on mechanisms that will ensure that routine case notifications begin to reflect the disease magnitude and trends. Data management software was upgraded in Myanmar and Nepal and further improvements made in the Windows-based EPI centre software in India. Training on data management and analysis for central and international level programme staff were conducted in Bangladesh, India, Myanmar and Thailand. The practice of quarterly and annual internal reviews and larger joint reviews every two/three years, inviting international experts for joint monitoring and evaluation together with national programmes and partners was continued. These have helped to objectively review the performance of the respective national TB programmes, and lead to substantial improvements in programme performance. 4.6 Resources Domestic funding for TB control continues to account for over half of the funding for national TB control programmes. By the end of 28, a total of 23 proposals were approved by the Global Fund in support of TB control programmes in the Region. In addition, nine Member countries benefit from funds from other development partners and donor governments with the exception of Bhutan and Maldives where the only external funds are through WHO country budgets. 23

35 All 11 Member countries continue to access quality-assured affordable anti-tb drugs on a regular basis through grants or direct procurement services of the Global Drug Facility. 4.7 Operational Research National TB programmes and partners are engaged in carrying forward several operational research projects. Examples are public-private mix (PPM) models in India and Indonesia; field testing of new diagnostics and shorter treatment regimens in India; approaches to community-based TB care in Bangladesh, India, Indonesia, Thailand and Timor-Leste. In addition, some support continues to be received through the small grants scheme under TDR. National workshops on operations research priority setting and dissemination are held regularly in India. 24

36 5 WHO support in the Region 5.1 Technical assistance All 11 countries in the Region continue to receive technical assistance through the WHO Regional office and country offices, and international technical partners, namely, CDC, International Centre for Veterinary and Medical Sciences (IVMS), Royal Foundation for Tuberculosis in the Netherlands (KNCV), Institute of Tropical Medicine (ITM, Belgium), the Union and a few independent consultants recruited through WHO and the three WHO Collaborating Centres, namely, the National TB Institute, (NTI) and TB Research Centre, (TRC) in India, and the SAARC TB and HIV/AIDS Centre in Nepal. Technical partners in countries in the Region also provided technical assistance during the year. Technical support missions were undertaken to all 11 Member countries during the year to provide assistance to national programmes in various areas, including laboratory assessments and laboratory capacity building, to establish MDR-TB and TB-HIV interventions, improve drug procurement and supply management, data management, and undertake impact assessments. Countries have also been assisted in developing these measures to address vulnerable populations at higher risk and cross-border areas and including them in their national plans for TB control and GF applications. Combined missions by staff from the HIV/AIDS, TB and Malaria units at WHO/SEARO were instituted from January 28 to review and plan next steps relating to WHO support to the national programmes and these were undertaken to Bangladesh, Bhutan, and Nepal during

37 The increase in funding for TB control in countries has generated a manifold increase in the demand for technical assistance. In this context, a global mechanism, the TB Technical Assistance Mechanism (TBTEAM) aimed at better coordination of technical assistance to countries has been developed by WHO/HQ, through joint efforts with all six WHO Regions and technical partners over the past year. A roster of experts who could potentially provide technical assistance to countries in various areas has been developed and all proposed technical assistance missions to countries mapped, with the aim of deploying suitable consultants to meet the technical assistance requirements of countries. This will also serve to facilitate seeking additional funding from the Global Fund or financial partners for the necessary technical assistance. 5.2 Strengthening national laboratory networks Technical assistance, coordinated through WHO, is being provided through the supra-national reference laboratories (SNRLs) based at the Institute of Medical and Veterinary Science (Australia), Institute of Tropical Medicine (Belgium), Central Reference Laboratory, Gauting (Germany), and the Tuberculosis Research Centre (India), to help establish culture and drug susceptibility testing (DST) facilities in countries in a phased manner, in line with national plans. Additional technical assistance requirements to support these plans have been identified. Nine countries have formally established linkages with SNRLs; Bhutan and Sri Lanka are in the process of being linked to the network of the SNRLs. Laboratory staff from several Member countries were trained in the management of TB laboratories, quality assurance, mycobacterial culture techniques, and drug susceptibility testing at an inter-country workshop held at the SNRL at Bangkok, supported by the Union in Capacity building, information exchange Training, exchange of information, and in-country technical support for policy formulation, guideline development and monitoring have been the key areas of work for WHO/SEARO and country office staff during the past year. Considerable attention and support was provided in the areas of strengthening laboratories and scaling up the management of TB-HIV and of MDR-TB. The regional and country offices have supported facilitation of national level training as well as training held at the three WHO collaborating centres, particularly the SAARC TB and HIV Centre. Modules on leadership and strategic management developed at SEARO were distributed to all countries. Several national programmes have 26

38 made use of these for training central and intermediate level staff. The WHO collaborative centres, the National TB Institute, Bangalore and the SAARC TB-HIV Center, Kathmandu, are also using these modules in their training and fellowship programmes. A regional workshop on planning and budgeting for TB control programmes was organized in Indonesia in April 28 for 1 out of the 11 Member countries in the Region. A regional workshop on health systems strengthening and TB control was held in Sri Lanka in August 28 and the annual Programme Managers meeting in the Maldives, in December 28. Study tours and exchange visits, between countries to learn from best practices, were also supported. 5.4 Resource mobilization Eight Member countries were benefiting from funds mobilized from the Global Fund as of the end of 28. Countries applying during the Round 8 GF call for applications were assisted in preparing proposals, and preparatory work to help countries applying during Round 9 has begun. Several Member countries were also assisted in mobilizing resources from other development partners and donor governments. Five workshops on GF grant negotiation and implementation, proposal writing, monitoring and evaluation, procurement and supply management and resubmission were organized together with the Global Fund staff during 28. A meeting of donors was held in Myanmar in December 28 to help resolve the acute crisis in funding for first-line drugs in Myanmar beyond 29, when the grants through GDF will come to an end. Additional funds for technical assistance to countries is being sourced through OGAC, funded through USAID. Some funding also continued through Stop TB at WHO/HQ, for organizing the recently-held regional workshops on planning and budgeting, TB and health systems strengthening and to support some staff working on TB in the Region. 5.5 Ensuring regular supplies of drugs and improving procurement and supply management All 11 countries were assisted in continuing to access quality-assured affordable anti-tb drugs on a regular basis either through grants or the direct procurement 27