Global tuberculosis report

215 Globl tuberculosis report

WHO Librry Ctloguing-in-Publiction Dt Globl tuberculosis report 215. 1.Tuberculosis epidemiology. 2.Tuberculosis, Pulmonry prevention nd control. 3.Tuberculosis economics. 4.Tuberculosis, Multidrug-Resistnt. 5.Annul Reports. I.World Helth Orgniztion. ISBN 978 92 4 15655 9 (NLM clssifiction: WF 3) World Helth Orgniztion 215 All rights reserved. Publictions of the World Helth Orgniztion re vilble on the WHO website (www.who.int) or cn be purchsed from WHO Press, World Helth Orgniztion, 2 Avenue Appi, 1211 Genev 27, Switzerlnd (tel.: +41 22 791 3264; fx: +41 22 791 4857; e-mil: bookorders@who.int). Requests for permission to reproduce or trnslte WHO publictions whether for sle or for non-commercil distribution should be ddressed to WHO Press through the WHO website (www.who.int/bout/licensing/copyright_form/en/index.html). The designtions employed nd the presenttion of the mteril in this publiction do not imply the expression of ny opinion whtsoever on the prt of the World Helth Orgniztion concerning the legl sttus of ny country, territory, city or re or of its uthorities, or concerning the delimittion of its frontiers or boundries. Dotted nd dshed lines on mps represent pproximte border lines for which there my not yet be full greement. The mention of specific compnies or of certin mnufcturers products does not imply tht they re endorsed or recommended by the World Helth Orgniztion in preference to others of similr nture tht re not mentioned. Errors nd omissions excepted, the nmes of proprietry products re distinguished by initil cpitl letters. All resonble precutions hve been tken by the World Helth Orgniztion to verify the informtion contined in this publiction. However, the published mteril is being distributed without wrrnty of ny kind, either expressed or implied. The responsibility for the interprettion nd use of the mteril lies with the reder. In no event shll the World Helth Orgniztion be lible for dmges rising from its use. Designed by minimum grphics Cover designed by Irwin Lw Printed in Frnce WHO/HTM/TB/215.22 ii n GLOBAL TUBERCULOSIS REPORT 215

Contents Abbrevitions Acknowledgements Prefce Executive summry 1 Chpter 1. Introduction 5 Chpter 2. Disese burden nd 215 trgets ssessment 8 Chpter 3. TB cse notifictions nd tretment outcomes 36 Chpter 4. Drug-resistnt TB 54 Chpter 5. Dignostics nd lbortory strengthening 69 Chpter 6. Addressing the co-epidemics of TB nd HIV 78 Chpter 7. Finncing 87 Chpter 8. Reserch nd development 15 Annexes 1. Access to the WHO globl TB dtbse 117 2. Country profiles for 22 high-burden countries 123 3. Regionl profiles for 6 WHO regions 147 4. Key TB indictors for individul countries nd territories, WHO regions nd the world 155 iv v ix GLOBAL TUBERCULOSIS REPORT 215 n iii

Abbrevitions ART ARV BCG BRICS CDR CHMP CI CPT CTD CROI CRS DST EMA EQA FDA FIND GDP GHE HBC HIV HVTN IDRI IGRA IMPAACT IPT LED LF-LAM LPA LTBI MDGs MDR-TB NAAT ntiretrovirl therpy ntiretrovirl (drug) Bcille-Clmette-Guérin Brzil, Russin Federtion, Indi, Chin, South Afric cse detection rtio Committee for Medicinl Products for Humn Use confidence intervl co-trimoxzole preventive therpy Centrl TB Division (Indi) Conference on Retroviruses nd Opportunistic Infections creditor reporting system drug susceptibility testing Europen Medicines Agency externl qulity ssessment US Food nd Drug Administrtion Foundtion for Innovtive New Dignostics gross domestic product government helth expenditures high-burden country humn immune-deficiency virus HIV Vccine Trils Network Infectious Disese Reserch Institute interferon gmm relese ssys Interntionl Mternl Peditric Adolescent AIDS Clinicl Trils Group isonizid preventive therpy light-emitting diode microscopy urine lterl flow liporbinomnnn line probe ssy ltent TB infection Millennium Development Gols multidrug-resistnt TB nucleic cid mplifiction test NHA NHI NIAID NRL NTP OBR OECD OOP PK PMDT PPM RNTCP RR-TB SDGs SMS SRL SRL-CE TAG TB TBTC TBVI TPP TST UHC UNAIDS USAID VR WHA WHO XDR-TB ZN Ntionl Helth Account ntionl helth insurnce US Ntionl Institute of Allergy nd Infectious Diseses ntionl reference lbortory ntionl TB progrmme optimized bckground regimen Orgniztion for Economic Coopertion nd Development out-of-pocket phrmcokinetic progrmmtic mngement of drugresistnt TB public-privte mix Revised Ntionl Tuberculosis Control Progrmme (Indi) rifmpicin-resistnt TB Sustinble Development Gols short messging services Suprntionl Reference Lbortory SRL Ntionl Centres of Excellence Tretment Action Group tuberculosis TB Tril Consortium Tuberculosis Vccine Inititive trget product profile tuberculin skin test universl helth coverge Joint United Ntions Progrmme on HIV/ AIDS US Agency for Interntionl Development vitl registrtion World Helth Assembly World Helth Orgniztion extensively drug-resistnt TB Ziehl-Neelsen iv n GLOBAL TUBERCULOSIS REPORT 215

Acknowledgements This globl TB report ws produced by core tem of 19 people: Lur Anderson, Ann Den, Dennis Flzon, Ktherine Floyd, Inés Grci Ben, Christopher Gilpin, Philippe Glziou, Yohhei Hmd, Tom Hitt, Avinsh Knchr, Irwin Lw, Christin Lienhrdt, Linh Nguyen, Andrew Sirok, Chrlmbos Sismnidis, Ln Syed, Hzim Timimi, Wyne vn Gemert nd Mtteo Zignol. The tem ws led by Ktherine Floyd. Overll guidnce ws provided by the Director of the Globl TB Progrmme, Mrio Rviglione. The dt collection forms (long nd short versions) were developed by Philippe Glziou nd Hzim Timimi, with input from stf f 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, Annemieke Brnds, Andre Brz, Dennis Flzon, Inés Grci Ben, Giulino Grgioni, Mede Gegi, Yohhei Hmd, Avinsh Knchr, Soleil Lbelle, Irwin Lw, Fud Mirzyev, Linh Nguyen, Andrew Sirok, Ln Syed, Hzim Timimi, Mukund Uplekr, Wyne vn Gemert nd Mtteo Zignol t WHO hedqurters; Tom Hitt from the Western Pcific Regionl Office; Ann Scrdigli, Ymil Silv Cbrer, Ezr Tesser, Eliud Wndwlo nd Mohmmed Yssin from the Globl Fund; nd Andre Pntoj (consultnt). Dt for the Europen Region were collected nd vlidted jointly by the WHO Regionl Of fice for Europe nd the Europen Centre for Disese Prevention nd Control (ECDC); we thnk in prticulr Encrn Gimenez, Vhur Hollo nd Csb Ködmön from ECDC for providing vlidted dt files nd Andrei Ddu from the WHO Regionl Of fice for Europe for his substntil contribution to follow-up nd vlidtion of dt for ll Europen countries. UNAIDS mnged the process of dt collection from ntionl AIDS progrmmes nd provided ccess to their TB/HIV dtset. Review nd vlidtion of TB/HIV dt ws undertken in collbortion with Theres Bbovic nd Michel Beusenberg from the WHO HIV deprtment, long with UNAIDS hedqurters, regionl nd country strtegic informtion dvisers. Mny people contributed to the nlyses, preprtion of figures nd tbles, nd writing required for the min chpters of the report. Chpter 2 (TB disese burden nd 215 trgets ssessment) ws prepred by Ktherine Floyd, Philippe Glziou nd Chrlmbos Sismnidis, with contributions from Lur Anderson, Tom Hitt, Irwin Lw nd Ikushi Onozki. Chpter 3, on TB notifictions nd tretment outcomes s well s the tretment of ltent TB infection, ws prepred by Ktherine Floyd, Hileyesus Gethun, Yohhei Hmd, Tom Hitt, Alberto Mtteelli, Aniss Sidibe, Ln Syed nd Mukund Uplekr, with contributions from Hnnh Monic Dis, Dennis Flzon, Achutn Sreenivs nd Hzim Timimi. Chpter 4, on drug-resistnt TB, ws prepred by Ann Den, Dennis Flzon, Linh Nguyen nd Mtteo Zignol, with input from Ktherine Floyd, Chrlmbos Sismnidis nd Krin Weyer. Chpter 5, on TB dignostics nd lbortory strengthening, ws prepred by Wyne vn Gemert, with input from Christopher Gilpin, Fud Mirzyev nd Krin Weyer. Chpter 6, on the co-epidemics of TB nd HIV, ws prepred by Ktherine Floyd, Hileyesus Gethun, Yohhei Hmd, Tom Hitt nd Avinsh Knchr, who re lso grteful to Bhrt Rewri for his contribution to Box 6.1. Chpter 7, on TB finncing, ws prepred by Ktherine Floyd, Inés Grci Ben nd Andrew Sirok. Chpter 8, on TB reserch nd development, ws prepred by Christin Lienhrdt (new TB drugs nd new TB vccines) nd Christopher Gilpin (new TB dignostics), with input from Krin Weyer nd Ktherine Floyd. Tom Hitt coordinted the finliztion of figures nd tbles for ll chpters nd ws the focl point for communictions with the grphic designer. Irwin Lw designed the report cover nd lso coordinted the review nd correction of proofs. 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 Michel Beusenberg, Theres Bbovic nd Jesus Mri Grci Cllej from the HIV deprtment in WHO nd collegues from UNAIDS for their creful review of Chpter 6; nd to Dniell Cirillo nd Tom Shinnick (new TB dignostics), Cherise Scott nd Mel Spigelmn (new TB drugs) nd Jonthn Dniels, Jennifer Woolley nd Tom Evns (new TB vccines) for their reviews of nd input to Chpter 8. Annex 1, which explins how to use the online globl TB dtbse, ws written by Hzim Timimi. The country profiles tht pper in Annex 2, the regionl profiles tht pper in Annex 3 nd the detiled tbles showing dt for key indictors for ll countries in the ltest yer for which informtion is vilble (Annex 4) were lso prepred by Hzim Timimi. The online technicl ppendix tht explins the methods used to estimte the burden of disese cused by TB (incidence, prevlence, mortlity) ws prepred by Philippe Glziou, with input from Ann Den, Crel Pretorius, Chrlmbos Sismnidis nd Mtteo Zignol. We thnk Colin Mthers of the WHO Mortlity nd Burden of Disese tem for his creful review. We thnk Pmel Billie in the Globl TB Progrmme s monitoring nd evlution unit for impeccble dministr- GLOBAL TUBERCULOSIS REPORT 215 n v

tive support, Doris M Ft from the WHO Mortlity nd Burden of Disese tem for providing TB mortlity dt extrcted from the WHO Mortlity Dtbse, nd UNAIDS for providing epidemiologicl dt tht were used to estimte HIV-ssocited TB mortlity. The entire report ws edited by Srh Glbrith-Emmi, who we thnk for her excellent work. We lso thnk, s usul, Sue Hobbs for her excellent work on the design nd lyout of this report. Her contribution, s lwys, ws very highly pprecited. The principl source of finncil support for WHO s work on globl TB monitoring nd evlution is the United Sttes Agency for Interntionl Development (USAID), without which it would be impossible to produce the Globl Tuberculosis Report. Production of the report ws lso supported by the governments of Jpn nd the Republic of Kore. We cknowledge with grtitude their support. In ddition to the core report tem nd those mentioned bove, the report benefited from the input of mny stf f working in WHO regionl nd country of fices 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 stf f not lredy mentioned bove, we thnk in prticulr Ann Volz, Mirth Del Grndo, Khurshid Alm Hyder, Rfel López Olrte, Nobu Nishikiori, André Ndongosieme, Kefs Smson, Krm Shh, nd Henriette Wembnym for their mjor contribution to fcilittion of dt collection, vlidtion nd review. WHO stf f in regionl nd country of fices WHO Africn Region Boubcr Abdel Aziz, Abdoulye Mrim Bïss, Esther Aceng-Dokotum, Hrur Admu, Incio Alvreng, Smuel Herms Andrinriso, Jvier Armburu, Cludin Augusto d Cruz, Ayodele Awe, Nyé Bh, Mrie Ctherine Broun, Bbou Bzie, Sirimn Cmr, Mlng Coly, Dvi Kokou Mwule, Ev De Crvlho, Noel Djemdji, Sithembile Dlmini-Nqeketo, Ismel Hssen Endris, Louis Gnd, Boingotlo Gsennelwe, Crolin Crdoso d Silv Gomes, Ptrick Hzngwe, Télesphore Hounsou, Jeuronlon Moses Kerkul, Michel Jose, Joel Kngngi, Nzuzi Ktondi, Kss Hilu Ketem, Khelifi Houri, Dniel Kibug, Hillry Kipruto, Aristide Désiré Komngoy Nzonzo, Ktherine Lo, Shrmil Lreef-Jh, Mwendweli Mboshe, Leonrd Mbemb, Mbumb Ngimbi Richrd, Julie Mugbekzi, Christine Musnhu, Ahmd NssuriI, Andre Ndongosieme, Denise Nkezimn, Wilfred Nkhom, Nicols Nkiere, Abel Nkolo, Ghisline Nkone Asseko, Ishmel Nysulu, Lurence Nyirmsrbwe, Smuel Ogiri, Dniel Olusoti, Amos Omoniyi, Hermnn Ongouo, Chijioke Oskwe, Felici Owusu-Antwi, Philip Ptrobs, Klpesh Rhevr, Hrill Nirin Rzkso, Richrd Oleko Rehn, Kefs Smson, Bbtunde Snni, Neem Gideon Simkoko, Susn Zimb-Tembo, Trore Tieble, Dest Tiruneh, Hubert Wng, Henriette Wembnym, Addislem Yilm, Assefsh Zehie. WHO Region of the Americs Jen Seme Alexndre, Monic Alonso Gonzlez, Pedro Avedillo, Crlos Ayl, Jen Seme Fils Alexndre, Angel Mnuel Alvrez, Miguel Angel Argón, Denise Arkki, Pedro Avedillo, Eldonn Boisson, Gustvo Brets, Mrgrette Bury, Dvid Chvrri, Betriz Cohenc, Mirth del Grndo, This dos Sntos, Mrcos Espinl, Ingrid Grcí, Yitdes Gebre, Mssimo Ghidinelli, Guillermo Gonzlvez, Percy Hlkyer, Kthryn Johnston, Sndr Jones, Frncisco Leon Brvo, Rfel Lopez Olrte, Roberto Montoy, Romeo Montoy, Enrique Perez, Soledd Pérez, Giovnni Rvsi, Jen Mrie Rwngbwob, Hns Sls, Alfonso Tenorio, Jorge Victori, Mrcelo Vil, Ann Volz. WHO Estern Mediterrnen Region Mohmed Abdel Aziz, Rehb Abdelhi, Ali Akbr, Smih Bghddi, Mi Eltigny Mohmmed, Kkr Qutubuddin, Ali Rez Aloudel, Sindni Ireneus Sebit, Syed Krm Shh, Bshir Suleimn, Rhim Tghizdeh. WHO Europen Region Andrei Ddu, Msoud Dr, Jmshid Gdoev, Dmitriy Pshkevich, Bogdn Shcherbk-Verln, Szbolcs Szigeti, Gzmend Zhuri. WHO South-Est Asi Region Mohmmd Akhtr, Vikrunnes Begum, Mri Regin Christin, Erwin Cooremn, Mrtin Dwihrdini, Md Khurshid Alm Hyder, Nvrtnsingm Jnkn, Kim Kwng Jin, Prth Prtim Mndl, Gimpolo Mezzbott, O Hyng Song, Mlik Prmr, Poknevych Igor, Rnjni Rmchndrn, Rim Kwng Il, Mukt Shrm, Achuthn Nir Sreenivs, Sber Sultn, Nmgy Tshering, Lungten Wngchuck. vi n GLOBAL TUBERCULOSIS REPORT 215

WHO Western Pcific Region Ahmdov Shll, Lur Gillini, Lepiti Hnsell, Corneli Hennig, Tom Hitt, Tuhid Islm, Nrntuy Jdmb, Ridh Jebenini, Woo-Jin Lew, Nobuyuki Nishikiori, Ktsunori Osug, Khnh Phm, Fbio Scno, Jcques Sebert, Mthid Thongseng, Ynni Sun, Rjendr-Prsd Ydv. Ntionl respondents who contributed to reporting nd verifiction of dt WHO Africn Region Mohmed Khirou Abdllhi Troré, Oumr Abdelhdi, Abderrmne Abdelrhim, Aben Foe Jen Louis, Kwmi Afutu, Gbriel Akng, Sofine Alihlss, Arlindo Tomás do Amrl, Rosmunde Amuteny, Angonou Séverin, Andrinsolo Lzso Rdonirin, Assoumni Younouss, Georges Bksw Ntmbwe, Bllé Boubkr, Adm Mrie Bngour, Jorge Brreto, Wilfried Bekou, Serge Bisut Fuez, Frnk Ade Bonsu, Miguel Cmrá, Evngelist Chiskitw, Amdou Cissé, Abdoul Krim Coulibly, António Rmos d Silv, Isis Dmbe, Dikite Aïch, Aw Helene Diop, Mrie Srr Diouf, Themb Dlmini, Sicelo Smuel Dlmini, Antoine Etoundi Evoun, Jun Eyene Acuresil, Lynd Fory, Gilberto Frot, Gsn Evriste, Michel Gsn, Abu George, Belineh Girm, Amnuel Hdegu Mebrhtu, Boukoulmé Hing, Hinikoye Aou Him Oumrou, Adm Jllow, Sf f Kmr, Mdou Kne, Knyerere Henry Shdreck, Nthn Kpt, Kesselly Deddeh, Botshelo Tebogo Kgwdir, Fnnie Khumlo, Désiré Aristide Komngoy Nzonzo, Ptrick Konwloh, Koukou Jcquemin, Andrgchew Kums, Kuye Joseph Oluwtoyin, Joseph Lsu, Gertrude Ly Ofli, Thoms Dougls Lere, Joseph Lou, Llng Mm-Mime, Jocelyn Mhoumbou, Lerole Dvid Mmetj, Ivn Mnhiç, Tseliso Mrt, Enos Msini, Fri Mvhung, Agnès Mezene, Slem Mohmeden, Louine Morel, Youwog Isidore Moyeng, Mpung Jmes Upile, Mry Mudiope, Frnk Mugbe Rwbinumi, Clif ford Munyndi, Betrice Mutyob, Lindiwe Mvusi, Aboubcr Mzembb, Fulgence Ndyikengurukiye, Thddée Ndikumn, Fith Ngri, Ngoulou Antoine, Lourenço Nhocun, Emmnuel Nkiligi, Adolphe Nkou Bikoe, Nii Nortey, Gérrd Nthizniye, Frnck Hrdin Okemb-Okombi, Emile Rkotondrmnn, Mrtin Rkotonjnhry, Thto Rleting, Rnivomhef Myrienne Bkoliriso Znjohry, Mohmmed Fezul Rujeedw, Agbenyegn Smey, Chrles Sndy, Kebb Snneh, Tndogo Soudogo, Emilie Srr Seck, Nichols Sizib, Kte Schnippel, Celestino Frncisco Teixeir, Gebreyesus Rhw Tekle, Kssim Trore, Eucher Dieudonné Yzipo, Eric Ismël Zoungrn. WHO Region of the Americs Rosmond Adms, Srit Aguirre Grcí, Shluddin Ahmed, Vlentin Antoniet Alrcon Guizdo, Xochil Alemán de Cruz, Kirn Kumr All, Mirin Alvrez, Aish Andrewin, Alister Antoine, Chris Archibld, Crlos Ayl Lun, Wiedjipreksh Blesr, Drurio Brreir, Ptrici Brtholomy, Beltrme Soledd, Dorothe Bergen Weichselberger, Mrí del Crmen Bermúdez Perez, Mrt Isbel Clon de Abrego, Mrtín Cstellnos Joy, Jorge Cstillo Crbjl, Annbell Cedeño Uglde, Krolyn Chong Cstillo, Eric Commiesie, Crlos Cruz, Ofeli Cuevs, Cecili de Arngo, Nild de Romero, Cmille Deleveux, Dy-Jun DeRoz, Khn Din, Luz Mrin Duque, Mercedes Espñ Cedeño, Alish Eugene, Sntigo Fdul, Fernndez Hugo, Cecili Figuero Benites, Gret Frnco, Victor Gllnt, Julio Gry Rmos, Izzy Gerstenbluth, Normn Gil, Mrgrit Godoy, Roscio Gomez, Betriz Gutierrez, Yskr Hlbi, Dorothe Hzel, Mri Henry, Tni Herrer, Crl Jeffries, Olg Joglr Jusino, Trcy- Ann Kernnet-Huggins, Athelene Linton, Cludi Lleren, Eugène Mduro, Andre Mldondo Svedr, Mrvin Mnznero, Belkys Mrcelino, Mrrero Figuero Antonio, Mrí de Lourdes Mrtínez, Zeidy Mt Azofeif, Timothy McLughlin-Munroe, Angelic Medin, Monic Mez, Roque Mirmontes, Leilwti Mohmmed, Jeetendr Mohnlll, Ernesto Moreno, Frncis Morey, Willy Morose, Denis Dnny Mosqueir Sls, Alice Neymour, Andres Oyol, Cheryl Peek-Bll, Toms Portillo, Ird Potter, Robert Prtt, Edwin Antonio Quiñonez Villtoro, Mnohr Singh Rjmnickm, Dottin Rmoutr, Ann Esther Reyes Godoy, Pul Ricketts, Rincon Andres, Cielo Rios, Dvid Rodriguez, Jorge Rodriguez De Mrco, Mrcel Rojs, Myrin Román, Monic Rondon, Arelisbel Ruiz, Wilmer Slzr, Hild Mrí Slzr Bolños, Mritz Smyo Peláez, Jon Simon, Nicol Skyers, Ntli Sos, Din Sotto, Stijnberg Deborh, Jckurlyn Sutton, Ariel Antonio Torres Rodríguez, Mribelle Tromp, Willim Turner, Meliss Vldez, Din Vrgs, Dniel Vázquez, Nestor Ver, Jun Jose Victori, An Mrí Vinuez, Michel Willims, Oritt Zchrih. WHO Estern Mediterrnen Region Njib Abdulziz Abdullh, Mohmmd Abouzeid, Khled Abu Rummn, Abu Sbrh Ndi, Ahmdi Shhnz, Abdul Ltif Al Khl, Mohmmed Redh Al Lwti, Al Sidi Khlood, Rshid Alhddry, Abdulbri Al-Hmmdi, Reem Alsifi, Kifh ALshqeldi, Wgdy Amin, Ngi Awd, Bhnsy Smir, Bennni Kenz, Molk Bouin, Swsen Boussett, Wlid Doud, Rchid Fourti, Mohmed Furjni, Aml Gll, Dhikryet Gmr, Assi Hissm, Klthoom Hssn, Abu Bkr Ahmd Hssn, Hw Hsssn Guessod, Slm Hudi, Bshrt Khn, Syed Doud Mhmoodi, Slh Ben Mnsour, Mulhm Mustf, Nsehi Mhshid, Ejz Qdeer, Mohmmd Khlid Seddiq, Sghir Mohmmed, Tmr Tyeb, Mohemmed Tben, Ycoub Him, Ammr Zidn. GLOBAL TUBERCULOSIS REPORT 215 n vii

WHO Europen Region Tleukhn Abildev, Ibrhim Abubkr, Alikhnov Ntvn, Ekkehrdt Altpeter, Elen Andrds Argonés, Delphine Antoine, Trude Mrgrete Arnesen, Andrei Astrovko, Zz Avlini, Avzbek Jlolov, Velimir Bereš, Yn Besstrschnov, Thorsteinn Blöndl, Oktm Bobokhojev, Bojovic Oliver, Snježn Brcklo, Bonit Brodhun, Ann Crgli, Aysoltn Chryev, Dniel Chemtob, Domnic Ion Chiotn, An Ciobnu, Nico Ciorn, Thierry Comolet, Rdmil Curcic, Edit Dvidvicene, Hyk Dvtyn, Gerrd de Vries, Irène Demuth, Antonio Diniz, Rquel Durte, Mlden Duronjic, Lnfrnco Fttorini, Lyly Gbbsov, Gsimov Viktor, Mjlind Gjocj, Lrus Jon Gudmundsson, Genndy Gurevich, Wlter Hs, Armen Hyrpetyn, Peter Helbling, Ilievsk-Poposk Biljn, Srh Jckson, Jkelj Andrz, Jonsson Jerker, Erhn Kbskl, Abdullt Kdyrov, Dmitriy Klimuk, Mri Korzeniewsk-Kosel, Kosnik Mitj, Kovcs Gbor, Meve Llor, Yn Levin, Irin Lucenko, Ekterin Mliukov, Donik Mem, Violet Mihilovic-Vucinic, Usmon Mihmnov, Vldimir Milnov, Uch Nnv, Anne Negre, Ntli Nizov, Zdenk Novkov, Jon O Donnell, Anlit Pce Ascik, Clr Plm Jordn, Olg Pvlov, Sbine Pfeiffer, Mri Grzi Pomp, Georget Gild Popescu, Kte Pulmne, Bozidrk Rkocevic, Vij Riekstin, Jerome Robert, Elen Rodríguez-Vlín, Krin Rønning, Kzimierz Roszkowski-Sliz, Gerrd Scheiden, Firuze Shripov, Aleksndr Simunovic, Cthrine Slorbk, Erik Slump, Hnn Soini, Ivn Solovic, Petr Svetin Sorli, Sergey Sterlikov, Jn Svecov, Tillyshykhov Mirzgleb, Shhnoz Usmonov, Tonk Vrlev, Piret Viiklepp, Kte Vulne, Jiri Wllenfels, Wnlin Mryse, Pierre Weicherding, Aysegul Yildirim, Zkosk Mj, Zsrnoczy Istvn, Hsn Žutic. WHO South-Est Asi Region Shin Ahmed, Aminth Aroosh, Si Thu Aung, Rtn Bhttri, Choe Tong Chol, Lurindo d Silv, Triy Novit Dinihri, Sulistyo Epid, Emddul Hque, Jittimnee Sirinph, Nirj Kulshresth, Myo Su Kyi, Biksh Lmichhne, Prmil Liynge, Consttino Lopes, Md. Mojibur Rhmn, Md. Mozzmel Hque, Nmwt Chwetsn, Nirup Pllewtt, Kirnkumr Rde, Chewng Rinzin, Sudth Smrweer, Gmini Senevirtne, Jnk Thilkrtne, Christin Widningrum, Biml Ydv. WHO Western Pcific Region Mohd Rotpi Abdullh, Pul Ai, Cecili Teres Arcig, Zirwtul Adilh Aziz, Mhfuzh Mohmd Azrnyi, Puntsg Bnzrgch, Christin Brej, Cheng Shiming, Phonenly Chittmny, Chou Kuok Hei, Nese Ituso Conwy, Jne Dowbobo, Myleen Ekiek, Fni Sen, Florence Flment, Ludovic Floury, Jiloris Frederick Dony, Ann Mrie Celin Grfin, Donn Me Gviol, Go Un-Yeong, Shkti Gounder, Neti Hermn, Anie Hryni Hj Abdul Rhmn, Dniel Houillon, Hjime Inoue, Noel Itogo, Tom Jck, Kng He-Young, Seiy Kto, Khin Mr Kyi Win, Dniel Lmr, Leo Lim, Liz Lopez, Skius Minwll, Henri-Pierre Mllet, Mo Tn Eng, Andre McNeill, Serfi Mo, Grizeld Mokoi, Nguyen Viet Nhung, Nguyen Binh Ho, Nou Chnly, Connie Olikong, Dorj Otgontsetseg, Sosi Penitni, Nukutu Pokur, Mrcelin Rbulimn, Asmh Rzli, Berek Reiher, Ris Bukbuk, Bernrd Rouchon, Temilo Seono, Hidekzu Shimd, Vit Skilling, Grnt Storey, Phnnsinh Sylvnh, Tgro Mrkleen, Tm Cheuk Ming, Silivi Tvite, Kyw Thu, Tieng Sivnn, Toms Cindy, Tong K Io, Alfred Tongnibei, Kzuhiro Uchimur, Kzunori Umeki, Lixi Wng, Yee Tng Wng, Du Xin. viii n GLOBAL TUBERCULOSIS REPORT 215

Prefce Dr Mrio Rviglione At meeting of stkeholders nd donors to the Globl TB Progrmme held in Oslo in September 1995, key discussion point relted to the need to monitor progress towrds globl trgets set in 1991 by the World Helth Assembly. The trgets the populr 7% cse detection rte nd 85% cure rte for new cses of smer-positive pulmonry TB were to be reched by 2. At the time of the meeting, no stndrdized globl monitoring system existed. While cler definitions of TB cses nd tretment outcomes were key components of WHO s then-new globl TB strtegy DOTS the only dt vilble to ssess trends in the disese cme from the epidemiologicl bulletins of better-of f countries nd occsionl d-hoc reports from low-income countries following reviews nd monitoring missions. Since TB is primrily disese of poor countries, this ws not good enough for the influentil people meeting in Oslo. Their request cme loud nd cler: WHO should strt immeditely to develop system tht would request ll Member Sttes to report essentil informtion on TB notifictions nd tretment outcomes, so tht progress or lck of progress could be monitored nd discussed t their next meeting. Though globl trgets hd been set in 1991, it nevertheless took four yers before such system ws recognized s necessity: this ws not yet the er of precision, ccountbility, nd evidence-bsed evlution. Since only couple of other progrmmes hd developed such systems by then, the field of TB ws mong the pioneers in this endevour. As result of the discussions in Oslo, Dr Art Kochi, then the Director of the Globl TB Progrmme, sked me to move quickly to crete globl monitoring nd evlution system tht would stisfy the request. Exctly 2 yers go, in October 1995, I strted setting up tem composed of hndful of people chrged with globlizing the locl recording nd reporting system recommended within the DOTS strtegy. Tht strtegy ws bsed on the model progrmmes tht Dr Krel Styblo hd developed in severl countries where the KNCV Tuberculosis Foundtion nd the Union were implementing modern TB control efforts. During severl months of intensive work, we creted dtbse nd stndrd dt collection form (in pper nd electronic formts) tht ws distributed to ll Member Sttes. By the summer of 1996, most countries hd provided informtion to WHO Hedqurters using stndrdized definitions so tht dt from one country could be compred esily with dt from nother. For the first time, we could ssess globl progress towrd the 2 trgets. The results were presented t the September 1996 meeting of donors nd other stkeholders. They showed tht fewer thn 2% of ll cses estimted worldwide were being detected nd tht the globl cure rte ws less thn 8%. In the following yers, our globl monitoring nd evlution system for TB evolved further, with the inclusion of dditionl informtion nd more sophisticted nlyses. For exmple, our tem led first by Dr Christopher Dye nd lter by Dr Ktherine Floyd GLOBAL TUBERCULOSIS REPORT 215 n ix

begn to monitor the finncing of TB control to ssess whether Member Sttes were investing s required. Lter, we integrted dt from the drug resistnce surveillnce system to enble us to ssess comprehensively ll the key indictors needed to monitor progress nd to identify nd correct problems. Our tem, under the guidnce of Dr Philippe Glziou, developed more precise estimtes of the burden of TB, improving the methodology to mesure incidence, prevlence nd mortlity. In prticulr, since 26, concerted ef forts hve been guided by the WHO Globl Tsk Force on TB Impct Mesurement, resulting in substntilly incresed dt from ntionl TB prevlence surveys nd much greter use of mortlity dt from vitl registrtion systems. As result of these ef forts, 2 yers lter, we re ble to judge firly precisely the sttus of the epidemic nd the response of Member Sttes. We cn ssess where people with TB re missing from notifiction systems; where cure rtes remin low nd filure rtes re high; where multidrug- resistnt TB is serious issue; nd where domestic funding must be complemented by interntionl finncing. None of this ws possible in 1995. We re now entering the er of the Sustinble Development Gols, in which prdigm shif ts re expected in ll sectors, including helth. TB is n infectious disese tht, despite ll progress, clims number of deths prlleled only by those from HIV/ AIDS. To end the epidemic (defined s n incidence of fewer thn 1 cses per million people) by 235 will require rpid upgrde of cre nd mngeril stndrds. During the next 2 yers, we will need to chnge our mentlity nd dopt ll ef fective innovtions, including those exploiting digitl technology, especilly in the relm of informtion mngement. Novel wys of dignosing nd reporting lredy exist nd their doption will help us evolve further towrds interventions tht re more userfriendly, cheper nd more sustinble. If fully dopted, these technologies will not only trnsform the wy we hndle cre nd surveillnce, but will increse the ef fectiveness of mngeril nd trining efforts for the benefit of those who suffer from TB. On the occsion of the publiction of this 2th WHO globl TB report, which coincides with the ssessment of the 215 globl TB trgets set s prt of the Millennium Development Gols, I m humbled by the progress in terms of impct nd opertions tht we hve witnessed in mny countries over two decdes. The Globl Report is testimony to the tireless ef forts of mny people worldwide, from Ntionl TB Progrmme stf f to community members, from clinicins nd nurses to those working for non-governmentl orgniztions who hve devoted themselves to the noble fight ginst clssic exmple of disese of poverty. Mrio Rviglione Director of the Globl TB Progrmme x n GLOBAL TUBERCULOSIS REPORT 215

Executive summry Bckground The yer 215 is wtershed moment in the bttle ginst tuberculosis (TB). It mrks the dedline for globl TB trgets set in the context of the Millennium Development Gols (MDGs), nd is yer of trnsitions: from the MDGs to new er of Sustinble Development Gols (SDGs), nd from the Stop TB Strtegy to the End TB Strtegy. It is lso two decdes since WHO estblished globl TB monitoring system; since tht time, 2 nnul rounds of dt collection hve been completed. Using dt from 25 countries nd territories, which ccount for more thn 99% of the world s popultion, this globl TB report documents dvnces in prevention, dignosis nd tretment of the disese. It lso identifies res where ef forts cn be strengthened. Min findings nd messges The dvnces re mjor: TB mortlity hs fllen 47% since 199, with nerly ll of tht improvement tking plce since 2, when the MDGs were set. In ll, ef fective dignosis nd tretment of TB sved n estimted 43 million lives between 2 nd 214. The MDG trget to hlt nd reverse TB incidence hs been chieved on worldwide bsis, in ech of the six WHO regions nd in 16 of the 22 high-burden countries tht collectively ccount for 8% of TB cses. Globlly, TB incidence hs fllen by n verge of 1.5% per yer since 2 nd is now 18% lower thn the level of 2. This yer s report describes higher globl totls for new TB cses thn in previous yers, but these reflect incresed nd improved ntionl dt rther thn ny increse in the spred of the disese. Despite these dvnces nd despite the fct tht nerly ll cses cn be cured, TB remins one of the world s biggest threts. In 214, TB killed 1.5 million people (1.1 million HIV-negtive nd.4 million HIV-positive). The toll comprised 89 men, 48 women nd 14 children. TB now rnks longside HIV s leding cuse of deth worldwide. HIV s deth toll in 214 ws estimted t 1.2 million, which included the.4 million TB deths mong HIVpositive people. 1 Worldwide, 9.6 million people re estimted to hve fllen ill with TB in 214: 5.4 million men, 3.2 million women nd 1. million children. Globlly, 12% of the 9.6 million new TB cses in 214 were HIV-positive. To reduce this burden, detection nd tretment gps must be ddressed, funding gps closed nd new tools developed. In 214, 6 million new cses of TB were reported to WHO, fewer thn two-thirds (63%) of the 9.6 million people estimted to hve fllen sick with the disese. This mens tht worldwide, 37% of new cses went undignosed or were not reported. The qulity of cre for people in the ltter ctegory is unknown. Of the 48 cses of multidrug-resistnt TB (MDR-TB) estimted to hve occurred in 214, only bout qurter of these 123 were detected nd reported. Although the number of HIV-positive TB ptients on ntiretrovirl therpy (ART) improved in 214 to 392 people (equivlent to 77% of notified TB ptients known to be co-infected with HIV), this number ws only one third of the estimted 1.2 million people living with HIV who developed TB in 214. All HIV-positive TB cses re eligible for ART. Funding gps mounted to US$ 1.4 billion for implementtion of existing interventions in 215. The most recent estimte of the nnul funding gp for reserch nd development is similr, t bout US$ 1.3 billion. From 216, the gol is to end the globl TB epidemic by implementing the End TB Strtegy. Adopted by the World Helth Assembly in My 214 nd with trgets linked to the newly dopted SDGs, the strtegy serves s blueprint for countries to reduce the number of TB deths by 9% by 23 (compred with 215 levels), cut new cses by 8% nd ensure tht no fmily is burdened with ctstrophic costs due to TB. 1 The cuse of TB deths mong HIV-positive people is clssified s HIV in the Interntionl clssifiction of diseses system. GLOBAL TUBERCULOSIS REPORT 215 n 1

Additionl highlights from the report Disese burden nd 215 trgets ssessment "" The quntity nd qulity of dt vilble to estimte TB disese burden continue to improve. These include direct mesurements of mortlity in 129 countries nd finl results from 18 ntionl TB prevlence surveys completed since 29, six of them in the pst yer (Ghn, Indonesi, Mlwi, Sudn, Zmbi nd Zimbbwe). "" Revised estimtes for Indonesi (1 million new cses per yer, double the previous estimte) explin the upwrd revision to WHO s globl estimtes of incident cses compred with those published in 214. Importntly, however, revisions lso f fect estimtes for previous yers nd the trend in TB incidence globlly s well s in Indonesi is still downwrd since round 2. "" Of the 9.6 million new TB cses in 214, 58% were in the South-Est Asi nd Western Pcific regions. "" The Africn Region hd 28% of the world s cses in 214, but the most severe burden reltive to popultion: 281 cses for every 1 people, more thn double the globl verge of 133. "" Indi, Indonesi nd Chin hd the lrgest number of cses: 23%, 1% nd 1% of the globl totl, respectively. "" Globlly, TB prevlence in 215 ws 42% lower thn in 199. The trget of hlving the rte compred with 199 ws chieved in three WHO regions the Region of the Americs, the South-Est Asi Region nd the Western Pcific Region nd in nine high-burden countries (Brzil, Cmbodi, Chin, Ethiopi, Indi, Mynmr, the Philippines, Ugnd nd Viet Nm). "" The trget of hlving the TB mortlity rte by 215 compred with 199 ws met in four WHO regions the Region of the Americs, the Estern Mediterrnen Region, the South-Est Asi Region nd the Western Pcific Region nd in 11 high-burden countries (Brzil, Cmbodi, Chin, Ethiopi, Indi, Mynmr, Pkistn, the Philippines, Ugnd, Viet Nm nd Zimbbwe). "" All three of the 215 trgets (for incidence, prevlence nd mortlity) were met in nine high-burden countries Brzil, Cmbodi, Chin, Ethiopi, Indi, Mynmr, the Philippines, Ugnd nd Viet Nm. TB cse notifictions nd tretment outcomes "" In the 2 yers since WHO estblished globl reporting system in 1995, it hs received reports of 78 million TB cses, 66 million of which were treted successfully. "" In 214, tht system mesured mrked increse in globl TB notifictions for the first time since 27. The nnul totl of new TB cses, which hd been bout 5.7 million until 213, rose to slightly more thn 6 million in 214 (n increse of 6%). This ws mostly due to 29% increse in notifictions in Indi, which followed the introduction of policy of mndtory notifiction in My 212, cretion of ntionl web-bsed reporting system in June 212 nd intensified ef forts to engge the privte helth sector. Indi ccounted for 27% of globl TB notifictions in 214. "" Globlly, the tretment success rte for people newly dignosed with TB ws 86% in 213, level tht hs been sustined since 25. Tretment success rtes require improvement in the Region of the Americs nd the Europen Region (75% in both regions in 213). Drug-resistnt TB "" Globlly, n estimted 3.3% of new TB cses nd 2% of previously treted cses hve MDR-TB, level tht hs chnged little in recent yers. "" In 214, n estimted 19 people died of MDR-TB. "" More TB ptients were tested for drug resistnce in 214 thn ever before. Worldwide, 58% of previously treted ptients nd 12% of new cses were tested, up from 17% nd 8.5% respectively in 213. This improvement is prtly due to the doption of rpid moleculr tests. "" If ll of the TB cses notified in 214 hd been tested for drug resistnce, n estimted 3 would hve been found to hve MDR-TB, with more thn hlf of them (54%) occurring in Indi, Chin nd the Russin Federtion. "" The number of cses detected (123 ) worldwide represented just 41% of this globl estimte, nd only 26% of the 48 incident cses of MDR-TB estimted to hve occurred in 214. Detection gps were worst in the Western Pcific Region, where the number of cses detected ws only 19% of the number of notified cses estimted to hve MDR-TB (the figure for Chin ws 11%). "" A totl of 111 people strted MDR-TB tretment in 214, n increse of 14% compred with 213. "" The rtio of ptients enrolled in tretment to ptients newly notified s hving MDR-TB or rifmpicin-resistnt TB ws 9% globlly. The rtio ws bove 9% in 15 of the 27 high MDR-TB burden countries s well s in the Europen Region nd the Region of the Americs. "" Globlly, only 5% of MDR-TB ptients were successfully treted. However, the 215 tretment success trget of 75% for MDR-TB ptients ws reched by 43 of the 127 countries nd territories tht reported outcomes for the 212 cohort, including three high MDR-TB burden countries (Estoni, Ethiopi nd Mynmr). "" Extensively drug-resistnt TB (XDR-TB) hd been reported by 15 countries by 215. An estimted 9.7% of people with MDR-TB hve XDR-TB. Dignostics nd lbortory strengthening "" The use of the rpid test Xpert MTB/RIF hs expnded substntilly since 21, when WHO first recommended its use. In ll, 4.8 million test crtridges were procured in 214 by 116 low- nd middle-income countries t concessionl prices, up from 55 in 211. "" By 215, 69% of countries recommended using Xpert MTB/RIF s the initil dignostic test for people t risk of 2 n GLOBAL TUBERCULOSIS REPORT 215

drug-resistnt TB, nd 6% recommended it s the initil dignostic test for people living with HIV. Addressing the co-epidemics of TB nd HIV "" In 214, n estimted 1.2 million (12%) of the 9.6 million people who developed TB worldwide were HIV-positive. The Africn Region ccounted for 74% of these cses. "" The number of people dying from HIV-ssocited TB peked t 57 in 24 nd hd fllen to 39 in 214 ( 32% decrese). "" Globlly, 51% of notified TB ptients hd documented HIV test result in 214, smll increse from 49% in 213. The figure ws highest in the Africn Region, t 79%. "" The number of people living with HIV who were treted with isonizid preventive therpy reched 933 in 214, n increse of bout 6% compred with 213. A lrge proportion of these people (59%) were in South Afric. Finncing "" The funding required for full response to the globl TB epidemic in low- nd middle-income countries is estimted t US$ 8 billion per yer in 215, excluding reserch nd development. Projections mde in 213 suggested tht, by 215, bout US$ 6 billion could be mobilized from domestic sources, leving blnce of US$ 2 billion needed from interntionl donors. "" Bsed on self-reporting by countries, funding for TB prevention, dignosis nd tretment reched US$ 6.6 billion in 215, up from US$ 6.2 billion in 214 nd more thn double the level of 26 (US$ 3.2 billion). "" Overll, 87% (US$ 5.8 billion) of the US$ 6.6 billion vilble in 215 is from domestic sources. "" Interntionl donor funding reported by countries to WHO hs incresed since 26, reching US$.8 billion in 215. "" The totl mount of interntionl donor funding recorded in the creditor reporting system of the Orgniztion for Economic Coopertion nd Development (OECD) is higher: the ltest dt show totl contributions of US$ 1 billion in 213. Of this mount, 77% ws from the Globl Fund. The lrgest country donor ws the government of the United Sttes of Americ, which contributed bout one third of the TB funding chnnelled vi the Globl Fund s well s bilterl funds of US$ 362 million for TB nd TB/ HIV in 213. 1 "" Domestic funding ccounts for more thn 9% of the totl funding in 215 in three country groups: Brzil, the Russin Federtion, Indi, Chin nd South Afric (BRICS); upper-middle-income countries; nd regions outside Afric nd Asi. "" Interntionl donor funding domintes in the group of 17 high-burden countries outside BRICS (72% of the totl funding vilble in 215) nd in low-income countries (81% of the totl funding vilble in 215). "" The cost per ptient treted for drug-susceptible TB in 214 rnged from US$ 1 5 in most countries with high burden of TB. The cost per ptient treted for MDR- TB ws typiclly US$ 5 1. Reserch nd development "" In the dignostics pipeline, tests bsed on moleculr technologies re the most dvnced. "" A dignostic pltform clled the GeneXpert Omni is in development. It is intended for point-of-cre testing for TB nd rifmpicin-resistnt TB using Xpert MTB/RIF crtridges. The device is expected to be smller, lighter nd less expensive thn currently vilble pltforms for point-of-cre nucleic cid detection nd will come with built-in, 4-hour bttery. WHO expects to evlute the pltform in 216. "" A next-genertion crtridge clled Xpert Ultr is lso in development. It is intended to replce the Xpert MTB/RIF crtridge nd could potentilly replce conventionl culture s the primry dignostic tool for TB. "" Eight new or repurposed nti-tb drugs re in dvnced phses of clinicl development. For the first time in six yers, n nti-tb drug cndidte (TBA-354) is in Phse I testing. "" Severl new TB tretment regimens for drug-susceptible nd/or drug-resistnt TB re being tested in Phse II or Phse III trils; t lest two more trils re scheduled to strt towrds the end of 215 or in erly 216. "" WHO hs issued interim guidnce on the use of bedquiline (in 213) nd delmnid (in 214). "" By the end of 214, 43 countries reported hving used bedquiline to tret ptients s prt of ef forts to expnd ccess to tretment for MDR-TB. "" Recent observtionl studies of the ef fectiveness of short tretment regimens for MDR-TB in Niger nd Cmeroon found tht 12-month regimen ws effective nd well-tolerted in ptients not previously exposed to second-line drugs. At lest 16 countries in Afric nd Asi hve introduced shorter regimens s prt of trils or observtionl studies under opertionl reserch conditions, nd WHO will ressess current guidnce on their use in 216. "" Fif teen vccine cndidtes re in clinicl trils. Their emphsis hs shif ted from children to dolescents nd dults. "" New dignostics, drugs nd vccines will be needed to chieve the trgets set in the End TB Strtegy. 1 Not ll of these bilterl funds re cptured in the OECD dtbse. For exmple, this does not record flows of funds between OECD countries, nd funding for TB/HIV my be coded s funding for HIV. GLOBAL TUBERCULOSIS REPORT 215 n 3

Box 1.1 Bsic fcts bout TB TB is n infectious disese cused by the bcillus Mycobcterium tuberculosis. It typiclly f fects the lungs (pulmonry TB) but cn f fect other sites s well (extrpulmonry TB). The disese is spred in the ir when people who re sick with pulmonry TB expel bcteri, for exmple by coughing. Overll, reltively smll proportion (5 15%) of the estimted 2 3 billion people infected with M. tuberculosis will develop TB disese during their lifetime. However, the probbility of developing TB is much higher mong people infected with HIV. The most common method for dignosing TB worldwide remins sputum smer microscopy (developed more thn 1 yers go), in which bcteri re observed in sputum smples exmined under microscope. However, developments in TB dignostics in the lst few yers men tht the use of rpid moleculr tests to dignose TB nd drug-resistnt TB is incresing, nd some countries re phsing out use of smer microscopy for dignostic (s opposed to tretment monitoring) purposes. In countries with more developed lbortory cpcity, cses of TB re lso dignosed vi culture methods (the current reference stndrd). Without tretment, the deth rte is high. Studies from the pre-chemotherpy er found tht bout 7% of people with sputum smerpositive pulmonry TB died within 1 yers, nd tht this figure ws 2% mong culture-positive (but smer-negtive) cses of pulmonry TB. Ef fective drug tretments were first developed in the 194s. The most ef fective first-line nti-tb drug, rifmpicin, becme vilble in the 196s. The currently recommended tretment for new cses of drug-susceptible TB is six-month regimen of four first-line drugs: isonizid, rifmpicin, ethmbutol nd pyrzinmide. Tretment success rtes of 85% or more for new cses re regulrly reported to WHO by its Member Sttes. Tretment for multidrug-resistnt TB (MDR-TB), defined s resistnce to isonizid nd rifmpicin (the two most powerful nti-tb drugs) is longer, nd requires more expensive nd more toxic drugs. For most ptients with MDR-TB, the current regimens recommended by WHO lst 2 months, nd tretment success rtes re much lower. New TB drugs re now emerging from the pipeline, nd combintion regimens tht include new compounds re being tested in clinicl trils. There re severl TB vccines in Phse I or Phse II trils. For the time being, however, vccine tht is ef fective in preventing TB in dults remins elusive. Tiemersm EW et l. Nturl history of tuberculosis: durtion nd ftlity of untreted pulmonry tuberculosis in HIV-negtive ptients: A systemtic review. PLoS ONE, 211, 6(4): e1761. 4 n GLOBAL TUBERCULOSIS REPORT 215

CHAPTER 1 Introduction Tuberculosis (TB) is mjor globl helth problem. It cuses ill-helth mong millions of people ech yer nd rnks longside the humn immunodeficiency virus (HIV) s leding cuse of deth worldwide. 1 In 214, there were n estimted 9.6 million new TB cses: 5.4 million mong men, 3.2 million mong women nd 1. million mong children. There were lso 1.5 million TB deths (1.1 million mong HIV-negtive people nd.4 million mong HIV-positive people), of which pproximtely 89 were men, 48 were women nd 14 were children. The number of TB deths is uncceptbly high: with timely dignosis nd correct tretment, lmost ll people with TB cn be cured. Bsic fcts bout TB re summrized in Box 1.1. The World Helth Orgniztion (WHO) hs published globl TB report every yer since 1997. The min im of these reports is to provide comprehensive nd up-to-dte ssessment of the TB epidemic nd progress in prevention, dignosis nd tretment of the disese t globl, regionl nd country levels, in the context of recommended globl TB strtegies nd trgets endorsed by WHO s Member Sttes. For the pst decde, the focus hs been on progress towrds 215 globl trgets for reductions in TB disese burden set in the context of the Millennium Development Gols (MDGs). The trgets re tht TB incidence should be flling (MDG Trget 6.c) nd tht TB prevlence nd mortlity rtes should be hlved compred with their 199 levels. The Stop TB Strtegy, 2 developed for the period 26 215, hs been WHO s recommended pproch to chieving these trgets (Box 1.2). With 215 mrking the MDG nd globl TB trget dedline, the specil emphsis nd most importnt topic of this 215 globl TB report is n ssessment of whether the 215 trgets hve been chieved. This ssessment is mde for the world, for the six WHO regions nd for the 22 high-burden countries tht collectively ccount for 8% of TB cses. The topics covered in the remining six chpters of the report re: TB cse notifictions nd tretment outcomes; drugresistnt TB; dignostics nd lbortory strengthening; ddressing the co-epidemics of TB nd HIV; finncing; nd reserch nd development. Since the end of 215 lso mrks the end of the MDG nd Stop TB Strtegy ers nd the strt of post-215 development frmework (216 23) of Sustinble Development Gols (SDGs) 3 nd n ssocited post-215 globl TB strtegy, 4 ech chpter of the report fetures content relted to the trnsition to the new End TB Strtegy (Box 1.3). As usul, the 215 globl TB report is bsed on dt collected in nnul rounds of globl TB dt collection from countries nd territories, including 194 Member Sttes. This is done using web-bsed system (https://extrnet.who.int/ tme), which ws opened for reporting in mid-mrch. In 215, 25 countries nd territories tht ccount for more thn 99% of the world s popultion nd estimted TB cses reported dt; this included 183 of WHO s 194 Member Sttes. Dt bout the provision of isonizid preventive therpy (IPT) to people living with HIV nd ntiretrovirl therpy (ART) for HIV-positive TB ptients, which were collected by the HIV deprtment in WHO nd the Joint United Ntions Progrmme on HIV/AIDS (UNAIDS), were lso used. Following review nd follow-up with countries, the results presented in the min prt of this report re bsed on dt vilble on 6 August 215. The report hs four nnexes. Annex 1 describes the contents of the globl TB dtbse, how dt were collected nd how to ccess the dt. Annex 2 contins country profiles for the 22 high-burden countries (profiles for other countries re vilble online 5 ) nd Annex 3 contins regionl profiles. Annex 4 provides detiled dt tbles for key indictors for the most recent yer for which dt or estimtes re vilble, for ll countries. As the 2th in the series, this 215 globl TB report mrks n importnt lndmrk in globl TB monitoring by WHO. 1 In 214, there were n estimted 1.2 million deths due to HIV; this includes.4 million deths from TB mong HIV-positive people. See unids.org. 2 Rviglione M, Uplekr M. WHO s new Stop TB strtegy. The Lncet, 26; 367: 952 5. 3 http://sustinbledevelopment.un.org/focussdgs.html 4 Uplekr M, Weil D, Lonnroth K, Jrmillo E, Lienhrdt C, Dis HM, et l. WHO s new End TB Strtegy. The Lncet. 215;385:1799 81. 5 www.who.int/tb/dt. GLOBAL TUBERCULOSIS REPORT 215 n 5

Box 1.2 The Stop TB Strtegy t glnce (26 215) VISION GOAL OBJECTIVES TARGETS A TB-free world To drmticlly reduce the globl burden of TB by 215 in line with the Millennium Development Gols (MDGs) nd the Stop TB Prtnership trgets n Achieve universl ccess to high-qulity cre for ll people with TB n Reduce the humn suffering nd socioeconomic burden ssocited with TB n Protect vulnerble popultions from TB, TB/HIV nd drug-resistnt TB n Support development of new tools nd enble their timely nd effective use n Protect nd promote humn rights in TB prevention, cre nd control n MDG 6, Trget 6.c: Hlt nd begin to reverse the incidence of TB by 215 n Trgets linked to the MDGs nd endorsed by the Stop TB Prtnership: 215: reduce prevlence of nd deths due to TB by 5% compred with bseline of 199 25: eliminte TB s public helth problem (defined s <1 cse per 1 million popultion per yer) COMPONENTS 1. Pursue high-qulity DOTS expnsion nd enhncement. Secure politicl commitment, with dequte nd sustined finncing b. Ensure erly cse detection, nd dignosis through qulity-ssured bcteriology c. Provide stndrdized tretment with supervision, nd ptient support d. Ensure ef fective drug supply nd mngement e. Monitor nd evlute performnce nd impct 2. Address TB/HIV, MDR-TB, nd the needs of poor nd vulnerble popultions. Scle up collbortive TB/HIV ctivities b. Scle up prevention nd mngement of MDR-TB c. Address the needs of TB contcts, nd of poor nd vulnerble popultions 3. Contribute to helth system strengthening bsed on primry helth cre. Help improve helth policies, humn resource development, finncing, supplies, service delivery nd informtion b. Strengthen infection control in helth services, other congregte settings nd households c. Upgrde lbortory networks, nd implement the Prcticl Approch to Lung Helth d. Adpt successful pproches from other fields nd sectors, nd foster ction on the socil determinnts of helth 4. Engge ll cre providers. Involve ll public, voluntry, corporte nd privte providers through public privte mix pproches b. Promote use of the Interntionl Stndrds for Tuberculosis Cre 5. Empower people with TB, nd communities through prtnership. Pursue dvoccy, communiction nd socil mobiliztion b. Foster community prticiption in TB cre, prevention nd helth promotion c. Promote use of the Ptients Chrter for Tuberculosis Cre 6. Enble nd promote reserch. Conduct progrmme-bsed opertionl reserch b. Advocte for nd prticipte in reserch to develop new dignostics, drugs nd vccines. 6 n GLOBAL TUBERCULOSIS REPORT 215

Box 1.3 The End TB Strtegy t glnce (216 235) VISION GOAL INDICATORS Reduction in number of TB deths compred with 215 (%) A WORLD FREE OF TB zero deths, disese nd suffering due to TB END THE GLOBAL TB EPIDEMIC MILESTONES TARGETS 22 225 SDG 23 End TB 235 35% 75% 9% 95% Reduction in TB incidence rte compred with 215 (%) 2% (<85/1 ) 5% (<55/1 ) 8% (<2/1 ) 9% (<1/1 ) TB-f fected fmilies fcing ctstrophic costs due to TB (%) 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 co-morbidities D. Preventive tretment of persons t high risk, nd vccintion ginst TB 2. BOLD POLICIES AND SUPPORTIVE SYSTEMS A. Politicl commitment with dequte resources for TB cre nd prevention B. Enggement of communities, civil society orgniztions, nd public nd privte cre providers C. Universl helth coverge policy, nd regultory frmeworks for cse notifiction, vitl registrtion, qulity nd rtionl use of medicines, nd infection control D. Socil protection, poverty llevition nd ctions on other determinnts of TB 3. INTENSIFIED RESEARCH AND INNOVATION A. Discovery, development nd rpid uptke of new tools, interventions nd strtegies B. Reserch to optimize implementtion nd impct, nd promote innovtions Trgets linked to the Sustinble Development Gols (SDGs). GLOBAL TUBERCULOSIS REPORT 215 n 7

CHAPTER 2 Disese burden nd 215 trgets ssessment Key fcts nd messges The dt vilble to estimte TB disese burden (incidence, prevlence, mortlity) continue to improve. In 214, dt from vitl registrtion (VR) systems nd/or mortlity surveys were used to estimte TB mortlity in 129 countries (up from three countries in 28). There hs been substntil progress in the implementtion of ntionl popultion-bsed surveys of the prevlence of TB disese since 28, with 18 surveys (of which 12 were first-ever ntionl surveys) completed between 29 nd August 215. Of these, results from six surveys were finlized in the pst yer (Ghn, Indonesi, Mlwi, Sudn, Zmbi, Zimbbwe), nd dditionl survey results becme vilble for the United Republic of Tnzni. Three dditionl surveys were begun in lte 214 or 215. Notifiction dt for 214 were reported by 25 countries nd territories. This chpter presents the ltest WHO estimtes of TB disese burden between 199 nd 215. Specil emphsis is given to ssessment of whether 215 trgets set in the context of the Millennium Development Gols (MDGs) were chieved. The trgets were tht incidence should be flling by 215 (MDG trget 6c) nd tht prevlence nd mortlity rtes should be hlved compred with 199 levels. Globlly in 214, there were n estimted 9.6 million incident cses of TB: 5.4 million mong men, 3.2 million mong women nd 1. million mong children. The globl totl is considerble upwrd revision compred with estimtes published in 214, following results from the ntionl prevlence survey in Indonesi. It is now estimted tht there re bout 1 million new TB cses per yer in Indonesi, twice the previously estimted level. Globlly in 214, there were n estimted 1.2 million new HIVpositive TB cses (12% of ll TB cses). Almost three-qurters of these cses were in the Africn Region. Globlly in 214, there were n estimted 1.5 million deths from TB: 1.1 million deths mong people who were HIVnegtive nd 39 deths mong people who were HIVpositive.* TB rnks longside HIV (1.2 million deths in 214, including the 39 TB deths mong HIV-positive people) s leding cuse of deth worldwide. The South-Est Asi nd Western Pcific Regions collectively ccounted for 58% of the world s TB cses in 214. The Africn Region hd 28% of the world s cses, but the most severe burden reltive to popultion (281 incident cses per 1 popultion on verge, more thn double the globl verge of 133). Indi, Indonesi nd Chin hd the lrgest numbers of cses (23%, 1% nd 1% of the globl totl, respectively). The MDG trget of hlting nd reversing TB incidence by 215 ws chieved globlly, in ll six WHO regions nd in 16 of the 22 high TB burden countries (HBCs). The TB incidence rte hs fllen t n verge rte of 1.5% per yer since 2. Globlly, the TB mortlity rte in 215 ws 47% lower thn in 199: the trget of 5% reduction ws lmost met. The trget ws chieved in four WHO Regions (the exceptions were the Africn nd Europen regions), nd in 11 HBCs. Globlly, the TB prevlence rte in 215 ws 42% lower thn in 199. The trget of 5% reduction ws met in three WHO regions nd in nine HBCs. All three 215 trgets were met in the Region of the Americs, the South-Est Asi Region nd the Western Pcific Region, nd in nine HBCs: Brzil, Cmbodi, Chin, Ethiopi, Indi, Mynmr, the Philippines, Ugnd nd Viet Nm. Between 2 nd 214, TB tretment lone sved 35 million lives mong HIV-negtive people; TB tretment nd ntiretrovirl therpy sved n dditionl 8 million lives mong HIV-positive people. * The underlying cuse of TB deths mong HIV-positive people is clssified s HIV in the interntionl clssifiction of diseses system. The burden of TB disese cn be mesured in terms of incidence (defined s the number of new nd relpse cses of TB rising in given time period, usully one yer), prevlence (defined s the number of cses of TB t given point in time) nd mortlity (defined s the number of deths cused by TB in given time period, usully one yer). This chpter presents the ltest WHO estimtes of TB incidence, prevlence nd mortlity between 199 nd 215. Specil emphsis is given to ssessment of whether 215 tr- gets set in the context of the Millennium Development Gols (MDGs) were chieved t globl level, in the six WHO regions nd in the 22 high TB burden countries (HBCs) tht collectively ccount for bout 8% of the world s TB cses. The trgets were tht incidence should be flling by 215 (MDG trget 6c) nd tht prevlence nd mortlity rtes should be hlved compred with their levels in 199 (Box 2.1). WHO updtes estimtes of the burden of disese cused by TB nnully, using the ltest vilble dt nd nlyticl 8 n GLOBAL TUBERCULOSIS REPORT 215

methods. 1,2 Since 26, concerted ef forts 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 2.1). Notifiction dt re consistently reported by bout 2 countries nd territories ech yer (25 in 214). For this report, direct mesurements of TB mortlity from ntionl or smple vitl registrtion (VR) systems were vilble for 127 countries (up from three countries in 28) nd dt from mortlity surveys were vilble for two countries. Between 29 nd August 215, 18 popultion-bsed surveys of the prevlence of TB disese (of which 12 were first-ever ntionl surveys) were completed. Of these, results from six surveys were finlized in the pst yer (Ghn, Indonesi, Mlwi, Sudn, Zmbi, Zimbbwe), nd dditionl survey results becme vilble for the United Republic of Tnzni. These results re reflected in prevlence estimtes published in this report, nd hve lso llowed improvements to estimtes of TB incidence nd mortlity. Those for Indonesi in prticulr hve hd mjor impct on globl estimtes of TB incidence nd prevlence. A summry of the min updtes to vilble dt nd methods is provided in Box 2.2. The chpter hs five mjor sections. The first three cover estimtes of TB incidence, prevlence nd mortlity in turn, including ssessment of whether the 215 trget ws met. The section on TB mortlity includes estimtes of the lives sved through TB tretment (including the dditionl benefit from ntiretrovirl therpy for HIV-positive TB ptients) between 2 nd 214. The fourth section presents estimtes disggregted by ge nd sex. The fif th nd finl section explins how WHO will updte the current lists of HBCs for the post-215 er. 2.1 TB incidence TB incidence hs never been mesured t ntionl level becuse this would require long-term studies mong lrge cohorts of people (hundreds of thousnds), involving high costs nd chllenging logistics. Notifictions of TB cses provide good proxy indiction of TB incidence in countries tht hve both high-performnce surveillnce systems (for exmple, there is little under-reporting of dignosed cses) nd where the qulity of nd ccess to helth cre mens tht few cses re not dignosed. In the lrge number of countries where these criteri re not yet met, better estimtes of TB incidence cn be obtined from n inventory study (n inventory study is survey to quntify the level of underreporting of detected TB cses; if certin conditions re met, cpture-recpture methods cn lso be used to estimte TB 1 The online technicl ppendix is vilble t www.who.int/tb/dt. 2 It should be highlighted tht these updtes f fect the entire time-series bck to 199. For this reson, estimtes presented in this chpter for 199 213 supersede those of previous reports nd direct comprisons (for exmple, 213 estimtes in this report nd 213 estimtes in the lst report) re not pproprite. incidence). 3 To dte, such studies hve been undertken in only few countries: exmples include Egypt, Irq, Pkistn nd Yemen. A recent exmple, from the Republic of Kore, is profiled in Box 2.3. The ultimte gol is to directly mesure TB incidence from TB notifictions in ll countries. This requires combintion of strengthened surveillnce, better quntifiction of under-reporting (i.e. the number of cses tht re missed by surveillnce systems) nd universl ccess to helth cre. A TB surveillnce checklist developed by the WHO Globl Tsk Force on TB Impct Mesurement defines the stndrds tht need to be met for notifiction dt to provide direct mesure of TB incidence (Box 2.1). By August 215, totl of 38 countries including 16 HBCs hd completed the checklist (Figure 2.1). Methods currently used by WHO to estimte TB incidence cn be grouped into four mjor ctegories (Figure 2.2). These re: 1. Cse notifiction dt combined with expert opinion bout cse detection gps. Expert opinion, elicited in regionl workshops or country missions, is used to estimte levels of under-reporting nd under-dignosis. Trends re estimted using either mortlity dt, surveys of the nnul risk of infection or exponentil interpoltion using estimtes of cse detection gps for three yers. In this report, this method is used for 12 countries tht ccounted for 51% of the estimted globl number of incident cses in 214. 2. Results from ntionl TB prevlence surveys. Incidence is estimted using prevlence survey results combined with either dynmic model or estimtes of the durtion of disese. This method is used for 19 countries tht ccounted for 46% of the estimted globl number of incident cses in 214. 3. Notifictions in high-income countries djusted by stndrd fctor to ccount for under-reporting nd under-dignosis. This method is used for 73 countries (ll high-income countries except the Netherlnds nd the United Kingdom), which ccounted for 3% of the estimted globl number of incident cses in 214. 4. Results from inventory/cpture-recpture studies. This method is used for 5 countries: Egypt, Irq, the Netherlnds, the United Kingdom nd Yemen. They ccounted for.5% of the estimted globl number of incident cses in 214. Further detils bout these methods re provided in the online technicl ppendix 1 nd in bckground documents prepred for the globl review of methods used to produce TB burden 3 Inventory studies cn be used to mesure the number of cses tht re dignosed but not reported. A guide on inventory studies is vilble t: www.who.int/tb/publictions/inventory_studies. GLOBAL TUBERCULOSIS REPORT 215 n 9

Box 2.1 215 globl TB trgets ssessment Bckground Globl trgets for reductions in TB disese burden by 215 were set within the context of the United Ntions Millennium Development Gols (MDGs). The trgets were tht TB incidence should be flling, nd tht TB mortlity nd prevlence rtes should be hlved by 215 compred with their level in 199. The trgets were dopted t regionl nd country levels. The Stop TB Strtegy (26 215) developed by WHO hd the overll gol of chieving these trgets (Chpter 1). Since 25, WHO hs published estimtes of TB incidence, prevlence nd mortlity nd n ssessment of progress towrds 215 trgets in its nnul globl TB report. With 215 mrking the MDG nd globl TB trget dedline, the specil emphsis nd most importnt topic of this 215 globl TB report is n ssessment of whether the 215 trgets were chieved. This ssessment is mde for the world, for the six WHO regions nd for the 22 high-burden countries (HBCs) tht collectively ccount for 8% of TB cses. It is built on the work of the WHO Globl Tsk Force on TB Impct Mesurement. The WHO Globl Tsk Force on TB Impct Mesurement The WHO Globl Tsk Force on TB Impct Mesurement ws estblished in 26, with the im of ensuring tht ssessment of whether 215 trgets were met should be s rigorous, robust nd consensus-bsed s possible. To fulfil this mndte, the Tsk Force greed upon three strtegic res of work: 1. Strengthened surveillnce in ll countries, towrds the ultimte gol of direct mesurement of TB incidence nd TB mortlity using notifiction nd vitl registrtion dt, respectively; 2. Ntionl TB prevlence surveys in 22 globl focus countries; 3. Periodic review nd updting of methods used to trnslte surveillnce nd survey dt into TB disese burden estimtes. A wide rnge of technicl, finncil nd development gencies, countries nd individul experts hve been engged in the work of the Tsk Force, nd full detils cn be found on the Tsk Force website. The Tsk Force s work on strengthened surveillnce hs covered four min topics. These re: " Development of TB surveillnce checklist of stndrds nd benchmrks (with ten core nd three supplementry stndrds). b This cn be used to systemticlly ssess the extent to which surveillnce system meets the stndrds required for notifiction nd vitl registrtion dt to provide direct mesurement of TB incidence nd mortlity, respectively. By August 215, 38 countries including 16 HBCs hd used the checklist (Figure 2.1). " 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, c nd ef forts to introduce such systems hve been supported. " Development of guide on inventory studies to mesure underreporting of detected TB cses, d nd support to such studies in priority countries. One of the min resons for uncertinty in estimtes of TB incidence is tht in mny countries, especilly those with lrge privte sector, cses my be detected but not reported. An inventory study cn be used to quntify the number of cses tht re detected but not reported to ntionl surveillnce systems, nd serve s bsis for ddressing gps in reporting. " Expnded use of dt from vitl registrtion (VR) systems nd mortlity surveys to produce estimtes of the number of TB deths, nd contributions to wider ef forts to promote VR systems. In this report, estimtes of TB mortlity re bsed on such dt sources for 129 countries (Figure 2.15). There hs been substntil success in the implementtion of ntionl TB prevlence surveys. Between 29 nd 215, 18 countries including 15/22 globl focus countries completed survey nd more re scheduled to do so by 216 (Figure 2.11, Figure 2.12). Results from these surveys hve provided lrge body of new evidence bout the burden of TB disese (Box 2.2) nd lso hve importnt policy, progrmmtic nd funding implictions (Box 2.4). A Tsk Force subgroup undertook mjor review nd updte of methods between June 28 nd October 29. Recommendtions were endorsed t full meeting of the Tsk Force in Mrch 21. A second thorough nd comprehensive review of these methods s well s possible lterntives ws undertken in 215, with the purpose of reching consensus on methods to be used for reporting in the 215 globl TB report on whether 215 trgets were met. The key recommendtion from the group of experts ws tht existing methods should be used the consensus ws to finish the cycle with estblished methods. e Looking forwrd: TB burden estimtes post-215 The End TB Strtegy includes mbitious trgets for reductions in TB incidence nd TB mortlity (Chpter 1). During the expert review of current methods used to estimte these indictors, there ws strong greement tht the min gol is to strengthen TB surveillnce so tht TB cses nd TB deths cn be directly mesured using notifiction nd vitl registrtion systems. e Therefore, the Tsk Force strtegic re of work relted to strengthened surveillnce needs to be continued. In the interim, for countries without high-performnce surveillnce systems, options for improving current methods tht were identified included the use of new sttisticl models, use of dynmic models (especilly for estimtion of TB incidence in countries with recent prevlence survey dt), nd implementtion of more inventory studies to mesure under-reporting. It ws lso greed tht strtegic selection of priority countries in which repet prevlence surveys should be done to mesure trends is importnt. b c d e www.who.int/tb/dvisory_bodies/impct_mesurement_tskforce www.who.int/tb/publictions/stndrdsndbenchmrks/en/ Electronic recording nd reporting for TB cre nd control. Genev, World Helth Orgniztion, 211 (WHO/HTM/TB/211.22). Avilble t www.who.int/tb/publictions/electronic_recording_reporting Assessing tuberculosis underreporting through inventory studies. Genev, World Helth Orgniztion, 213 (WHO/HTM/TB/212.12). Avilble t: www.who.int/tb/publictions/inventory_studies vvv www.who.int/tb/dvisory_bodies/impct_mesurement_ tskforce/meetings/globl_consulttion_meeting_report.pdf 1 n GLOBAL TUBERCULOSIS REPORT 215

Box 2.2 Updtes to estimtes of TB disese burden in this report nd updtes tht re nticipted in the ner future UPDATES IN THIS REPORT 1. New dt from ntionl TB prevlence surveys Between October 214 nd August 215, finl results from surveys in Ghn, Indonesi, Mlwi, Sudn, the United Republic of Tnzni, Zmbi nd Zimbbwe becme vilble. The size of Indonesi s popultion nd TB burden mens tht upwrd revisions to estimtes bsed on the prevlence survey f fect globl estimtes of the bsolute number of incident cses (lthough importntly, globl trends in TB incidence re not f fected nd the impct on estimtes of globl TB deths is smll given reltively low cse ftlity rtio in Indonesi). In the other countries, updted estimtes re either higher (Ghn, Mlwi, United Republic of Tnzni, Zmbi) or lower (Sudn, Zimbbwe) thn previous estimtes. Post-survey estimtes re lmost lwys more precise thn erlier estimtes tht were indirectly derived from incidence (Figure B2.2.1). 2. Newly reported dt nd updted estimtes from other gencies New VR dt were reported to WHO between mid-214 nd mid-215 nd some countries mde corrections to historicl dt. UNAIDS published updted HIV estimtes in August 214. The United Ntions Popultion Division published new estimtes in July 215. In most instnces, ny resulting chnges to TB burden estimtes re well within the uncertinty intervls of previously published estimtes, nd trends re generlly consistent. For the first time, estimtes of TB mortlity (HIV-negtive) in Indonesi could be produced using dt from smple vitl registrtion system, f ter djustment for incomplete coverge nd ill-defined cuses of deth. For South Afric, estimtes of TB mortlity (HIV-negtive) were obtined from the Institute of Helth Metrics nd Evlution; these estimtes use dt from the ntionl vitl registrtion system, djusted for widespred miscoding of deths cused by HIV nd TB,,b nd replce previous indirect estimtes derived from TB incidence nd the cse ftlity rtio. FIGURE B2.2.1 Estimtes of TB prevlence (ll ges, ll forms of TB) for 17 countries, before (in blue) nd f ter (in red) results from ntionl prevlence surveys becme vilble. Pnels re ordered ccording to the before-f ter dif ference. Lo PDR Indonesi Cmbodi Thilnd Chin Pkistn Mynmr Asi UR Tnzni Mlwi Ghn Nigeri Zmbi Rwnd Sudn Ethiopi Zimbbwe Gmbi.25.5 1. 2. 5. 1..25.5 1. 2. 5. 1. Prevlence per 1 popultion (log scle) Prevlence per 1 popultion (log scle) The wide uncertinty intervl of the post-survey estimte for the United Republic of Tnzni is becuse lbortory chllenges ment tht it ws only possible to directly estimte the prevlence of smer-positive (s opposed to bcteriologiclly confirmed) TB. Afric 3. Updted methods for estimting TB burden In Mrch 215, the WHO Globl Tsk Force on TB Impct Mesurement convened n expert group to review methods for estimting TB disese burden (see Box 2.1). In generl, the meeting recommended tht current methods should be retined, especilly for the purposes of reporting on whether 215 trgets were met. An exception ws methods used to estimte the burden of TB disese mong children, which hve been published by WHO since 213 nd which re not relevnt to reporting on 215 trgets. It ws recommended tht WHO should updte methods used to estimte TB incidence mong children by implementing n ensemble pproch in which estimtes derived from cse notifictions djusted for under-detection nd under-reporting c re combined with estimtes derived from dynmic modelling. d An dditionl recommendtion ws tht HIV-positive TB mortlity in children should be estimted using similr pproch to tht used for disggregting TB/HIV mortlity by sex. Estimtes of childhood TB incidence nd mortlity presented in this report re bsed on these recommendtions. 4. In-depth epidemiologicl reviews t country level Estimtes for Angol were revised bsed on discussions with experts from the NTP nd prtners. They should however be considered preliminry, pending the findings of n ongoing epidemiologicl review. Estimtes for Kzkhstn were updted in Februry 215 following n in-depth review conducted by WHO stf f (hedqurters nd the Regionl Of fice for Europe) in close collbortion with the Ministry of Helth. UPDATES ANTICIPATED IN THE NEAR FUTURE Updtes to estimtes of disese burden re expected within the next yer for three countries in which ntionl TB prevlence survey hs been recently completed (Ugnd, July 215) or is scheduled for completion round the end of 215 (Bngldesh, Mongoli). Estimtes of TB incidence my be updted following the implementtion of inventory studies to mesure underreporting of detected TB in Chin, Indonesi, the Philippines, Thilnd nd Viet Nm. An expert review of methods used to estimte the burden of MDR-TB is scheduled for 216. b c d Murry C, Ortbld K, Guinovrt C et l. Globl, regionl, nd ntionl incidence nd mortlity for HIV, tuberculosis, nd mlri during 199 213: systemtic nlysis for the Globl Burden of Disese Study 213. Lncet 214; 384: 15 7. 2559949. Groenewld P, Nnnn N, Bourne D et l. Identifying deths from AIDS in South Afric. AIDS 25; 19: 193 21. 15668545. Jenkins H, Tolmn A, Yuen C et l. Incidence of multidrug-resistnt tuberculosis disese in children: systemtic review nd globl estimtes. Lncet 214; 383: 1572 9. 246718. Dodd P, Grdiner E, Coghln R et l. Burden of childhood tuberculosis in 22 high-burden countries: mthemticl modelling study. Lncet Glob Helth 214; 2: e453 9. 2513518 GLOBAL TUBERCULOSIS REPORT 215 n 11

n FIGURE 2.1 Countries tht hd completed systemtic ssessment of TB surveillnce using the WHO TB surveillnce checklist of stndrds nd benchmrks by August 215 High-burden countries (16) Other countries (22) n FIGURE 2.2 Min method used to estimte TB incidence Min method Cse notifictions, expert opinion Prevlence survey Cse notifictions, stndrd djustment Cpture recpture No dt Not pplicble In the first method, cse notifiction dt re combined with expert opinion bout cse detection gps (under-reporting nd under-dignosis), nd trends re estimted using either mortlity dt, repet surveys of the nnul risk of infection or exponentil interpoltion using estimtes of cse detection gps for three yers. For ll high-income countries except the Netherlnds nd the United Kingdom, notifictions re djusted by stndrd mount or mesure of under-reporting from inventory studies, to ccount for cse detection gps. For further detils bout ll four methods, see text. 12 n GLOBAL TUBERCULOSIS REPORT 215

Box 2.3 Low level of under-reporting of detected TB cses in the Republic of Kore A ntionl cse-bsed nd internet-bsed TB notifiction system is key element of the NTP in the Republic of Kore, linked to the initition of response mesures including outbrek investigtions, evlution of contcts nd TB cse mngement. The online TB reporting system ws estblished in 2. All TB ptients who re treted in public helth centres re notified to the Kore Ntionl TB Surveillnce System (KNTSS). In 26, ntionl survey found tht only 67.6% of ptients dignosed nd treted in the privte sector were notified, despite legl frmework mking notifiction of TB cses mndtory. Since 28, the coverge of routine TB surveillnce hs been systemticlly ssessed using record-linkge of medicl records from the Ntionl Helth Insurnce (NHI) system nd records from the KNTSS dtbse. b Ntionl identifiction numbers re used for record-linkge. Dt on levels of under-reporting of TB cse notifictions in 212 nd 213 re presented in Tble B2.3.1. Under-reporting ws defined s filing to report detected cse within 6 months. TABLE B2.3.1 Under-reporting of detected TB cses in the Republic of Kore 212 213 Ntionl helth insurnce system 36 735 33 8 Ntionl TB surveillnce system 32 515 31 534 Under-reporting 11.5% 6.7% Under-reporting to the ntionl TB surveillnce system ws found to be lower when cses were dignosed in generl hospitls (8%, 212 213) compred with privte clinics (24%). A regultion is being put in plce tht mkes reimbursement from the ntionl helth insurnce system conditionl upon notifiction of cses by prescribing physicins, s prt of 5-yer pln for TB elimintion (213 217). In 211, the ntionl helth insurnce system covered 9% of medicl expenses relted to TB, nd reimbursement coverge is plnned to rech 1% for TB ptients in 216. The new regultion regrding conditionl reimbursement nd the plnned increse in coverge of helth insurnce to 1% for TB ptients should ensure close to zero level of under-reporting of detected cses in the ner future. b WJ Lew, EG Lee, JY Bi et l. An Internet-bsed surveillnce system for tuberculosis in Kore. Int J Tuberc Lung Dis, 26; 1:1241 7. YS Prk, SJ Hong, YK Boo et l. The ntionl sttus of tuberculosis using ntionwide medicl records survey of ptients with tuberculosis in Kore. Tuberc Respir Dis (Seoul), 212; 73:48 55. estimtes tht ws held 31 Mrch 2 April 215 (Box 2.1). 1,2 In 214, there were n estimted 9.6 million incident cses of TB (rnge, 9.1 million 1. million) 3 globlly, equivlent to 133 cses per 1 popultion (Tble 2.1, Tble 2.2). The bsolute number of incident cses is flling slowly (Figure 2.3), t n verge rte of 1.5% per yer 2 214 nd 2.1% between 213 nd 214. The cumultive reduction in the TB incidence rte 2 214 ws 18%. Most of the estimted number of cses in 214 occurred in Asi (58%) nd the Africn Region (28%); 4 smller proportions of cses occurred in the Estern Mediterrnen Region (8%), the Europen Region (3%) nd the Region of the Americs (3%). The 22 HBCs tht hve been given highest priority t the globl level since 2 (listed in Tble 2.1 nd Tble 2.2) ccounted for 83% of ll estimted incident cses worldwide. The six countries tht stnd out s hving the lrgest number of incident cses in 214 were Indi, Indonesi, Chin, Nigeri, Pkistn nd South Afric; these nd the other five countries tht mke up the top ten in terms of numbers of cses re highlighted in Figure 2.4. Indi, Indonesi nd Chin lone ccounted for combined totl of 43% of globl cses in 214. The 9.6 million incident TB cses in 214 included 1.1 million 1.3 million (11 13%) mong people living with HIV, with best estimte of 1.2 million (12%) (Tble 2.1, Tble 2.2). The proportion of TB cses co-infected with HIV ws highest in countries in the Africn Region (Figure 2.5). Overll, 32% of TB cses were estimted to be co-infected with HIV in this region, which ccounted for 74% of TB cses mong people living with HIV worldwide. In prts of southern Afric, more thn 5% of TB cses were co-infected with HIV (Figure 2.5). Following systemtic review of evidence bout mortlity cused by MDR-TB undertken in 213 nd consensus bout wht indictors to use for reporting on the burden of MDR-TB, 5 this report includes updted globl estimtes of MDR-TB incidence nd mortlity. The best estimte is tht there were 48 (rnge, 36 6 ) new cses of MDR-TB worldwide in 214 (see lso Chpter 4). This totl includes cses of primry nd cquired MDR-TB. The number of incident TB cses reltive to popultion size (the incidence rte) vries widely mong countries (Figure 2.6, Figure 2.7). The lowest rtes re found predominntly in high-income countries including most countries in western Europe, Cnd, the United Sttes of Americ, Austrli nd New Zelnd. In these countries, the incidence rte is less thn 1 cses per 1 popultion per yer. Most countries in the Region of the Americs hve rtes below 5 per 1 popultion per yer nd this is the region with 1 The online technicl ppendix is vilble t www.who.int/tb/dt. 2 All bckground documents re vilble t www.who.int/tb/ dvisory_bodies/impct_mesurement_tskforce/meetings/ consulttion_pril_215_tb_estimtes_subgroup/en/ 3 Rnge refers here nd elsewhere to the 95% uncertinty intervl. 4 Asi refers to the WHO Regions of South-Est Asi nd the Western Pcific. 5 See Box 5.3, Chpter 5 in the 214 globl TB report. GLOBAL TUBERCULOSIS REPORT 215 n 13

n TABLE 2.1 Estimted epidemiologicl burden of TB, 214. Best estimtes re followed by the lower nd upper bounds of the 95% uncertinty intervl. Numbers in thousnds. b c POPULATION MORTALITY b HIV-POSITIVE TB MORTALITY PREVALENCE INCIDENCE HIV-POSITIVE INCIDENT TB CASES Afghnistn 31 628 14 1 18 <.1.1 11 56 18 6 53 67.3.2.4 Bngldesh c 159 78 81 59 11.2.1.2 64 34 1 36 32 41.6.4.7 Brzil 26 78 5.3 4.9 5.7 2.4 1.8 3.2 11 51 18 9 86 95 16 14 17 Cmbodi 15 328 8.9 6.3 12.8.6 1. 1 87 12 6 54 66 1.8 1.6 2. Chin 1 369 436 38 37 4.7.5.9 1 2 1 1 1 4 93 86 1 13 11 16 DR Congo 74 877 52 38 68 6.3 5. 7.7 4 21 64 24 22 27 34 27 42 Ethiopi 96 959 32 22 43 5.5 4.4 6.8 19 16 24 2 16 24 19 15 23 Indi 1 295 292 22 15 35 31 25 38 2 5 1 7 3 5 2 2 2 2 3 11 96 12 Indonesi 254 455 1 66 15 22 13 32 1 6 1 3 2 1 7 1 4 63 41 9 Keny 44 864 9.4 6.7 12 8.1 6.4 1 12 64 19 11 11 11 4 38 42 Mozmbique 27 216 18 12 26 37 29 45 15 8 24 15 12 18 85 65 11 Mynmr 53 437 28 2 37 4.1 3.3 5.1 24 19 31 2 18 22 19 15 24 Nigeri 177 476 17 91 28 78 53 11 59 45 74 57 34 87 1 59 16 Pkistn 185 44 48 11 11 1.3.8 1.9 63 53 74 5 37 65 6.4 4.4 8.7 Philippines 99 139 1 9. 11 <.1.1 41 36 47 29 25 32 2.5 2. 3.2 Russin Federtion 143 429 16 15 16 1.1.8 1.3 16 7 27 12 11 13 5.5 4.5 6.6 South Afric 53 969 24 22 26 72 58 89 38 21 59 45 4 51 27 24 31 Thilnd 67 726 7.4 3.9 12 4.5 2.3 7.4 16 11 22 12 61 19 15 7.8 24 Ugnd 37 783 4.5 3.2 6.1 6.4 5. 8.1 6 33 95 61 53 69 28 24 32 UR Tnzni 51 823 3 13 54 28 15 43 27 11 51 17 8 29 62 29 11 Viet Nm 92 423 17 11 23 1.9 1.3 2.5 18 76 33 13 11 15 7 5.7 8.5 Zimbbwe 15 246 2.3 1.4 3.4 5.2 3.2 7.8 44 24 71 42 29 58 25 17 35 High-burden countries 4 552 74 94 79 1 1 32 28 36 1 9 2 12 8 7 5 8 5 93 85 1 AFR 963 361 45 35 56 31 27 35 3 2 2 8 3 6 2 7 2 4 3 87 79 95 AMR 981 613 17 16 18 6 5.2 6.8 35 27 44 28 27 29 36 34 38 EMR 635 745 88 43 15 3.2 2.6 4. 1 88 1 2 74 61 89 12 1 15 EUR 97 279 33 33 34 3.2 2.7 3.7 44 33 56 34 32 35 2 18 21 SEAR 1 96 87 46 35 57 62 51 74 5 4 4 4 6 5 4 3 7 4 4 21 18 24 WPR 1 845 184 88 81 95 4.9 4.2 5.7 2 1 1 9 2 4 1 6 1 5 1 6 31 28 35 Globl 7 239 269 1 1 97 1 3 39 35 43 13 11 14 9 6 9 1 1 1 2 1 1 1 3 Numbers for mortlity, prevlence nd incidence shown to two significnt figures. Totls (HBCs, regionl nd globl) re computed prior to rounding. Mortlity excludes deths mong HIV-positive TB cses. Deths mong HIV-positive TB cses re clssified s HIV deths ccording to ICD-1 nd re shown seprtely in this tble. For Bngldesh, joint ressessment of estimtes of TB disese burden will be undertken following completion of the ntionl TB prevlence survey. 14 n GLOBAL TUBERCULOSIS REPORT 215

n TABLE 2.2 Estimted epidemiologicl burden of TB, 214. Best estimtes re followed by the lower nd upper bounds of the 95% uncertinty intervl. Rtes per 1 popultion except where indicted. POPULATION (THOUSANDS) MORTALITY HIV-POSITIVE TB MORTALITY PREVALENCE INCIDENCE HIV PREVALENCE IN INCIDENT TB CASES (%) Afghnistn 31 628 44 32 57.3.2.3 34 178 555 189 167 212.5.4.7 Bngldesh b 159 78 51 37 68.1.1 44 211 659 227 2 256.2.1.2 Brzil 26 78 2.6 2.4 2.7 1.2.9 1.6 52 25 89 44 42 46 17 16 19 Cmbodi 15 328 58 41 78 5.3 4.1 6.7 668 565 78 39 353 428 3. 2.8 3.2 Chin 1 369 436 2.8 2.7 2.9 <.1.1 89 78 12 68 63 73 1.4 1.2 1.7 DR Congo 74 877 69 5 9 8.4 6.7 1 532 282 859 325 295 356 14 11 17 Ethiopi 96 959 33 23 44 5.7 4.6 7. 2 161 243 27 168 25 9.3 8.2 1 Indi 1 295 292 17 12 27 2.4 2. 2.9 195 131 271 167 156 179 5. 4.5 5.4 Indonesi 254 455 41 26 59 8.5 5.2 13 647 513 797 399 274 546 6.2 5.1 7.5 Keny 44 864 21 15 28 18 14 22 266 142 427 246 24 252 36 34 38 Mozmbique 27 216 67 44 96 134 16 165 554 295 893 551 435 68 57 5 63 Mynmr 53 437 53 38 7 7.7 6.1 9.5 457 352 575 369 334 46 9.7 7.9 12 Nigeri 177 476 97 51 156 44 3 61 33 253 417 322 189 488 18 15 22 Pkistn 185 44 26 6. 61.7.4 1. 341 285 42 27 21 35 1.3 1 1.5 Philippines 99 139 1 9.1 11 <.1.1 417 367 471 288 254 324.9.7 1.1 Russin Federtion 143 429 11 11 11.7.6.9 19 49 192 84 76 93 4.6 3.8 5.3 South Afric 53 969 44 41 48 134 17 164 696 39 1 9 834 737 936 61 56 66 Thilnd 67 726 11 5.7 18 6.6 3.4 11 236 161 326 171 9 276 13 12 14 Ugnd 37 783 12 8.4 16 17 13 21 159 87 253 161 141 183 45 42 48 UR Tnzni 51 823 58 26 14 53 3 84 528 215 979 327 155 561 37 32 42 Viet Nm 92 423 18 12 25 2 1.4 2.7 198 83 362 14 116 167 5.4 5 5.9 Zimbbwe 15 246 15 9.5 22 34 21 51 292 158 465 278 193 379 6 55 65 High-burden countries b 4 552 74 21 17 24 6.9 6.1 7.8 227 23 253 176 165 188 12 1 13 AFR 963 361 46 36 58 32 28 36 33 288 375 281 25 313 32 28 37 AMR 981 613 1.7 1.6 1.8.6.5.7 36 28 45 28 27 29 13 12 14 EMR 635 745 14 6.8 23.5.4.6 16 139 183 117 96 14 1.7 1.3 2.2 EUR 97 279 3.7 3.6 3.8.3.3.4 48 36 61 37 35 39 5.9 5.4 6.5 SEAR 1 96 87 24 19 3 3.3 2.7 3.9 286 233 343 211 192 232 5.2 4.3 6.1 WPR 1 845 184 4.8 4.4 5.1.3.2.3 116 14 128 85 8 89 2. 1.8 2.3 Globl 7 239 269 16 13 18 5.3 4.8 5.9 174 158 19 133 126 141 12 11 13 Mortlity excludes deths mong HIV-positive TB cses. Deths mong HIV-positive TB cses re clssified s HIV deths ccording to ICD-1 nd re shown seprtely in this tble. For Bngldesh, joint ressessment of estimtes of TB disese burden will be undertken following completion of the ntionl TB prevlence survey. GLOBAL TUBERCULOSIS REPORT 215 n 15

n FIGURE 2.3 Estimted bsolute numbers of TB cses nd deths (in millions per yer), 199 214 TB incidence 2 TB deths Millions 1 8 6 4 All TB cses Millions 1.5 1 TB deths mong HIV-negtive people 2 HIV-positive TB cses 199 1995 2 25 21 215 199 1995 2 25 21 215.5 TB deths mong HIV-positive people HIV-ssocited deths re clssified s HIV deths ccording to ICD-1. n FIGURE 2.4 Estimted TB incidence: top-ten countries, 214. The rnge shows the lower nd upper bounds of the 95% uncertinty intervl. The bullet mrks the best estimte. Incidence: bsolute numbers Incidence: rtes Indi Lesotho Indonesi South Afric Chin Swzilnd Nigeri Djibouti Pkistn Nmibi South Afric Mozmbique Bngldesh Timor Leste Philippines Gbon DR Congo DPR Kore Ethiopi Ppu New Guine..5 1. 1.5 2. Millions 3 6 9 Rte per 1 popultion per yer the lowest burden of TB on verge. Most of the HBCs hve rtes of round 15 3 cses per 1 popultion per yer (Tble 2.2, Figure 2.7); HBCs with mrkedly lower rtes in 214 were Brzil, Chin nd the Russin Federtion, while rtes were bove 5 per 1 popultion in Mozmbique nd South Afric. Other countries in the top ten worldwide in terms of incidence rtes in 214 re shown in Figure 2.4. Globlly, the incidence rte ws reltively stble from 199 up until round 2, nd then strted to fll (Figure 2.8), chieving the MDG trget fr hed of the 215 dedline. The MDG trget hs lso been met in ll six WHO regions nd in 16 of the 22 HBCs (Figure 2.9, Figure 2.1, Tble 2.3). 2.2 TB prevlence In countries with reltively high burden of TB (round 1 cses per 1 popultion or more), the prevlence of bcteriologiclly-confirmed pulmonry TB cn be directly mesured in ntionwide popultion-bsed surveys using smple sizes of round 5 people. Survey results cn be used to produce ntionl estimte of TB prevlence tht includes ll forms of TB. The cost of survey usully rnges from US$ 1 to 4 million, nd comprehensive theoreticl nd prcticl guidnce on survey design, implementtion, 16 n GLOBAL TUBERCULOSIS REPORT 215

n TABLE 2.3 215 trgets ssessment: globl, WHO regions nd 22 high-burden countries b GLOBAL INDICATORS AND 215 TARGETS INDICATOR TB INCIDENCE RATE TB PREVALENCE RATE TB MORTALITY RATE TARGET INCIDENCE RATE FALLING 5% REDUCTION IN PREVALENCE RATE BY 215 COMPARED WITH 199 5% REDUCTION IN MORTALITY RATE BY 215 COMPARED WITH 199 Globl Met Almost met Almost met WHO REGION Africn (AFR) Met Not met Not met Americs (AMR) Met Met Met Estern Mediterrnen (EMR) Met Not met Met Europen (EUR) Met Not met Not met South-Est Asi (SEAR) Met Met Met Western Pcific (WPR) Met Met Met 22 HIGH-BURDEN COUNTRIES AFR DR Congo Not met Not met Not met Ethiopi Met Met Met Keny Met Not met Not met Mozmbique Not met Not met Almost met Nigeri Not met Not met Not met South Afric Met Not met Not met Ugnd Met Met Met UR Tnzni Met Not met Not met Zimbbwe Met Not met Met AMR Brzil Met Met Met EMR Afghnistn Not met Not met Not met Pkistn Not met Not met Met EUR Russin Federtion Met Not met Not met SEAR Bngldesh b Not met Not met Not met Indi Met Met Met Indonesi Met Not met Not met Mynmr Met Met Met Thilnd Met Not met Almost met WPR Cmbodi Met Met Met Chin Met Met Met Philippines Met Met Met Viet Nm Met Met Met Met (green) mens tht the trget ws chieved before or by the end of 215. Not met (ornge) mens tht the trget will not be chieved by the end of 215. Almost met (light green) mens tht the reduction ws in the rnge 4 49%, ccording to the best estimte. Vlues for 215 were bsed on n lgorithm tht selects the best performing mong fmily of exponentil smoothing vi stte-spce models of the 25 214 time-series. For Bngldesh, joint ressessment of estimtes of TB disese burden will be undertken following completion of the ntionl TB prevlence survey. GLOBAL TUBERCULOSIS REPORT 215 n 17

n FIGURE 2.5 Estimted HIV prevlence in new nd relpse TB cses, 214 HIV prevlence in new TB cses, ll ges (%) 4 5 19 2 49 5 No dt Not pplicble n FIGURE 2.6 Estimted TB incidence rtes, 214 Estimted new TB cses (ll forms) per 1 popultion per yer 9.9 1 19 2 49 5 124 125 299 3 499 5 No dt Not pplicble 18 n GLOBAL TUBERCULOSIS REPORT 215

n FIGURE 2.7 Globl distribution of estimted TB incidence by rte nd bsolute number, 214. The size of ech bubble is proportionl to the size of the country s popultion. High-burden countries re shown in red. 2 Indi 4 WHO region SEAR Cses per yer (thousnds) 15 1 Chin Indonesi Cses per yer (thousnds) 3 2 1 EUR AMR WPR EMR 1 2 Rte per 1 popultion per yer AFR 5 Russin Viet Federtion Nm Nigeri Pkistn Bngldesh South Afric Philippines Democrtic DR Congo Ethiopi People's UR Tnzni Republic Mozmbique Mynmr of Kore Thilnd Keny Cmbodi Afghnistn Zimbbwe Timor-Leste Nmibi Djibouti Swzilnd Lesotho Brzil Ugnd Kiribti 1 2 3 4 5 6 7 8 Rte per 1 popultion per yer nlysis nd reporting of results is vilble. 1 Repet surveys conducted bout every ten yers llow trends in disese burden to be ssessed. HBCs tht hve completed repet surveys in the lst ten yers include Cmbodi, Chin, the Philippines nd Thilnd. Repet surveys re plnned in Mynmr nd Viet Nm round 216 217; fourth survey is lso plnned in the Philippines in 216. Countries in which surveys hve been implemented or re plnned in the ner future re shown in Figure 2.11 nd Figure 2.12. In the 199s nd erly 2s, there ws typiclly no or one survey per yer, nd ll the surveys tht were done were in Asi. Between 29 nd 216, n unprecedented number of ntionl TB prevlence surveys hve been or will be conducted, in both Afric nd Asi (Figure 2.12, Box 2.1, Box 2.2). The results nd lessons lerned from one of the most recent surveys, in Indonesi, re highlighted in Box 2.4. 1 TB prevlence surveys: hndbook. Genev, World Helth Orgniztion, 211 (WHO/HTM/TB/21.17). Avilble t www.who.int/tb/dvisory_ bodies/impct_mesurement_tskforce/resources_documents/ thelimebook/ In low- nd medium-burden countries, smple sizes nd costs for surveys become prohibitively lrge. If survey dt re not vilble, prevlence cn be indirectly estimted s the product of incidence nd the verge durtion of disese, but with considerble uncertinty. Detils bout the methods used to produce estimtes of TB prevlence re provided in the online technicl ppendix nd in bckground documents prepred for the globl review of methods used to produce TB burden estimtes tht ws held 31 Mrch 2 April 215 (Box 2.1). 2,3 There were n estimted 13 million prevlent cses (rnge, 11 million 14 million) of TB in 214 (Tble 2.1), equivlent to 174 cses per 1 popultion (Tble 2.2). By the end of 215, it is estimted tht the prevlence rte will hve fllen 42% globlly since 199, missing the trget (Figure 2.8, Tble 2.3). However, two regions met the trget before 215 (the Region of the Americs nd the Western Pcific Region) nd the South-Est Asi Region reched the trget (ccord- 2 The online technicl ppendix is vilble t www.who.int/tb/dt. 3 All bckground documents re vilble t www.who.int/tb/ dvisory_bodies/impct_mesurement_tskforce/meetings/ consulttion_pril_215_tb_estimtes_subgroup/en/ GLOBAL TUBERCULOSIS REPORT 215 n 19

Box 2.4 The 213/214 ntionl TB prevlence survey in Indonesi: min results, nd policy, progrmmtic nd funding implictions A ntionl survey of the prevlence of TB disese in Indonesi ws successfully implemented in 213/214 under the ledership of the Ntionl TB Progrmme nd the Ntionl Institute of Helth Reserch nd Development. The min objective of the survey ws to estimte the prevlence of pulmonry TB (bcteriologicllyconfirmed) mong the generl popultion ged 15 yers old. Methods nd min results Survey methods from design through implementtion, nlysis nd reporting of results followed the interntionl recommendtions of the WHO Globl Tsk Force on TB Impct Mesurement. All survey prticipnts were screened for symptoms by interview nd chest X-ry exmintion. Prticipnts with ny current symptom suggestive of TB or rdiologicl lesion(s) in the lung were requested to submit two sputum specimens (one spot nd one erly-morning) tht were exmined by microscopy (AFB) nd culture (LJ solid medi). A totl of 112 35 people of ll ges were enumerted, from 156 clusters round the country. Of these, there were 76 576 eligible individuls ged 15 yers old. All eligible individuls were invited to prticipte in the survey, of whom 67 994 (89%) did so. Of those who prticipted, 15 446 (23%) screened positive nd were eligible for sputum exmintion. A totl of 426 TB cses were identified by the survey (Figure B2.4.1). The excellent prticiption rte s well s other survey indictors (for exmple, very low levels of missing dt) show tht the survey ws implemented to high stndrd. The TB prevlence rte per 1 popultion ged 15 yers old ws estimted to be 257 (95% CI: 21 33) for smer-positive TB, nd 759 (95% CI: 59 961) for bcteriologiclly-confirmed TB. Cler nd consistent ge nd sex dif ferentils were observed for both smer-positive nd bcteriologiclly-confirmed TB, with higher rtes mong men nd older ge groups (Figure B2.4.2). The finl survey results were used in combintion with other sources of informtion (such s notifiction dt, mortlity dt from smple vitl registrtion system nd previous ntionl TB prevlence surveys) to updte estimtes of the burden of TB disese in Indonesi (Figure B2.4.3). Both survey results nd these updted estimtes were discussed nd greed upon in ntionl consensus meetings involving ll key stkeholders tht were held in September nd October 214. Lessons lerned The key lessons lerned from the survey were: 1. The burden of TB disese in Indonesi is much higher thn previously thought. b Revised figures for 213 re n estimted TB incidence rte of 43 (rnge, 278 55) per 1 popultion nd n estimted prevlence (ll forms of TB, nd including children s well s dults) of 66 (rnge, 523 813) per 1 popultion. The 213/214 survey hs provided more ccurte mesurement of TB disese burden compred with erlier surveys, since unlike previous surveys it included systemtic chest X-ry screening of the entire survey popultion nd bcteriologicl testing for ll those with signs or symptoms suggestive of TB. 2. When nlysed longside results from previous surveys, TB incidence is flling, in line with the MDG trget for TB. TB prevlence nd mortlity re lso flling. In ddition, the cse ftlity rtio (the proportion of incident cses tht die from TB) is estimted t 11%, considerbly better thn the globl verge of 16%. 3. Overll, only bout one third of the estimted 1 million incident cses tht occur ech yer re being detected nd reported to ntionl uthorities. 4. The number of TB ptients receiving tretment in public nd privte hospitls, without linkge or reporting to the ntionl TB progrmme, ws much lrger thn expected. A high proportion of detected cses (bout 5%) hd not been reported. 5. A high proportion of people with TB hd not been detected t the time of the survey, showing serious delys in TB dignosis nd tretment. Policy, progrmmtic nd funding implictions The mjor implictions of survey results, some of which require high-level policy ction, include: 1. TB wrrnts being one of the top helth priorities in Indonesi. 2. Funding needs for TB prevention, dignosis nd tretment re considerbly lrger thn previously thought. Additionl resources will need to be mobilized t ntionl, provincil nd district levels. 3. Expnsion of helth insurnce coverge is crucil to support high qulity TB dignosis nd tretment in public nd privte hospitls (nd in the privte sector in generl), to ensure tht TB disese does not impose finncil burden on ptients nd their households, nd to ensure pproprite cost-recovery for cre providers. 4. The current policy of mndtory cse notifiction needs to be strongly enforced to reduce under-reporting of detected cses. This could be fcilitted by systems tht mke it esier for cre providers to notify cses, such s user-friendly electronic surveillnce system, nd by incentives for reporting (or penlties for not reporting). 5. Screening nd dignostic tools tht hve higher sensitivity thn current symptom screening nd smer microscopy need to be introduced or expnded to help reduce the number of undetected cses in the community, s well s to reduce the possibility of over-dignosis. Exmples include much wider use of chest X-ry screening nd rpid moleculr dignostics. 6. Referrl mechnisms between helth centres nd hospitls in both the public nd privte sectors need to be strengthened nd wreness of TB incresed throughout the popultion nd mong helth cre workers. These mesures will lso help to reduce the number of undetected cses in the community. Conclusions nd next steps The 213/214 ntionl survey of the prevlence of TB disese in Indonesi is one of the highest qulity ntionl TB prevlence surveys conducted to dte, nd the importnce of the evidence it 2 n GLOBAL TUBERCULOSIS REPORT 215

FIGURE B2.4.1 Consort digrm of the 213 214 ntionl TB prevlence survey in Indonesi Enumerted popultion: 112 35 Not eligible to prticipte: 35 774 (31.8%) 33 26 were less thn 15 yers old 2 568 were resident for less thn 1 month Eligible to prticipte: 76,576 (68.2%) Did not prticipte: 8 632 (11.3%) Prticipted: 67 944 (88.7%) Negtively screened: 52 498 (77.3%) Positively screened, eligible for sputum exmintion: 15 446 (22.7%) Symptom nd chest X-ry positive: 4 459 (28.9%) Symptom positive only: 3 844 (24.9%) Chest X-ry positive only: 6 743 (43.7%) Other: 4 (2.6%) Did not submit sputum: 35 (2.%): 174 refused, 131 could not produce sputum Submitted t lest one sputum specimen: 15 141 (98.%) Submitted two sputum specimens: 14 568 Submitted only one specimen: 573 of which 557 were spot specimens nd 16 were morning specimens No lbortory result: 14 (.1%) Lbortory results were vilble: 15 127 (99.9%) All lbortory results were norml: 13 836 At lest one smer ws positive Culture results: MTB: 141 NTM: 14 Negtive: 129 Contmintion: 6 NA: 1 Both smers were negtive Culture results: MTB: 259 NTM: 386 Contmintion: 333 NA: 22 Pnel review Not TB cses 14 7 TB cses: 426 Definite cse: 419 Probble cse: 7 Smer positive TB Bcteriologiclly confirmed TB FIGURE B2.4.2 2 15 1 75 5 25 Overll, nd ge nd sex-specific TB prevlence rtes s mesured in the 213 214 ntionl TB prevlence survey in Indonesi, with 95% confidence intervls 15 24 25 34 35 44 45 54 55 64 65 Mle Femle All 15 24 25 34 35 44 45 54 55 64 65 Mle Femle All Rte per 1 popultion GLOBAL TUBERCULOSIS REPORT 215 n 21

FIGURE B2.4.3 Trends in estimted rtes of incidence, prevlence nd mortlity in Indonesi, 199 215. Lef t pnel: the incidence rte (green) is shown longside notifictions of TB cses (blck). Centre nd right pnels: The horizontl dshed lines represent the Stop TB Prtnership trgets of 5% reduction in prevlence nd mortlity rtes by 215 compred with 199. Shded res represent uncertinty bnds. Incidence Prevlence Mortlity (HIV-negtive) Rte per 1 popultion per yer 6 4 2 Rte per 1 popultion 1 5 Rte per 1 popultion per yer 75 5 25 199 1995 2 25 21 215 199 1995 2 25 21 215 199 1995 2 25 21 215 hs produced is cler. Following wide dissemintion of findings, results hve been used to help develop the ntionl strtegic pln 215 22 nd the preprtion of Concept Note required for finncing from the Globl Fund. A survey report hs been finlized nd results will be summrized in pper for peer-reviewed journl. b Tuberculosis prevlence surveys: hndbook. Genev: World Helth Orgniztion; 21 (WHO/HTM/TB/21.17). Avilble t: http:// www.who.int/tb/dvisory_bodies/impct_mesurement_tskforce/ resources_documents/thelimebook/en/ Other exmples of countries where survey hs shown tht the burden of TB ws higher thn previously include Los PDR (211), Nigeri (212), Ghn (213), Mlwi (213) nd Zmbi (214). ing to the best estimte) in 215 (Figure 2.13). 1 TB prevlence is flling in ll of the other three regions. Among the 22 HBCs, nine re ssessed to hve met the trget of 5% reduction from 199 levels (Figure 2.14, Tble 2.3). 2.3 TB mortlity TB mortlity mong HIV-negtive people cn be directly mesured using dt from ntionl VR systems, provided tht these systems hve high coverge nd cuses of deth re ccurtely coded ccording to the ltest revision of the Interntionl clssifiction of diseses (ICD-1). Smple VR systems covering representtive res of the country (e.g. s in Chin) provide n interim solution. Mortlity surveys cn lso be used to estimte deths cused by TB. In 214, 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 rte, or from ecologicl modelling bsed on mortlity dt from countries with VR systems. TB mortlity mong 1 Vlues for 215 were estimted using n lgorithm tht selects the best performing mong fmily of exponentil smoothing vi stte-spce models of the 25 214 time-series. 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 (such s TB) re of ten not relibly recorded. For this 215 report, countryspecific estimtes of TB deths mong HIV-positive people were produced using the Spectrum sof twre tht hs been used for HIV burden estimtes for over decde. Until 28, WHO estimtes of TB mortlity used VR dt for only three countries. This ws substntilly improved to 89 countries in 29; however, most of the dt were from countries in the Europen Region nd the Region of the Americs, which ccounted for less thn 1% of the world s TB cses. In 211, the first use of smple VR dt from Chin nd survey dt from Indi enbled further mjor improvement to estimtes of TB mortlity. For the current report, VR dt of suf ficient coverge nd qulity were vilble for 127 countries (Figure 2.15) including Indonesi nd South Afric for the first time (Box 2.2), nd survey dt were vilble for two countries (Indi nd Viet Nm). The combined totl of 129 countries ccounted for 43% of the estimted number of TB deths globlly in 214. The Africn Region is the prt of the world in which there is the gretest need to introduce or strengthen vitl registrtion system in which cuses of deth re clssified ccording to the ICD system. 22 n GLOBAL TUBERCULOSIS REPORT 215

n FIGURE 2.8 Globl trends in estimted rtes of TB incidence (199-214), nd prevlence nd mortlity rtes (199 215). Lef t: Estimted incidence rte including HIV-positive TB (green) nd estimted incidence rte of HIV-positive TB (red). Centre nd right: The horizontl dshed lines represent the Stop TB Prtnership trgets of 5% reduction in prevlence nd mortlity rtes by 215 compred with 199. Shded res represent uncertinty bnds. Mortlity excludes TB deths mong HIV-positive people. Incidence Prevlence Mortlity Rte per 1 popultion per yer 15 1 5 Rte per 1 popultion 3 25 2 15 1 5 Rte per 1 popultion per yer 3 25 2 15 1 5 199 1995 2 25 21 215 199 1995 2 25 21 215 199 1995 2 25 21 215 n FIGURE 2.9 Estimted TB incidence rtes by WHO region, 199 214. Estimted TB incidence rtes (green) nd estimted incidence rtes of HIV-positive TB (red). Shded res represent uncertinty bnds. 4 Afric 6 The Americs 15 Estern Mediterrnen 3 2 4 1 Rte per 1 popultion per yer 1 199 1995 2 25 21 215 Europe 6 4 2 199 1995 2 25 21 215 South Est Asi 2 5 199 1995 2 25 21 215 Western Pcific 15 1 2 1 5 199 1995 2 25 21 215 199 1995 2 25 21 215 199 1995 2 25 21 215 GLOBAL TUBERCULOSIS REPORT 215 n 23

Approximtely 9% of totl TB deths (mong HIV-negtive nd HIV-positive people) nd 8% of TB deths mong HIV-negtive people occurred in the Africn nd South-Est Asi Regions in 214. Indi nd Nigeri ccounted for bout one third of globl TB deths (both including nd excluding those mong HIV-positive people). The number of TB deths (mong HIV-negtive people) per 1 popultion verged 16 globlly in 214 (Tble 2.2) nd 21 when TB deths mong HIV-positive people re included. There is considerble vrition mong countries (Figure 2.17), rnging from <1 TB deth per 1 popultion (exmples include most countries in western Europe, Cnd, the United Sttes of Americ, Austrli nd New Zelnd) to more thn 4 deths per 1 popultion in much of the Africn Region s well s five HBCs (Afghnistn, Bngldesh, Cmbodi, Indonesi nd Mynmr). Globlly, the mortlity rte (excluding deths mong HIVn FIGURE 2.1 Estimted TB incidence rtes, 22 high burden countries, 199 214. Estimted TB incidence rtes (green) nd estimted incidence rtes of HIV positive TB (red). Shded res represent uncertinty bnds. Afghnistn Bngldesh Brzil Cmbodi Chin 1 2 6 15 2 75 15 4 1 1 5 1 5 25 2 5 Rte per 1 popultion per yer DR Congo Ethiopi Indi Indonesi Keny 5 3 4 2 2 3 15 2 1 1 1 5 Mozmbique Mynmr Nigeri Pkistn Philippines 5 6 4 4 4 3 3 2 2 2 1 1 6 3 4 2 2 1 3 4 2 2 1 Russin Federtion South Afric Thilnd Ugnd UR Tnzni 15 4 8 8 9 1 3 6 6 6 2 4 4 5 3 1 2 2 Viet Nm Zimbbwe 3 8 6 2 4 1 2 199 1995 2 25 21 215 199 1995 2 25 21 215 199 1995 2 25 21 215 199 1995 2 25 21 215 199 1995 2 25 21 215 For Bngldesh, joint ressessment of estimtes of TB disese burden will be undertken following completion of the ntionl TB prevlence survey. Detils bout the methods used to produce estimtes of TB mortlity re provided in the online technicl ppendix nd in bckground documents prepred for the globl review of methods used to produce TB burden estimtes tht ws held 31 Mrch 2 April 215 (Box 2.1). 1,2 There were n estimted 1.5 million TB deths in 214 (Tble 2.1, Figure 2.2): 1.1 million mong HIV-negtive people nd 39 mong HIV-positive people (TB deths mong HIV-positive people re clssified s HIV deths in ICD-1). 3 TB rnks longside HIV s leding cuse of deth from n infectious disese (Figure 2.16, Figure 2.16b). 4 1 The online technicl ppendix is vilble t www.who.int/tb/dt. 2 All bckground documents re vilble t www.who.int/tb/ dvisory_bodies/impct_mesurement_tskforce/meetings/ consulttion_pril_215_tb_estimtes_subgroup/en/ 3 Interntionl sttisticl clssifiction of diseses nd relted helth problems, 1th revision (ICD-1), 2nd ed. Genev: World Helth Orgniztion; 27. 4 WHO Globl Helth Observtory dt repository, vilble t http:// pps.who.int/gho/dt/node.min.ghecod?lng=en (ccessed 27 August 215). 24 n GLOBAL TUBERCULOSIS REPORT 215

n FIGURE 2.11 Countries in which ntionl popultion-bsed surveys of the prevlence of TB disese hve been implemented using currently recommended screening nd dignostic methods since 199 or re plnned in the ner future: sttus in August 215 No ntionl survey plnned Ntionl survey plnned b Ntionl survey ongoing c One ntionl survey completed d Repet ntionl survey plnned 1 repet ntionl survey completed e Not pplicble b c d e Screening methods include field chest X-ry; culture is used to confirm dignosis. A country hs submitted t lest drf t survey protocol nd budget pln to the WHO Globl Tsk Force for TB Impct Mesurement. Countries were implementing field opertions in August 215 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 culture exmintion ws used to dignose TB cses. In the Philippines, repet survey is plnned in 216. n FIGURE 2.12 Globl progress in implementing ntionl surveys of the prevlence of TB disese, ctul (22 215) nd expected (216 217) Number of surveys 7 6 5 4 3 2 1 Asi GFC Afric GFC Non GFC Globl focus countries (GFC) selected by WHO Globl Tsk Force on TB Impct Mesurement Gmbi DPR Kore Nepl Lo PDR Nigeri Mongoli Mozmbique Ethiopi Rwnd Sudn Zimbbwe Keny South Afric Philippines Cmbodi UR Tnzni Ghn Zmbi Ugnd Philippines Cmbodi Mlysi Indonesi Eritre Thilnd Viet Nm Bngldesh Mynmr Chin Pkistn Thilnd Mlwi Indonesi Bngldesh Viet Nm Mynmr 22 23 24 25 26 27 28 29 21 211 212 213 214 215 216 217 GLOBAL TUBERCULOSIS REPORT 215 n 25

n FIGURE 2.13 Estimted TB prevlence rtes 199 215, by WHO region. Shded res represent uncertinty bnds. The horizontl dshed lines represent the Stop TB Prtnership trget of 5% reduction in the prevlence rte by 215 compred with 199. Rte per 1 popultion 4 3 2 1 1 Afric The Americs Estern Mediterrnen 1 75 2 5 1 25 Europe South Est Asi Western Pcific 3 6 4 2 5 2 1 199 1995 2 25 21 215 199 1995 2 25 21 215 199 1995 2 25 21 215 n FIGURE 2.14 Estimted TB prevlence rtes 199 215, 22 high burden countries. Shded res represent uncertinty bnds. The horizontl dshed lines represent the Stop TB Prtnership trget of 5% reduction in the prevlence rte by 215 compred with 199. Rte per 1 popultion Afghnistn Bngldesh Brzil Cmbodi Chin 8 2 25 6 75 2 2 15 4 5 1 15 15 1 1 2 25 5 5 5 DR Congo Ethiopi Indi Indonesi Keny 1 6 5 5 75 4 1 4 4 5 3 3 25 2 2 5 2 1 1 Mozmbique Mynmr Nigeri Pkistn Philippines 15 4 6 1 1 3 1 4 5 5 2 1 2 5 Russin Federtion South Afric Thilnd Ugnd UR Tnzni 5 8 15 3 1 4 6 2 3 1 4 1 5 2 1 2 5 Viet Nm Zimbbwe 199 1995 2 25 21 215 199 1995 2 25 21 215 199 1995 2 25 21 215 1 8 75 6 5 4 25 2 199 1995 2 25 21 215 199 1995 2 25 21 215 For Bngldesh, joint ressessment of estimtes of TB disese burden will be undertken following completion of the ntionl TB prevlence survey. 26 n GLOBAL TUBERCULOSIS REPORT 215

n FIGURE 2.15 Countries (in red) for which TB mortlity is estimted using mesurements from vitl registrtion systems (n=127) nd/or mortlity surveys (n=2) n TABLE 2.4 Estimted cse ftlity rtios (CFRs) in the bsence of tretment CATEGORY OF TB CASE CFR (95% UNCERTAINTY INTERVAL) HIV-negtive, not on TB tretment.43 (.28.53) HIV-positive, not on TB tretment or ART.78 (.65.94) positive people) 1 fell 47% between 199 nd 215, nrrowly missing the trget of 5% reduction (Figure 2.8, Tble 2.3). However, two WHO regions met the trget bout ten yers in dvnce of the dedline (the Region of the Americs nd the Western Pcific Region), nd the Estern Mediterrnen nd South-Est Asi Regions reched the trget (ccording to the best estimte) by 215 (Figure 2.18). 2 TB mortlity hs been flling rpidly in the Europen Region since round 25, but not fst enough to rech the trget given the increse in mortlity levels tht occurred during the 199s. In the Africn Region, mortlity is flling but only slowly. Among the 22 HBCs, 11 re ssessed to hve met the 5% reduction trget (Figure 2.19, Tble 2.3). 1 Trends in TB mortlity rtes re restricted to TB deths mong HIV-negtive people, given tht TB deths mong HIV-positive people re clssified s HIV deths in ICD-1. 2 Vlues for 215 were estimted using n lgorithm tht selects the best performing mong fmily of exponentil smoothing vi stte-spce models of the 25 214 time-series. 2.3.1 Estimted number of lives sved by TB tretment, 2 214 The ctul numbers of TB deths (presented bove) cn be compred with the number of TB deths tht would hve occurred in the bsence of TB tretment, to give n estimte of the lives sved 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 2.1) multiplied by the relevnt cse ftlity rtio (Tble 2.4). 3 Estimtes re conservtive becuse they do not ccount for the impct of TB control or ART on the level of TB incidence, or the indirect, downstrem impct of these interventions on future levels of infections, cses nd deths. Between 2 nd 214, TB tretment lone sved n estimted 35 million lives mong HIV-negtive people (Tble 2.5). Among HIV-positive people, TB tretment supported by ART sved n dditionl 8.4 million lives. 2.4 Estimtes disggregted by ge nd sex This section presents estimtes of TB incidence nd TB mortlity disggregted by ge nd sex. Specificlly, estimtes re shown for men (defined s mles ged 15 yers), women 3 Further detils bout methods used to estimte lives sved, including CFRs for dif ferent ctegories of TB cse, re provided in the online technicl ppendix, vilble t www.who.int/tb/dt. GLOBAL TUBERCULOSIS REPORT 215 n 27

n TABLE 2.5 Cumultive number of lives sved by TB nd TB/HIV interventions 2 214 (in millions), globlly nd by WHO region. Best estimtes re followed by 95% uncertinty intervls. HIV-NEGATIVE PEOPLE HIV-POSITIVE PEOPLE TOTAL WHO REGION BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL AFR 4.2 3.4 5.1 5.9 5.3 6.5 1.1 9. 11.2 AMR 1.4 1.2 1.5.31.28.33 1.7 1.6 1.8 EMR 2.6 2.1 3..6.56.75 2.6 2.2 3. EUR 2.1 1.9 2.4.13.12.14 2.3 2. 2.5 SEA 15.7 13.7 17.7 1.6 1.4 1.8 17.3 15.3 19.3 WPR 9.2 8.3 1..29.27.32 9.5 8.6 1.3 Globl 35.2 3.9 39.4 8.4 7.6 9.2 43.5 39.2 47.8 n FIGURE 2.16 Top cuses of deth worldwide in 212.,b Deths from TB mong HIV-positive people re shown in grey. c Ischemic hert disese Stroke Lower respirtory infections Chronic obstructive pulmonry disese TB Trchel, bronchus, lung cncers Dirrhel diseses n FIGURE 2.16b Estimted number of deths from HIV/AIDS nd TB in 214. Deths from TB mong HIV-positive people re shown in grey.,b TB HIV/AIDS.5 1. 1.5 Millions For HIV/AIDS, the ltest estimtes of the number of deths in 214 tht hve been published by UNAIDS re vilble t www.unids. org/en/resources/documents/215/hiv_estimtes_with_uncertinty_ bounds_199-214. For TB, the estimtes for 214 re those published in this report. b Deths from TB mong HIV-positive people re of ficilly clssified s deths cused by HIV/AIDS in the Interntionl clssifiction of diseses. Dibetes mellitus HIV/AIDS Rod injury 1 2 3 4 5 6 7 Millions This is the ltest yer for which estimtes for ll cuses re currently vilble. See WHO Globl Helth Observtory dt repository, vilble t http://pps.who.int/gho/dt/node.min.ghecod (ccessed 27 August 215). b For HIV/AIDS, the ltest estimtes of the number of deths in 212 tht hve been published by UNAIDS re vilble t www.unids. org/en/resources/documents/215/hiv_estimtes_with_uncertinty_ bounds_199-214. For TB, the estimtes for 212 re those published in this report. c Deths from TB mong HIV-positive people re of ficilly clssified s deths cused by HIV/AIDS in the Interntionl clssifiction of diseses. 28 n GLOBAL TUBERCULOSIS REPORT 215

n FIGURE 2.17 Estimted TB mortlity rtes excluding TB deths mong HIV positive people, 214 Estimted TB deths per 1 popultion.9 1 3.9 4 9.9 1 19 2 39 4 Not pplicble n FIGURE 2.18 Estimted TB mortlity rtes 199 215, by WHO region. Estimted TB mortlity excludes TB deths mong HIV-positive people. Shded res represent uncertinty bnds. The horizontl dshed lines represent the Stop TB Prtnership trget of 5% reduction in the mortlity rte by 215 compred with 199. 8 Afric 6 The Americs 4 Estern Mediterrnen 6 4 3 Rte per 1 popultion per yer 4 2 8 6 Europe 2 6 4 South Est Asi 2 1 25 2 15 Western Pcific 4 2 2 1 5 199 1995 2 25 21 215 199 1995 2 25 21 215 199 1995 2 25 21 215 The width of n uncertinty bnd nrrows s the proportion of regionl mortlity estimted using vitl registrtion dt increses or the qulity nd completeness of the vitl registrtion dt improves. GLOBAL TUBERCULOSIS REPORT 215 n 29

n FIGURE 2.19 Estimted TB mortlity rtes 199 215, 22 high burden countries. Estimted TB mortlity excludes TB deths mong HIV-positive people. The horizontl dshed lines represent the Stop TB Prtnership trget of 5% reduction in the mortlity rte by 215 compred with 199. Uncertinty is due to djustments mde to the mortlity dt from vitl registrtion systems tht were reported by countries (mortlity dt from vitl registrtion systems re represented by the x symbol). 1 75 5 25 Afghnistn Bngldesh b Brzil Cmbodi Chin 2 9 6 2 15 6 4 1 3 2 1 5 Rte per 1 popultion per yer DR Congo Ethiopi Indi Indonesi Keny 125 15 3 1 75 4 1 75 2 5 5 5 2 25 1 25 Russin Federtion South Afric Thilnd Ugnd UR Tnzni 25 15 1 4 2 15 3 75 15 1 2 5 1 1 5 5 1 25 5 Viet Nm 8 6 4 2 199 1995 2 25 21 215 199 1995 2 25 21 215 6 4 2 Mozmbique Mynmr Nigeri Pkistn Philippines 2 12 15 6 15 15 9 1 4 1 1 6 5 5 5 3 2 Zimbbwe 199 1995 2 25 21 215 199 1995 2 25 21 215 199 1995 2 25 21 215 b The width of n uncertinty bnd nrrows s the proportion of regionl mortlity estimted using vitl registrtion dt increses or the qulity nd completeness of the vitl registrtion dt improves. For Bngldesh, joint ressessment of estimtes of TB disese burden will be undertken following completion of the ntionl TB prevlence survey. (defined s femles ged 15 yers) nd children (defined s people ged <15 yers). The cut-of f of 15 yers is used becuse it is consistent with the ge ctegories for which notifiction dt re reported nd with the cut-of f used in current guidelines to define people eligible to prticipte in TB prevlence survey. 1 Detils of the methods used to produce disggregted estimtes re provided in the online technicl ppendix. 2 1 TB prevlence surveys: hndbook. Genev: World Helth Orgniztion; 211 (WHO/HTM/TB/21.17). Avilble t www.who.int/tb/dvisory_ bodies/impct_mesurement_tskforce/resources_documents/ thelimebook 2 The online technicl ppendix is vilble t www.who.int/tb/dt. 2.4.1 TB incidence Estimtes of TB incidence mong men nd women were produced by using notifiction dt combined with the ssumption tht the men:women rtio of notified cses (1.7 globlly) 3 ws the sme s the rtio for incident cses. 4 In 214, there were n estimted 5.4 million (rnge, 5.1 5.8 million) incident cses mong men nd 3.2 million (rnge, 3. 3.4 million) mong women. 3 See lso Tble 3.2 in Chpter 3. 4 Evidence from ntionl prevlence surveys of bcteriologiclly-positive TB consistently show bigger rtios of prevlence to notifictions in men thn women. This mens tht the implicit ssumption mde here, tht there is no sex dif ferentil in the detection of incident cses, my not be correct. With currently vilble dt, it is not possible to estimte mle nd femle cse detection rtios for ll countries, but if nything the estimtes presented in this chpter re underestimting the shre of totl TB incidence tht is ccounted for by men. 3 n GLOBAL TUBERCULOSIS REPORT 215

n FIGURE 2.2 Globl progress in reporting of TB cses mong children, 1995 214. Lef t pnel: Number of notifictions of cses mong children reported to WHO. Right pnel: Percentge of cse notifictions reported to WHO tht re ge-disggregted. 4 3 Cse notifictions 14 ge group 4 ge group 5 14 ge group 1 8 Completeness of reporting Number (thousnds) 2 1 Percentge 6 4 2 new smer-positive new smer-negtive nd smer not done new extrpulmonry new nd relpse, ll forms 1995 2 25 21 215 1995 2 25 21 215 Before 213 childhood cse notifictions included smer-positive, smer-negtive, smer not done nd extrpulmonry TB for ll new ptients. Af ter 213 (shown s gp in the grph) childhood cse notifiction include ll new nd relpse cses irrespective of cse type. n FIGURE 2.21 Reporting of new nd relpse TB cse notifictions disggregted by ge, 214 Age disggregtion (new) Age disggregtion (new nd relpse) No ge disggregtion No dt reported Not pplicble GLOBAL TUBERCULOSIS REPORT 215 n 31

Box 2.5 Estimting TB incidence mong children: chllenges, progress to dte nd next steps It is well recognized tht estimting the incidence of TB in children is dif ficult nd tht published estimtes vry.,b There re t lest four mjor resons for this: 1. TB in children is rrely bcteriologiclly confirmed. Direct exmintion of sputum smers nd tuberculin skin testing both suf fer from very poor dignostic performnce. TB in children is thus condition tht is usully cliniclly dignosed bsed on combintion of signs nd symptoms tht re not specific to TB. Cse definitions re inconsistent mong countries nd within countries over time (s result of chnges in medicl prctice). 2. Peditricins who dignose TB do not lwys report cses to public helth uthorities. Childhood TB is not usully public helth priority nd ef fective linkges between NTPs nd the hospitls nd clinics where children re usully dignosed re lcking. Reporting of cses is therefore of ten incomplete nd not supported by legl frmework. 3. TB cses mong children re less likely to be dignosed in countries with high burden of TB compred with dults. Sick children my be evluted in fcilities with little to no cpcity to dignose childhood TB, nd dignostic chllenges (the low specificity of clinicl signs nd symptoms) trnslte into low ccess to qulity dignosis nd cre services. 4. Dif ferent methods hve been used to produce estimtes. These include dynmic model nd sttisticl pproches. The estimtes included in this report re bsed on combining results from dynmic model, c sttisticl pproch bsed on recent study, d nd methods previously used by WHO b in sttisticl ensemble model. e Estimtes from the dynmic model nd sttisticl pproches using the most updted dt for 214 were found to be similr. This hs contributed to more robust combined estimte compred with those produced using the dynmic model or sttisticl pproches on their own. In turn, this mens tht the uncertinty intervl from the ensemble pproch is nrrower thn those of estimtes produced from ech pproch used on its own. Nonetheless, the uncertinty intervl reltive to the best estimte is bout twice s lrge s the reltive uncertinty of the overll TB incidence estimte for ll ges. The lck of overlp between the estimte of childhood TB incidence in this report nd the one published in the 214 edition b illustrtes the dif ficulties in producing such estimtes (explined bove) nd limittions in the documenttion of uncertinty. The estimtes in this report use n updted methodologicl pproch recommended by the WHO Globl Tsk Force on TB Impct Mesurement (Box 2.1, Box 2.2). However, even using this pproch does not llow ll sources of uncertinty, such s uncertinty due to model specifiction, to be fully quntified in prctice. The vribility nd lck of stbility in recently published estimtes of TB incidence mong children is concerning. Addressing this chllenge requires much greter commitment from ntionl public helth uthorities to the definition nd ppliction of consistent cse definitions, to ensuring reporting of cses bsed on legl frmework nd ensuring tht children who re close contcts of people with TB re thoroughly investigted using up-to-dte ntionl recommendtions. JA Seddon nd D Shingdi. Epidemiology nd disese burden of tuberculosis in children: globl perspective. Infect Drug Resist, 7:153 65, null 214. World Helth Orgniztion. Globl tuberuclosis report 214. World Helth Orgniztion, Genev; 214. (WHO/HTM/TB/214.8). See prticulrly Box 2.5 in Chpter 2. PJ Dodd, E Grdiner, R Coghln, nd JA Seddon. Burden of childhood tuberculosis in 22 high-burden countries: mthemticl modelling study. Lncet Glob Helth 214; 2:e453 9. HE Jenkins, AW Tolmn, CM Yuen et l. Incidence of multidrugresistnt tuberculosis disese in children: systemtic review nd globl estimtes. Lncet, 214; 383:1572 9. For detils, see the online technicl ppendix to this report t www. who.int/tb/dt. b c d e Globl progress in reporting of cses mong children since 1995 (the first yer in which such dt were requested for the 14 ge group) nd since 25 (when further disggregtion for those ged 4 nd 5 14 ws requested) is shown in Figure 2.2. By 214, reporting of ge-disggregted notifiction dt ws lmost universl (Figure 2.21). In 214, 359 new nd relpse cses mong children were reported, n increse of bout 3% compred with 213. The lrgest increses were in Indi (bout 3 ) nd the Philippines (bout 1 ). Cmbodi nd Mynmr reported ge-disggregted dt for the first time. Producing estimtes of TB incidence mong children is chllenging (Box 2.5). However, progress is being mde, bsed on collbortions estblished in 213 between WHO nd cdemic groups working on the estimtion of TB disese burden mong children, s well s recommendtions from globl consulttion held erlier in 215 (Box 2.1, Box 2.2). Methods to estimte TB incidence in children were updted for this report compred with those used to produce estimtes published in 213 nd 214. The updted methods involve use of n ensemble pproch in which results from two independent methods re combined. The first method is bsed on the WHO pproch used since 212, with the modifiction tht child-specific cse detection rtios (s opposed to one rtio for ll ges) re used ccording to previously published methods 1 tht were updted to use more recent notifiction dt. 2 The second method is 1 HE Jenkins, AW Tolmn, CM Yuen et l. Incidence of multidrug-resistnt tuberculosis disese in children: systemtic review nd globl estimtes. Lncet, 214; 383:1572 9. 2 This is in line with WHO suggestions documented in 214. See Sismnidis C, Lw I, Glziou P,et l. The burden of tuberculosis disese in children. Lncet. 214; 384(9951):1343. doi: 1.116/S14-6736(14)6181-9. 32 n GLOBAL TUBERCULOSIS REPORT 215

n FIGURE 2.22 The mle:femle rtios of TB deths mong dults (ged 15 yers), globlly nd by WHO region HIV-negtive HIV-positive AFR AMR EMR EUR SEAR WPR Globl 1 2 3 4 5 Sex Rtio (M:F) 1 2 3 4 5 Sex Rtio (M:F) dynmic model tht uses dult TB prevlence estimtes nd prmeters relted to the nturl history of TB in children. Globl nd regionl estimtes of TB incidence mong children using this ensemble pproch re shown in Tble 2.6. The totl estimted number of incident cses in 214 ws 1 million, with CDR of 36%. The Africn nd South-Est Asi Regions ccount for bout one third of globl cses ech. 2.4.2 TB mortlity To produce estimtes of TB deths mong HIV-negtive dults, mortlity dt from VR systems disggregted by ge nd sex were used. Dt were vilble for 113 countries (ll middle or high-income countries). For countries without VR dt, estimtes were produced using n imputtion model tht included risk fctors known to be ssocited with TB mortlity. This model ws used to estimte the rtios of the mle to femle nd child to dult number of TB deths. TB deths mong HIV-positive people were disggregted by sex nd ge using the ssumption tht the mle to femle nd children to dult rtios re similr to the corresponding rtios of AIDS deths estimted by UNAIDS. TB deths mong HIV-negtive people There were n estimted 7 TB deths mong HIVnegtive men nd 34 mong HIV-negtive women in 214 (Tble 2.7). The mle: femle rtio ws lso bove two in ll six WHO regions (lef t pnel of Figure 2.22). There were n dditionl 81 (rnge, 69 93 ) TB deths mong HIV-negtive children, equivlent to 7% of the totl number of HIV-negtive TB deths. n TABLE 2.6 Estimted number of incident cses of TB mong children in 214, globlly nd by WHO region WHO REGION NUMBER OF TB CASE NOTIFICATIONS BEST ESTIMATE ESTIMATED TB INCIDENCE UNCERTAINTY INTERVAL AFR 9 523 33 29 37 AMR 1 489 27 25 29 EMR 42 28 8 64 97 EUR 9 898 31 28 34 SEAR 168 31 34 31 37 WPR 37 273 15 13 17 Globl 358 521 1 9 1 1 n TABLE 2.7 Estimted number of TB deths mong HIV-negtive dults disggregted by sex, globlly nd by WHO region WHO REGION BEST ESTIMATE WOMEN UNCERTAINTY INTERVAL BEST ESTIMATE MEN UNCERTAINTY INTERVAL AFR 13 81 17 28 17 4 AMR 5 4 2 5 8 11 9 7 12 EMR 26 8 6 43 55 76 11 EUR 9 5 7 8 11 24 22 26 SEAR 15 9 21 28 16 4 WPR 29 21 37 53 43 64 Globl 34 27 42 7 53 88 TB deths mong HIV-positive people There were n estimted 19 TB deths mong HIV-positive men nd 14 mong HIV-positive women in 214 GLOBAL TUBERCULOSIS REPORT 215 n 33

n TABLE 2.8 Estimted number of TB deths mong HIV-positive dults disggregted by sex, globlly nd by WHO region WHO REGION BEST ESTIMATE WOMEN UNCERTAINTY INTERVAL BEST ESTIMATE MEN UNCERTAINTY INTERVAL AFR 12 11 14 13 94 17 AMR 1 7 1 5 1 9 3 9 3 2 4 7 EMR 73 55 92 2 1 3 2 7 EUR 85 71 98 2 3 1 8 2 8 SEA 13 1 15 45 34 57 WPR 1 3 1 1 1 6 3 3 2 5 4 World 14 12 16 19 15 23 (Tble 2.8). Most of these deths were in the Africn Region, where the mle:femle rtio ws close to one (right pnel of Figure 2.22). The mle:femle rtio in other regions vried from round 2 4, with best estimtes of 2.4 3.5. There were n dditionl 55 (rnge, 5 6 ) TB deths mong HIV-positive children, equivlent to 14% of the totl number of HIV-positive TB deths. The totl number of TB deths mong children (136, rnge 115 157 ) corresponds to CFR of 13.6% (compred with 15.5% in dults). 2.5 HBC lists to be used by WHO in the post-215 er 2.5.1 Bckground nd brief history The concept of high burden country hs become very fmilir nd widely used in the context of TB. The initil definition of HBCs in 1998 ws bsed on the burden of TB in bsolute terms. Its purpose ws to llow focused interventions in the countries responsible for 8% of the globl burden (mesured in terms of the estimted number of incident cses), since progress in these countries would trnslte into globl impct. The concept ws subsequently pplied to TB/HIV (in 25) nd MDR-TB (in 28). The current list of 22 HBCs (fetured throughout this chpter) hs not chnged since 22, nd the HBC lists for TB/HIV nd MDR-TB hve not been updted since 29 nd 28, respectively. 1 With the end of the MDGs nd Stop TB Strtegy in 215 nd the trnsition to new er of Sustinble Development Gols (SDGs) nd the End TB Strtegy (Chpter 1), 215 ws the idel yer in which to revisit ll three HBC lists nd consider their future. 1 For the TB/HIV list, see Tble 6.1 in Chpter 6. For the MDR-TB list, see Tble 4.1 in Chpter 4. 2.5.2 Process used to revisit HBC lists nd their use post-215 The process of revisiting HBC lists strted with the development of discussion pper by the Globl TB Progrmme in WHO. This provided brief history of the current HBC lists, nd identified their potentil dvntges nd disdvntges, drwing on input provided from cross the WHO TB network, by mjor globl technicl nd finncil gencies, nd by individuls who plyed leding role in the originl estblishment nd definition of ech list. An online survey ws then conducted in My 215, focused on elicittion of feedbck bout the dvntges nd disdvntges of the lists, principles nd design chrcteristics relted to their use post-215, nd which of four high-level options for the use of lists f ter 215 ws preferred. 2 Bsed on feedbck received on the discussion pper nd the results of the online survey, proposl ws then presented for considertion by WHO s Strtegic nd Technicl Advisory Group for TB (STAG-TB) in June 215. Full detils re vilble in the discussion pper prepred for the STAG-TB meeting. 3 2.5.3 Proposl presented to STAG-TB, June 215 The proposl presented t the June 215 meeting of STAG-TB cn be summrized s follows: "" Three updted lists, for ech of TB, MDR-TB nd TB/HIV. "" Ech list includes 3 countries, defined s the top 2 in terms of bsolute numbers of cses, plus the 1 countries with the most severe burden in reltive terms tht do not lredy pper in the top 2 ( 2+1 ). "" Two options for defining the dditionl top ten tht hve severe burden in reltive terms were presented for considertion. The first ws to use rtes per cpit for the TB list, nd the proportion of TB cses with MDR-TB nd TB/ HIV for the other two lists. The second ws to use rtes per cpit for ll three lists. It ws lso recognized tht for the dditionl top ten, threshold in terms of minimum number of cses ws relevnt. The TB list with nd without threshold of 1 cses ws presented. "" A lifetime of five yers for ll three lists, 216 22. The STAG-TB recognized the vlue of HBC lists nd endorsed the proposl for three 2+1 lists tht would hve lifetime of five yers. It ws recommended to use rtes per cpit to define the dditionl top-ten countries, nd to lso use 2 These were: 1) Discontinue the use of HBC lists; 2) Continue to use three HBC lists (TB, MDR-TB, TB/HIV) but updte them using the originl criteri; 3) Continue to use three HBC lists (TB, MDR-TB, TB/HIV) but define them using new criteri; 4) Define one HBC list only. 3 World Helth Orgniztion. Use of high TB burden country lists in the post-215 er. Genev: World Helth Orgniztion; 215. (Discussion pper). Avilble t: www.who.int/tb/dt. This document ws updted in August 215 to reflect the recommendtions provided during the STAG-TB meeting nd to use the ltest estimtes of disese burden prepred for this report. 34 n GLOBAL TUBERCULOSIS REPORT 215

threshold for minimum number of cses. It ws noted tht countries with high rtes but smll numbers of cses re best included s prt of regionl HBC lists (if such lists re considered useful t tht level). 2.5.4 Definition of HBC lists to be used by WHO post-215, nd ssocited next steps Following the STAG-TB meeting, the Globl TB Progrmme finlized the definition of the HBC lists to be used by WHO post-215, s follows: "" Three HBC lists, one for ech of TB, MDR-TB nd TB/HIV. "" Ech list includes 3 countries, defined s the top 2 in terms of bsolute numbers nd n dditionl ten tht hve the highest rtes per cpit nd tht re not lredy prt of the top 2. 1 For inclusion in the lists on the bsis of rtes, countries must lso hve minimum of 1 incident cses per yer (for the TB list) or 1 cses per yer (for the TB/HIV nd MDR-TB lists). "" The estimtes of TB disese burden used to define the lists re the most up-to-dte estimtes vilble in 215 i.e. those published in this 215 globl TB report. "" The lists will hve lifetime of five yers, 216 22. In ech list, the resulting list ccounts for 86 9% of the globl number of cses. There re two mjor next steps in 215. The first is further communiction by the Globl TB Progrmme to WHO Member Sttes, technicl prtners nd funding gencies bout the finl definition of the lists. The second is meeting to be held on 3 November in ssocition with the interntionl conference on TB nd lung diseses (orgnized by the Union in Cpe Town, South Afric). This will focus on implementtion of the End TB Strtegy (Chpter 1) with prticulr ttention to the 3 countries in the new HBC list for TB. Strting in 216, the new lists of 3 HBCs for TB, TB/HIV nd MDR-TB will be used by WHO, including in the next edition of the globl TB report. 1 Some countries with the highest numbers in bsolute terms lso rnk in the top ten in terms of rtes. GLOBAL TUBERCULOSIS REPORT 215 n 35

CHAPTER 3 TB cse notifictions nd tretment outcomes Key fcts nd messges 215 is lndmrk yer in globl monitoring of TB cse notifictions nd tretment outcomes by WHO: it is twenty yers since system for nnul collection of these dt from ll countries ws estblished in 1995. Between 1995 nd 214, dt compiled vi this system show tht cumultive totl of 78 million cses of TB were notified to WHO nd 66 million TB ptients were successfully treted. In 214, 6.3 million cses of TB were notified by ntionl tuberculosis progrmmes (NTPs) nd reported to WHO: just over 6 million individuls were newly dignosed in 214 nd 261 were previously dignosed TB ptients whose tretment regimen ws chnged. In 214, most notified TB cses were dults. Children (ged <15 yers) ccounted for 6.5% of notified cses, rnging from 3.4% in the Western Pcific Region to 9.5% in the Estern Mediterrnen Region. The mle:femle rtio of notified cses cross ll ge groups ws 1.7 globlly, rnging from 1. in the Estern Mediterrnen Region to 2.1 in the Western Pcific Region. Among pulmonry TB cses, 58% were bcteriologiclly confirmed (s opposed to cliniclly dignosed) in 214; this ws unchnged from 213. For the first time since 27, there ws noticeble increse in globl TB notifictions in 214 (these hd stbilized t round 5.7 5.8 million new nd relpse cses for 27 213). The increse is explined by 29% increse in notifictions in Indi, linked to the introduction of policy of mndtory notifiction, new web-bsed nd cse-bsed reporting system tht hs been rolled out ntionwide nd greter enggement of the country s lrge privte helth sector. Indi ccounted for 27% of globl TB notifictions in 214, followed by Chin (14%). The privte helth sector, providers of helth services in the public sector tht re not directly linked to NTPs nd community workers or volunteers cn mke importnt contributions to the notifiction nd tretment of TB cses. For exmple, 12% of notifictions in Indi were from the privte sector in 214, nd 55% of notifictions in Chin were from public hospitls outside the NTP network. In six of 41 countries tht reported dt, more thn 5% of notifictions were from community referrls in res where community enggement ctivities were in plce. Globlly, notifictions of newly dignosed TB cses in 214 represented 63% (95% uncertinty intervl, 6 66%) of estimted incident cses. The best estimte of the gp between notifictions of new episodes of TB (new nd relpse cses) nd incident cses ws 3.6 million cses. Two fctors explin gps between notifictions nd estimted incidence. The first is under-reporting of dignosed TB cses: for exmple, of cses detected nd treted in the privte sector. The second is under-dignosis. Resons for under-dignosis include poor ccess to helth cre nd filure to detect cses when people with TB visit helth cre fcilities. Intensified ef forts, such s those lredy being mde in Indi, re needed to ensure tht ll cses re detected, notified to ntionl surveillnce systems, nd treted ccording to interntionl stndrds. Globlly in 213, the tretment success rte for new cses of TB ws 86%. Improvement in tretment outcomes is needed in the Region of the Americs nd the Europen Region, where tretment success rtes in 213 were 75% nd 76%, respectively. The mngement of ltent TB infection (LTBI) is criticl component of the new post-215 End TB Strtegy, nd WHO issued guidnce for upper-middle nd high-income countries with n incidence rte of less thn 1 per 1 popultion in 215. In mny of these countries, LTBI policies re in plce nd detection nd tretment is being provided. However, there re lso policy-prctice gps tht need to be ddressed nd systems for routine recording nd reporting of dt need to be improved. Routine recording nd reporting of the numbers of TB cses dignosed nd treted by ntionl TB progrmmes (NTPs) nd monitoring of tretment outcomes ws one of the five components of the globl TB strtegy (DOTS) lunched by WHO in the mid-199s; this remined core element of its successor, the Stop TB Strtegy (26 215), nd is prt of the new End TB Strtegy (Chpter 1). With the stndrd definitions of cses nd tretment outcomes recommended by WHO nd ssocited recording nd reporting frmework s foundtion, the number of people dignosed nd treted for TB nd ssocited tretment outcomes is routinely monitored by NTPs in lmost ll countries, which in turn report these dt to WHO in nnul rounds of globl TB dt collection (Chpter 1). 215 is lndmrk yer in globl monitoring of TB cse notifictions nd tretment outcomes by WHO: it is twenty yers since system for nnul collection of these 36 n GLOBAL TUBERCULOSIS REPORT 215

dt from ll countries ws estblished in 1995. Between 1995 nd 214, dt compiled vi this system show tht cumultive totl of 78 million cses of TB were notified to WHO nd 66 million TB ptients were successfully treted. 1 This chpter hs six prts. Section 3.1 summrizes the totl number of people dignosed with TB nd notified by NTPs in 214; these numbers re lso disggregted by cse type, ge nd sex. Section 3.2 presents nd discusses the specific contribution to totl cse notifictions of public public nd public privte mix (PPM) inititives. Section 3.3 highlights the role of community enggement in TB detection nd tretment. Section 3.4 presents trends in notifictions between 199 nd 214 nd compres these with trends in estimted TB incidence. The rtios of notified to estimted incident cses (n indictor known s the cse detection rte or CDR) re provided for selected yers. Section 3.5 describes the ltest dt on tretment outcomes (for cses registered for tretment in 213) s well s tretment outcomes chieved in selected yers since 1995. Section 3.6, the finl prt of the chpter, introduces new topic to the globl TB report: policy nd prctices relted to tretment of ltent TB infection (LTBI). This is core component of the End TB Strtegy, which covers the period 216 235 (Chpter 1). 3.1 Cse notifictions in 214 by type of disese, ge nd sex Box 3.1 lists the definitions of TB cses recommended by WHO s prt of n updted recording nd reporting frmework issued in Mrch 213, 2 nd tht were used in the 214 nd 215 rounds of globl TB dt collection. These updted definitions were necessry to ccommodte dignosis using Xpert MTB/RIF nd other WHO-endorsed moleculr tests (Chpter 5), s well s of fering n opportunity to improve spects of the previous (26) frmework, such s inclusion of more comprehensive reporting of TB cses mong children. Notifictions of TB cses in 214 re summrized globlly, for the six WHO regions nd for the 22 high TB-burden countries (HBCs) in Tble 3.1. In 214, 6.3 million people with TB were notified to NTPs nd reported to WHO. Of these, just over 6 million hd new episode of TB (shown s the totl of new nd relpse cses) nd 261 hd lredy been dignosed with TB but their tretment ws chnged to retretment regimen. For the first time since 27, there ws noticeble increse in globl TB notifictions in 214, which hd previously stbilized t 5.7 5.8 million new nd relpse cses for the seven yers from 27 213 (Figure 3.1). The increse is mostly explined by 29% increse in notifictions in Indi, linked to the introduction of policy of mndtory notifiction, new web-bsed nd cse-bsed reporting system tht 1 These figures re for new nd relpse cses. See Box 3.1 for cse definitions. 2 Definitions nd reporting frmework for tuberculosis 213 revision. Genev, World Helth Orgniztion; 213 (WHO/HTM/TB/213.2). Avilble t: www.who.int/tb/publictions/definitions. hs been rolled out ntionwide, nd greter enggement of the country s lrge privte helth sector. Indi ccounted for 27% of globl TB notifictions in 214 (Box 3.2, Figure 3.3), up from 22% in 213. The South-Est Asi nd Western Pcific Regions (which include Indi nd Chin, respectively) together ccounted for 63% of notifictions of new nd relpse cses globlly, nd the Africn Region for 21%. The other three regions ccounted for reltively smll proportions of cses. Among pulmonry TB cses, 58% were bcteriologiclly confirmed (s opposed to cliniclly dignosed) in 214; this ws unchnged from 213. In both the Estern Mediterrnen 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 old (Figure 3.4). A similr pttern is evident in the South-Est Asi Region. Elsewhere, nd most noticebly in the Africn Region, notifiction rtes in 214 peked in younger dults. Most countries re now ble to report notifictions disggregted by both ge nd sex (Tble 3.2). In 214, dults ccounted for most of the notified cses. Children (ged <15 yers) ccounted for only 6.5% of notifictions, lthough this rnged from 3.4% in the Western Pcific Region to 9.5% in the Estern Mediterrnen Region. The globl mle:femle sex rtio ws 1.7, but mong HBCs this rtio vried from.7 in Afghnistn to 3. in Viet Nm. Vrition mong countries in the child:dult nd mle:femle rtios of cses my reflect rel dif ferences in epidemiology, dif ferentil ccess to or use of helth cre services linked to the NTP, nd/or differentil reporting prctices. Evidence from recent ntionl TB prevlence surveys shows tht the mle:femle rtio for bcteriologiclly-confirmed TB mong dults is typiclly round 2 3 in Asin countries nd 1 2 in Afric, nd tht the rtio of prevlent to notified cses is systemticlly higher mong men thn women (suggesting tht women with TB hve higher chnce of being notified). 3,4 3.2 Contribution of public public nd public privte mix inititives to TB cse notifictions nd tretment support in 214 Ensuring proper dignosis, stndrdized tretment nd prompt notifiction of ll TB cses to NTPs requires collbortion with the full rnge of helth cre providers. Engging ll cre providers in TB cre nd control is component four of the Stop TB Strtegy nd prt of pillr two (of three) of the post-215 End TB Strtegy (Chpter 1). In recent yers, mny countries hve mde con siderble progress in scling up PPM inititives. However, demon- 3 Onozki I, Lw I, Sismnidis C et l. Ntionl tuberculosis prevlence surveys in Asi 199 212: n overview of results nd lessons lerned. Trop Med Int Helth 215; 2(9):1128 1145. doi: 1.1111/tmi.12534. Epub 215 Jun 7. 4 WHO nd prtners re prepring pper summrizing results from recent prevlence surveys in Afric. It is nticipted tht this will be published in 216. GLOBAL TUBERCULOSIS REPORT 215 n 37

Box 3.1 WHO definitions of TB cses recommended for use since Mrch 213 nd tht were used in the 214 nd 215 rounds of globl TB dt collection Bcteriologiclly confirmed cse of TB A ptient from whom biologicl specimen is positive by smer microscopy, culture or WHO-pproved rpid dignostic test (such s Xpert MTB/RIF). All such cses should be notified, regrdless of whether TB tretment is strted. Cliniclly dignosed cse of TB A ptient who does not fulfil the criteri for bcteriologiclly confirmed TB but hs been dignosed with ctive TB by clinicin or other medicl prctitioner who hs decided to give the ptient full course of TB tretment. This definition includes cses dignosed on the bsis of X-ry bnormlities or suggestive histology nd extrpulmonry cses without lbortory confirmtion. Cliniclly dignosed cses subsequently found to be bcteriologiclly positive (before or f ter strting tretment) should be reclssified s bcteriologiclly confirmed. Cse of pulmonry TB Any bcteriologiclly confirmed or cliniclly dignosed cse of TB involving the lung prenchym or the trcheobronchil tree. Miliry TB is clssified s pulmonry TB becuse there re lesions in the lungs. Tuberculous intr-thorcic lymphdenopthy (medistinl nd/or hilr) or tuberculous pleurl ef fusion, without rdiogrphic bnormlities in the lungs, constitute cse of extrpulmonry TB. A ptient with both pulmonry nd extrpulmonry TB should be clssified s cse of pulmonry TB. Cse of extrpulmonry TB Any bcteriologiclly confirmed or cliniclly dignosed cse of TB involving orgns other thn the lungs, e.g. bdomen, genitourinry trct, joints nd bones, lymph nodes, meninges, pleur, skin. New cse of TB A ptient who hs never been treted for TB or hs tken nti-tb drugs for less thn one month. Retretment cse of TB A ptient who hs been treted for one month or more with nti-tb drugs in the pst. Retretment cses re further clssified by the outcome of their most recent course of tretment into four ctegories. 1. Relpse ptients hve previously been treted for TB, were declred cured or tretment completed t the end of their most recent course of tretment, nd re now dignosed with recurrent episode of TB (either true relpse or new episode of TB cused by reinfection). 2. Tretment f ter filure ptients hve previously been treted for TB nd their most recent course of tretment filed i.e. they hd positive sputum smer or culture result t month 5 or lter during tretment. 3. Tretment f ter loss to follow-up ptients hve previously been treted for TB nd were declred lost to follow-up t the end of their most recent course of tretment. 4. Other previously treted ptients re those who hve previously been treted for TB but whose outcome f ter their most recent course of tretment is unknown or undocumented. Cse of multidrug-resistnt TB (MDR-TB) TB tht is resistnt to two first-line drugs: isonizid nd rifmpicin. For most ptients dignosed with MDR-TB, WHO recommends tretment for 2 months with regimen tht includes second-line nti-tb drugs. Cse of rifmpicin-resistnt TB (RR-TB) A ptient with TB tht is resistnt to rifmpicin detected using phenotypic or genotypic methods, with or without resistnce to other nti-tb drugs. It includes ny resistnce to rifmpicin, whether mono-resistnce, multidrug resistnce, polydrug resistnce or extensive drug resistnce. Definitions nd reporting frmework for tuberculosis 213 revision. Genev, World Helth Orgniztion, 213 (WHO/HTM/TB/213.2). Avilble t www.who.int/tb/publictions/definitions. n FIGURE 3.1 Globl trends in bsolute number of notified TB cses (blck) nd estimted TB incidence (green), 199 214. Cse notifictions include new nd relpse cses (ll forms). Cses per yer (millions) 9 6 3 199 1995 2 25 21 215 Rte per 1 popultion per yer 15 1 5 199 1995 2 25 21 215 38 n GLOBAL TUBERCULOSIS REPORT 215

n TABLE 3.1 Cse notifictions, 214 TOTAL NOTIFIED NEW AND RELAPSE RETREAT- MENT EXCLUDING RELAPSE PULMONARY BACTERI O- LOGICALLY CONFIRMED NEW OR PREVIOUS TREATMENT HISTORY UNKNOWN PULMONARY CLINICALLY DIAGNOSED EXTRA- PULMONARY PULMONARY BACTERIO- LOGICALLY CONFIRMED RELAPSE PULMONARY CLINICALLY DIAGNOSED EXTRA- PULMONARY PERCENTAGE OF PULMO- NARY CASES BACTERIO- LOGICALLY CONFIRMED Afghnistn 32 712 31 746 966 14 737 8 573 7 227 1 29 65 Bngldesh 196 797 191 166 5 631 16 767 42 832 37 46 2 989 863 39 72 Brzil 81 512 73 97 7 542 41 12 17 81 9 479 3 62 1 488 48 7 Cmbodi 43 738 43 59 679 12 168 11 286 18 31 445 79 141 51 Chin 826 155 819 283 6 872 235 74 526 16 32 348 25 125 33 DR Congo 116 894 115 795 1 99 75 631 13 494 19 566 4 298 1 892 914 84 Ethiopi 119 592 119 592 4 87 41 575 37 93 49 Indi 1 683 915 1 69 547 74 368 754 268 343 32 275 52 124 679 112 66 66 Indonesi 324 539 322 86 1 733 193 321 11 991 19 653 6 449 1 391 1 66 Keny 89 294 88 25 1 269 34 997 3 872 14 64 3 569 2 947 1 53 Mozmbique 58 27 57 773 497 24 43 23 455 6 276 1 542 2 7 5 Mynmr 141 957 138 352 3 65 42 68 7 35 16 18 5 276 3 65 45 39 Nigeri 91 354 86 464 4 89 49 825 29 46 4 764 2 415 64 Pkistn 316 577 38 417 8 16 122 537 12 35 57 463 7 42 426 221 52 Philippines 267 436 243 379 24 57 92 991 139 95 4 161 6 277 41 Russin Federtion 136 168 12 34 33 828 37 296 4 894 8 763 7 982 6 753 652 49 South Afric 318 193 36 166 12 27 155 473 16 482 33 522 7 43 2 693 566 6 Thilnd 71 618 67 722 3 896 34 394 21 115 1 244 1 969 63 Ugnd 46 171 44 187 1 984 26 79 11 854 4 18 1 499 468 17 69 UR Tnzni 63 151 61 571 1 58 23 583 23 38 13 6 1 8 51 Viet Nm 12 87 1 349 1 738 49 938 25 179 18 118 7 114 69 Zimbbwe 32 16 29 653 2 363 11 224 13 151 3 99 1 369 49 High-burden countries 5 16 146 4 961 362 198 784 2 179 178 1 763 137 653 169 223 666 137 416 4 796 56 AFR 1 342 4 1 3 852 41 548 635 56 399 155 212 57 39 782 11 217 3 81 62 AMR 228 476 215 243 13 233 127 864 4 746 32 51 1 193 2 918 1 21 76 EMR 465 677 453 393 12 284 183 63 151 696 13 959 12 368 866 874 56 EUR 321 421 266 58 55 363 112 416 76 759 39 175 23 935 11 483 2 29 61 SEAR 2 58 65 2 482 74 98 531 1 188 654 632 418 389 819 152 498 117 97 715 64 WPR 1 375 572 1 335 816 39 756 449 845 734 179 13 85 44 354 3 37 1 316 4 Globl 6 314 151 6 53 436 26 715 2 697 969 2 34 953 88 596 283 13 147 491 9 297 58 Blnk cells indicte dt not reported. New nd relpse includes cses for which the tretment history is unknown. strting progress in terms of the contribution of non-ntp public nd privte sector providers to totl cse notifictions requires systemtic recording of the source of referrl nd plce of TB tretment loclly, nd reporting nd nlysis of ggregted dt ntionlly. In mny countries, dt relted to the contribution of privte sector providers re still not collected or reported through routine monitoring systems, lthough there re excellent exmples of how this cn be done (Box 3.2). The vilble dt show tht the pproch to nd contribution of PPM vries cross countries, nd is relted to the number nd type of helth cre providers. Tble 3.3 shows ten prominent exmples of countries (including HBCs) where public-public mix interventions contributed between 11% nd 55% of totl notifictions in 214. Tble 3.3b presents ten prominent exmples of countries (including HBCs) where public-privte mix interventions contributed between 12% nd 46% of totl cse notifictions. GLOBAL TUBERCULOSIS REPORT 215 n 39

Box 3.2 Substntil increses in TB notifictions in Indi 213 214 the role of mndtory notifiction nd e-helth interventions The number of new nd relpse TB cses notified in Indi reched 1.61 million in 214, 29% increse compred with 1.24 million in 213 (Figure B3.2). This substntil increse is due to better reporting of detected cses to ntionl uthorities (s opposed to n increse in the underlying TB incidence), which cn be explined by three mjor fctors: " The introduction of policy of mndtory notifiction of TB cses in My 212; " The lunch of new web-bsed system (Nikshy) for csebsed notifiction by the Centrl TB Division (CTD) nd the Ntionl Informtics Centre in June 212; b " Incresed nd intensified ef forts to engge with the privte sector by the Revised Ntionl Tuberculosis Control Progrmme (RNTCP), which hve been fcilitted by Nikshy. FIGURE B3.2 Cse notifictions in Indi, 2 214 2. Cses per yer (millions) 1.5 1..5 2 25 21 214 Mndtory notifiction ws introduced in recognition of the fct tht while the privte sector provides tretment for pproximtely 5% of TB ptients, c most of these cses were not being reported to the RNTCP. Nikshy ws introduced s prt of ef forts to fcilitte reporting of TB cses, including those treted in the privte sector. The system is vilble for reporting of cses by both public nd privte helth cre fcilities. It is ccessible vi ndroid-bsed smrtphones nd web-portl, both of which fcilitte the process of notifying cses. Since its rollout ntionwide by the end of 212, reporting from the privte sector hs grown nd dt qulity hs improved. By June 215, more thn 4.6 million TB ptients hd been reported by over 4 public nd over 9 privte helth cre fcilities, with bout 5 TB cses being dded to the system ech dy. Nikshy hs lso eliminted the time previously tken to trnsmit lbortory results to tretment sites nd peripherl units. Nikshy cptures dt tht re importnt for both progrmme mngement nd clinicl cre. These include detils of who notified TB cse, who provides direct observtion of tretment (DOT), ptient trnsfers, nd contct trcing, s well s demogrphic nd clinicl detils of the individul TB ptient such s ge, sex, HIV sttus, bcteriology nd drug-susceptibility test results, nd tretment outcomes. This hs llowed the RNTCP to generte reports consistent with updted definitions of cse definitions nd tretment outcomes recommended by WHO since 213 (Box 3.1). This includes ge nd sex-disggregted dt for ll new nd relpse cses, which could not be produced using the old reporting system. The CTD uses five vribles to void entry of duplicte records in Nikshy. The greter grnulrity of the dt being recorded in Nikshy is lso llowing better forecsting of TB drug requirements for children nd dults, nd provides informtion on the nutritionl sttus of ptients. To support the introduction nd implementtion of Nikshy, online videos in English nd Hindi were used to trin frontline workers, nd mobile-phone short messging services (SMS) were used to ensure regulr contct of users with progrmme mngers t ll levels. Mngers cn now receive reports on cse-finding, sputum conversion nd tretment outcome vi SMS. Ptients hlf of whom hve mobile number entered in the system lso benefit from SMS reminders for visits relted to follow-up of tretment. Trditionl pper-bsed nd ggregted qurterly reporting will be phsed out in 216, nd reporting will be entirely through Nikshy. In the next phse of Nikshy s development, the im is to cpture geosptil dt to enble sptil surveillnce, nd to use nd record br-codes on mediction boxes for drug supply chin nd inventory mngement. Linking up with other electronic services my lso llow electronic pyments to ptients nd providers, nd ccess to the ntionl unique identifiction number (Adhr) d nd relted socil support schemes for TB ptients. The cities of Mumbi, Ptn nd Mehsn lredy provide good exmples of how digitl technologies re helping the RNTCP to rech out to providers who re involved in TB cre but who hve previously been outside the rech of ntionl surveillnce. In these settings, privte providers cn phone cll centres free of chrge to ensure free nti-tb medictions for their ptients. Ptients receive e-vouchers for stndrdized medictions, which they cn redeem t no chrge t privte chemists. Cll centres lso issue reminders to ptients for follow-up visits vi telephone clls nd SMS. This digitl system is linked with the RNTCP, so tht progrmme stf f receive lerts nd cn tke ctions s necessry. Incentives for notifiction re pid to providers electroniclly, s re pyments for lbortory tests. e-lerning tools hve lso been introduced to fcilitte the dissemintion of the Stndrds for TB Cre in Indi, nd e-lerning techniques hve lso been useful for rpid, lrgescle trining of stf f on the use of the cll centres. b c d http://pib.nic.in/newsite/erelese.spx?relid=83486 http://nikshy.gov.in/aboutnikshy.htm Stynryn S, Nir SA, Chdh SS, et l. From where re tuberculosis ptients ccessing tretment in Indi? Results from cross-sectionl community bsed survey of 3 districts. PLoS One 211; 6: e2416 https://resident.uidi.net.in/ 4 n GLOBAL TUBERCULOSIS REPORT 215

n FIGURE 3.2 Cse notifiction nd estimted TB incidence rtes by WHO region, 199 214. Regionl trends in cse notifiction rtes (new nd relpse cses, ll forms) (blck) nd estimted TB incidence rtes (green). Shded res represent uncertinty bnds. 4 Afric 6 The Americs 15 Estern Mediterrnen 3 2 4 1 Rte per 1 popultion per yer 1 6 4 Europe 2 2 South Est Asi 5 15 1 Western Pcific 2 1 5 199 1995 2 25 21 215 199 1995 2 25 21 215 199 1995 2 25 21 215 In Chin, lrge proportion of people with TB seek cre from public hospitls, nd vrious models of hospitl engge ment exist. In 214, public hospitls contributed 55% of ll notified TB cses. A web-bsed system for reporting of communicble diseses hs plyed key role in ensuring tht TB cses detected in public hospitls outside the NTP network re notified. Medicl college hospitls in Indi, specility lung hospitls nd generl hospitls in Indonesi, hospitls owned by socil security orgniztions in Peru nd other Ltin Americn countries, nd the hospitls of helth insurnce orgniztions in Egypt re other exmples of public helth cre providers tht re mking importnt contributions to TB cse notifictions. In 214, public sector medicl college hospitls in Indi lone reported 176 TB cses. Given tht helth centres nd hospitls re of ten mnged by dif ferent deprtments within ministries of helth nd tht ministries such s those for eduction, socil welfre, defence or justice cn lso be involved in providing helth services, implementing public-public mix pproches is essentil in mny prts of the world. Public-privte mix pproches re necessry in countries with lrge privte sector, including most HBCs in the South-Est Asi nd Western Pcific regions nd n incresing number of countries in the Africn Region, where the privte medicl sector is growing rpidly. The steep rise in TB cse notifictions from privte sector cre providers in Indi between 213 nd 214 (from 85 to 195 in 214) is prticulrly impressive. Further detils re provided in Box 3.2. A lrge increse of more thn 3% in notifictions from the privte sector in Pkistn between 213 nd 214 is lso notble chievement. Both countries hve mde concerted ef forts to increse notifictions of detected cses by the privte sector, nd these re now pying of f. The privte helth sector in Afric is of ten considered insignificnt in terms of its contribution to provision of TB cre. Dt from Keny, Mlwi nd Nigeri show tht this is not lwys the cse. In 214 s in 213, lmost one in five cses notified in Mlwi ws reported by privte cre provider, even though TB drugs re generlly not vilble in privte phrmcies (unlike in Keny nd Nigeri). Most of the contributions to TB cse notifictions in Mlwi re referrls of people with TB signs nd symptoms to the public sector by the front-line, community-bsed privte helth cre providers. These of ten include clinicl of ficers, nurses nd trditionl helers. Engging such front-line cre providers, including drug shops nd phrmcies, fcilittes erly cse detection. The Mlwi exmple should prompt other countries tht hve not previously considered PPM to be of importnce to revisit their strtegies. In ll settings, PPM interventions should lso be designed to help not only detection of TB cses, but lso erly detection by providers where cre is of ten sought first. GLOBAL TUBERCULOSIS REPORT 215 n 41

n FIGURE 3.3 Cse notifiction nd estimted TB incidence rtes, 22 high-burden countries, 199 214. Trends in cse notifiction rtes (new nd relpse cses, ll forms) (blck) nd estimted TB incidence rtes (green). Shded res represent uncertinty bnds. 2 15 1 5 3 2 1 Afghnistn Bngldesh Brzil Cmbodi Chin 2 1 5 4 3 2 1 1 75 5 25 DR Congo Ethiopi Indi Indonesi Keny 2 15 1 5 6 4 2 6 4 2 15 1 5 3 2 1 Rtes per 1 popultion per yer Mozmbique Mynmr Nigeri Pkistn Philippines 5 6 4 4 3 4 3 3 2 4 2 2 1 1 1 2 2 Russin Federtion South Afric Thilnd Ugnd UR Tnzni 15 4 8 8 9 1 3 6 6 6 2 4 4 5 3 1 2 2 Viet Nm 3 Zimbbwe 8 199 1995 2 25 21 215 199 1995 2 25 21 215 199 1995 2 25 21 215 6 2 4 1 2 199 1995 2 25 21 215 199 1995 2 25 21 215 For Bngldesh, joint ressessment of estimtes of TB disese burden will be undertken following completion of the ntionl TB prevlence survey. n FIGURE 3.4 Regionl TB notifiction rtes by ge, 214 3 Rte per 1 popultion per yer 2 1 AFR AMR SEAR EMR EUR WPR 14 15 24 25 34 35 44 45 54 55 64 65 Age group (yers) Countries not reporting cses in these ctegories re excluded. Cses included mke up 87% of reported cses nd exclude the following high burden countries: Afghnistn, Ethiopi, Mozmbique nd Thilnd. 3.3 Community contributions to TB notifictions nd tretment support Despite the best ef forts of helth systems, bout one third of people who develop TB globlly re still either not dignosed, or their cses re not reported (see section 3.5). Dif ficulty in ccessing helth fcilities is one of the resons why people with TB my not be dignosed, nd cn lso hve negtive impct on tretment dherence. Access to helth cre cn be f fected by socil nd politicl fctors (such s stigm nd discrimintion, nd the vilbility of cross-border services for migrnts), nd economic brriers (for exmple, the cost of trnsport). The role of community enggement in contributing to TB prevention, dignosis nd tretment, especilly where people with TB hve poor ccess to forml helth services, is therefore well-recognized. Fostering such community prticiption hs been n explicit component of the Stop TB Strtegy nd strong colition with civil society 42 n GLOBAL TUBERCULOSIS REPORT 215

n TABLE 3.2 Notifictions of new nd relpse TB cses by ge nd sex, 214 14 YEARS 15 YEARS AGE UNKNOWN % AGED < 15 YEARS MALE/ FEMALE RATIO Afghnistn* 4 454 18 856 7 227 19.7 Bngldesh* 6 262 18 743 3.3 1.5 Brzil 2 368 71 62 3.2 2.1 Cmbodi 12 5 31 9 28 1.2 Chin 4 164 815 119.5 2.3 DR Congo* 3 438 71 91 292 4.6 1.3 Ethiopi* 15 917 13 675 13 1.2 Indi 95 79 1 513 838 5.9 1.9 Indonesi 23 17 299 636 7.2 1.4 Keny 8 448 8 846 9.5 1.5 Mozmbique Mynmr 36 31 11 987 64 26 1.6 Nigeri 5 463 85 891 6. 1.5 Pkistn 27 245 281 172 8.8 1. Philippines 12 191 46 965 38 422 21 1.8 Russin Federtion 3 195 98 433 712 3.1 2.3 South Afric 31 977 274 189 1 1.3 Thilnd* 119 34 275.3 2.5 Ugnd 3 316 4 871 7.5 1.8 UR Tnzni 6 463 55 18 1 1.5 Viet Nm* 144 49 785.3 3. Zimbbwe 2 29 27 363 7.7 1.3 High-burden countries 34 684 4 283 264 46 717 6.6 1.7 AFR 9 523 963 88 2 298 8.6 1.4 AMR 1 489 198 35 1 935 5. 1.7 EMR 42 28 399 43 7 945 9.5 1. EUR 9 898 25 946 719 3.8 2. SEAR 168 31 2 248 65 19 394 7. 1.8 WPR 37 273 1 63 252 38 422 3.4 2.1 Globl 358 521 5 123 464 7 713 6.5 1.7 Blnk cells indicte dt tht could not be reported for the ge ctegories shown. indictes vlues tht cnnot be clculted. * New cses only. TABLE 3.3 Contribution of public-public mix to notifictions of TB cses in selected countries, 214 COUNTRY NUMBER OF TB CASES NOTIFIED BY NON-NTP PUBLIC SECTOR CARE PROVIDERS TOTAL NUMBER OF TB CASES NOTIFIED CONTRIBUTION OF NON-NTP PUBLIC SECTOR CARE PROVIDERS TO TOTAL CASE NOTIFICATIONS (%) Chin 458 356 826 155 55 Côte d Ivoire 2 279 23 75 9.5 Egypt 1 375 7 467 18 El Slvdor 1 16 2 22 46 Indi 189 857 1 683 915 11 Indonesi 57 586 324 539 18 Irq 2 748 8 341 33 Peru 8 164 31 461 26 Sri Lnk 4 457 9 473 47 Yemen 3 39 9 693 35 Includes ll contributions from non-ntp providers of cre in the public sector, including public hospitls, public medicl colleges, prisons/ detention centres, militry fcilities, rilwys nd public helth insurnce orgniztions. TABLE 3.3b Contribution of public-privte mix to notifictions of TB cses in selected countries, 214 COUNTRY NUMBER OF TB CASES NOTIFIED BY PRIVATE SECTOR CARE PROVIDERS TOTAL NUMBER OF TB CASES NOTIFIED CONTRIBUTION OF PRIVATE SECTOR CARE PROVIDERS TO TOTAL NOTIFICATIONS (%) Bngldesh 22 96 196 797 12 Ethiopi 16 876 119 592 14 Indi 194 992 1 683 915 12 Irn 3 93 1 395 3 Irq 3 83 8 341 46 Keny 18 2 89 294 2 Mlwi 3 5 17 723 2 Mynmr 25 978 141 957 18 Nigeri 13 31 91 354 14 Pkistn 55 254 316 577 17 Privte sector providers include privte individul nd institutionl providers, corporte/business sector providers, mission hospitls, nongovernmentl orgniztions nd fith-bsed orgniztions. GLOBAL TUBERCULOSIS REPORT 215 n 43

Box 3.3 Definitions of key terms nd indictors used to monitor community enggement Community-bsed TB ctivities. These cover wide rnge of ctivities tht contribute to the detection, referrl nd tretment of people with drug-susceptible, drug-resistnt nd HIV-ssocited TB. They re conducted outside the premises of forml helth fcilities (e.g. hospitls, helth centres nd clinics) in community-bsed structures (e.g. schools, plces of worship, congregte settings, mrkets) nd homesteds. Community helth workers nd community volunteers crry out communitybsed TB ctivities, depending on the ntionl nd locl context. Community helth workers. These re people with some forml eduction who hve been given trining to contribute to community-bsed helth services, including TB prevention nd ptient cre nd support. Their profile, roles nd responsibilities vry gretly mong countries, nd their time is of ten compensted by incentives in kind or in csh. Community volunteers. These re people who hve been systemticlly sensitized bout TB prevention nd cre, either through short, specific trining scheme or through repeted, regulr contct sessions with professionl helth workers. Core indictors for routine monitoring of community-bsed TB ctivities In 213, three core indictors were defined nd greed by WHO nd prtners. These re: 1. Percentge of TB notifictions from community referrls. This indictor mesures the proportion of notified TB ptients (ll forms of TB) who were referred by community helth worker or community volunteer. 2. Percentge of registered TB ptients who received tretment support in the community. This indictor mesures the proportion of TB ptients who were supported during tretment by community helth worker or community volunteer. 3. Percentge of registered TB ptients who received tretment support in the community who were successfully treted. This indictor mesures the proportion of TB ptients who received tretment support from community helth worker or community volunteer during their TB tretment nd who were successfully treted. orgniztions nd communities is one of the four principles underpinning the End TB Strtegy (Chpter 1). Estblishing nd strengthening collbortion with nongovernmentl nd other civil society orgniztions to scle up communitybsed TB ctivities, nd enhncing their role in the design nd implementtion of ntionl TB strtegic plns, re importnt. Accurte monitoring of the contributions of communities to TB notifictions nd tretment support requires stndrd definitions of key concepts nd indictors, nd stndrdized systems for recording nd reporting of dt. These were developed in 213 nd re shown in Box 3.3. Dt for the three core indictors were collected for the first time in 213, with focus on 13 countries in the Africn nd South-Est Asi regions tht were known to be recording nd reporting such informtion. In 214, dt collection ws expnded nd 22 countries from the sme two regions reported dt. Bsed on these two yers of experience, dt collection ws expnded in the 215 round of globl TB dt collection to cover the Europen, Estern Mediterrnen nd Western Pcific regions. Following consulttions with WHO stf f in Regionl nd Country Of fices, totl of 69 countries were trgeted for reporting of dt. Of these, 41 reported dt for t lest one of the three core indictors; 34 (83%) reported dt on the percentge of TB ptients who received tretment support in the community, nd 3 (73%) reported dt on the percentge of TB notifictions tht originted from community referrls. A summry of the contribution of communities to TB notifictions nd tretment support is provided in Tble 3.4. About one third (14/41) of countries reported ntionwide coverge of community enggement in cse notifiction, nd 41% (17/41) reported ntionwide coverge of communitybsed tretment support. In res where community-bsed referrl ctivities were in plce, the percentge of notified TB ptients ccounted for by community referrls rnged from 2% in Mynmr nd Sri Lnk to 73% in Cmbodi. The proportion of TB ptients receiving community-bsed tretment support rnged from 2% in Mlysi, Romni nd Sierr Leone to 1% in Keny, Pkistn nd Tjikistn. Reporting of the tretment success rte mong TB ptients who received tretment support in the community hs continued to be chllenge. Among the 41 countries tht reported dt relted to community enggement, only 26 (41%) reported informtion for this indictor. Even in these countries, there re concerns with the ccurcy of the reported dt. For exmple, while the generl tendency ws for tretment outcomes to improve between 213 nd 214 mong ptients receiving tretment support from community volunteer or community helth worker, there were lrge yer-to-yer chnges in some countries tht ppered implusible. Intensified ef forts re needed to improve the ccurcy of dt for this indictor, nd/or to revisit its sttus s core indictor. For exmple, it my be more pproprite to ssess this indictor s prt of periodic evlution, rther thn through routine reporting. This is being considered by WHO s prt of wider ef forts to develop expnded guidnce on community enggement. It is lso importnt to note tht there re countries in which community-bsed TB ctivities re routine com- 44 n GLOBAL TUBERCULOSIS REPORT 215

Box 3.4 The ENGAGE-TB pproch: progress nd highlights to dte The ENGAGE-TB pproch ims to integrte community-bsed TB ctivities into the work of nongovernmentl orgniztions nd other civil society orgniztions tht were previously not engged in TB prevention, dignosis nd tretment. Pilot projects were strted in 212 with funding from the Bristol-Myers Squibb Foundtion Secure the Future in five countries: the Democrtic Republic of the Congo, Ethiopi, Keny, South Afric nd the United Republic of Tnzni. In Ethiopi, TB ctivities were integrted into mternl nd child helth ctivities nd cervicl cncer screening. In Keny, they were integrted into mternl nd child helth ctivities nd livelihood inititives. In the other three countries, they were integrted into HIV progrmmes. By the end of 214, the totl popultion covered by the pilot projects hd reched 8 million nd 24 previously unengged nongovernmentl orgniztions hd strted to implement community-bsed TB ctivities. In pilot res, community referrls of people with signs nd symptoms suggestive of TB contributed 5 68% of notified TB ptients in 213 nd 214, nd 2 89% of ll TB ptients hd benefited from community-bsed tretment support during the sme period. ponent of TB services, but where it is not yet possible to quntify this contribution. For exmple, Zimbbwe hs recently finlized revisions to its ntionl monitoring nd evlution system nd will be ble to report dt on community contributions strting in 216. In the ner future, it is lso nticipted tht Mlwi will incorporte routine reporting of community contributions within the existing monitoring nd evlution system. In ddition to improving the documenttion nd reporting of community-bsed TB ctivities, ef forts to engge nongovernmentl orgniztions tht hve previously not been involved in TB prevention, dignosis nd tretment hve continued using the ENGAGE-TB pproch. 1 In ddition to five focus countries (the Democrtic Republic of the Congo, Ethiopi, Keny, South Afric nd the United Republic of Tnzni), five dditionl countries hve now integrted the ENGAGE-TB pproch into their ntionl strtegies nd mobilized funding for its implementtion. These re Burkin Fso, Côte d Ivoire, Mlwi, Nmibi nd Zimbbwe. Progress mde to dte in the originl five countries is described in Box 3.4. 3.4 Trends in cse notifictions 199 214 nd estimtes of the cse detection rte Globlly, the number of TB cses newly dignosed nd notified per 1 popultion remined reltively stble between 199 nd 2, rose shrply between 2 nd 28, nd then fell slowly from 29 to 213 (Figure 3.1). In terms of bsolute numbers, there ws n increse from 1995 to 2, more pronounced increse from 2 to 28 nd then very little chnge from 28 to 213 (Figure 3.1). Between 213 nd 214, these ptterns chnged, with cler upwrd increse in terms of rtes nd bsolute numbers. This chnge is driven by n increse in the South-Est Asi Region (Figure 3.2), which itself reflects the lrge increse in notifictions (of 366 cses) in Indi between 213 nd 214 (Figure 3.3, Box 3.2). 1 http://www.who.int/tb/people_nd_communities/en/ Globlly nd in ll WHO regions, cler gp exists between the numbers of notified cses nd the estimted numbers of incident cses. However, this gp hs nrrowed in the lst 15 yers, especilly in the Estern Mediterrnen nd Western Pcific regions nd to lesser extent in the South-Est Asi Region (Figure 3.2). Trends in the 22 HBCs re shown in Figure 3.3; for other countries these trends re illustrted in country profiles tht re vilble online. 2 The cse detection rte (CDR) 3 for TB is n indictor tht is included within the Millennium Development Gols (MDG) frmework. For given country nd yer, the CDR is clculted s the number of new nd relpse TB cses (see Box 3.1 for definitions) tht were notified by NTPs (Tble 3.1), divided by the estimted number of incident cses of TB tht yer. The CDR is expressed s percentge; it gives n pproximte 4 indiction of the proportion of ll incident TB cses tht re ctully dignosed nd reported to NTPs or ntionl surveillnce systems. The best estimte of the CDR for ll forms of TB globlly in 214 ws 63% (rnge, 6 66%), up from 48 52% in 25 nd 36 4% in 1995 the yer in which the DOTS strtegy begn to be introduced nd expnded (Tble 3.5). 5 The best estimte of the globl gp between notifictions (of new episodes of TB i.e. new nd relpse cses) nd incident cses in 214 ws 3.6 million cses. At regionl level, the highest CDRs in 214 were estimted to be in the Region of the Americs (best estimte 77%; rnge, 75 81%), the Western Pcific Region (best estimte 85%; rnge, 81 9%) nd the Europen Region (best estimte 79%; rnge, 75 83%). The other regions hd estimted CDRs of 43 75%, with best estimtes in the rnge 48 62%. 2 www.who.int/tb/dt 3 The CDR is ctully rtio rther thn rte, but the term rte hs become stndrd terminology in the context of this indictor. 4 It is pproximte becuse of uncertinty in the underlying incidence of TB nd becuse notified cses re not necessrily subset of incident cses tht occurred in the sme yer; see Chpter 2 for further discussion. 5 The rnges represent 95% uncertinty intervls. There is uncertinty in estimtes of the CDR becuse of uncertinty in estimtes of TB incidence (the denomintor). GLOBAL TUBERCULOSIS REPORT 215 n 45

TABLE 3.4 Community contributions to TB cse notifictions nd tretment support for TB ptients (ll forms) in 41 countries, 213 214. Dt re for the bsic mngement units (BMUs) tht reported dt. b c COUNTRIES CONTRIBUTION TO TB NOTIFICATIONS, 214 CONTRIBUTION TO TREATMENT ADHERENCE SUPPORT, 213 TB PATIENTS (ALL FORMS) WHO RECEIVED TOTAL TB NOTIFICATIONS (ALL FORMS) FROM COMMUNITY REFERRALS IN 214 TREATMENT ADHERENCE SUPPORT IN THE COMMUNITY IN 213 GEOGRAPHIC NUMBER % OF BMU NOTIFICATIONS COVERAGE OF DATA REPORTING BY BMUs NUMBER % OF ALL TB PATIENTS GEOGRAPHIC COVERAGE OF DATA REPORTING BY BMUs Afghnistn 1 88 7 661/722 1 89 13 336/722 Bngldesh 79 477 61 478/88 Not vilble Botswn Not vilble 5 316 63 27/27 Bulgri 229 15 22/22 Not vilble Burkin Fso 299 5 86/86 1 569 39 3/86 Burundi 796 11 17/17 1 335 18 17/17 Cmbodi 14 115 73 43/93 Not vilble Côte d Ivoire 8 165 36 151/184 7 785 29 134/184 DR Congo 12 649 57 95/516 7 22 49 95/516 Eritre 12 4 69/69 Not vilble Ethiopi 14 399 38 364/957 11 314 22 76/957 Georgi 28 82 3/77 Not vilble Ghn 326 16 49/216 11 392 73 216/216 Guine b 1 37 11 55/465 1 37 12 55/465 Indi 19 713 3 1 2/3 394 726 69 52 3 394/3 394 Indonesi 8 77 11 47/511 4 218 14 27/511 Keny 3 535 9 798/3 32 78 813 1 3 46/3 32 Lesotho Not vilble 9 649 9 17/34 Mdgscr 5 914 52 72/215 382 5 72/215 Mlysi Not vilble 84 2 15/146 Mongoli 351 8 32/32 731 16 32/32 Mozmbique b 2 868 5 323/323 5 656 11 251/323 Mynmr 1 34 2 171/354 1 65 5 165/354 Nmibi Not vilble 6 463 63 31/34 Nepl 457 3 75/75 363 19 5/75 Nigeri Not vilble 55 995 56 774/774 Pkistn Not vilble 231 557 1 1 137/1 36 Republic of Moldov Not vilble 3 38 78 57/57 Romni Not vilble 32 2 177/177 Rwnd 1 188 2 515/515 2 889 48 515/515 So Tome nd Principe 19 69 1/1 Not vilble Senegl 1 11 1 76/76 891 7 76/76 Sierr Leone 3 65 4 17/17 187 2 17/17 South Afric c 928.3 Not vilble Not vilble Sri Lnk 85 2 26/26 1 637 18 26/26 Tjikistn 883 14 19/19 6 495 1 19/19 Timor-Leste Not vilble 244 7 18/18 Ugnd Not vilble 26 44 55 117/117 UR Tnzni 1 416 18 168/168 49 412 75 168/168 Uzbekistn b 7 191 64 4 278/4 516 2 812 96 4 433/4 516 Viet Nm Not vilble 1 721 99 815/815 Twenty-eight countries did not submit dt for either indictor: Algeri, Angol, Armeni, Azerbijn, Benin, Bhutn, Cmeroon, Cpe Verde, Centrl Africn Republic, Chd, Congo, Gbon, Gmbi, Guine-Bissu, Kiribti, Liberi, Mlwi, Mli, Muritni, Niger, Philippines, Sudn, Swzilnd, Thilnd, Togo, Turkey, Zmbi nd Zimbbwe. The proportion of ptients receiving tretment support in the community ws clculted using the totl cohort (ll BMUs) of TB ptients strting tretment in 213 s the denomintor. Dt disggregted by BMU were not reported. The proportion of notifictions tht cme from community referrls ws clculted using the totl cohort (ll BMUs) of TB ptients notified in 214 s the denomintor. Dt disggregted by BMU were not reported. 46 n GLOBAL TUBERCULOSIS REPORT 215

n TABLE 3.5 Estimtes of the cse detection rte for new nd relpse cses %, 1995 214. Best estimtes re followed by the lower nd upper bounds of the 95% uncertinty intervl 1995 2 25 21 214 Afghnistn 19 18 21 47 44 51 53 48 59 53 47 6 Bngldesh 21 2 23 26 24 28 38 36 41 45 41 5 53 47 6 Brzil 79 73 85 73 67 8 84 79 9 82 78 86 82 78 86 Cmbodi 24 22 26 27 25 3 52 49 56 65 59 7 72 66 8 Chin 33 31 35 33 31 35 75 71 79 87 81 94 88 82 95 DR Congo 31 29 33 39 36 42 53 5 56 53 49 57 48 43 52 Ethiopi 11 9.3 13 33 27 4 48 41 57 66 55 8 6 49 73 Indi 59 56 61 49 47 51 48 47 5 59 55 62 74 7 8 Indonesi 4 2.9 5.8 8.9 6.5 13 26 19 37 3 22 44 32 23 46 Keny 62 6 64 72 7 74 81 79 82 82 8 84 8 78 82 Mozmbique 23 18 32 23 17 31 3 25 36 33 27 4 39 31 49 Mynmr 1 9.3 11 16 14 17 53 5 56 66 61 72 7 64 78 Nigeri 4.3 3.4 5.7 6.5 4.9 9.1 13 11 18 16 11 24 15 1 26 Pkistn 3.9 3.3 4.6 2.9 2.4 3.6 34 29 4 56 45 73 62 48 83 Philippines 42 39 46 42 38 46 47 44 51 58 52 65 85 76 97 Russin Federtion 6 56 64 75 7 8 65 62 69 84 77 92 85 77 94 South Afric 59 53 67 58 51 65 6 53 68 73 65 82 68 61 77 Thilnd 41 26 78 23 14 43 39 24 74 56 34 1 59 36 11 Ugnd 23 19 27 3 25 37 48 43 55 62 55 7 72 64 83 UR Tnzni 28 16 62 32 2 61 31 2 54 31 2 58 36 21 77 Viet Nm 34 3 38 57 5 65 64 58 71 71 61 84 77 65 94 Zimbbwe 61 44 92 67 54 86 66 54 83 76 59 1 7 51 1 High-burden countries 34 33 36 35 33 36 48 46 5 57 54 6 62 58 66 AFR 28 26 3 34 32 37 44 41 47 5 46 55 48 43 54 AMR 69 66 72 71 68 74 76 74 79 76 73 79 77 75 81 EMR 22 19 24 23 2 27 44 39 5 58 5 69 61 51 75 EUR 58 57 6 65 63 67 69 67 72 8 76 84 79 75 83 SEAR 38 35 42 35 32 39 43 39 46 52 47 57 62 56 68 WPR 36 35 38 38 36 4 69 66 71 79 75 83 85 81 9 Globl 37 36 39 38 36 4 5 48 52 58 55 61 63 6 66 indictes vlues tht cnnot be clculted. Estimtes for ll yers re reclculted s new informtion becomes vilble nd techniques re refined, so they my dif fer from those published previously. The lower nd upper bounds re defined s the 2.5th nd 97.5th centiles of outcome distributions produced in simultions. All regions hve improved their estimted CDRs since the mid-199s, with improvements prticulrly evident since 2. Among the 22 HBCs, the highest rtes of cse detection in 214 (>8%) were estimted to be in Brzil, Chin, the Philippines nd the Russin Federtion. The lowest rtes, with best estimtes of 5% or less, were in the Democrtic Republic of the Congo, Indonesi, Mozmbique, Nigeri nd the United Republic of Tnzni. There re two mjor resons for gp between notifictions nd estimted incidence. The first is underreporting of dignosed TB cses, for exmple becuse privte sector providers fil to notify cses. This is one of the resons for reltively low CDR in Indonesi (see lso Box 2.4, Chpter 2). The second is under-dignosis of people with TB for resons such s poor ccess to helth cre nd filure to recognize TB signs nd symptoms nd test for TB when people do present to helth cre fcilities. A good exmple is Nigeri, where the 212 ntionl TB prevlence survey suggested tht this is mjor reson for the low CDR. 1 It should lso be cknowledged tht the estimtes of TB incidence re uncertin, nd the gp between the estimted number of incident cses nd 1 World Helth Orgniztion. Globl tuberculosis report 214. Genev: World Helth Orgniztion; 214 (WHO/HTM/TB/214.8). See pp1 11. GLOBAL TUBERCULOSIS REPORT 215 n 47

Box 3.5 Definitions of tretment outcomes for new nd relpse cses recommended for use since Mrch 213 nd tht were used in the 214 nd 215 rounds of globl TB dt collection Cured A pulmonry TB ptient with bcteriologiclly-confirmed TB t the beginning of tretment who ws smer- or culturenegtive in the lst month of tretment nd on t lest one previous occsion. Completed tretment A TB ptient who completed tretment without evidence of filure but with no record to show tht sputum smer or culture results in the lst month of tretment nd on t lest one previous occsion were negtive, either becuse tests were not done or becuse results re unvilble. Died A TB ptient who died from ny cuse during tretment. Filed A TB ptient whose sputum smer or culture is positive t month five or lter during tretment. Lost to follow-up A TB ptient who did not strt tretment or whose tretment ws interrupted for two consecutive months or more. Not evluted A TB ptient for whom no tretment outcome is ssigned. This includes cses trnsferred out to nother tretment unit s well s cses for whom the tretment outcome is unknown to the reporting unit. Successfully treted A ptient who ws cured or who completed tretment. Cohort A group of ptients in whom TB hs been dignosed, nd who were registered for tretment during specified time period (e.g. the cohort of new cses registered in the clendr yer 212). This group forms the denomintor for clculting tretment outcomes. The sum of the ptients included in the bove tretment outcome ctegories should equl the number of cses registered. It should be highlighted tht in the new definitions recommended since Mrch 213 ny ptient found to hve drug-resistnt TB nd plced on second-line tretment should be removed from the drug-susceptible TB outcome cohort. This mens tht mngement of the stndrd TB register nd of the second-line TB tretment register needs to be coordinted to ensure proper ccounting of the outcomes of tretment (see lso Chpter 4). Definitions nd reporting frmework for tuberculosis 213 revision. Genev, World Helth Orgniztion, 213 (WHO/HTM/TB/213.2). Avilble t www.who.int/tb/publictions/definitions. the number of notifictions could be under- or over-stted. Intensified ef forts re needed to ensure tht ll cses re detected, notified to ntionl surveillnce systems, nd treted ccording to interntionl stndrds. Progress towrds the gol of universl helth coverge, implementtion of PPM inititives such s those described in section 3.2, nd ensuring tht there is n ef fective regultory frmework tht includes mndtory notifiction of cses re ll essentil to reduce underreporting nd under-dignosis, nd constitute prt of the End TB Strtegy (Chpter 1). The current sttus of progress towrds universl helth coverge from finncing perspective is discussed further in Chpter 7. 3.5 Tretment outcomes The definitions of TB tretment outcomes for new nd relpse cses of TB tht re recommended by WHO s prt of n updted recording nd reporting frmework issued in Mrch 213, nd used in the 215 round of globl TB dt collection, re shown in Box 3.5. 1 Most of these cses (97% globlly) hve drug-susceptible TB, but in some prts of the world, especilly countries of the former Soviet Union, more thn 2% of new nd relpse cses hve MDR-TB (Chpter 4). Universl ccess to drug susceptibility testing, s clled for in the End TB Strtegy (Chpter 1), is required to ensure tht ll people with TB receive pproprite tretment. Dt on tretment outcomes for new nd relpse cses of 1 Tretment outcomes for people dignosed with rifmpicin-resistnt nd MDR-TB re presented in Chpter 4. TB re shown for the world, the six WHO regions nd the 22 HBCs in Tble 3.6 nd Figure 3.5. Globlly, the tretment success rte for the 5.4 million new nd relpse cses tht were treted in the 213 cohort ws 86%. It is impressive tht s the size of the globl tretment cohort grew from 1. million in 1995 to 4.2 million in 25 nd 5.4 million in 213, the tretment success rte first improved nd hs subsequently been sustined t high level. Among the six WHO regions, the highest tretment success rtes were in the Western Pcific Region, the South- Est Asi Region nd the Estern Mediterrnen Region. The tretment success rte ws 79% in the Africn Region. The lowest tretment success rtes were in the Region of the Americs nd the Europen Region (both 75%). In the Region of the Americs, tretment outcomes would probbly be considerbly improved if the number of ptients in the not evluted ctegory could be reduced. In the Europen Region, rtes of tretment filure, deth nd loss to follow-up, s well s the proportion of ptients without documented tretment outcome, ll need to be reduced. One explntion for the poor outcomes in this region my be tht the proportion of new nd relpse cses tht hve drugresistnt TB is high (Chpter 4). All cses need to be tested for susceptibility to first-line drugs, nd those with rifmpicin-resistnt nd MDR-TB enrolled on second-line rther thn first-line regimens. Most of the 22 HBCs hve reched or exceeded tretment success rte of 85%. Improvements re still needed in 48 n GLOBAL TUBERCULOSIS REPORT 215

n TABLE 3.6 Tretment success for ll new nd relpse cses (%) nd cohort size (thousnds), 1995 213. Tretment success (%) 1995 2 25 21 211 212 213 Afghnistn 85 9 86 88 88 88 Bngldesh 71 81 9 91 91 92 93 Brzil 17 71 72 72 73 72 72 Cmbodi 91 91 91 89 94 94 93 Chin 93 93 92 95 95 95 95 DR Congo 74 78 85 89 87 88 87 Ethiopi 61 8 78 77 89 91 89 Indi 25 34 87 89 89 88 88 Indonesi 91 87 89 89 88 86 88 Keny 75 8 81 86 87 86 86 Mozmbique b 39 75 79 85 87 88 Mynmr 67 82 83 88 88 89 87 Nigeri 49 79 75 81 85 86 86 Pkistn 7 74 82 9 92 91 93 Philippines 6 88 89 9 87 88 9 Russin Federtion 65 68 67 66 65 69 68 South Afric 58 63 69 53 77 77 78 Thilnd 64 69 71 83 82 81 81 Ugnd 44 63 73 68 73 77 75 UR Tnzni 73 78 83 89 88 9 91 Viet Nm 89 92 92 92 93 91 89 Zimbbwe 53 69 66 76 8 81 8 High-burden countries 53 67 85 86 88 88 88 AFR 6 71 74 73 79 81 79 AMR 5 76 75 73 75 75 75 EMR 79 81 82 88 89 87 91 EUR 67 75 77 74 73 76 75 SEAR 33 5 87 89 89 88 88 WPR 8 9 9 92 93 92 92 Globl 57 69 84 84 87 86 86 b. Cohort size (thousnds) 1995 2 25 21 211 212 213 Afghnistn 3.1 1 26 26 29 31 Bngldesh 11 38 119 15 148 165 184 Brzil 46 34 78 78 71 75 77 Cmbodi 4.4 15 34 4 37 38 36 Chin 131 214 788 877 856 885 842 DR Congo 16 36 65 19 92 15 112 Ethiopi 5.1 3 39 152 91 45 44 Indi 265 349 1 71 1 229 1 29 1 288 1 244 Indonesi 3 52 244 296 314 329 326 Keny 6.5 28 98 9 82 98 81 Mozmbique 11 13 18 2 21 23 Mynmr 7.9 17 73 127 135 137 136 Nigeri 9.5 16 35 78 84 9 92 Pkistn.8 4.1 117 256 255 111 289 Philippines 9 5 81 162 19 214 216 Russin Federtion.5 3.6 74 94 89 9 83 South Afric 28 86 259 338 292 328 321 Thilnd 2 23 49 48 49 58 66 Ugnd 15 14 21 4 43 26 45 UR Tnzni 2 24 59 59 59 62 64 Viet Nm 38 53 55 88 89 14 12 Zimbbwe 9.7 14 43 46 4 38 35 High-burden countries 739 1 119 3 43 4 43 4 252 4 337 4 475 AFR 178 365 886 1 22 1 13 1 142 1 165 AMR 129 111 187 2 191 22 21 EMR 46 64 226 386 391 242 432 EUR 34 42 221 255 244 251 241 SEAR 318 512 1 639 1 98 1 986 2 114 2 11 WPR 296 36 1 3 1 24 1 233 1 344 1 298 Globl 1 1 1 453 4 188 5 28 5 146 5 295 5 437 Blnk cells indicte dt not reported. indictes vlues tht cnnot be clculted. Cohorts before 212 include new cses only. For the 212 nd 213 cohorts, 14 nd 16 high-burden countries respectively included both new nd relpse cses, s recommended in the revised recording nd reporting frmework issued by WHO in 213 (see Definitions nd reporting frmework for tuberculosis 213 revision. Genev, World Helth Orgniztion, 213 (WHO/HTM/TB/213.2). Avilble t www.who.int/tb/publictions/definitions. b Tretment outcomes in Mozmbique re for new pulmonry bcteriologiclly-confirmed cses only. Introduction of monitoring of outcomes for other cses ws strted in 215. GLOBAL TUBERCULOSIS REPORT 215 n 49

Box 3.6 Outcomes of TB tretment by HIV sttus In the 215 round of globl TB dt collection, 14 countries reported tretment outcomes for the 213 ptient cohort tht were disggregted by HIV sttus. This ws n increse from 133 countries tht reported such dt for 212. These 14 countries included 22 of the 41 high TB/HIV burden countries (listed in Tble 6.1 of Chpter 6) nd collectively ccounted for 71% (n= 397 ) of the HIV-positive TB ptients reported by NTPs in 213, similr to the level of 212 (7%). Overll, the tretment success rte in 213 ws worse for HIVpositive TB ptients (73%) compred with HIV-negtive TB ptients (88%), similr to levels in 212 (Figure B3.6). The dif ference ws smller in the Africn region (75% nd 84%, respectively). There were lrge dif ferences in the Europen nd Estern Mediterrnen Regions, where the tretment success rtes mong HIV-positive TB ptients were only 47% nd 6% respectively, compred with 8% nd 91% mong HIV-negtive ptients. The tretment success rte in the Europen Region were much worse thn in 212 (47% versus 57%), minly reflecting dt for Ukrine. This country ccounted for 8% of the HIV-positive TB ptients for whom tretment outcomes in 213 were reported, but did not report dt in 212. More encourgingly, the tretment success rte for HIV-positive TB ptients in the Western Pcific Region ws substntilly better in 213 compred with 212 (73% vs 57%). Globlly, the proportion of TB ptients who died during tretment remined more thn three times higher mong HIV-positive TB ptients (11% versus 3.5%). In the Africn Region, HIV-positive TB ptients were lmost twice s likely to die compred with HIV-negtive TB ptients (9.8% versus 5.1%). Dif ferentils were lrger in the Europen Region (21% versus 6.6%) nd the Estern FIGURE B3.6 Outcomes of TB tretment by HIV sttus, 213 1 Percentge of cohort Mediterrnen Region (17% versus 1.8%). The proportion of ptients ctegorized s lost to follow-up, who my lso hve died of TB, ws lso higher for those who were HIV-positive (6.5% versus 4.6%), similr to levels in 212. The proportion of HIV-positive TB ptients for whom the tretment outcome ws not evluted ws reltively similr globlly (8.1% compred with 7.6% of HIVnegtive TB ptients), lthough there ws noticeble drop in the Western Pcific Region (from 3% of ptients in 212 to 12% in 213). This is the min explntion for the lrge improvement in the tretment success rte for HIV-positive TB ptients in this region. 8 6 4 2 Tretment success Filed Died HIV+ Lost to follow-up HIV Not evluted Countries with no tretment outcome dt for HIV-positive TB ptients were excluded from the nlysis. Brzil, the Russin Federtion, South Afric, Thilnd, Ugnd nd Zimbbwe. Tretment outcomes in 213 were worse mong HIVpositive TB ptients compred with HIV-negtive TB ptients (Box 3.6). Further ef forts re needed to nrrow this gp. 3.6 Detection nd tretment of ltent TB infection Ltent TB infection (LTBI) is defined s the presence of immune responses to Mycobcterium tuberculosis ntigens without clinicl evidence of ctive TB. Most people with LTBI hve no signs or symptoms of TB disese nd re not infectious. However, they re t risk of developing ctive TB disese nd becoming infectious. The lifetime risk of TB disese for person with documented LTBI is estimted t 5 15%, with the mjority of cses occurring within the first five yers f ter initil infection. 1 The risk of LTBI rectivtion cn be reduced by preventive tretment. WHO hs issued globl recommendtions on the tretment of LTBI for people living with HIV nd for 1 Gethun H, Mtteelli A, Chisson RE, Rviglione M. Ltent Mycobcterium tuberculosis infection. New Engl J Med. 215;372(22):2127 35. children ged less thn 5 yers old who re close contcts of TB cse. 2,3 Most recently, WHO hs issued guidelines on the mngement of LTBI tht re trgeted t upper-middle nd high-income countries with n estimted incidence rte of less thn 1 per 1 popultion. 4 In these countries, systemtic testing nd tretment of LTBI is recommended for wider rnge of risk groups: people living with HIV, dult s well s child contcts of pulmonry TB cses, ptients with silicosis, ptients inititing nti-tumour necrosis fctor (TNF) tretment, ptients on dilysis, nd trnsplnt ptients (Tble 3.7). The mngement of LTBI is criticl component of the new post-215 End TB Strtegy (Chpter 1), nd is one of the interventions tht cn help countries to chieve the mbi- 2 World Helth Orgniztion. Guidelines for intensified tuberculosis cse-finding nd isonizid preventive therpy for people living with HIV in resource-constrined settings. Genev: World Helth Orgniztion; 211. 3 World Helth Orgniztion. Recommendtions for investigting contcts of persons with infectious tuberculosis in low- nd middle income countries. Genev: World Helth Orgniztion; 212. 4 World Helth Orgniztion. Guidelines on the mngement of ltent tuberculosis infection. Genev: World Helth Orgniztion; 215. Avilble t: http://www.who.int/tb/publictions/ltbi_document_pge/ en/ 5 n GLOBAL TUBERCULOSIS REPORT 215

n TABLE 3.7 WHO recommendtions for the mngement of ltent TB infection, by country group COUNTRY GROUP AT RISK POPULATIONS TESTING ALGORITHM TREATMENT OPTIONS High-income nd upper middleincome countries with n estimted TB incidence rte of less thn 1 per 1 popultion Strongly recommended for the following risk groups: 1) People living with HIV; 2) Adults nd children who re household or close contcts of pulmonry TB cses; 3) Clinicl indictions ptients with silicosis; ptients inititing nti-tnf tretment; ptients on dilysis; trnsplnt ptients. Exclude ctive TB using TB investigtions. A positive IGRA or TST test result is required to dignose LTBI. 6 months dily isonizid 9 months dily isonizid 3 months weekly rifpentine plus isonizid 3 to 4 months dily isonizid plus rifmpicin 3 to 4 months dily rifmpicin Resource-limited nd other middleincome countries with n estimted TB incidence rte of more thn 1 per 1 popultion 1) People living with HIV; 2) Children under 5 yers of ge who re household contcts of TB cse. Exclude ctive TB using TB investigtions. An LTBI test is not required prior to LTBI tretment, but is encourged for people living with HIV. IGRA should not replce TST. 6 months dily isonizid n FIGURE 3.5 Tretment outcomes for new nd relpse cses, 213, globlly, for the six WHO regions nd 22 high-burden countries Afghnistn Bngldesh Brzil Cmbodi Chin DR Congo Ethiopi Indi Indonesi Keny Mozmbique b Mynmr Nigeri Pkistn Philippines Russin Federtion South Afric Thilnd Ugnd UR Tnzni Viet Nm Zimbbwe High-burden countries AFR AMR EMR EUR SEAR WPR Globl tious trgets of 9% reduction in the TB incidence rte nd 95% reduction in TB deths by 235, compred with 215 levels. LTBI mngement cn lso contribute to TB elimintion, especilly in low TB incidence settings. In this context, country prepredness for the progrmmtic implementtion of LTBI mngement (including ddressing well-recognized chllenges such s tretment dherence) is of growing priority nd importnce. A two-pronged pproch is required, in which: (1) tretment for LTBI is provided in ll countries to people living with HIV nd children ged less thn 5 yers old who re household or close contcts of TB cse; nd (2) tretment for LTBI is provided to dditionl risk groups in upper-middle nd high-income countries with n incidence rte of less thn 1 per 1 popultion. Dt on the tretment of LTBI mong people living with HIV re lredy collected routinely, with dt presented in this report (Chpter 6). In 214 nd 215, WHO expnded dt collection relted to LTBI through discussions during regionl meetings of NTP mngers (or their equivlent) nd other ntionl stkeholders in four WHO regions, nd by conducting specil survey of existing policy nd prctices in upper-middle income nd high-income countries with n incidence rte of less thn 1 per 1 popultion (shown in Figure 3.6). The min results re summrized below. 2 4 6 8 1 Percentge of cohort (%) Tretment success Filure Died Lost to follow-up Not evluted b Tretment outcomes re for new cses only. Tretment outcomes in Mozmbique re for new pulmonry bcteriologiclly-confirmed cses only. Introduction of monitoring of outcomes for other cses ws strted in 215. GLOBAL TUBERCULOSIS REPORT 215 n 51

n FIGURE 3.6 The 113 upper-middle-income nd high-income countries with n estimted incidence rte of less thn 1 per 1 popultion tht re the primry udience for 215 WHO guidelines on the mngement of ltent TB infection n FIGURE 3.7 Reported policies nd prctices for ltent TB infection (LTBI) in upper-middle-income nd high-income countries with n estimted incidence rte of less thn 1 per 1 popultion, four WHO regions Number of countries 35 3 25 2 15 1 5 AMR EMR EUR WPR WHO region Ntionl policy on LTBI exists Testing nd tretment for LTBI being provided for people living with HIV, nd/or children who re close contcts of TB cses. Two countries in the Africn Region (Algeri nd Seychelles) were included in the survey, both of which reported tht they hd ntionl policies on LTBI nd were providing LTBI testing nd tretment for people living with HIV nd/or children who re close contcts of TB cses. One country in the South-Est Asi Region (Mldives) ws invited to prticipte in the survey but no response ws received. 3.6.1 Results from survey of LTBI policy nd prctice in upper-middle nd high-income countries with n incidence rte of less thn 1 per 1 popultion Dt were reported by 74 (69%) of the 18 countries invited to prticipte in the survey. 1 Among these countries, 76% (56/74) hd ntionl policy on LTBI but higher number (68/74, 92%) were providing testing for LTBI nd preventive tretment for people living with HIV nd/or children who were contcts of TB cses. This demonstrtes gp between policy nd prctice, which existed in three of four WHO regions (Figure 3.7). Systemtic testing nd tretment for LTBI in other risk groups for whom it is recommended ws reported by only few countries. Testing for LTBI nd exclusion of ctive TB Of the 68 countries implementing systemtic testing nd tretment of LTBI in t lest one t-risk popultion, 3 (44%) relied only on the tuberculin skin test (TST); the other 38 countries used both TST nd interferon-gmm relese ssys (IGRAs) to test for LTBI. 2 TST ws the only test used in most countries in the Estern Mediterrnen Region (7%, 7/1) nd the Americs (73%, 11/15). Both tests were common- 1 Five countries or territories with very smll popultions nd numbers of TB cses were not included in the survey: Bermud, Monco, Sn Mrino, Turks nd Cicos Islnds, US Virgin Islnds. 2 In the remining six countries, specific t-risk popultions were not identified. 52 n GLOBAL TUBERCULOSIS REPORT 215

ly used in the Europen Region (81%, 25/31). Shortges of TST were reported by 34 countries. To exclude ctive TB prior to strting tretment for LTBI, most countries (62%, 42/68) used combintion of clinicl screening for TB symptoms nd chest X-ry; this is consistent with WHO recommendtions. A further 24 countries used these methods but supplemented them with dditionl dignostic tests including smer microscopy, culture, nd moleculr testing. The remining country used only clinicl symptoms to exclude ctive TB. Tretment regimens In just over hlf of the 68 countries (35/68, 51%), the only option for LTBI tretment ws dily regimen of isonizid for six or nine months. Rifmycin-contining regimens were used in other countries, but to dte the shortest nd simplest regimen ( weekly dose of rifpentine plus isonizid for 12 weeks) hd been dopted by only five of these countries. Recording nd reporting Recording nd reporting gps were evident in mny countries. Of the 4 countries providing testing nd tretment for LTBI for people living with HIV, only 21 hd system for recording nd reporting dt. Of the 53 countries providing LTBI to children ged less thn five who were household or close contcts of TB cses, 33 hd system for recording or reporting dt. A monitoring nd evlution frmework for LTBI is being developed by WHO nd is expected to be vilble in 216. Key messges nd conclusions Overll, the survey shows tht intensified efforts re needed to ensure tht ntionl LTBI policies re in plce, s foundtion for progrmmtic mngement of LTBI using stndrdised pproches. Such policies should prioritize nd trget popultion groups with the highest risk of progression to ctive disese in whom the benefits of preventive tretment outweigh the potentil risks. Ef forts re needed to promote the use of short tretment regimens, such s weekly rifpentine plus isonizid for 12 weeks, which would hve potentil benefits in terms of cceptbility, dherence, nd tolerbility compred to the stndrd isonizid regimen. Systems for routine collection nd nlysis of dt re required in ll countries nd shortges in the supply of TST must be ddressed. GLOBAL TUBERCULOSIS REPORT 215 n 53

CHAPTER 4 Drug-resistnt TB Key fcts nd messges Drug-resistnt TB poses mjor thret to control of TB worldwide. By the end of 214, dt on nti-tb drug resistnce were vilble for 153 countries, ccounting for more thn 95% of the world s popultion nd estimted TB cses. Eighty of these countries hve continuous surveillnce systems, while the others rely on epidemiologicl surveys. In 214, the first-ever drug resistnce surveys were completed in the Democrtic People s Republic of Kore (North Hwnghe Province), Irq, Ppu New Guine (four provinces), Turkmenistn nd Ukrine; repet surveys were completed in Irn, Lesotho, Morocco nd Senegl. In mid-215, drug resistnce surveys were ongoing in 13 countries. These included the first ntionwide surveys in the Democrtic Republic of the Congo, Indi nd Sudn. Globlly, n estimted 3.3% (95% CI: 2.2 4.4%) of new cses nd 2% (95%CI: 14 27%) of previously treted cses hve MDR-TB; these levels hve remined virtully unchnged in recent yers. In 214, there were n estimted 48 (rnge: 36 6 ) new cses of MDR-TB worldwide, nd pproximtely 19 (rnge: 12 26 ) deths from MDR-TB. Among ptients with pulmonry TB who were notified in 214, n estimted 3 (rnge: 22 37 ) hd MDR-TB. More thn hlf of these ptients were in Indi, Chin nd the Russin Federtion. Extensively drug-resistnt TB (XDR-TB) hs been reported by 15 countries. On verge, n estimted 9.7% (95% CI: 7.4 12%) of people with MDR-TB hve XDR-TB. There ws mjor progress in coverge of drug susceptibility testing (DST) between 213 nd 214. Worldwide, 12% of new bcteriologiclly-confirmed TB cses nd 58% of previously treted TB ptients were tested for drug resistnce in 214, up from 8.5% nd 17% respectively in 213 (representing proportionl increses of 43% nd 223%, respectively). Coverge ws highest in the Europen Region (97% of new cses). In the South-Est Asi nd Western Pcific regions combined, two-thirds of previously treted cses underwent testing. Globlly in 214, 123 ptients with MDR -TB or rifmpicinresistnt tuberculosis (RR-TB) were notified, of whom bout 75% lived in the Europen Region, Indi, South Afric or Chin. This ws equivlent to 41% of the 3 notified TB ptients who were estimted to hve MDR-TB in 214. The number of notified MDR/RR-TB cses in 214 ws lmost the sme s in 213. A mjor dignostic gp hs therefore persisted, nd ws worst in the Western Pcific Region where detected cses represented 19% of estimted cses. The figure for Chin ws 11%. People with MDR-TB or RR-TB re eligible for second-line tretment with MDR-TB regimens. A totl of 111 people were strted on MDR-TB tretment in 214, n increse of 14% compred with 213. The rtio of enrolled to notified MDR/ RR-TB cses ws 9% globlly, nd >9% in 15 high MDR-TB burden countries s well s the Europen Region nd the Region of Americs. The rtio ws <6% in 3 high MDR-TB burden countries: Chin (49%), Mynmr (44%) nd Nigeri (53%). The 215 tretment success trget of 75% for MDR-TB ptients ws reched by 43 of the 127 countries nd territories tht reported outcomes for the 212 cohort. Only three high MDR-TB burden countries (Estoni, Ethiopi, nd Mynmr) chieved tretment success rte of 75%. Globlly, only 5% of ptients on MDR-TB tretment were successfully treted, lrgely due to high rtes of mortlity nd loss to follow-up. Despite progress in responding to the chllenge of drugresistnt TB, serious detection nd tretment gps remin. Intensified efforts to close these gps re urgently required. Drug-resistnt TB continues to threten globl TB control nd remins mjor public helth concern in mny countries. The first prt of this chpter (section 4.1) summrizes the progress mde in the globl coverge of surveillnce of nti-tb drug resistnce, using the most recent dt gthered from epidemiologicl surveys nd continuous surveillnce systems, with focus on multidrug-resistnt TB (MDR-TB) 1 nd extensively drug-resistnt TB (XDR-TB). 2 The second prt 1 Defined s resistnce to t lest rifmpicin nd isonizid, the two most powerful first-line nti-tb drugs. 2 XDR-TB is defined s MDR-TB plus resistnce to t lest one fluoroquinolone nd second-line injectble. of this chpter presents n ssessment of globl nd ntionl progress in dignosing nd treting rifmpicin-resistnt (RR- TB) nd MDR-TB (section 4.2). 4.1 Surveillnce of drug-resistnt TB 4.1.1 Progress in the coverge of drug resistnce surveillnce Since the lunch of the Globl Project on Anti-tuberculosis Drug Resistnce Surveillnce in 1994, dt on drug resistnce hve been systemticlly collected nd nlysed from 153 countries worldwide (79% of 194 WHO Member Sttes). 54 n GLOBAL TUBERCULOSIS REPORT 215

This number includes 8 countries tht hve continuous surveillnce systems bsed on routine dignostic drug susceptibility testing (DST) of ll TB ptients, nd 73 countries tht rely on epidemiologicl surveys of representtive smples of ptients. Over the pst two decdes, ll 22 high TB nd/or 27 high MDR-TB burden countries (for totl of 36 countries) hve either estblished continuous surveillnce system or conducted t lest one survey to monitor drug resistnce. Progress towrds chieving globl coverge of drug resistnce surveillnce dt is shown in Figure 4.1. Continuous surveillnce for MDR-TB, bsed on routine DST of TB ptients nd systemtic collection nd nlysis of dt, is the most ef fective pproch to monitor trends in drug resistnce. The number of countries tht cn rely on dt generted by continuous surveillnce systems is incresing, following mjor ef forts to scle up the vilbility of culture nd DST services. In the pst two yers, n dditionl 1 countries estblished high qulity continuous surveillnce systems to monitor drug resistnce in new nd previously treted TB cses. Severl countries of the estern Europen nd centrl Asin regions, where proportions of MDR-TB mong TB cses re the highest, hve estblished high qulity surveillnce systems to monitor drug resistnce. These re Belrus, Estoni, Georgi, Kzkhstn, Ltvi, Lithuni, the Russin Federtion (t subntionl level) nd Tjikistn. Surveys conducted every five 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, due to lck of lbortory cpcity or resources. In 214, the first-ever drug resistnce surveys were completed in the Democrtic People s Republic of Kore (North Hwnghe Province), Irq, Ppu New Guine (four provinces), Turkmenistn nd Ukrine; repet surveys were completed in Irn, Lesotho, Morocco nd Senegl. Of the 36 high TB nd/or MDR-TB burden countries, 26 hve generted drug resistnce dt through epidemiologicl surveys. Nerly hlf of these (14 countries) hve conducted surveys recently, between 21 nd 214. These re Afghnistn (Centrl region), Azerbijn, Bngldesh, Kyrgyzstn, Mynmr, Nigeri, Pkistn, the Philippines, Tjikistn, Thilnd, Ugnd, Ukrine, Uzbekistn nd Viet Nm. Three countries hve not completed survey since the mid-199s: the Democrtic Republic of the Congo, Keny nd Zimbbwe. However, ntionl survey is currently being implemented in ll three of these countries. Six high TB nd/or MDR-TB burden countries (Afghnistn, Brzil, the Democrtic Republic of the Congo, Indi, Indonesi nd the Russin Federtion) still rely on drug resistnce surveillnce dt gthered from sub-ntionl res only. This sitution will improve in the ner future. In 214, Brzil lunched lrge ntionwide sentinel system to monitor drug resistnce. The Democrtic Republic of the Congo nd Indi re currently conducting ntionl surveys, nd in Indonesi the first-ever ntionwide drug resistnce survey is n FIGURE 4.1 Globl coverge of surveillnce dt on drug resistnce, 1994 215 Yer of most recent dt 1995 1999 2 24 25 29 21 214 Ongoing survey in 215 No dt Subntionl dt only Not pplicble GLOBAL TUBERCULOSIS REPORT 215 n 55

n TABLE 4.1 Estimted proportion of TB cses tht hve MDR-TB, globlly nd for 27 high MDR-TB burden countries nd WHO regions b ESTIMATED % OF NEW TB CASES 95% WITH CONFIDENCE MDR-TB INTERVAL ESTIMATED % OF RE- TREATMENT TB CASES 95% WITH CONFIDENCE MDR-TB INTERVAL Armeni 9.4 7. 12 43 38 49 Azerbijn 13 1 16 28 22 37 Bngldesh 1.4.7 2.5 29 24 34 Belrus 34 32 36 69 66 72 Bulgri 2.3 1.3 3.8 23 17 31 Chin 5.7 4.5 7. 26 22 3 DR Congo b 2.2.3 4.1 11 6.2 16 Estoni 19 14 27 62 42 79 Ethiopi 1.6.9 2.8 12 5.6 21 Georgi 12 1 13 39 35-44 Indi 2.2 1.9 2.6 15 11 19 Indonesi 1.9 1.4 2.5 12 8.1 17 Kzkhstn 26 25 27 58 57 59 Kyrgyzstn 26 23 31 55 52 58 Ltvi 8.2 5.8 11 3 21 4 Lithuni 14 12 16 49 43 55 Mynmr 5. 3.1 6.8 27 15 39 Nigeri 2.9 2.1 4. 14 1 19 Pkistn 3.7 2.5 5. 18 13 23 Philippines 2. 1.4 2.7 21 16 29 Republic of Moldov 24 21 26 62 59 65 Russin Federtion 19 14 25 49 4 59 South Afric 1.8 1.4 2.3 6.7 5.4 8.2 Tjikistn 8.1 6.9 9.4 52 47 57 Ukrine 22 2 24 56 5 61 Uzbekistn 23 18 3 62 53 71 Viet Nm 4. 2.5 5.4 23 17 3 High MDR-TB burden countries 3.8 2.2 5.4 22 13 31 AFR 2.1.5 3.7 11 6.7 16 AMR 2.4 1.3 3.5 11 6.5 16 EMR 3.2 2.3 4.1 18 12 25 EUR 15 1 2 48 43 53 SEAR 2.2 1.9 2.6 16 14 18 WPR 4.4 2.5 6.3 22 18 25 Globl 3.3 2.2 4.4 2 14 27 Best estimtes re for the ltest vilble yer. The estimtes for DR Congo re indirect estimtes bsed on dt from countries in the sme epidemiologicl region. scheduled for implementtion in 216. The remining countries should consider conducting ntionwide drug resistnce surveys in the short term to better understnd the burden of MDR-TB nd to guide the plnning of dignostic, tretment nd cre services. In mid-215, drug resistnce surveys were ongoing in 13 countries. These included the first-ever ntionwide surveys in the Democrtic Republic of the Congo, Indi nd Sudn; nd repet surveys in Bolivi, Chin, Côte d Ivoire, Keny, Nmibi, Romni, Rwnd, Venezuel, South Afric nd Zimbbwe. Centrl nd Frncophone Afric remin the prts of the world where drug resistnce surveillnce dt re most lcking, lrgely s result of wek lbortory infrstructure. These countries should consider conducting drug resistnce surveys using Xpert MTB/RIF to t lest obtin ntionlly representtive estimte of the proportion of TB ptients with rifmpicin resistnce. 4.1.2 Percentge of new nd previously treted TB cses tht hve MDR-TB Globlly in 214, there were n estimted 3.3% (95% CI: 2.2 4.4%) of new cses nd 2% (95%CI: 14 27%) of previously treted cses with MDR-TB (Tble 4.1). These estimtes re essentilly unchnged from those published in recent globl TB reports. The proportions of new nd previously treted TB cses with MDR-TB t the country level re shown in Figure 4.2 nd Figure 4.3, nd for the 27 high MDR-TB burden countries lso in Tble 4.1. Estern Europen nd centrl Asin countries continue to hve the highest levels of MDR-TB. Among new cses, the proportions with MDR-TB were highest in Belrus, Estoni, Kzkhstn, Kyrgyzstn, the Republic of Moldov, the Russin Federtion, Ukrine nd Uzbekistn. Among previously treted TB cses, the proportions with MDR-TB were highest in Belrus, Estoni, Kzkhstn, Kyrgyzstn, the Republic of Moldov, Tjikistn, Ukrine nd Uzbekistn. In the Russin Federtion, even though the verge proportion of previously treted cses with MDR-TB does not exceed 5%, the proportion is well bove 5% in severl Federl Subjects. Levels of drug resistnce mong new cses remin low (<3%) in mny prts of the world, including in lmost ll countries in the Region of the Americs; most Africn countries where drug resistnce surveys hve been conducted; most of the South-Est Asi Region; most of western Europe; nd severl countries in the Western Pcific Region. 4.1.3 Estimted globl incidence of MDR-TB nd estimted number of MDR-TB cses mong notified TB ptients in 214 Dt compiled from surveys nd continuous surveillnce of drug resistnce mong TB ptients cn be used to estimte the totl number of incident cses of MDR-TB worldwide nd the totl number of deths from MDR-TB in 214. Methods 56 n GLOBAL TUBERCULOSIS REPORT 215

n FIGURE 4.2 Percentge of new TB cses with MDR-TB Percentge of cses 2.9 3 5.9 6 11.9 12 17.9 18 No dt Subntionl dt only Not pplicble Figures re bsed on the most recent yer for which dt hve been reported, which vries mong countries. Dt reported before the yer 2 re not shown. n FIGURE 4.3 Percentge of previously treted TB cses with MDR-TB Percentge of cses 5.9 6 11.9 12 29.9 3 49.9 5 No dt Subntionl dt only Not pplicble Figures re bsed on the most recent yer for which dt hve been reported, which vries mong countries. Dt reported before the yer 2 re not shown. In six countries or territories, the high percentges of previously treted cses with MDR-TB refer to only smll number (1 8) of notified TB cses. These re: Bhrin; Belize; Bonire, Sint Eusttius nd Sb; Cyprus; Isrel; nd So Tomé nd Principe. GLOBAL TUBERCULOSIS REPORT 215 n 57

used to produce these estimtes re described in detil in n online technicl ppendix (vilble t www.who.int/tb/ dt). The number of incident cses includes cses mong notified TB ptients, cses mong people dignosed with TB tht were not notified to ntionl TB progrmmes (NTPs) in whom dignosis of MDR-TB ws missed, nd cses mong people not dignosed with TB t ll. Globlly in 214, there were n estimted 48 (rnge: 36 6 ) incident cses of MDR-TB. This number is essentilly unchnged from those published in recent globl TB reports, despite n upwrd revision to globl estimtes of the burden of TB following results from the 213/214 ntionl TB prevlence survey in Indonesi (which indicted tht there re bout 1 million rther thn.5 million incident TB cses per yer in this country; see Chpter 2). The explntion is tht the upwrd revision to the estimted number of incident cses of MDR-TB in Indonesi (equivlent to pproximtely 12 extr cses) hs been compensted for by reductions in the reported numbers of previously treted cses in severl high MDR-TB burden countries (for exmple, Indi); this ctegory of cse (especilly those not defined s relpse cses) hs n importnt influence on estimtes of the totl number of incident cses of MDR-TB. 1 There were pproximtely 19 (rnge: 12 26 ) deths from MDR-TB in 214, comprble to estimtes published in recent globl TB reports. Dt compiled from surveys nd continuous surveillnce of drug resistnce mong TB ptients lso llow the production of globl s well s country-specific estimtes of the number of MDR-TB cses mong notified TB ptients with pulmonry TB. These re the MDR-TB cses tht could be detected if ll notified ptients were tested for drug resistnce to rifmpicin nd isonizid using WHO-recommended dignostic tests. Globlly, in 214 there were n estimted 3 (rnge: 22 37 ) MDR-TB cses mong notified TB ptients; this is unchnged from the estimte for 213. 2 Of the 3 cses, 53% were mong new cses nd 47% were mong previously treted cses. Of note, the incresed number of TB cses notified in Indi between 213 nd 214 (Chpter 3) nd the higher proportions of MDR-TB detected in Ukrine in the ltest survey of drug resistnce were counter-blnced by lower numbers of new TB cses notified in Chin, the Russin Federtion nd Ukrine nd lower numbers of previously treted TB cses notified in Indi nd 1 The number of incident cses of MDR-TB is estimted s the sum of the number of cses in three distinct groups. These re (i) new cses of TB; (ii) relpse cses nd (iii) ll previously treted cses of TB, excluding those in the relpse ctegory. A review of methods used by WHO to estimte MDR-TB incidence nd mortlity is scheduled for 216. In line with retining current methods for the 215 trgets ssessment, methods to estimte the burden of MDR-TB hve not been chnged this yer (see lso Chpter 2, prticulrly Box 2.1 nd Box 2.2). Further detils bout the methods used to estimte the burden of MDR-TB re provided in the online technicl ppendix, vilble t www.who.int/ tb/dt 2 WHO. Globl tuberculosis report 214. Genev: World Helth Orgniztion; 214 (WHO/HTM/TB/214.8). severl Estern Europen countries. Country-specific estimtes re discussed in section 4.2. Given the incresing use of moleculr dignostics tht detect RR-TB (Chpter 5), their growing importnce in detection of TB ptients with RR-TB (section 4.2) nd the fct tht the recommended tretment for people with RR-TB is the sme s for those with MDR-TB, monitoring nd evlution of the response to drug-resistnt TB requires more ttention to nd emphsis on the underlying burden of RR-TB. The burden of rifmpicin resistnce is presented in Box 4.1 nd compred with tht of MDR-TB. 4.1.4 Resistnce to second-line drugs XDR-TB, defined s MDR-TB plus resistnce to t lest one fluoroquinolone nd second-line injectble, hd been reported by 15 countries globlly by the end of 214. A totl of 83 countries nd five territories reported representtive dt from continuous surveillnce or surveys regrding the proportion of MDR-TB cses tht hd XDR-TB. Combining their dt, the verge proportion of MDR-TB cses with XDR-TB ws 9.7% (95% CI: 7.4 12%), similr to estimtes for previous yers (9.% in 213 nd 9.6% in 212). Fourteen of these countries reported 1 XDR-TB cses in the most recent yer for which dt were vilble. Among those countries, the proportion of MDR-TB cses with XDR-TB ws highest in Belrus (29% in 214), Georgi (15% in 214), Ltvi (19% in 214) nd Lithuni (25% in 213). Among the 36 high TB nd/ or MDR-TB burden countries, 23 hve surveillnce dt on second-line drug resistnce but only eight hve estblished ntionl continuous surveillnce system for second-line drug resistnce mong ptients with MDR-TB. Incresed ef forts should be mde to ensure tht ll ptients dignosed with MDR-TB undergo testing for susceptibility to fluoroquinolones nd injectble gents, nd tht results re recorded nd reported. The proportion of MDR-TB cses with resistnce to ny fluoroquinolone for which testing ws done, including ofloxcin, levofloxcin nd moxifloxcin, ws 21% (95% CI: 8.3 34%). 4.2 Mngement of drug-resistnt TB 4.2.1 Coverge of drug susceptibility testing (DST) Trgets included in the Globl Pln to Stop TB 211 215 cll for 2% of ll new bcteriologiclly-confirmed TB cses (i.e. those considered to be t high risk for MDR-TB) s well s ll previously treted cses to undergo DST to first-line TB drugs. 3 According to WHO recommendtions, ll ptients with MDR-TB should undergo testing for susceptibility to fluoroquinolones nd second-line injectble gents, to determine if they hve XDR-TB. There ws mjor progress in DST coverge between 213 3 The Globl Pln to Stop TB 211 215: trnsforming the fight towrds elimintion of tuberculosis. Genev: World Helth Orgniztion; 21 (WHO/HTM/STB/21.2). 58 n GLOBAL TUBERCULOSIS REPORT 215

Box 4.1 Monitoring nd evlution of progress in the response to drug-resistnt TB: the incresing importnce of rifmpicin-resistnt TB (RR-TB) Following the rollout of moleculr tests for the detection of M. tuberculosis nd rifmpicin resistnce (line probe ssys nd Xpert MTB/RIF) (Chpter 5), the Globl TB Progrmme in WHO hs collected nd reported notifictions of drug-resistnt TB tht combine rifmpicin-resistnt TB (RR-TB) nd MDR-TB since 213. All RR-TB nd/or MDR-TB cses detected by either rpid moleculr dignostics or conventionl DST re reported s cses of drug-resistnt TB. Furthermore, in ccordnce with WHO recommendtions to enrol ll ptients dignosed with RR-TB on n MDR-TB drug regimen, tretment enrolment nd tretment outcomes of ptients receiving MDR-TB tretment hve been reported for ll ptients dignosed with RR-TB, including those tht did not hve MDR-TB. To dte, estimtes of the burden of drug-resistnt TB t globl, regionl nd country levels hve focused on MDR-TB. The number of cses with MDR-TB will be slightly lower thn the combined number of cses with MDR-TB or RR-TB (tht is not MDR-TB). This mens tht when the burden of MDR-TB is used s the denomintor for estimting detection nd tretment coverge, the vlues for both indictors will be slightly overstted. For these resons, it is becoming incresingly importnt to estimte the combined burden of MDR-TB nd RR-TB. In 214, the globl proportion of TB cses with MDR-TB, irrespective of tretment history, ws 7.7% (95%CI: 4.6 1.8%), with n estimted number of MDR-TB cses mong notified pulmonry TB ptients of 3. In the sme yer, the globl proportion of TB cses with RR-TB ws 8.8% (95%CI: 6.2 11.3%), mening tht there were pproximtely 4 dditionl cses of RR-TB tht were not MDR-TB. In future globl TB reports, greter emphsis will be given to estimtes of the combined burden of MDR-TB nd RR-TB when ssessing globl, regionl nd ntionl progress in the detection nd tretment of drug-resistnt TB. Compnion Hndbook to the WHO Guidelines for the Progrmmtic Mngement of Drug-Resistnt Tuberculosis. Genev: World Helth Orgniztion; 214 (WHO/HTM/TB/214.11). http://pps.who.int/ iris/bitstrem/1665/13918/1/978924154889_eng.pdf. nd 214 (Figure 4.4, Figure 4.5). Globlly in 214, 12% of the 2.7 million new bcteriologiclly-confirmed TB cses nd 58% of the.7 million previously treted TB ptients were tested for drug resistnce in 214, up from 8.9% nd 17% respectively in 213. This represents proportionl increses in DST coverge of 43% nd 223% mong new nd previously treted cses, respectively. 1 Coverge ws highest in the Europen Region, where 97% of new cses were tested in 214 (Tble 4.2). In the South- Est Asi nd Western Pcific regions combined, two-thirds of previously treted cses underwent testing, reflecting reltively better ccess to DST in these regions. Levels of testing remined below 5% mong new cses in the South-Est Asi nd Estern Mediterrnen regions, while there ws substntil increse in testing coverge mong new bcteriologiclly confirmed cses in the Africn Region (from.9% in 213 to 6.4% in 214). Testing coverge mong previously treted cses lso improved considerbly in most regions, notbly from 5.8% to 67% in the South-Est Asi Region (driven lrgely by improved reporting from Indi) nd from 9.6% to 33% in the Africn Region. Among the 27 high MDR-TB burden countries which ccount for >85% of estimted MDR-TB cses in the world the proportion of TB ptients who were tested for drug susceptibility in 214 vried mrkedly (Tble 4.2). In nine of the 12 Europen countries tht reported dt, testing ws done for 95% of new cses; three of these countries reported universl coverge mong previously treted cses. Among 1 These figures re bsed on dt reported by 16 (73%) countries nd territories for new TB cses nd by 157 (72%) countries nd territories for previously treted cses. n FIGURE 4.4 DST coverge mong new cses nd enrolment on MDR-TB tretment, compred with the trgets in the Globl Pln to Stop TB, 211 215. Lines indicte the plnned trgets, blue circles show the ctul sitution in 29 214. Percentge of cses (%) Number of ptients 25 2 15 1 5 3 25 2 15 1 5. DST coverge mong new bcteriologicllyconfirmed cses 29 21 211 212 213 214 215 b. Enrolment on MDR-TB tretment 29 21 211 212 213 214 215 GLOBAL TUBERCULOSIS REPORT 215 n 59

n FIGURE 4.5 DST coverge in previously treted TB cses, globlly nd for WHO regions, 29 214. Numbers of cses tested re shown for ech br. Percentge of retretment cses (%) Afric 7 The Americs Estern Mediterrnen Europe 6 13 73 48 234 5 4 615 29 221 34 919 43 828 4 31 952 32 97 8724 3 4234 5239 7143 559 5454 2 3139 11 15 2273 1 1274 434 4294 3716 5299 1257 1458 29 21 211 212 213 214 29 21 211 212 213 214 29 21 211 212 213 214 29 21 211 212 213 214 South-Est Asi Western Pcific Globl 7 247 336 54 56 6 44 59 5 38 584 4 3 2 125 42 9128 66 568 1 19 18 5137 43 98 48 22 49 582 569 1264 1935 3663 937 254 29 21 211 212 213 214 29 21 211 212 213 214 29 21 211 212 213 214 DST is for rifmpicin only or for both rifmpicin nd isonizid. the high MDR-TB burden countries outside Europe, testing mong new cses ws highest in Mynmr (24%) nd Chin (19%). Among previously treted cses, testing coverge ws higher overll, nd reched 96% in Viet Nm, 88% in Indonesi nd 75% in the Democrtic Republic of the Congo. In South Afric, the equivlent of 69% of ll notified TB cses were tested, lthough DST dt were not vilble seprtely for new nd previously treted cses. Among MDR-TB ptients notified in 214, only 24% hd DST performed for both fluoroquinolones nd second-line injectble drugs. Coverge ws lowest in the Europen Region, likely s result of incomplete reporting of DST results from lbortories. Evidence of progress in DST coverge notwithstnding, dignostic DST must be further expnded, especilly given the cll for universl DST in the post-215 End TB Strtegy (Chpter 1). This requires continued strengthening of lbortory cpcity nd wider uptke of new rpid dignostics (see Chpter 5), s well s incresed deployment of informtion nd communiction technologies (ICT) to improve the completeness of reporting from lbortory nd tretment centres. 4.2.2 Notifiction of RR-TB nd MDR-TB cses Globlly, 123 cses of MDR-TB or RR-TB, who re eligible for tretment with MDR-TB regimens, were notified to WHO in 214. Indi, the Russin Federtion nd South Afric ccounted for lmost hlf of the totl (Tble 4.3). These 123 cses represented 41% of the estimted 3 (rnge, 22 37 ) MDR-TB cses mong pulmonry TB ptients tht were notified in 214 (Figure 4.6), 1 nd 26% of the estimted 48 (rnge: 36 6 ) incident MDR-TB cses in the world in 214. The number of MDR/RR-TB cses reported for 214 ws nerly identicl to the ltest figure for 213. In this context, it should be highlighted tht the dt vilble t the time of preprtion of this report show tht the number of MDR/RR- TB cses detected globlly in 213 ws lower thn previously published, 2 following downwrd correction to numbers originlly reported for Indi. Increses in the number of detected cses did however occur between 213 nd 214 in Indi (23 162 to 25 748), Chin (4 183 to 5 87), the Russin Federtion (13 521 to 15 585), nd Mynmr (1 984 to 3 495). There were reductions between 213 nd 214 in the Philippines, South Afric, Ukrine, Uzbekistn nd severl other countries (Figure 4.7). The resons for the pprent stgntion in detection, given incresing DST coverge, re not cler nd should be investigted s mtter of priority. A comprison of the number of Xpert MTB/RIF crtridges procured nd the number of MDR/RR-TB cses detected in eight countries is provided in Box 4.2. The number of notified MDR/RR-TB cses s proportion of the estimted number of MDR-TB cses mong pulmonry TB ptients rnged from 19% in the Western Pcific Region to 8% in the Africn Region. In Kzkhstn, South 1 When compred with the estimte of ll MDR/RR-TB cses (not just the MDR-TB cses), this vlue would decrese to 36% (see lso Box 4.1). 2 The number published in the 214 globl TB report ws 136 in 213. 6 n GLOBAL TUBERCULOSIS REPORT 215

n TABLE 4.2 DST coverge mong TB nd MDR-TB cses, globlly nd for 27 high MDR-TB burden countries nd WHO regions, 214 NEW BACTERIOLOGICALLY CONFIRMED CASES RETREATMENT CASES CONFIRMED MDR TB CASES NUMBER WITH DST RESULTS % OF CASES WITH DST RESULT NUMBER WITH DST RESULTS % OF CASES WITH DST RESULT NUMBER WITH DST b RESULTS % OF CASES WITH DST RESULT Armeni 343 96 5 17 1 1 Azerbijn 2 59 >1 3 91 >1 84 1 Bngldesh 12 573 12 4 959 51 182 19 Belrus 1 99 97 877 84 1 251 1 Bulgri 639 8 11 45 36 97 Chin 45 664 19 17 21 54 DR Congo 545.7 6 135 75 41 19 Estoni 175 >1 29 71 47 96 Ethiopi 2 45 6 7 682 25 15 Georgi 1 7 95 634 61 357 93 Indi 12 795 1.7 214 29 69 3 572 25 Indonesi 1 58.5 8 445 88 229 35 Kzkhstn 9 597 >1 6 377 >1 Kyrgyzstn Ltvi 483 99 17 86 7 1 Lithuni 968 >1 294 1 232 86 Mynmr 1 295 24 15 166 >1 Nigeri Pkistn 361 11 685 72 2 38 98 Philippines 4 415 4.7 2 196 67 868 8 Republic of Moldov 1 764 99 831 61 277 31 Russin Federtion 31 25 84 13 925 28 South Afric 3 416 42 Tjikistn 2 432 1 8 64 371 1 Ukrine 13 833 97 9 77 69 Uzbekistn 11 956 >1 5 888 77 927 29 Viet Nm 2 756 5.5 8 511 96 246 78 High MDR TB burden countries 172 56 8.6 357 719 64 15 467 22 AFR 4 94 6.4 31 952 33 3 898 35 AMR 3 531 24 8 724 32 66 2 EMR 8 44 4.6 13 73 52 2 465 78 EUR 18 569 97 48 234 52 5 294 14 SEAR 45 56 3.8 247 336 67 4 61 27 WPR 92 81 21 54 56 62 2 251 3 Globl 326 31 12 44 59 58 19 124 24 Blnk cells indicte dt not reported. indictes vlues tht cnnot be clculted. The percentges my exceed 1% s result of the inclusion of extrpulmonry ptients mong cses tested or indequte linkges between lbortory nd clinicl registers. DST is for rifmpicin only or for both rifmpicin nd isonizid. b DST for fluoroquinolone nd second-line injectble drug. GLOBAL TUBERCULOSIS REPORT 215 n 61

TABLE 4.3 Estimted MDR-TB cses in 214, notified cses of rifmpicin-resistnt TB nd MDR-TB nd enrolments on MDR-TB tretment in 214, nd tretment outcome reporting for 212 cohort, globlly nd for 27 high MDR-TB burden countries nd WHO regions ESTIMATED MDR-TB AMONG NOTIFIED PULMONARY TB CASES, 214 NOTIFIED MDR/RR-TB CASES, 214 CASES ENROLLED ON MDR- TB TREATMENT, 214 MDR-TB CASES REPORTED WITH TREATMENT OUTCOME DATA, 212 COHORT b BEST ESTIMATE UNCERTAINTY INTERVAL NUMBER NOTIFIED/ ESTIMATED MDR-TB (%) NUMBER ENROLLED/ NOTIFIED MDR/RR TB (%) NUMBER % b Armeni 16 14 19 111 69 12 >1 115 >1 Azerbijn 1 3 1 1 1 5 1 7 77 814 81 373 63 Bngldesh 4 8 3 4 6 2 994 21 945 95 55 98 Belrus 1 7 1 6 1 8 1 282 75 1 93 >1 2 52 >1 Bulgri 72 53 91 44 61 29 66 44 9 Chin 52 42 61 5 87 11 2 846 49 1 96 63 DR Congo 2 8 98 4 5 442 16 436 99 134 >1 Estoni 62 48 75 5 81 48 96 5 81 Ethiopi 1 3 7 2 3 53 39 557 >1 271 95 Georgi 64 59 7 441 69 51 >1 623 >1 Indi 71 57 85 25 748 36 24 73 93 9 874 8 Indonesi 6 8 5 2 8 4 1 812 27 1 284 71 432 >1 Kzkhstn 4 9 4 8 5 5 877 >1 7 315 >1 7 213 95 Kyrgyzstn 2 1 8 2 1 1 267 63 1 157 91 775 81 Ltvi 84 66 1 71 85 7 99 9 82 Lithuni 3 27 34 279 93 271 97 219 81 Mynmr 9 6 5 12 3 495 39 1 537 44 443 57 Nigeri 3 3 2 5 4 2 798 24 423 53 154 >1 Pkistn 12 8 8 15 3 243 27 2 662 82 858 54 Philippines 11 8 6 13 3 27 2 68 89 1 798 >1 Republic of Moldov 1 5 1 4 1 6 925 62 93 >1 856 96 Russin Federtion 39 33 45 15 585 4 21 94 >1 16 21 >1 South Afric 6 2 5 1 7 3 18 734 >1 11 538 62 8 84 52 Tjikistn 88 81 95 92 >1 84 89 535 77 Ukrine 13 12 14 7 735 6 8 21 >1 5 556 8 Uzbekistn 7 6 1 7 9 4 955 71 3 665 74 1 491 86 Viet Nm 5 1 3 9 6 3 2 198 43 1 532 7 713 >1 High MDR-TB burden countries 26 18 33 17 35 41 98 245 92 61 635 87 AFR 32 15 49 25 531 8 17 352 68 1 246 56 AMR 7 4 7 9 3 3 745 54 3 568 95 2 866 97 EMR 15 12 19 4 348 29 3 423 79 1 271 57 EUR 72 62 81 42 293 59 49 74 >1 37 638 >1 SEAR 99 9 11 33 264 34 28 536 86 11 566 77 WPR 71 47 94 13 437 19 8 85 66 6 176 >1 Globl 3 22 37 122 618 41 11 83 9 69 763 86 Notified cses of MDR/RR-TB in 214 s percentge of the best estimte of MDR-TB cses mong ll cses of pulmonry TB in the sme yer. The percentge my exceed 1% if estimtes of the number of MDR-TB re too conservtive nd if linkge between the clinicl nd lbortory registers is indequte. Percentges shown re slightly higher thn wht would be expected if n estimte for ll RR-TB cses (rther thn MDR-TB) ws used s denomintor (see lso Box 4.1). The percentge of MDR-TB cses originlly notified in 212 with outcomes reported. The percentge my exceed 1% s result of updted informtion bout MDR-TB cses in 212, indequte linkges between notifiction systems for TB nd MDR-TB, the inclusion of RR-TB cses in the numertor who were not confirmed MDR-TB, nd the inclusion in the tretment cohort of cses of MDR-TB from yer prior to 212. 62 n GLOBAL TUBERCULOSIS REPORT 215

Box 4.2 The roll-out of rpid TB dignostics compred with chnges in the number of cses of MDR/RR-TB notified by ntionl TB progrmmes Globl progress in the detection of drug-resistnt TB should be relted to the roll-out of moleculr dignostics such s Xpert MTB/RIF nd line probe ssys (LPAs). However, s use of these technologies expnds, the number of tests required to detect one cse my increse. This is becuse initil use of the test is likely to focus on groups with higher risk of hving MDR/ RR-TB (such s previously treted TB ptients), in line with policy recommendtions, b nd then broden to cover people t lower risk for drug-resistnce (such s ptients being evluted for TB). Vrition mong countries is lso expected given dif ferences in the prevlence of MDR/RR-TB (for exmple, the prevlence of MDR-TB is much higher in Ukrine compred with Bngldesh). The reltionship between nnul procurements of Xpert MTB/RIF crtridges nd notifictions of MDR/RR-TB cses for 8 high MDR-TB burden countries is shown in Figure B4.2.1. These countries re mong the mjor users of Xpert globlly (ech hving procured 42 82 crtridges in 214) nd Xpert is of ten the leding dignostic test for drug resistnce tht is in use. Although there ws substntil vrition in the number of MDR/RR-TB cses reported for every 1 Xpert crtridges procured, the rtio tended to decrese over time in ll countries. It ws striking tht shrp flls in the number of MDR/RR-TB cses detected for every 1 Xpert crtridges procured in Ethiopi nd the Philippines between 213 nd 214 occurred longside n bsolute reduction in the totl number of reported MDR/RR-TB cses. The resons for this re not well understood. Possible explntions include issues with reporting of cses, s opposed to ctul levels of testing or lbortory results, nd lg times between orders nd ctul use of tests. For further detils bout these technologies, see Chpter 5. b Xpert MTB/RIF implementtion mnul: technicl nd opertionl how-to ; prcticl considertions. Genev: World Helth Orgniztion; 214 (WHO/HTM/TB/214.1). http://pps.who.int/iris/ bitstrem/1665/112469/1/9789241567_eng.pdf. FIGURE B4.2.1 The number of MDR/RR-TB cses reported for every 1 Xpert crtridges procured in selected high MDR-TB burden countries, 211 214 Bngldesh Ethiopi Indonesi Nigeri Number (log scle) 64 32 16 8 4 2 1 64 32 16 8 4 2 1 Pkistn Philippines Ukrine Viet Nm 211 212 213 214 211 212 213 214 211 212 213 214 211 212 213 214 Afric, nd Tjikistn the figure ws bove 1% (Tble 4.3), indicting either repeted reporting of cses when informtion systems re bsed on lbortory results without linkge to ptient registers, nd/or tht estimtes of MDR-TB re too conservtive (for exmple, becuse drug resistnce surveillnce dt hve become outdted). 4.2.3 Enrolment of notified RR-TB nd MDR-TB cses on tretment The number of ptients enrolled globlly on MDR-TB tretment ws 111 in 214, up from 97 in 213. There ws 13% increse in enrolments between 213 nd 214 in the 27 high MDR-TB burden countries, with increments exceeding 1 ptients in Indi, Pkistn, the Russin Federtion nd Uzbekistn. Globlly, the number of ptients strting second-line GLOBAL TUBERCULOSIS REPORT 215 n 63

n FIGURE 4.6 Number of MDR TB cses estimted to occur mong notified pulmonry TB cses, 214 Estimted MDR-TB cses 199 2 1999 2 19 999 2 49 999 5 No dt Not pplicble MDR-TB tretment ws 9% of those notified with MDR/ RR-TB in 214 (Tble 4.3). The rtio ws over 9% in 15 high MDR-TB burden countries, the Europen Region nd the Region of Americs. The rtio ws lowest in the Western Pcific (66%) nd Africn (68%) regions. In eight high MDR-TB burden countries, enrolments outstripped notifictions of MDR/RR-TB (Figure 4.7). This my be cused by empiricl tretment of TB ptients considered t risk of hving MDR-TB but for whom lbortory-confirmed dignosis ws missing, incomplete reporting of lbortory dt, or enrolment of witing lists of people with MDR- TB who were detected before 214. In contrst, the rtio of enrolled to dignosed cses ws under 6% in 3 high MDR-TB burden countries in 214, nd below 5% in Chin (49%) nd Mynmr (44%). These low rtios show tht progress in detection is fr outstripping cpcity to provide tretment but my lso reflect weknesses in dt collection systems. Overll, while the number of ptients being enrolled on tretment for MDR-TB continues to increse, progress flls fr short of Globl Pln trgets (Figure 4.4b, Tble 4.3). Getting closer to the Globl Pln trgets requires intensifiction of ef forts in mny countries, but prticulrly Chin nd the Russin Federtion. These two countries rnk second nd third globlly in terms of estimted numbers of cses, while levels of detection nd tretment coverge remin reltively low. Continued support to NTPs through updted guidnce, s well s direct technicl ssistnce provided through the mechnisms of the Regionl Green Light Committees nd the Globl Drug-resistnt TB Inititive (www.stoptb.org/wg/ mdrtb/), is expected to improve globl detection nd tretment of drug-resistnt TB. In 214, 49 countries nd territories reported treting people with XDR TB (Figure 4.8). Globlly, 4 44 ptients with XDR-TB were enrolled on tretment (higher thn the level of 3 284 in 213). Most of the cses in 214 were notified from Indi (1 262, up from 392 in 213), Ukrine (657), South Afric (562), Belrus (431), nd Kzkhstn (318). 4.2.4 Accelerting the scle-up of detection nd enrolment on tretment for people with drug-resistnt TB: the role of models of cre nd non-ntp providers In mny countries, one of the resons for indequte ccess to dignosis nd tretment of drug-resistnt TB is tht the network for the progrmmtic mngement of drugresistnt TB (PMDT) is too centrlized. Hospitl-bsed models of cre, which re still dominnt in mny countries, re brrier to the expnsion of PMDT becuse they depend on hospitls or referrl centres. Greter use of mbultory cre s prt of decentrlized PMDT services is necessry to expnd ccess. However, ntionl policies nd prctices vry nd hospitliztion is still the predominnt model of cre in mny countries. Among the 27 high MDR-TB burden countries, the Democrtic Republic of the Congo reported the lowest level of 64 n GLOBAL TUBERCULOSIS REPORT 215

n FIGURE 4.7 MDR TB cses nd dditionl rifmpicin resistnt TB cses detected (red) compred with TB cses enrolled on MDR TB tretment (blue), globl trend nd trend in 27 high MDR TB burden countries, 29 214 Globl 125 1 75 5 25 Armeni Azerbijn Bngldesh 2 12 12 18 16 14 12 1 8 Belrus Bulgri Chin DR Congo 26 8 6 4 21 6 4 16 3 11 6 1 4 2 1 8 6 4 2 2 1 8 6 4 2 2 1 Number of cses Estoni 9 Ethiopi 6 Georgi 8 Indi 3 8 7 7 4 6 2 5 6 2 4 1 5 3 4 2 Indonesi 2 Kzkhstn 9 Kyrgyzstn Ltvi 14 16 8 16 12 7 13 12 6 1 8 1 5 4 7 8 4 3 4 6 Lithuni 6 Mynmr 4 Nigeri 8 Pkistn 3 5 3 6 4 2 4 2 3 1 2 1 2 3 2 1 Philippines Republic of Moldov Russin Federtion South Afric 4 12 25 3 75 5 25 29 21 211 212 213 214 1 8 6 4 2 Tjikistn Ukrine Uzbekistn Viet Nm 1 11 6 25 9 7 5 2 15 1 5 4 2 3 29 21 211 212 213 214 29 21 211 212 213 214 29 21 211 212 213 214 The globl totl of MDR/RR-TB cses detected in 213 (123 1) is lower thn previously published in the 214 Globl TB Report (136 412) following revisions to dt reported by Indi. 2 1 2 15 1 5 GLOBAL TUBERCULOSIS REPORT 215 n 65

n FIGURE 4.8 Number of ptients with lbortory confirmed XDR TB strted on tretment in 214 Number of ptients 1 9 1 99 1 499 5 No dt Not pplicble hospitliztion (5% of MDR-TB ptients), followed by Mynmr (1%). In contrst, hospitliztion for 1% of MDR-TB ptients in 214 (t lest for prt of their tretment) ws reported by 1 high MDR-TB countries, including two of the top three MDR-TB burden countries: Chin nd the Russin Federtion. In further six high MDR-TB burden countries, t lest 9% of MDR-TB ptients were hospitlized. When MDR-TB ptients re hospitlized the durtion of sty ws reltively short in Indonesi, t five dys, nd rnged from 3 6 dys in five other countries (Bngldesh, Chin, Estoni, Ethiopi, Mynmr). In the other 15 countries tht reported dt, the verge length of sty ws 16 dys. The number of visits to helth fcility f ter dignosis of MDR-TB lso vried mrkedly, from less thn 3 (Bngldesh, Estoni, Mynmr, nd South Afric) to over 7 (Armeni, Georgi, Indonesi, Russin Federtion nd Ukrine). The involvement of ll relevnt non-ntp helth cre providers is importnt to scle up PMDT nd improve ccess to services. Unfortuntely, relible dt on these ctivities re of ten not collected by NTPs. In 214, only nine high MDR-TB burden countries provided informtion on the numbers of ptients strted on MDR-TB tretment by non-ntp helth cre providers. The Philippines, Ltvi nd Kyrgyzstn reported tht 22%, 14% nd 11% respectively of MDR-TB cses were treted by non-ntp providers, while figures of 1 5% were reported to be treted in the privte sector in Mynmr, Viet Nm nd four Estern Europen countries: Armeni, Republic of Moldov, Ukrine nd Uzbekistn. In 214, only 39 countries (including 13 of the 27 high MDR-TB burden countries) reported tht pllitive nd endof-life cre were provided within the scope of their NTPs. This finding ttests to the huge unmet need for such services, which should be delivered longside proper infection control mesures (since most of these ptients remin source of infection). 4.2.5 Tretment outcomes for ptients with MDR-TB nd XDR-TB The Globl Pln included trget tht ll countries should report outcomes for ll notified MDR-TB cses by 215. A totl of 127 countries nd territories reported tretment outcomes for cses strted on MDR-TB tretment in 212. The country cohort size rnged from 1 to 16 cses. The number of cses reported in nnul cohorts hs stedily incresed in ll six WHO regions over time (with the exception of smll decrese in the Region of the Americs between the 211 nd the 212 cohorts). The totl reched 7 cses globlly in 212, 33% more thn in 211 (Tble 4.3 nd Figure 4.9). The use of electronic systems to mnge MDR-TB ptient dt could help to improve the completeness of reporting on tretment outcomes. One of the Globl Pln trgets is for ll 27 high MDR-TB countries to mnge their dt on tretment of MDR-TB ptients electroniclly by 215. By 214, 15 of these countries reported tht ntionl electronic dtbses were in plce for TB ptients nd nother six hd systems for MDR- TB ptients only. 66 n GLOBAL TUBERCULOSIS REPORT 215

n FIGURE 4.9 Tretment outcomes for ptients dignosed with MDR TB by WHO Region, 27 212 cohorts. The totl number of cses with outcome dt is shown beside ech br Afric The Americs 27 4 57 27 1 464 28 5 496 28 1 732 29 6 143 29 2 298 21 6 176 21 2 413 211 8 26 211 2 916 212 1 246 212 2 866 Estern Mediterrnen Europe 27 128 27 4 214 28 262 28 7 181 29 511 29 12 133 21 676 21 2 598 211 874 211 31 889 212 1 271 212 37 638 South-Est Asi Western Pcific 27 315 27 453 28 483 28 758 29 1 597 29 1 27 21 3 113 21 2 455 211 4 35 211 4 238 212 11 566 212 6 176 27 Globl 11 144 2 4 6 8 1 Percentge of cohort 28 15 912 29 21 211 212 23 79 35 431 52 482 69 763 Tretment success Filure Died Lost to follow-up Not evluted 2 4 6 8 1 Percentge of cohort Overll, the proportion of MDR-TB ptients in the 212 cohort who successfully completed tretment (i.e. cured or tretment completed) ws 5%; 16% died, 16% were lost to follow-up, tretment filed for 1% nd 8% hd no outcome informtion (Figure 4.9). The tretment success rte ws highest in the Estern Mediterrnen Region (65%), nd lowest in the Europen nd South-Est Asi regions (49%). In the 212 cohort, tretment filure ws highest in the Europen Region (13%), nd the deth rte ws highest in the South- Est Asi Region (21%). The Globl Pln trget of chieving tretment success rte of 75% by 215 hd lredy been reched in 4 of the 122 countries tht reported outcome dt for the 212 cohort, including three of the 27 high MDR-TB burden countries (Estoni, Ethiopi, nd Mynmr). Between 27 nd 212, more thn 1 people who strted MDR-TB tret- GLOBAL TUBERCULOSIS REPORT 215 n 67

ment were reported to hve hd successful outcome nd numbers hve incresed over time (dt not shown). Among 2 685 XDR-TB ptients in the 212 cohorts of 41 countries for whom outcomes were reported, 682 (26%) completed tretment successfully; 89 (3%) died; tretment filed for 51 (19%); nd 684 (25%) were lost to follow-up or their tretment outcome ws not evluted. The Russin Federtion ccounted for 51% of the XDR-TB ptients for whom outcomes were reported in 212. The high mortlity of XDR-TB ptients in South Afric (47%) is likely to be ssocited with high level of HIV co-infection in TB ptients (see Chpter 6). The introduction of new drugs nd novel regimens could potentilly improve the tretment outcomes of ptients with MDR- nd XDR-TB. By the end of 214, t lest 43 countries reported hving used bedquiline to tret ptients s prt of ef forts to expnd ccess to tretment for MDR-TB, either for compssionte use or under norml progrmmtic conn FIGURE 4.1 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 214 Yes No No dt Not pplicble ditions in the public or privte sectors (Figure 4.1). Most (75%) of these ptients were from two countries: the Russin Federtion nd South Afric. In ddition, t lest 16 countries in Afric nd Asi hve introduced shorter regimens s prt of trils or observtionl studies under opertionl reserch conditions, nd severl hve strted to include repurposed drugs in tretment regimens, to try to improve the tretment outcomes of MDR-TB nd XDR-TB ptients. Since the strt of globl monitoring, tretment success rtes mong ptients with MDR-TB nd XDR-TB hve remined consistently nd uncceptbly low. Mjor ef forts re required to ddress this sitution, using mesures tht re prt of the End TB Strtegy. These include dequte resources for detection nd tretment nd building cpcity mong helth cre workers to provide high qulity cre. Reserch nd development is lso crucil. Without new TB drugs nd regimens, it will be very dif ficult to improve tretment outcomes in the ner future. 68 n GLOBAL TUBERCULOSIS REPORT 215

CHAPTER 5 Dignostics nd lbortory strengthening Key fcts nd messges The End TB Strtegy clls for the erly dignosis of TB nd universl drug susceptibility testing (DST), highlighting the criticl role of lbortories in the post-215 er for rpidly nd ccurtely detecting TB nd drug resistnce. Lbortory confirmtion of TB nd drug resistnce is essentil to ensure tht individuls with TB re correctly dignosed nd hve ccess to the pproprite tret ment s soon s possible. Of the 5.2 million incident (new nd relpse) pulmonry TB ptients notified globlly in 214, 3. million (58%) were bcteriologiclly confirmed, i.e., were smer- or culturepositive or positive ccording to WHO-recommended rpid dignostic such s Xpert MTB/RIF. Among new (previously untreted) cses of bcteriologiclly confirmed TB, 12% hd ccess to DST; mong previously treted cses, 58% hd ccess to DST. A new WHO Policy frmework for implementing tuberculosis dignostics ws published in April 215. This provides n overview of ll current WHO policy recommendtions on TB dignostics nd the role of ech test within ef fective dignostic lgorithms cross lbortory network. The document lso describes the mngeril, technicl nd opertionl processes required for developing nd implementing comprehensive ntionl strtegy for TB lbortories. WHO hs recently issued policy recommendtions on the use of the urine lterl flow liporbinomnnn (LF-LAM) ssy (Alere Determine TM TB LAM Ag test). The test is not recommended for TB screening or dignosis of TB in most popultion groups. However, it is recommended to help with the dignosis of TB in two popultion groups: HIV-positive people who re inptients with signs or symptoms of TB nd who hve CD4 cell count less thn or equl to 1 cells/µl, nd HIV-positive people who re seriously ill (both inptients nd outptients) with dnger signs, regrdless of CD4 count or if the CD4 count is unknown. The use of the rpid moleculr test Xpert MTB/RIF continues to expnd in line with WHO recommendtions for its use since December 21. By the end of 214, 69% of countries reported tht ntionl policy by the end of 214 indicted the use of Xpert MTB/RIF s the initil dignostic test for people t risk of drug-resistnt TB, nd 6% reported tht ntionl policy indicted its use s the initil dignostic test for people living with HIV. In 116 of the 145 countries eligible for concessionl pricing tht hve purchsed the technology, totl of 3 763 GeneXpert mchines hd been procured for use in the public sector by the end of 214. In 214 lone, 4.8 million Xpert MTB/ RIF test crtridges were procured, up from 55 in 211. Ensuring the qulity of microscopy networks is criticl, given tht smer microscopy remins the most widely used tool for TB dignosis in low- nd middle-income countries. Among the 22 HBCs, only four reported n externl qulity ssessment scheme tht encompssed ll microscopy centres in 214, nd five more reported progrmme tht included t lest 9% of centres. Severl sources of guidnce nd trining pltforms hve been developed to ssist TB reference lbortories to implement qulity mngement system tht meets interntionl ccredittion stndrds. In 214, 123 of 173 responding countries nd territories (71%) indicted tht forml qulity mngement system towrds chieving lbortory ccredittion hd t lest been strted t the ntionl reference lbortory (NRL). In 215, the WHO TB Suprntionl Reference Lbortory Network expnded to include three newly designted Ntionl Centres of Excellence in the Russin Federtion. The three lbortories re of prticulr vlue for estblishing nd mintining high-qulity lbortory services within the country for the progrmmtic mngement of drug-resistnt TB, including through the coordintion of technicl ssistnce, provision of monitoring nd supervision, nd orgniztion of trining for lbortory stf f involved in dignostic testing for drug resistnce nd monitoring of tretment for ptients with drug-resistnt TB. The microbiologicl detection of TB nd drug susceptibility using rpid WHO-recommended dignostics, together with n ef ficient system for trnsfer of specimens nd results, llows ptients to be correctly dignosed nd strted on the most ef fective tretment regimen s erly s possible. One of the core components of the first pillr of the post-215 End TB Strtegy (Chpter 1) is the erly dignosis of TB, including universl drug susceptibility testing (DST). Opertionl guidnce on the implementtion of the strtegy clls for ll ptients to receive DST t lest for rifmpicin, with further tests for drug susceptibility to first nd second-line drugs for ny TB ptients found to hve rifmpicin resistnce. A wellequipped nd stf fed, qulity-ssured lbortory network with n ef ficient referrl system is therefore n essentil requirement for ny ntionl TB progrmme (NTP) in the post-215 er. For decdes, resource-constrined countries hve relied on sputum smer microscopy s the primry method for detect- GLOBAL TUBERCULOSIS REPORT 215 n 69

ing TB. While inexpensive nd requiring miniml biosfety stndrds, microscopy is not sensitive test (prticulrly for people living with HIV nd children) nd it provides no informtion on the resistnce profile of the bcilli. Furthermore, microscopy is not ble to distinguish between Mycobcterium tuberculosis complex nd non-tuberculosis mycobcteri. Bcteriologicl culture is considered the reference stndrd for detecting TB, but suf fers from the disdvntges tht results tke weeks to obtin nd tht testing requires well-equipped lbortory, highly trined stff, nd n efficient trnsport system to ensure the vibility of specimens. Phenotypic DST on cultured specimens is the conventionl method used to detect resistnce to first- nd second-line TB drugs, nd fster commercil liquid culture systems re now vilble. Building dequte culture cpcity in mny countries with high burden of TB hs been slow, given the cost nd infrstructure requirements. In recent yers, limited but growing number of rpid nd more sensitive tests for TB nd drug-resistnt TB bsed on moleculr methods, including Xpert MTB/RIF (Cepheid, USA) nd line probe ssys (LPAs), hve become vilble to replce or complement existing conventionl tests. Despite the dvntges of moleculr tests, conventionl microscopy nd culture remin necessry for monitoring ptients response to tretment. Furthermore culture-bsed DST methods re currently the only methods vilble for ccurte testing of susceptibility to second-line drugs. Of the 5.2 million incident pulmonry TB ptients notified globlly in 214, only 3. million (58%) were bcteriologiclly confirmed, i.e., were smer- or culture-positive or positive ccording to WHO-recommended rpid dignostic such s Xpert MTB/RIF (Chpter 3). The remining 42% of ptients who were not bcteriologiclly confirmed were dignosed cliniclly, i.e. bsed on symptoms, chest X-ry bnormlities or suggestive histology. The common symptoms of TB combined with the poor specificity of X-ry screening my result in flse dignoses nd people without TB being enrolled on TB tretment when it is not needed. Furthermore, low rte of lbortory confirmtion reflects under-dignosis of true TB cses nd contributes in prt to the continuing globl gp between notified nd estimted incident TB cses: 6 million nd 9.6 million in 214, respectively (Chpter 3). The proportion of new nd previously treted cses receiving DST hs stedily incresed but much remins to be done. Globlly, 12% of new bcteriologiclly-confirmed TB cses nd 58% of those previously treted for TB were tested for drug resistnce in 214 (Chpter 4). Lbortory strengthening nd new dignostics re crucil to improve the proportion of notified TB cses with definitive (bcteriologiclly confirmed) dignosis of TB, nd to close detection nd tretment gps for TB nd drug-resistnt TB. This chpter summrizes the sttus of progress in 214. Section 5.1 highlights key developments in WHO guidnce on TB dignostics nd lbortory strengthening during 214 215. Section 5.2 presents the sttus of lbortory cpcity globlly, regionlly nd ntionlly in 214, bsed on dt reported to WHO by countries in 215. Here, the focus is on the 36 countries in the combined list of 22 high burden countries (HBCs) nd 27 high MDR-TB burden countries. Section 5.3 describes recent ctivities to strengthen TB lbortories, including qulity mngement systems, externl qulity ssessment nd the WHO TB Suprntionl Reference Lbortory (SRL) Network. 5.1 Developments in WHO policy guidnce on TB dignostics nd lbortory strengthening, 214 215 The WHO Globl TB Progrmme follows systemtic process for development of policy recommendtions on TB dignostics, involving synthesis of the vilble evidence on performnce nd cost ef fectiveness through systemtic reviews, met-nlyses nd modelling s pproprite, ssessment of the evidence by n externl Guideline Development Group using the GRADE pproch, 1 nd development of policy guidnce 2 for dissemintion to Member Sttes nd other stkeholders. Policy documents re reviewed periodiclly, nd revised s necessry when new evidence becomes vilble. In June 215, WHO convened Guideline Development Group to review the evidence on the use of the urine lterl flow liporbinomnnn (LF-LAM) ssy (Alere Determine TM TB LAM Ag test, Alere Inc, USA) for detection of TB in people living with HIV. A liporbinomnnn (LAM) ntigen is lipopolyscchride present in mycobcteril cell wlls, which is relesed from metboliclly ctive or degenerting bcteril cells nd ppers to be present only in people with ctive TB disese. Tests bsed on the detection of LAM in urine hve the potentil to be point-of-cre tests for TB. Further dvntges over sputum-bsed testing re tht urine is esy to collect nd store, nd lcks the infection control risks ssocited with sputum collection. The urinry LAM ssys currently vilble re unsuitble s generl dignostic or screening tests for TB, due to suboptiml sensitivity. However, unlike trditionl dignostic methods for TB, they demonstrte improved sensitivity mong people living with HIV, which further increses s CD4 counts fll. Following the Guideline Development Group s evlution of the LF-LAM ssy, the resulting 215 WHO policy recommendtions on its use re summrized in Box 5.1. In the coming yer, evlutions nd updted reviews re plnned for severl other technologies. These include LPAs for detection of resistnce to first- nd second-line drugs (Hin LifeScience, Germny; nd Nipro Corp., Jpn); the use of sequencing for detection of resistnce-conferring muttions; nd the Xpert Ultr ssy nd GeneXpert Omni (Cepheid, USA). Further potentil technologies on the evlu- 1 www.grdeworkinggroup.org 2 WHO hndbook for guideline development, 2nd ed. Genev, World Helth Orgniztion; 214. Avilble t: http://www.who.int/kms/ hndbook_2nd_ed.pdf. 7 n GLOBAL TUBERCULOSIS REPORT 215

Box 5.1 WHO recommendtions on urine lterl flow liporbinomnnn (LF-LAM) ssy (Alere Determine TM TB LAM Ag test, Alere Inc, USA) The 215 WHO recommendtions on LF-LAM ssy re: 1. LF-LAM should not be used for the dignosis of TB, except s specificlly described below for persons with HIV with low CD4 counts or who re seriously ill (strong recommendtion; low qulity of evidence). 2. LF-LAM my be used to ssist in the dignosis of TB in HIV-positive dult inptients with signs or symptoms of TB (pulmonry nd/or extrpulmonry) who hve CD4 cell count less thn or equl to 1 cells/µl, or HIV-positive ptients who re seriously ill regrdless of CD4 count or with unknown CD4 count (conditionl recommendtion; low qulity of evidence). Remrks " This recommendtion lso pplies to HIV-positive dult outptients with signs nd symptoms of TB (pulmonry nd/or extrpulmonry) who hve CD4 cell count less thn or equl to 1 cells/µl, or HIV-positive ptients who re seriously ill regrdless of CD4 count or with unknown CD4 count, bsed on the generlistion of dt from inptients. " This recommendtion lso pplies to children, bsed on the generlistion of dt from dults while cknowledging very limited dt nd concern regrding the low specificity of the LF-LAM ssy in children. 3. LF-LAM should not be used s screening test for TB (strong recommendtion; low qulity of evidence). seriously ill is defined bsed on four dnger signs: respirtory rte > 3/min, temperture >39 C, hert rte >12/min nd unble to wlk unided. tion horizon include severl rpid nd sensitive dignostic tests tht re expected to be vilble for use t reference lbortory level s well s closer to or t the point of ptient cre (Chpter 8). In April 215, new WHO Policy frmework for implementing tuberculosis dignostics ws published. 1 This document provides comprehensive guidnce on the mngeril, technicl nd opertionl processes required for developing nd implementing comprehensive ntionl strtegy for TB lbortories, which encompss erly dignosis of TB nd universl ccess to DST s well s systemtic screening of contcts of people with TB nd high-risk groups. The positioning of WHO-recommended dignostics t dif ferent levels of lbortory network is described, nd templtes of dignostic lgorithms re presented. This generic policy frmework 1 WHO Policy frmework for implementing tuberculosis dignostics. Genev, World Helth Orgniztion; 215. Avilble t: http://www. who.int/tb/publictions/implementing_tb_dignostics/en/ cn be dpted nd customized t country level to ccount for the wide vrition in country resources nd needs, s well s dif ferences in the epidemiology of TB, HIV-ssocited TB nd drug-resistnt TB. A comprehensive list of existing WHO policy documents, including on the use of microscopy, culture, DST nd non-commercil nd moleculr dignostic methods, is vilble t: www.who.int/tb/lbortory/policy_sttements. 5.2 Sttus of lbortory cpcity globlly, regionlly nd ntionlly Smer microscopy continues to be the most widely used tool for TB dignosis in low- nd middle-income countries, despite its shortcomings. A microscopy network with dequte popultion coverge nd high qulity performnce (see Section 5.3) is therefore criticl. The Globl Pln to Stop TB 211 215 includes the trget tht countries mintin t lest one smer microscopy centre per 1 popultion. 2 Globlly, the trget hs been met (1.1 centres per 1 popultion in 214), but significnt disprities remin t regionl nd country levels (Tble 5.1). For exmple, the Western Pcific nd Estern Mediterrnen regions hd less thn one centre per 1 popultion in 214. The trget now requires country-specific dpttion given the incresed use of Xpert MTB/RIF s n initil dignostic test, especilly in settings with high burdens of HIV nd MDR-TB. In ddition, it is importnt to emphsize tht geogrphic vritions in the TB epidemic within country s well s differences in ccess between urbn nd rurl settings require tht the number nd plcement of microscopy centres re strtegiclly considered within countries. Fluorescent light-emitting diode (LED) microscopy is more sensitive thn conventionl Ziehl Neelsen (ZN) light microscopy nd hs further qulittive, opertionl nd cost dvntges. In 29, WHO recommended tht LED microscopy be phsed in s n lterntive for ZN microscopy. Globlly, the switch to LED microscopes hs been grdul: the technology ws reported to hve been present in only 7% of microscopy centres in 214, up from 2% in 212. Nonetheless, mjor progress is evident in certin countries. Among HBCs, mjor dopters of LED microscopy include South Afric (1% of microscopy sites in 214), Chin (38%), Mynmr (31%), Bngldesh (22%), Keny (21%) nd Mozmbique (21%). Adoption of LED microscopy remins prticulrly low in Indonesi (%), Afghnistn (<1%), Brzil (<1%), Philippines (<1%), the Democrtic Republic of the Congo (1%), Indi (2%), nd Viet Nm (2%). The current trget in the Globl Pln to Stop TB 211 215 for both culture nd DST (to t lest rifmpicin nd isonizid) 2 The Globl Pln to Stop TB, 211 215. Genev, World Helth Orgniztion; 21 (WHO/HTM/STB/21.2). GLOBAL TUBERCULOSIS REPORT 215 n 71

n TABLE 5.1 Lbortory cpcity, 214 SMEAR MICROSCOPY CULTURE DRUG SUSCEPTIBILITY TESTING LINE PROBE ASSAY XPERT MTB/RIF HIGH TB BURDEN HIGH MDR-TB BURDEN NUMBER OF LABORATORIES LABORATORIES PER 1 POPULATION PERCENTAGE OF LABORATORIES USING LED MICROSCOPES YES NO Afghnistn 72 2.3 < 1 3.5 1 Armeni 26.9 4 1 1.7 1 1.7 1 1.7 2 Azerbijn 72.7 4 7 3.6 3 1.6 2 1 7 Bngldesh 1 14.7 22 3 <.1 3 <.1 1 <.1 38 Belrus 154 1.6 2 29 15 8 4.2 8 4.2 15 Brzil 3 382 1.6 < 1 324 7.9 26.6 1 <.1 48 Bulgri 34.5 38 3 21 9 6.2 4 2.8 Cmbodi 215 1.4 13 4 1.3 3 1 17 Chin 2 952.2 38 1 825 6.7 399 1.5 157.6 654 DR Congo 1 64 2.1 1 4.3 3.2 1 <.1 39 Estoni 6.5 33 2 7.6 2 7.6 2 7.6 4 Ethiopi 2 972 3.1 9 8.4 8.4 8.4 28 Georgi 11.3 9 2 2.5 1 1.2 2 2.5 11 Indi 13 583 1 2 67.3 62.2 5.2 121 Indonesi 5 689 2.2 2.4 15.3 2 <.1 41 Kzkhstn 466 2.7 85 24 22 6.3 12 3.5 23 Keny 1 92 4.3 21 3.3 3.3 5.6 7 Kyrgyzstn 131 2.2 8 7 6 2 1.7 2 1.7 8 Ltvi 12.6 5 13 1 2.5 1 2.5 2 Lithuni 13.4 15 6 1 6 1 2 3.4 4 Mozmbique 336 1.2 21 3.6 2.4 1.2 24 Mynmr 492.9 31 3.3 2.2 2.2 38 Nigeri 1 765 1 15 8.2 8.2 6.2 96 Pkistn 1 483.8 3 12.3 5.1 4.1 42 Philippines 2 561 2.6 < 1 22 1.1 4.2 1 <.1 84 Republic of Moldov 59 1.4 4 4.9 4 4.9 4 4.9 28 Russin Federtion 5 347 3.7 6 45 14 299 1 6.2 96 South Afric 27.4 1 12 1.1 12 1.1 12 1.1 27 Tjikistn 84 1 6 5 3 1.6 3 1.8 14 Thilnd 98 1.3 3 53 3.9 2 1.5 12.9 14 Ugnd 1 365 3.6 18 5.7 5.7 3.4 74 Ukrine 676 1.5 65 7.2 24 2.7 3.3 25 UR Tnzni 945 1.8 14 4.4 1 <.1 3.3 59 Uzbekistn 325 1.1 < 1 7 1.2 2.3 3.5 24 Viet Nm 989 1.1 2 23 1.2 2.1 2.1 3 Zimbbwe 22 1.4 1 2.7 2.7 1.3 62 High-burden countries 1.1 8 3.1 1.3 High MDR-TB burden countries 1 7 3.2 1.1.4 AFR 1.6 14 1 1.2.3 AMR 2 2 15.7.3 EMR.7 5 2.2.3.2 EUR 1.2 5 11 5.5 1.6 SEAR 1.2 3.4.3.2 WPR.5 16 6 1.3.5 Globl 1.1 7 4.7 1.3.5 indictes vlues tht cnnot be clculted. The regionl nd globl figures re ggregtes of dt reported by low- nd middle-income countries nd territories. Dt for the vribles shown in the tble re not requested from high-income countries in the WHO dt collection form. NUMBER OF LABORATORIES LABORATORIES PER 5 MILLION POPULATION NUMBER OF LABORATORIES LABORATORIES PER 5 MILLION POPULATION NUMBER OF LABORATORIES LABORATORIES PER 5 MILLION POPULATION NUMBER OF SITES 72 n GLOBAL TUBERCULOSIS REPORT 215

cpcity is one lbortory per 5 million popultion. In 214, 12 of the 27 high MDR-TB burden countries did not rech the trget (Tble 5.1), nd severl countries with lrge TB cselods continue to completely lck in-country cpcity for phenotypic DST (Figure 5.1). In 214, 12 countries reported more thn 1 notified TB cses but no cpcity to perform phenotypic DST: Afghnistn, Burkin Fso, Chd, Congo, Equtoril Guine, Gbon, Guine-Bissu, Ppu New Guine, Sierr Leone, Somli, South Sudn nd Timor Leste. Among these, Equtoril Guine nd Sierr Leone lso reported lcking ny cpcity for Xpert MTB/RIF testing, which would t lest llow for detection of rifmpicin resistnce. Ptients with MDR-TB require DST for second-line drugs to refine nd optimize their tretment regimen. Some countries with smll cselods of MDR-TB ptients hve resonbly opted to rely on prtner lbortories (including WHO Suprntionl Reference Lbortories) for such testing, insted of building in-country cpcity. However, 28 countries with reported RR/MDR-TB cses indicted tht they hd neither in-country cpcity nor linkge with prtner lbortory for second-line DST: Albni, Cmbodi, Centrl Africn Republic, Chd, Congo, Djibouti, Eritre, Gbon, Ghn, Guine, Guine-Bissu, Guyn, Jordn, Keny, Kuwit, Mlwi, Mli, Muritni, Muritius, Morocco, Pnm, Prguy, So Tome nd Principe, Sudi Arbi, Syrin Arb Republic, Togo, Turkmenistn nd Yemen. Countries with sizeble TB nd MDR-TB cselods should im s priority to build sustinble in-country cpcity to undertke DST to t lest rifmpicin, to llow the timely dignosis of drug-resistnt strins. As high-throughput moleculr tool for use t centrl nd regionl levels, LPAs hve been dopted by mny countries for rpid first-line DST (to rifmpicin nd isonizid) on smer-positive specimens or cultures. In 214, 92 countries nd territories reported t lest one fcility with cpcity to perform LPA tests. Of the 27 high MDR-TB burden countries, 13 reported LPA cpcity in more thn one lbortory per 5 million popultion. Following initil WHO recommendtions issued in December 21, Xpert MTB/RIF hs been quickly dopted by countries s n ef fective tool for the rpid detection of TB nd rifmpicin resistnce t lower levels of the helth system. By the end of December 214, totl of 3 763 GeneXpert instruments comprising 17 883 modules hd been procured in the public sector in 116 of the 145 countries eligible for concessionl pricing. In 214, 4.8 million test crtridges were procured by eligible countries (Figure 5.2), up from 55 in 211. Of these, 51% (2.4 million) went to South Afric. The originl WHO policy guidnce on Xpert MTB/RIF issued in 21 recommends its use s the initil dignostic test in individuls suspected of hving MDR-TB or HIV-ssocited TB (strong recommendtions). A policy updte in 213 expnded its recommended uses, including for the dignosis of TB in children, on selected specimens for the dignosis n FIGURE 5.1 Globl cpcity for drug-susceptibility testing (DST), 214 1st- nd 2nd-line DST 1st-line DST only Xpert MTB/RIF only No cpcity No dt Not pplicble Dt for 213 were used if dt for 214 were not reported (n=6). GLOBAL TUBERCULOSIS REPORT 215 n 73

n FIGURE 5.2 Xpert MTB/RIF crtridge procurements in 214 t concessionl prices Xpert MTB/RIF crtridges procured in 214 (thousnds) 4 5 49 5 99 1 299 3 Not eligible for preferentil pricing Not pplicble of extrpulmonry TB, nd for ll individuls suspected of hving pulmonry TB (conditionl recommendtions). High-burden countries hve lrgely dopted the strong recommendtions on its use s the initil dignostic test for individuls suspected of hving MDR-TB or HIV-ssocited TB (Tble 5.2). While 19 of the 22 high TB burden countries hve indicted policies on the use of Xpert MTB/RIF for individuls suspected of hving HIV-ssocited TB, not ll of the 41 TB/HIV priority countries reported hving such policy: by the end of 214, Centrl Africn Republic, Chd, Chin, Cote d Ivoire, Mlwi, Mynmr, Nmibi, Sierr Leone nd Sudn indicted tht Xpert MTB/RIF ws not yet the initil dignostic test for people suspected of hving HIV-ssocited TB (see lso Box 6.2 in Chpter 6). Incresingly, countries re lso updting their policies to include the use of Xpert MTB/RIF for children nd for detection of extrpulmonry TB (5% nd 41% of ll reporting countries, respectively). A smll number of countries with suf ficient resources, including South Afric, Swzilnd nd Moldov, re lso plcing Xpert MTB/RIF s the initil dignostic test for ll people suspected of hving TB. Some countries tht cnnot f ford the use of Xpert MTB/RIF s the initil dignostic test for ll people with suspected TB hve introduced dignostic lgorithms in which chest X-ry is used s n initil screening tool, with those with X-ry bnormlities then eligible for testing using Xpert MTB/ RIF. As countries continue to scle-up coverge of Xpert MTB/RIF testing, lgorithms should be widened to increse ptient ccess to the test s sensitive nd rpid tool both for detection of rifmpicin resistnce nd for TB cse-finding. The growing number of drug-resistnt cses being detected by Xpert MTB/RIF nd LPAs requires djustment of country culture nd phenotypic DST cpcities. The introduction of Xpert MTB/RIF nd LPAs reduces the need for culture s the initil dignostic test, but t the sme time the growing detection of drug-resistnt TB cses requires culture cpcity for monitoring of tretment nd DST of other nti-tb drugs to guide tretment djustments. It is lso impertive tht the incresing cpcity of countries to dignose drug-resistnt TB is mtched by incresed cpcity to provide pproprite tretment to ll dignosed cses (see lso Chpter 4). One of the min resons for low TB nd drug-resistnt TB cse detection rtes in mny prts of the world (Chpter 3) is the existence of significnt privte sector, in which cre providers frequently dignose people with TB nd drug-resistnt TB but fil to notify these to ntionl uthorities. The qulity of dignostic services in the privte sector is highly vrible or unknown. Furthermore, in some settings, lbortories in the public sector tht re not under the uspices of the NTP lso dignose TB nd drug-resistnt TB without necessrily following recommended guidelines nd qulity ssurnce procedures. Collbortion between NTPs nd ll lbortories of fering TB nd drug-resistnt TB dignosis is criticl to ensure tht ntionl guidelines re followed, tht pproprite dignostic tests re used, nd tht ptients dignosed 74 n GLOBAL TUBERCULOSIS REPORT 215

n TABLE 5.2 Incorportion of WHO policy guidnce on Xpert MTB/RIF, 214 YES NO HIGH TB BURDEN HIGH MDR-TB BURDEN PEOPLE LIVING WITH HIV XPERT MTB/RIF AS THE INITIAL DIAGNOSTIC TEST PEOPLE AT RISK OF DRUG-RESISTANT TB CHILDREN SUSPECTED OF HAVING TB EXTRAPULMONARY TB USING SELECTED SPECIMENS Afghnistn Armeni Azerbijn Bngldesh Belrus Brzil Bulgri Cmbodi Chin DR Congo Estoni Ethiopi Georgi Indi Indonesi Kzkhstn Keny Kyrgyzstn Ltvi Lithuni Mozmbique Mynmr Nigeri Pkistn Philippines Republic of Moldov Russin Federtion South Afric Tjikistn Thilnd Ugnd Ukrine UR Tnzni Uzbekistn Viet Nm Zimbbwe High-burden countries 86% 1% 77% 64% High MDR-TB burden countries 85% 93% 81% 7% AFR 72% 84% 67% 4% AMR 52% 48% 35% 3% EMR 56% 62% 38% 44% EUR 5% 57% 45% 44% SEAR 55% 82% 36% 45% WPR 72% 83% 56% 5% Globl 6% 69% 5% 41% The regionl nd globl figures re ggregtes of dt reported by low- nd middle-income countries nd territories. Dt for the vribles shown in the tble re not requested from high-income countries in the WHO dt collection form. GLOBAL TUBERCULOSIS REPORT 215 n 75

with TB nd drug-resistnt TB re notified to the NTP nd receive proper cre. In 214, 17 of 36 high TB nd MDR-TB burden countries reported some level of collbortion with lbortories in the privte sector, nd 23 reported collbortion with non-ntp lbortories in the public sector. 5.3 Strengthening TB lbortories globlly, regionlly nd ntionlly Strengthening TB lbortories involves not only equipping them with modern dignostics suitble to the vrious levels of the network (Section 5.2), but lso ensuring the qulity of every step in the dignostic process, from the collection nd testing of smples, to the recording nd reporting of results. Implementing system of qulity mngement should be priority cross ll TB lbortories in network. A comprehensive qulity mngement system llows for the necessry ctivities to be crried out t the right time nd by the ppropritely trined people, for the necessry equipment nd consumbles to be in stock, nd for ll mnuls, guidelines, forms nd stndrd operting procedures to be in plce so tht processes re crried out correctly. Severl sources of guidnce nd trining pltforms hve been developed to ssist TB reference lbortories to implement qulity mngement system tht meets interntionl ccredittion stndrds. The GLI stepwise process towrds TB lbortory ccredittion is n online interctive guide 1 divided into four phses, developed by the Royl Tropicl Institute (KIT), the Union, the United Sttes Centers for Disese Control nd Prevention, the United Sttes Agency for Interntionl Development (USAID) nd WHO. The frmework known s the WHO guide for the stepwise lbortory improvement process towrd ccredittion in the Africn Region (SLIPTA) is bsed on 12 qulity-system essentils, nd it is pplicble to ll lbortory settings nd disciplines. The United Sttes Centers for Disese Control nd Prevention hs developed tsk-bsed mentoring progrmme known s Strengthening lbortory mngement towrds ccredittion (SLMTA). The Foundtion for Innovtive New Dignostics (FIND) hs modified both the SLMTA progrmme nd the SLIPTA frmework to include TB-specific guidnce, to form TB-SLMTA nd TB-SLIPTA. In 214, 123 of 173 responding countries nd territories (71%) indicted tht forml qulity mngement system towrds chieving lbortory ccredittion hd t lest been strted t the ntionl reference lbortory (NRL). Qulity ssurnce of microscopy remins criticl ctivity of ll lbortory networks, nd comprehensive externl qulity ssessment (EQA) progrmme should be implemented tht includes on-site evlution, rndom blinded rechecking, nd pnel testing. Of the 14 countries nd territories tht reported dt on the number of smer microscopy centres undergoing EQA in 213, only 34% indicted the existence of scheme tht covered ll centres in the country, with further 16% covering t lest 9% of cen- 1 http://gliqulity.org tres. Among the 22 HBCs, only four reported scheme tht encompssed ll centres in 214 (Bngldesh, Indi, Ugnd nd Zimbbwe) nd five more reported progrmme tht included t lest 9% of centres (Cmbodi, Chin, Pkistn, South Afric nd Viet Nm). Qulity-ssured DST is criticl to ensure ccurte detection of drug resistnce to inform tretment decisions nd to void flse dignoses. Of the high TB nd MDR-TB burden countries tht reported on EQA coverge of DST lbortories in 214 (34 of 36), 24 (71%) reported hving scheme tht encompssed ll DST lbortories. Of the 116 reporting countries globlly, 78 (67%) indicted scheme tht encompssed ll lbortories. Ensuring qulity needs to be priority for ll levels of lbortory network. As key prtner in strengthening the cpcity nd qulity of TB lbortories globlly, the WHO TB Suprntionl Reference Lbortory (SRL) Network comprises 36 lbortories tht provide long-term technicl ssistnce to low- nd middle-income countries under the frmework of collbortive greements. The network ws formed in 1994 to ensure the qulity of drug resistnce surveys, but tody SRLs provide wide rnge of technicl ssistnce services, including trining, on-site supervisory missions, guidnce to the development of ntionl lbortory strtegic plns, nd proficiency testing. 156 countries nd territories reported hving forml link with prtner SRL in 214. The SRL Network lso includes Ntionl Centres of Excellence (SRL-CEs), which re well-performing ntionl nd regionl TB reference lbortories in lrge, middle-income countries. These SRL-CEs hve similr terms of reference (nd ntionl sttus) to tht of n SRL but with n in-country focus for its lbortory strengthening ctivities. To meet its objectives, SRL-CE commits to provide minimum service requirements including estblishing forml links with t lest two intermedite level lbortories within the country nd undertking t lest one nnul technicl ssistnce visit to ech lbortory. A SRL-CE needs to be nominted by its NTP to the WHO country office, estblish collbortive greement with n existing SRL, undergo lbortory ssessment by WHO, nd ctively implement qulity mngement system towrds ccredittion. In 214, the Ministry of Helth of the Russin Federtion nominted TB lbortories of three Federl Institutes to undergo evlutions to ssess their suitbility for designtion s SRL-CEs: Centrl Tuberculosis Reserch Institute, Moscow; Novosibirsk Tuberculosis Reserch Institute, Novosibirsk; nd Url Reserch Institute for Phthisiopulmonology, Yekterinburg. Following ssessment missions, ll three of the lbortories were recognized s performing well, with high-qulity infrstructure nd high clibre of suitbly-qulified technicl stf f. They were ll subsequently designted s SRL-CEs in April 215. These lbortories hve prticulr vlue for estblishing nd mintining high-qulity lbortory services within the country for the 76 n GLOBAL TUBERCULOSIS REPORT 215

n FIGURE 5.3 The WHO TB Suprntionl Reference Lbortory Network Boston, USA Atlnt, USA Mexico City, Mexico Gudeloupe, Frnce Copenhgen, Denmrk Rig, Ltvi Moscow, Russi Antwerp, Belgium Yekterinburg, Russi Novosibirsk, Russi London, UK Borstel, Germny Guting, Germny Prgue, Czech Republic Miln, Itly Zgreb, Croti Porto, Portugl Rome, Itly Seoul, Republic of Kore Brcelon, Spin Le Hmm, Algeri Ciro, Egypt New Delhi, Indi Cotonou, Benin Stockholm, Sweden Chenni, Indi Kmpl, Ugnd Krchi, Pkistn Hong Kong, Chin SAR Bngkok, Thilnd Tokyo, Jpn Sntigo, Chile Johnnesburg, South Afric Buenos Aires, Argentin Adelide, Austrli Suprntionl Reference Lbortory Suprntionl Reference Lbortory Coordinting Centre Cndidte Suprntionl Reference Lbortory Ntionl Centre of Excellence Brisbne, Austrli progrmmtic mngement of drug-resistnt TB, including through the coordintion of technicl ssistnce, provision of monitoring nd supervision, nd orgniztion of trinings to lbortory stf f involved in dignostic testing for drug resistnce nd monitoring of tretment for ptients with drug-resistnt TB. The SRL network s of July 215 is shown in Figure 5.3. GLOBAL TUBERCULOSIS REPORT 215 n 77

CHAPTER 6 Addressing the co-epidemics of TB nd HIV Key fcts nd messges In 214, n estimted 1.2 million (12%) of the 9.6 million people who developed TB worldwide were HIV-positive. The Africn Region ccounted for 74% of the estimted number of HIVpositive incident TB cses. The number of people dying from HIV-ssocited TB peked t 57 in 24 nd hs since fllen to 39 in 214 ( reduction of 32%). In 214, HIV-ssocited TB deths ccounted for 25% of ll TB deths (mong HIV-negtive nd HIV-positive people) nd one third of the estimted 1.2 million deths from HIV/AIDS. In 24, WHO recommended the implementtion of 12 collbortive TB/HIV ctivities. Between 25 nd 214, n estimted 5.8 million lives were sved by TB/HIV interventions. Globlly, 51% of notified TB ptients hd documented HIV test result in 214, smll increse from 49% in 213. The figure ws highest in the Africn Region, t 79%, nd 9% in 18 of the 41 high TB/HIV burden countries. The prevlence of HIV co-infection mong TB ptients is highest in the Africn Region. Of the 1.1 million TB ptients with known HIV sttus in 44 countries, 39% were HIV-positive in 214, slight decline compred with 41% in 213. The proportion of TB ptients who were known to be HIV-positive in the Africn Region rnged from 6% in Eritre to 73% in Swzilnd. In 214, coverge of ntiretrovirl therpy (ART) for notified TB ptients who were known to be co-infected with HIV reched 77% globlly. Further ef forts re needed to rech the trget of 1%. This is especilly the cse given tht the number of HIVpositive TB ptients on ART in 214 represented only 33% of the estimted number of people living with HIV who developed TB in 214. Coverge of co-trimoxzole preventive therpy (CPT) mong HIV-positive TB ptients remins high, nd incresed slightly to 87% globlly nd 89% in the Africn Region in 214. The number of people living with HIV who were treted with isonizid preventive therpy (IPT) reched 933 in 214, n increse of bout 6% compred with 213. However, provision of IPT ws reported by just 23% of countries globlly, including only 13 of the 41 high TB/HIV burden countries. As in previous yers, lrge proportion of the people living with HIV who were initited on IPT were in South Afric (59%), lthough in most countries tht reported dt in 213 nd 214, coverge levels grew. Preventing TB deths mong HIV-positive people requires intensified scle-up of TB prevention, dignosis nd tretment interventions, including erlier initition of ART mong people living with HIV nd those with HIV-ssocited TB. Incresed ef forts in joint TB nd HIV progrmming could fcilitte further scle-up nd consolidtion of collbortive TB/HIV ctivities. Globlly, people living with HIV re 26 times more likely to develop TB disese thn those who re HIV-negtive. 1 Beginning in the 198s, the HIV epidemic led to mjor upsurge in TB cses nd TB mortlity in mny countries, especilly in southern nd estern Afric (Chpter 2). In 214, 1.2 million (12%) of the 9.6 million people who developed TB worldwide were HIV-positive (Chpter 2, Tble 2.1); 74% of these HIV-positive TB cses were in the Africn Region. The number of people dying from HIV-ssocited TB peked t 57 in 24 nd hs since fllen to 39 in 214 ( reduction of 32%). 2 However, this still represents n enormous burden of preventble deths nd ill-helth. In 214, TB deths mong HIV-positive people ccounted for 25% of ll TB deths (mong HIV-negtive nd HIV-positive people) nd one third of the estimted 1.2 million deths from HIV/AIDS. 3 Current trends indicte tht the trget set by WHO, UNAIDS nd the Stop TB Prtnership to hlve the number of HIV-ssocited TB deths by 215 (compred with 24) will not be met globlly (Chpter 2). 4 WHO recommendtions on the interventions needed to 1 The probbility of developing TB mong people living with HIV divided by the probbility of developing TB mong HIV-negtive people is the incidence rte rtio (IRR). The men estimted globl IRR (ll ges) in 214 ws 26 (rnge 24 28). However, there is considerble vrition mong countries: in 214, the medin IRR ws 23 (interqurtile rnge 14-36). Further detils re provided in the online technicl ppendix. 2 Estimtes of the totl burden of TB disese nd of the number of TB cses nd deths mong HIV-positive people re updted nnully by WHO. For further detils, see Chpter 2 nd the online technicl ppendix (www.who.who.int/dt). 3 http://www.unids.org/en/resources/documents/215/hiv_estimtes_ with_uncertinty_bounds_199-214 4 Of the 41 countries with the highest burden of HIV ssocited TB, 17 re estimted to hve met the trget by the end of 214. 78 n GLOBAL TUBERCULOSIS REPORT 215

prevent TB in HIV-positive people nd to reduce the impct of HIV mong TB ptients were first issued in 24, nd re collectively known s collbortive TB/HIV ctivities. 1 They include: estblishing nd strengthening coordintion mechnisms for delivering integrted TB nd HIV services; HIV testing for ll TB ptients s well s people with TB signs or symptoms; providing ntiretrovirl therpy (ART) nd cotrimoxzole preventive therpy (CPT) to ll HIV-positive TB ptients; providing HIV prevention services for TB ptients; intensifying TB cse-finding mong people living with HIV; of fering isonizid preventive therpy (IPT) to people living with HIV who do not hve ctive TB; nd preventing the trnsmission of TB infection in helth cre nd congregte settings. The ltter three ctivities re referred to s the Three Is for HIV/TB nd, together with erlier ART, re the principl interventions for preventing TB mong people living with HIV. Between 25 nd 214, TB/HIV interventions sved n estimted 5.8 million lives. 2 In ddition, use of the rpid moleculr test, Xpert MTB/RIF nd erly ART mong HIV positive TB ptients re incresingly considered criticl components of collbortive TB/ HIV ctivities. WHO recommends the use of Xpert MTB/RIF s the primry dignostic test for TB mong people living with HIV who hve TB signs nd symptoms, nd ART for ll HIV-positive TB ptients within the first eight weeks of strting TB tretment (irrespective of their CD4 cell count). Erly initition of ART (within two weeks of strting TB tretment) is lso importnt, prticulrly for TB ptients with profound immunosuppression (e.g. CD4 cell count less thn 5) mong whom it hs been shown to significntly improve survivl. WHO begn monitoring the implementtion of collbortive TB/HIV ctivities in 24. This chpter presents the ltest sttus of progress, using dt for ech yer from 24 through 214. 6.1 HIV testing nd documenttion of HIV sttus mong TB ptients WHO recommends tht routine HIV testing should be of fered to ll TB ptients, to ll those with TB signs nd symptoms, nd to prtners of known HIV-positive TB ptients. 3 In the WHO online dt collection system, dt re reported for TB ptients only. In 214, 3.2 million notified TB ptients hd documented HIV test result, equivlent to 51% of notified TB cses (Tble 6.1, Figure 6.1). This represented n increse from 3 million nd 49% respectively in 213, nd more thn 17 times the cov- 1 An updte ws issued in 212. See WHO policy on collbortive TB/HIV ctivities: guidelines for ntionl progrmmes nd other stkeholders. Genev, World Helth Orgniztion, 212 (WHO/ HTM/TB/212.1). Avilble t http://whqlibdoc.who.int/ publictions/212/9789241536_eng.pdf 2 Estimtes of lives sved by TB nd HIV interventions re covered in more detil in Chpter 2. 3 WHO policy on collbortive TB/HIV ctivities: guidelines for ntionl progrmmes nd other stkeholders. Genev: World Helth Orgniztion; 212 (WHO/ HTM/TB/212.1). Avilble t http://whqlibdoc.who.int/ publictions/212/9789241536_eng.pdf erge reported in 24 (Figure 6.1). There were 89 countries in which 75% of TB ptients hd documented HIV test result in 214 (Figure 6.2); this ws unchnged from 213. Overll, mong the 41 countries identified s priorities for the globl TB/HIV response (listed in Tble 6.1), 6% of notified TB ptients hd documented HIV test result in 214, up from 58% in 213. There hs been stedy increse in these 41 countries since 27. However, levels of coverge vry significntly, rnging from 5% in Indonesi to 99% in Rwnd in 214. 4 Eighteen of the 41 countries reported tht 9% of TB ptients knew their HIV sttus in 214, of which five (Botswn, Keny, Mozmbique, Rwnd nd Swzilnd) hve mnged to mintin this level since 211. A further 14 countries (Burkin Fso, Cmbodi, Cmeroon, Côte d Ivoire, Lesotho, Mlwi, Nmibi, Nigeri, South Afric, Togo, Ugnd, Tnzni, Zmbi nd Zimbbwe) hve reported tht 8% TB ptients know their HIV sttus since 211. In seven high TB/HIV burden countries, the percentge of TB ptients who know their HIV sttus hs remined persistently low, t under 5% since 211: Chin, Congo, the Democrtic Republic of the Congo, Indonesi, Mli, Mynmr nd Sudn. 5 The percentge of TB ptients with known HIV sttus remins highest in the Africn Region, where it continues to increse nd reched 79% in 214, up from 78% in 213 (Tble 6.1, Figure 6.1). Of the 47 Africn countries, 3 countries reported 75% of TB ptients hd documented HIV test result in 214, nd 23 chieved levels of 9% (Figure 6.2). n FIGURE 6.1 Percentge of notified TB ptients with known HIV sttus, 24 214 Percentge of notified TB ptients 1 75 5 25 Africn region Globl Regions outside Afric 24 25 26 27 28 29 21 211 212 213 214 4 In Indi, the ntionl figure fell slightly between 213 nd 214, from 63% to 61%. This reflects lrge increse in notifictions (see Chpter 3, Box 3.2) from the privte sector (included in the denomintor), without corresponding increse in reporting relted to HIV testing. When nlysis is restricted to units tht reported dt in both 213 nd 214, the percentge of TB ptients who knew their HIV sttus rose from 63% to 72%. 5 The reported figure is lso reltively low for the Russin Federtion. However, this is becuse the denomintor vilble for clcultions is the totl number of new nd relpse cses tht were notified while the numertor vilble for clcultions includes only new TB ptients in the civilin sector. In prctice, testing coverge is estimted to be close to 1% in the Russin Federtion. GLOBAL TUBERCULOSIS REPORT 215 n 79

n TABLE 6.1 HIV testing for TB ptients, tretment for HIV-positive TB ptients nd prevention of TB mong people living with HIV, 41 high TB/HIV burden countries nd WHO regions, 214. Numbers in thousnds except where indicted. ESTIMATED HIV-POSTIVE INCIDENT TB CASES NUMBER OF NOTIFIED TB PATIENTS WITH KNOWN HIV STATUS % OF NOTIFIED TB PATIENTS WITH KNOWN HIV STATUS % OF TB PATIENTS WITH AN HIV TEST RESULT WHO WERE HIV-POSITIVE % OF NOTIFIED HIV-POSITIVE TB PATIENTS STARTED ON ART NUMBER OF HIV-POSTIVE TB PATIENTS ON ART AS % OF ESTIMATED HIV-POSITIVE INCIDENT TB CASES b NUMBER OF HIV-POSITIVE PEOPLE PROVIDED WITH IPT % OF PEOPLE NEWLY ENROLLED IN HIV CARE WHO WERE NOTIFIED AS A TB CASE THE SAME YEAR Angol 23 14 34 28 5 1 Botswn 4.5 4.1 5. 5.5 91 6 78 57 Brzil 16 14 17 57 7 17 Burkin Fso 1.2 1. 1.3 5.6 96 12 86 47 9.8 Burundi 1.9 1.6 2.1 6.7 91 14 68 32 Cmbodi 1.8 1.6 2. 36 81 2.7 98 52.9 19 Cmeroon 2 17 23 23 87 37 7 3 Centrl Africn Republic 7.6 5.9 9.4 5.2 51 34 Chd 6. 4.7 7.4 6.6 54 19 56 12 Chin 13 11 16 344 42 1.5 69 28 2.9 Congo 5.5 4.3 6.9 1.3 13 29 24 1.7 Côte d Ivoire 8.5 7.5 9.6 22 93 24 21 13 3.2 Djibouti.54.44.65 1.9 84 8.5 68 2 DR Congo 34 27 42 53 46 14 67 14 4.4 Ethiopi c 19 15 23 89 75 9.7 39 18 1 22 Ghn 11 5.2 19 12 77 24 39 1 Hiti 3.7 3.2 4.3 14 88 19 54 38 22 Indi 11 96 12 1 35 61 4.3 9 36 3.1 Indonesi 63 41 9 15 4.6 16 26 1. Keny 4 38 42 84 95 36 87 65 Lesotho 12 8.5 16 9.1 93 72 74 41 Mlwi 19 1 31 16 93 54 92 43 135 1.5 Mli.71.64.78 2.6 43 14 1 52 Mozmbique 85 65 11 56 96 52 81 28 94 Mynmr 19 15 24 56 4 11 9 3 3. 8.5 Nmibi 5.6 4.8 6.5 9.1 92 44 84 6 Nigeri 1 59 16 84 92 19 75 12 26 Russin Federtion 5.5 4.5 6.6 67 d 38 Rwnd 1.8 1.5 2.1 5.9 99 25 87 72 Sierr Leone 2.3 1.7 3. 11 87 12 68 39 1.3 8.8 South Afric 27 24 31 295 93 61 79 53 552 1 Sudn 1.2.65 2. 5.5 27 6. 45 12 18 Swzilnd 5.9 4.2 7.9 5.4 97 73 79 53 1.2 Thilnd 15 7.8 24 51 71 13 69 31 Togo.83.67 1. 2.5 97 21 76 48 Ugnd 28 24 32 44 95 45 81 57 Ukrine 8.1 7. 9.3 39 97 2 56 53 16 UR Tnzni 62 29 11 58 91 35 83 27 23 12 Viet Nm 7. 5.7 8.5 74 73 5.2 73 4 Zmbi 38 25 52 4 93 61 73 46 Zimbbwe 25 17 35 29 89 68 86 66 3 15 High TB/HIV burden countries 1 1 1 1 2 2 84 6 18 78 34 916 9. AFR 87 79 95 1 64 79 39 77 37 876 9.1 AMR 36 34 38 169 74 13 63 2 29 8.4 EMR 12 1 15 68 15 2.4 63 7.9.5 2 EUR 2 18 21 2 62 8.2 58 31 21 32 SEAR 21 18 24 1 171 45 5.1 85 24 3. 3.7 WPR 31 28 35 552 4 2.3 68 27 3.7 3.9 Globl 1 2 1 1 1 3 3 224 51 16 77 33 933 8.9 Blnk cells indicte dt not reported. indictes vlues tht cnnot be clculted. Best estimtes re followed by the lower nd upper bounds of the 95% uncertinty intervl. b The numertor (i.e. ll notified HIV-positive TB cses on ART) includes ll notified new, relpse nd non-relpse retretment cses. The denomintor (i.e. estimted HIV-positive incident TB cses) includes new nd relpse cses only. c In 214, ART nd IPT dt were missing for 3 of Ethiopi s 11 regions, which in previous yers hd ccounted for bout one third of the ntionl totls. In the 8 regions tht reported dt, 65% of HIV-positive TB ptients were on ART. d Dt for the Russin Federtion re for new TB ptients in the civilin sector only. 8 n GLOBAL TUBERCULOSIS REPORT 215

n FIGURE 6.2 Percentge of notified TB ptients with known HIV sttus by country, 214 Percentge of notified TB ptients 14 15 49 5 74 75 No dt Not pplicble Dt for the Russin Federtion re for new TB ptients in the civilin sector only. In the Region of the Americs nd the Europen Region, there were smll improvements between 213 nd 214: from 72% to 74% nd from 59% to 62% respectively. 1 Lrger increses were evident in some countries in the Americs, notbly Bolivi (7% to 77%), Chile (35% to 5%), Colombi (74% to 8%), Guteml (8% to 86%), Mexico (77% to 85%), Nicrgu (69% to 77%) nd Peru (66% to 74%). In the other three WHO regions in which concentrted HIV epidemics re the norm, the percentge of TB ptients with known HIV sttus hs remined low (15% 45%). Impressive gins were mde in three countries, however: Mynmr (from 12% to 4%), Sri Lnk (from 49% to 78%) nd the Philippines (from 2% to 2%). In Cmbodi, 81% of TB ptients knew their HIV sttus in 214, similr to the level chieved in 213. It should lso be noted tht in Chin, 91% of TB ptients knew their HIV sttus in the counties defined s hving high TB/HIV burden, much higher thn the ntionl verge of 42%. In some countries with concentrted epidemics, the progrmmtic fesibility nd vlue of testing ll TB ptients for HIV hs been questioned, especilly in settings where both ccess to HIV tretment nd funding re limited. At the sme time, HIV testing for TB ptients is bsic stndrd of cre nd provides pthwy to HIV tretment nd prevention 1 Figures for the Europen Region re n underestimte, due to under-estimtion of testing coverge for the Russin Federtion. services. Ntionl progrmmes should im to ensure tht the benefits of HIV testing re vilble to TB ptients, their prtners, fmilies nd the community t lrge, in the context of their specific progrmmtic settings. 2 6.2 Levels of HIV infection mong TB ptients with HIV test results Globlly, 16% of TB ptients with n HIV test result were HIVpositive (Tble 6.1). The figure ws 18% mong the 41 high TB/ HIV burden countries tht ccounted for more thn 94% of estimted HIV-positive incident TB cses in 214. Overll, the percentge of TB ptients testing HIV-positive hs been flling globlly since 28 (Figure 6.3). The highest rtes of HIV co-infection were reported for TB ptients in the Africn Region (Tble 6.1), where 39% of those with n HIV test result were HIV-positive (compred with 41% in 213). The percentge of TB ptients found to be HIV-positive in the 28 Africn countries in the list of 41 high TB/HIV burden countries rnged from bout 1% in Angol nd Ethiopi to more thn 7% in Lesotho nd Swzilnd. In ll other regions, the percentge of TB ptients with documented HIV test result who were HIV-positive ws much lower. 2 WHO policy on collbortive TB/HIV ctivities: guidelines for ntionl progrmmes nd other stkeholders. Genev: World Helth Orgniztion; 212 (WHO/ HTM/TB/212.1). Avilble t http://whqlibdoc.who.int/ publictions/212/9789241536_eng.pdf GLOBAL TUBERCULOSIS REPORT 215 n 81

n FIGURE 6.3 Percentge of notified TB ptients with known HIV sttus who were HIV-positive, nd percentge of notified HIV-positive TB ptients enrolled on co-trimoxzole preventive therpy (CPT) nd ntiretrovirl therpy (ART), 27 214 1 Notified TB ptients with known HIV sttus who were HIV-positive 1 Notified HIV-positive TB ptients strted on CPT 1 Notified HIV-positive TB ptients strted on ART Percentge of notified TB ptients 8 6 4 2 8 6 4 2 8 6 4 2 27 28 29 21 211 212 213 214 27 28 29 21 211 212 213 214 27 28 29 21 211 212 213 214 Globlly, totl of 528 HIV-positive TB ptients were reported by NTPs in 214. This represented less thn 5% of the 1.2 million HIV-positive people estimted to hve developed TB in the sme yer (Figure 6.4), lthough there ws considerble vrition mong regions. The proportion ws highest in the Europen Region (81%), followed by the Region of the Americs (6%) nd the Africn Region (5%), nd much lower in the Estern Mediterrnen, South- Est Asi nd Western Pcific Regions (13%, 29% nd 39%, respectively). 6.3 Antiretrovirl therpy nd co-trimoxzole preventive therpy for HIV-positive TB ptients 6.3.1 Antiretrovirl therpy ART is n intervention tht cn hve n importnt impct on TB morbidity nd mortlity mong HIV-positive TB ptients. The number of notified HIV-positive TB ptients on ART hs grown from very low level in 24 (Figure 6.4) to rech 392 in 214. Among HIV-positive TB ptients notified by NTPs in 214, 1 77% were on ART globlly (Tble 6.1, Figure 6.3), further improvement compred with 73% in 213. In the Africn Region in 214, 77% of HIV-positive TB ptients reported by NTPs were strted on ART (up from 72% in 213). ART coverge incresed in 28 of the 41 high TB/HIV burden countries between 213 nd 214 (dt not shown). Among the top-ten high TB/HIV burden countries, the biggest increses between 213 nd 214 were in the Democrtic Republic of the Congo (48% to 67%), Mozmbique (72% to 81%), the United Republic of Tnzni (73% to 83%), Nigeri (67% to 75%) nd South Afric (72% to 79%). Five other countries reported increments of more thn 1%: Cmbodi, Djibouti, Mli, Mynmr nd Viet Nm. Six of the 41 high TB/HIV burden countries hve not yet reched levels 1 In the nnul WHO TB dt collection form, countries re sked to report the number of TB ptients notified in the most recent clendr yer who were living with HIV nd who strted or continued on ART. n FIGURE 6.4 ART enrolment mong HIV-positive TB ptients compred with the reported number of HIV-positive TB ptients nd the estimted number of HIV-positive people who developed TB, 24 214 Number of TB ptients (thousnds) 15 1 5 Estimted HIV positive incident TB cses Notified HIV positive TB ptients HIV positive TB ptients on ART 24 26 28 21 212 214 Notified HIV-positive TB ptients on ART includes new nd relpse TB cses plus prevlent TB cses re-registered for tretment chnge (e.g. f ter tretment filure). Estimted HIV-positive incident TB cses includes only new nd relpse TB cses. of 5%: Sudn, Ethiopi, Ghn, Indonesi, Congo nd Côte d Ivoire. In these countries, concerted ef forts re needed to improve coverge. Erly initition of ART is importnt to reduce mortlity. WHO recommends tht ART should be initited s soon s possible f ter TB tretment is strted, nd within the first two to eight weeks of tretment. WHO lso encourges progrmmes to estblish mechnisms to monitor the timeliness of ART through ntionl dt collection systems, nd hs provided guidnce bout how to do this. 2 A recent exmple from Indi is highlighted in Box 6.1. Despite overll progress in ART coverge, there is sub- 2 World Helth Orgniztion. WHO guide to monitoring nd evlution of collbortive TB/HIV ctivities. Genev: World Helth Orgniztion; 215. Avilble t http://www.who.int/tb/publictions/monitoringevlution-collbortive-tb-hiv/en/ 82 n GLOBAL TUBERCULOSIS REPORT 215

Box 6.1 Monitoring when ART is initited for HIV-positive TB ptients: n exmple from Indi In October November 214, dt from 7 fcilities in Indi where ART is provided were extrcted from system designed to cpture erly wrning indictors relted to the development of drug resistnce nd the qulity of cre. This ws done by the Ntionl AIDS Control Orgniztion nd WHO Indi. Of the 9468 people living with HIV who hd been enrolled in HIV cre, 1871 (19%) developed TB within two yers (Tble B6.1.1). Dt on the timing of initition on ART were nlysed for these individuls. TABLE B6.1.1 Initition on ART for HIV-positive TB ptients in 62 fcilities in Indi, October November 214 STUDY COHORT (ADULTS, N=9468) NUMBER Ptients dignosed with TB 1871 Ptients lredy on ART t the time of TB dignosis stntil gp between the number of HIV-positive TB ptients strted on ART, nd the estimted totl number of HIV-positive people with TB who re in need of both TB tretment nd ART. The globl number of HIV-positive TB ptients reported to be strted on ART by NTPs in 214 represented only 33% of the estimted 1.2 million HIV-positive people who developed TB in the sme yer (Tble 6.1, Figure 6.4). The rtio of ptients strted on ART in 214 to the estimted number of HIV-positive people who developed TB in 214 ws bove 5% in only 14 of the 41 high TB/HIV burden countries: Botswn, Burkin Fso, Cmbodi, Keny, Mlwi, Mli, Nmibi, Rwnd, South Afric, Swzilnd, Ugnd, Ukrine, the United Republic of Tnzni nd Zmbi (Figure 6.5). While this is n improvement from only eight countries in 213, much remins to be done to improve the detection of TB mong HIV-positive people, the coverge of HIV testing mong TB ptients, nd enrolment of HIV-positive TB ptients on ART. 362 Time between strt of TB tretment nd ART initition, for the 1429 HIV-positive TB ptients who were not lredy on ART <2 weeks 2 (14%, 95% CI: 12 16%) 2 8 weeks 933 (65%, 95% CI: 63 68%) >8 weeks 296 (21%, 95% CI: 19 23%) Medin 23 dys The medin time between the strt of TB tretment nd ART ws 23 dys. About 8% of HIV-positive TB ptients were strted on ART within eight weeks of TB dignosis, in line with WHO recommendtions. These sttistics bout ART coverge mong ll estimted HIV-positive TB cses cn lso be compred with the level of ART coverge mong ll people living with HIV. Globlly, over 15 million people were on ART s of 31 Mrch 215. 1 By the end of 214, 4% (uncertinty intervl, 37% 45%) of the estimted number of people living with HIV were receiving ART. This is more thn the estimted level of 33% for HIV-positive people who hve TB, but lso fr from universl coverge. Mjor ef forts re urgently required to improve ccess nd nrrow these gps. The UNAIDS 9-9-9 fst trck tretment trgets (by 22, 9% of people living with HIV know their sttus, 9% of those who know their sttus re on ART, nd 9% of those on ART hve suppressed virl lod) provide pltform for doing this. 2 6.3.2 Co-trimoxzole preventive therpy Globlly, 427 HIV-positive TB ptients were enrolled on CPT in 214, representing 87% of ll notified HIV-positive TB ptients, similr to levels chieved in 213 (Figure 6.3). The Africn nd South-Est Asi regions mintined their prticulrly high levels of enrolment on CPT from 213, t 89% nd 85% respectively. Of the 34 high TB/HIV burden countries (out of totl of 41) tht reported dt, only four reported tht less thn 5% of HIV-positive TB ptients were enrolled on CPT in 214: Côte d Ivoire (24%), Congo (27%), Indonesi (41%) nd Ukrine (44%). 6.4 Intensified TB cse-finding nd initition of isonizid preventive therpy mong people living with HIV The high proportion of people with undignosed TB found in utopsy studies of HIV-positive people 3,4,5 shows tht substntil ef forts re needed to ensure ef fective TB screening mong people living with HIV, so tht TB is promptly dignosed nd treted nd so tht those without ctive TB disese re provided with IPT s well s ART. ART reduces the individul risk of TB disese mong people living with HIV by 65%, 6 irrespective of CD4 cell count. Its impct is further enhnced when IPT is lso provided. Recently, IPT for six 1 How AIDS chnged everything MDG 6. 15 yers, 15 lessons of hope from the AIDS response. Genev: UNAIDS; 215. Avilble t: http://www.unids. org/en/resources/documents/215/mdg6_15yers- 15lessonsfromtheAIDSresponse 2 Understnding Fst-Trck. Genev: UNAIDS; 215. Avilble t http:// www.unids.org/sites/defult/files/medi_sset/2156_jc2743_ Understnding_FstTrck_en.pdf) 3 Cox JA et.l. An utopsy study describing cuses of deth nd compring clinico-pthologicl findings mong hospitlized ptients in Kmpl, Ugnd; Plos One, 212;7(3):e33685. doi: 1.1371/journl. pone.33685. Epub 212 Mr 14. 4 Wong EB et.l. Cuses of deth on ntiretrovirl therpy: postmortem study from South Afric; Plos One 212;7(1):e47542. doi: 1.1371/journl.pone.47542. Epub 212 Oct 16. 5 Kille AM et.l. High prevlence of tuberculosis dignosed during utopsy exmintion t Muhimbili Ntionl Hospitl in Dr es Slm, Tnzni; Tnzni Journl of Helth Reserch 213; 15. 6 Suthr AB et l. Antiretrovirl therpy for prevention of tuberculosis in dults with HIV: systemtic review nd met-nlysis. PLoS Med 212, 9(7): e1127. doi:1.1371/journl.pmed.1127). GLOBAL TUBERCULOSIS REPORT 215 n 83

n FIGURE 6.5 Number of HIV-positive TB ptients on ART s percentge of estimted HIV-positive incident TB cses, 214 Percentge 24 25 49 5 74 75 1 No dt Not pplicble The numertor (i.e. ll notified HIV-positive TB cses on ART) includes ll notified new, relpse nd non-relpse retretment cses. The denomintor (i.e. estimted HIV-positive incident TB cses) includes new nd relpse cses only. months combined with ART for people with CD4 counts of >5 cells/mm 3 ws found to reduce the risk of severe HIVrelted illness by 44% nd the risk of deth from ny cuse by 35%. 1 6.4.1 Intensified cse-finding Systemtic screening for TB mong people living with HIV is recommended by WHO s n essentil component of the HIV pckge of cre, long with ART, IPT nd infection control. It is the first essentil step before both IPT initition nd TB dignosis. In 214, 78 countries reported bout seven million people enrolled in HIV cre who were screened for TB, up from 5.5 million in 64 countries in 213. Being screened for TB does not necessrily gurntee completion of the TB dignostic pthwy. As prt of ef forts to improve the utility of TB screening, WHO encourges monitoring of the full cscde of intensified TB cse finding, including: 1) identifiction of TB in those who screened positive for TB symptoms; nd 2) documenttion of wht TB investigtions were done to dignose or rule out TB disese. In December 21, the rpid moleculr test Xpert MTB/RIF ws endorsed by WHO with strong recommendtion for its use s the initil dignostic test for TB in two groups: people 1 The TEMPRANO ANRS 12136 Study Group; A Tril of Erly Antiretrovirls nd Isonizid Preventive Therpy in Afric. The New Englnd Journl of Medicine 215; DOI:1. 156/NEJMo157198. living with HIV with TB signs nd symptoms, nd people t high risk of hving MDR-TB (Chpter 5). This ws reiterted in the 213 updte to WHO policy recommendtions on the use of Xpert MTB/RIF, 2 nd in the 214 Xpert MTB/RIF implementtion mnul in which it is recommended tht people living with HIV should be prioritized for testing with Xpert MTB/RIF when resources re limited. 3 Discussions t Globl Forum of Xpert MTB/RIF implementers held in 214 indicted tht mjor motivtion for the roll-out of Xpert MTB/RIF ws of ten the ntionl response to multidrug-resistnt TB (MDR-TB), 4 rther thn dignosis of TB mong people living with HIV. To mximize the detection of TB cses mong HIV-positive people, Xpert MTB/RIF needs to be widely implemented in settings where HIV cre is provided, using ll vilble funding sources. Erly detection of TB in HIV cre settings cn in turn help to 2 Policy updte: Xpert MTB/RIF ssy for the dignosis of pulmonry nd extrpulmonry TB in dults nd children. Genev: World Helth Orgniztion; 213 (WHO/HTM/TB/213.16). Avilble t: http://who. int/tb/lbortory/xpert_policyupdte/en/ 3 Xpert MTB/RIF implementtion mnul: technicl nd opertionl how-to ; prcticl considertions. Genev: World Helth Orgniztion; 214 (WHO/HTM/TB/214.1). Avilble t: http://who.int/tb/publictions/ xpert_implem_mnul/en/ 4 Meeting Report of the Xpert MTB/RIF Implementers Globl Forum, 1 2 My 214. Genev: World Helth Orgniztion; 214. Avilble t: http:// www.stoptb.org/wg/gli/ssets/documents/xpert%2 Implementers%2Globl%2Forum%2meeting%2report.pdf. 84 n GLOBAL TUBERCULOSIS REPORT 215

Box 6.2 The use of Xpert MTB/RIF in dignosis of TB mong people living with HIV Dt on ntionl policies for using Xpert MTB/RIF s the initil dignostic test for TB mong people living with HIV were collected s prt of the 215 round of globl TB dt collection. Additionl dt were requested from 15 countries with the highest TB/HIV burden, of which nine responded: Ethiopi, Indi, Indonesi, Lesotho, Mynmr, South Afric, Ugnd, the United Republic of Tnzni nd Zimbbwe. Of the 41 high TB/HIV burden countries, 33 (8%) hd ntionl policy on the use of Xpert MTB/RIF by the end of 214. The eight countries tht did not report hving such policy in plce were Centrl Africn Republic, Chd, Chin, Côte d Ivoire, Mynmr, Nmibi, Sierr Leone nd Sudn. Of the nine countries tht responded to the more detiled survey, ll except Mynmr reported policy tht recommended Xpert MTB/RIF s the initil dignostic test for TB mong people living with HIV. A ntionlly stndrdized TB dignostic lgorithm for people living with HIV tht included Xpert MTB/RIF ws lso reported in these eight countries. Typiclly, Xpert MTB/RIF testing ws restricted to secondry nd tertiry level helth cre fcilities. Exceptions were Ethiopi nd South Afric, which reported vilbility t ll levels including t primry helth cre fcilities. In generl, routine documenttion nd reporting of Xpert MTB/RIF test results mong people living with HIV ws stted to be mjor chllenge, reflecting the fct tht ntionl registers nd reporting systems do not cpture such dt. To improve testing for TB mong people living with HIV nd ensure tht progress cn be monitored, wider doption of the WHO recommendtion to use Xpert/MTB RIF s the initil dignostic test nd updting of ntionl monitoring nd evlution systems tht will llow systemtic recording nd reporting re required. The use of Xpert MTB/RIF by HIV service providers, including in peripherl fcilities, lso needs to be promoted. A guide to monitoring nd evlution for collbortive TB/HIV ctivities. Genev: World Helth Orgniztion; 215 (WHO/HTM/ TB/215.2). Avilble t: http://www.who.int/tb/publictions/m_ nd_e_document_pge/en/ ensure prompt initition of ART. Recent nlysis suggests tht there hs been progress in dopting the WHO recommendtion to use Xpert MTB/RIF s the initil dignostic test for TB mong people living with HIV, but tht more remins to be done (Box 6.2). In 214, 76 countries reported dt bout the number of notified TB cses mong those newly enrolled in HIV cre to UNAIDS (up from 59 countries in 213). Unfortuntely, there were dt qulity problems for eight of these countries. Among the remining 68 countries, 9% (211 /2 34 ) of those newly enrolled in HIV cre in 214 were lso notified with TB in the sme yer. Among the 41 high TB/HIV burden countries, the proportion rnged from 2 3% in Chin, Côte d Ivoire, Indi nd Mlwi to 38% in the Russin Federtion (Tble 6.1). Ensuring good qulity dt nd monitoring trends in this indictor re importnt to trck the impct of HIV cre, especilly ART, on the burden of TB in people living with HIV. 6.4.2 Initition on isonizid preventive therpy A totl of 49 countries (representing more thn 6% of the estimted globl burden of HIV-ssocited TB) reported inititing people living with HIV on IPT. The totl number ws 933 people in 214, n increse from just over 6 people in 213 (Figure 6.6). Thirteen of the 41 high TB/HIV burden countries reported provision of IPT in 214, nd coverge mong people living with HIV who were newly enrolled in cre ws 41%. Coverge rnged from 5% in Swzilnd to 97% in Hiti. As in previous yers, South Afric ccounted for high proportion (59%) of the globl totl in 214: 552 HIVn FIGURE 6.6 Provision of isonizid preventive therpy (IPT) to people living with HIV, 25 214 Number of people living with HIV (thousnds) 1 8 6 4 2 Rest of Afric Rest of world South Afric Globl 25 26 27 28 29 21 211 212 213 214 GLOBAL TUBERCULOSIS REPORT 215 n 85

positive people were strted on IPT, out of 1 34 (53%) people living with HIV who were newly enrolled in cre. There ws evidence of IPT scle-up in the pst four yers in other countries in the Africn Region. Countries reporting higher numbers in 214 compred with previous yers included Mlwi (135 ), Mozmbique (94 ), Zimbbwe (3 ) Nigeri (26 ), the United Republic of Tnzni (23 ) nd Hiti (22 ). Nonetheless, 77% of countries did not report provision of IPT s prt of HIV cre in 214, including 68% (28/41) of the high TB/HIV burden countries. As with TB screening, it is cler tht countries continue to find it chllenging to provide IPT nd to record nd report dt on its provision or tretment completion. A good exmple is Nmibi, where reporting on provision of IPT ws not fesible in 214 following the withdrwl of donor funding tht hd previously supported the stf f required to record nd report dt. In 213, more thn 15 people newly enrolled in HIV cre were reported to hve been provided with IPT in Nmibi. Globl coverge of IPT is thus understted. 6.5 Improving dt qulity Ech yer, ef forts re mde to improve the qulity of dt relted to collbortive TB/HIV ctivities tht re reported s prt of globl monitoring ef forts by WHO nd UNAIDS. Two chllenges in prticulr hve been evident: discrepncies between the number of HIV-positive TB ptients on ART reported by TB nd HIV progrmmes, nd inconsistencies in the number of people reported to be newly enrolled in HIV cre for the sme country within the sme dt collection form (this number is requested twice in the WHO Universl Access Helth Sector TB indictors reported through the UNAIDS globl reporting system for HIV for two seprte indictors: enrollment on IPT, nd TB notifictions mong those newly enrolled in HIV cre). Encourgingly, the number of countries reporting discrepnt dt fell in 214 compred with 213, nd in lmost ll instnces these discrepncies were resolved following communictions with ntionl TB nd HIV progrmmes. There were two countries for which discrepnt dt on provision of ART reported by ntionl HIV nd TB progrmmes could not be reconciled (Botswn nd Côte d Ivoire) nd four countries for which discrepncies in dt bout the number of people newly enrolled in HIV cre could not be resolved (Guine-Bissu, Mongoli, Sint Vincent nd the Grendines nd Uzbekistn). In 215, WHO published A guide to monitoring nd evlution for collbortive TB/HIV ctivities 1 nd the Consolidted strtegic informtion guide for the helth sector. 2 Both documents hve hrmonized TB/HIV indictors using the sme indictor definitions, to help ensure reporting of the sme dt through globl reporting systems for HIV nd TB. These guidelines lso provide consolidted set of indictors for monitoring progress in the implementtion of collbortive TB/HIV ctivities. Countries re being encourged to dopt, monitor nd routinely report on these indictors. UNAIDS is currently undertking review of the Globl AIDS Response Progress Reporting (GARPR) indictors, in the context of these two guidnce documents. 1 World Helth Orgniztion. A guide to monitoring nd evlution of collbortive TB/HIV ctivities: 215 revision. Genev: World Helth Orgniztion; 215. Avilble t: http://www.who.int/tb/publictions/ monitoring-evlution-collbortive-tb-hiv/en/ 2 World Helth Orgniztion. Consolidted strtegic informtion guidelines for HIV in the helth sector. Genev: World Helth Orgniztion; 215. Avilble t: http://who.int/hiv/pub/guidelines/strtegic-informtionguidelines/en/ 86 n GLOBAL TUBERCULOSIS REPORT 215

CHAPTER 7 Finncing Key fcts nd messges The funding required for full response to the globl TB epidemic in low- nd middle-income countries is estimted t bout US$ 8 billion per yer in 215 (excluding reserch nd development for new TB dignostics, drugs nd vccines). Of the US$ 8 billion required in 215, bout two thirds (US$ 5.3 billion) is for the detection nd tretment of drugsusceptible TB; 2% (US$ 1.6 billion) for tretment of MDR-TB; 8% (US$.6 billion) for rpid dignostic tests nd ssocited lbortory strengthening, much of which is to improve detection of drug-resistnt TB; nd 6% (US$.5 billion) for collbortive TB/HIV ctivities. Projections mde in 213 suggested tht in 215, bout US$ 6 billion could be mobilized from domestic sources nd tht US$ 2 billion would be needed from interntionl donors. The 123 countries tht reported finncil dt to WHO in 215 ccount for 95% of reported TB cses globlly. Bsed on this self-reporting by countries, funding for TB prevention, dignosis nd tretment reched US$ 6.6 billion in 215, up from US$ 6.2 billion in 214 nd more thn double the level of 26 (US$ 3.2 billion). Compred with the estimted globl resource requirement of US$ 8 billion in 215 for full response to the TB epidemic in low nd middle-income countries, this leves gp of round US$ 1.4 billion. Countries themselves reported smller gps, mounting to US$.8 billion in 215; this reflects the fct tht ntionl plns for scling up TB prevention, dignosis nd tretment re less mbitious thn the trgets set in the Globl Pln to Stop TB, 211 215 in mny countries. Overll, 87% (US$ 5.8 billion) of the US$ 6.6 billion vilble in 215 is from domestic sources. Interntionl donor funding hs incresed since 26, reching US$.8 billion in 215. However, the globl verge for the shre of funding provided from domestic sources concels enormous vrition mong individul countries s well s country groups. Domestic funding domintes (93 94% of the totl funding vilble in 215) in three (not mutully exclusive) groups: Brzil, the Russin Federtion, Indi, Chin nd South Afric (BRICS); upper middle-income countries; nd regions outside Afric nd Asi. In ddition to BRICS, only one HBC (Thilnd) hs consistently reported levels of domestic funding tht exceed contributions from interntionl donor funding in recent yers. Interntionl donor funding domintes in the group of 17 HBCs outside BRICS (72% of the totl funding vilble in 215) nd in low-income countries (81% of the totl funding vilble in 215). At the individul country level, interntionl donor funding remins bsolutely criticl in most of the 22 HBCs. In four HBCs (Afghnistn, Bngldesh, the Democrtic Republic of the Congo nd Mozmbique), 9% of vilble funding in 215 is from interntionl donor sources. The cost per ptient treted for drug-susceptible TB in 214 fell into the rnge of US$ 1 US$ 5 in most countries with high burden of TB. The cost per ptient treted for MDR-TB ws most of ten in the rnge US$ 5 1, but the verge vried from US$ 6 826 in low-income countries to US$ 21 265 in upper middle-income countries. Helth finncing dt from ntionl helth ccounts provide insights into the current sttus of progress towrds universl helth coverge (UHC). Two suggested benchmrks required to chieve UHC re tht helth spending reches t lest 6% of gross domestic product (GDP) nd tht out-of-pocket expenditures ccount for less thn 15% of totl helth spending. Most countries, including ll of the 22 HBCs nd ll low-income countries, hve not yet reched these benchmrks. Among HBCs, Brzil, Thilnd nd South Afric re closest to doing so. Progress in TB prevention, dignosis nd tretment requires dequte funding sustined over mny yers. WHO begn nnul monitoring of funding for TB in 22, with findings published in globl TB reports nd peer-reviewed publictions. 1 Prticulr ttention hs lwys been given to the 22 high-burden countries (HBCs) tht ccount for bout 8% 1 The most recent publiction is: Floyd K, Fitzptrick C, Pntoj A nd 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. The Lncet Globl Helth, 213; 1: e15 15. of estimted incident cses (Chpter 2) nd bout 8% of TB cses reported by ntionl TB progrmmes (NTPs) to WHO (Chpter 3). This chpter covers five min topics. It strts with summry of the most up-to-dte estimtes of finncil resources required for full response to the TB epidemic in 215. This is followed by presenttion nd discussion of trends in funding for TB prevention, dignosis nd tretment by ctegory of expenditure nd source of funding for the period 26 (when the Stop TB Strtegy nd Globl Pln to Stop TB 26 215 were GLOBAL TUBERCULOSIS REPORT 215 n 87

both lunched) 1,2 to 215, for 123 countries (ccounting for 95% of reported TB cses in 213) for which dt were vilble. The third prt of the chpter nlyses funding gps reported by NTPs to WHO, with brekdowns by ctegory of expenditure nd country group. The fourth prt of the chpter includes the ltest estimtes of the unit costs of tretment for drug-susceptible nd multidrug-resistnt TB (MDR-TB). The new End TB Strtegy includes 225 milestones for 75% reduction in TB deths nd 5% reduction in the TB incidence rte, compred with bseline of 215 (Chpter 1). Achievement of these milestones requires tht universl helth coverge (UHC), defined s ccess for ll to essentil preventive nd tretment helth cre interventions, with finncil protection, is in plce by 225. 3,4 In this context, the fif th nd finl prt of the chpter introduces new topic to the globl TB report: n nlysis of helth finncing dt nd wht insights these cn offer bout the current sttus of progress towrds UHC. Further country-specific dt cn be found in finnce profiles tht re vilble online. 5 7.1 Estimtes of funding required in 215 for full response to the globl TB epidemic An updted version of the Globl Pln to Stop TB 26 215, covering the lst five yers of the pln, ws issued in 21. 6 This set out the ctions nd estimted funding requirements for full response to the TB epidemic for the five-yer period 211 215 in low nd middle-income countries, bsed on the Stop TB Strtegy, with the overll gol of chieving the 215 globl trgets for reductions in cses of nd deths from TB i.e. tht incidence should be flling nd tht prevlence nd mortlity rtes should be hlved compred with their levels in 199 (Chpter 1, Chpter 2). Key components of the pln included incresing the number of ptients detected nd treted ccording to WHO s recommended strtegy from 5.8 million in 211 to 6.9 million by 215 (equivlent to more thn 8% of the forecst number of incident cses in 215 t the time the projections were done); ensuring testing for drug susceptibility for ll previously treted ptients nd ll new ptients with known risk fctors for MDR-TB by 215; enrolment of ll reported TB ptients with MDR-TB (projected t pproximtely 3 ) in 215 on second-line tretment; HIV testing of ll ptients with TB; nd prompt initition of ART in ll HIV-positive TB ptients. 1 Rviglione M, Uplekr M. WHO s new Stop TB strtegy. Lncet 26; 367: 952 5. 2 The Globl Pln to Stop TB, 26 215. Genev, World Helth Orgniztion; 26 (WHO/HTM/STB/26.35). 3 World Helth Orgnistion, World Bnk Group. Monitoring progress towrds universl helth coverge t country nd globl levels. Frmework, mesures nd trgets. Genev: World Helth Orgniztion; 214 (WHO/ HIS/HIA/14.1). 4 World Helth Orgnistion. The World Helth Report 21: Helth systems finncing: the pth to universl coverge. Genev, World Helth Orgniztion; 21. 5 www.who.int/tb/dt 6 The Globl Pln to Stop TB, 211 215. Genev, World Helth Orgniztion; 21 (WHO/HTM/STB/21.2). From Jnury to Mrch 213, the Globl Pln dtsets were used in combintion with new country-specific plnning nd budgeting work with nine high TB or high MDR-TB burden countries to produce updted estimtes of funding needs for TB prevention, dignosis nd tretment in low nd middle-income countries. 7 The nine countries were Ethiopi, Indi, Indonesi, Kzkhstn, Keny, Nigeri, Pkistn, South Afric nd Ukrine. Anlyses were conducted in the context of estimtes of funding needs nd funding gps required for the Globl Fund s replenishment ef forts in 213. 8 WHO subsequently extended these nlyses to cover ll lownd middle-income countries, including those not eligible to pply to the fund. 9 Notble countries (in terms of TB burden nd funding requirements) tht re not eligible to pply to the Globl Fund include Brzil, Chin nd the Russin Federtion. During the course of the work done for the first prereplenishment meeting held in April 213, it should be highlighted tht the Globl Fund, WHO, UNAIDS, nd other prtners greed tht funding needs for ART for HIV-positive TB ptients should be included in estimtes of HIV resource needs to void double counting. For this reson, the estimtes of resource requirements for TB/HIV interventions included in the updted estimtes of resource needs for TB re lower thn those shown in the Globl Pln. The totl funding required in ll low nd middle-income countries ws estimted t bout US$ 8 billion in 215. Of this totl, bout two-thirds (US$ 5.3 billion) ws for the detection nd tretment of drug-susceptible TB; 2% (US$ 1.6 billion) for tretment of MDR-TB; 8% (US$.6 billion) for rpid dignostic tests nd ssocited lbortory strengthening, especilly for the detection of MDR-TB; nd 6% (US$.5 billion) for collbortive TB/HIV ctivities (excluding ART). It ws lso estimted tht of the totl required in 215, bout US$ 6 billion could be mobilized from domestic sources nd round US$ 2 billion would be needed from interntionl donor sources. The cpcities of Brzil, the Russin Federtion, Indi, Chin nd South Afric (BRICS, which collectively ccount for lmost 5% of reported TB cses worldwide) to mobilize most of their funding needs from domestic sources, in contrst with other country groups including the 17 other HBCs nd low-income countries (mostly in Afric) where lrge mounts of interntionl funding would be needed, were highlighted. 7 Funding required for reserch nd development for new TB dignostics, drugs nd vccines ws not considered. In the Globl Pln, it is estimted tht bout US$ 2 billion per yer is needed for reserch nd development. In 213, funding for reserch nd development mounted to US$.7 billion (see http://www.tretmentctiongroup. org/tbrd214). 8 The Globl Fund to Fight AIDS, Tuberculosis nd Mlri fourth replenishment (214 216): needs ssessment. Genev, Globl Fund to Fight AIDS, Tuberculosis nd Mlri; 213. 9 Floyd K, Fitzptrick C, Pntoj A nd 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. The Lncet Globl Helth, 213; 1: e15 15. 88 n GLOBAL TUBERCULOSIS REPORT 215

n FIGURE 7.1 Funding for TB prevention, dignosis nd tretment by intervention re, 26 215 (constnt 215 US$ billions) US$ billions 7 6 5 4 3 2 1 Other Drug-susceptible TB TB/HIV Totl MDR-TB 26 27 28 29 21 211 212 213 214 215 7.2 TB funding, overll nd by ctegory of expenditure nd source of funding, 26 215 Dt reported by NTPs to WHO since 26 llowed nlysis of funding trends 26 215 in 123 countries (Tble 7.1). These countries ccounted for 95% of the globl number of TB cses reported in 214, nd included 12 low nd middleincome countries plus three high TB nd/or MDR-TB burden countries tht hve reched high-income sttus (Estoni, Ltvi nd the Russin Federtion). The methods used to collect, review nd nlyse finncil dt re summrized in Box 7.1. n FIGURE 7.2 Funding for drug-susceptible TB nd MDR-TB, 26 215, by country group (constnt 215 US$ millions) BRICS 17 other HBCs Other low- nd middle-income countries (n=97) 2 125 1 US$ millions 15 1 5 1 75 5 25 75 5 25 26 29 212 215 26 29 212 215 26 29 212 215 Drug-susceptible TB MDR-TB n FIGURE 7.3 Funding for TB prevention, dignosis nd tretment by funding source, 26 215 (constnt 215 US$ billions) US$ billions 7 6 5 4 3 2 1 26 27 28 29 21 211 212 213 214 215 Totl Domestic (NTP budget) Inptient nd outptient cre (best estimte likely >95% is domestic funding ) Globl Fund (NTP budget) Other interntionl donors (NTP budget) 96% of funding for inptient nd outptient cre is ccounted for by middle nd high-income countries; such countries do not typiclly receive interntionl donor funding for inptient nd outptient cre services. Dt is n estimte bsed on country-reported utiliztion. In these 123 countries, funding for TB prevention, dignosis nd tretment reched US$ 6.6 billion in 215, up from US$ 6.2 billion in 214 nd more thn double the US$ 3.2 billion tht ws vilble in 26 (Figure 7.1). Of the totl of US$ 6.6 billion, most is for the dignosis nd tretment of drug-susceptible TB (US$ 3.9 billion). Funding for MDR-TB hs grown, especilly since 29, reching US$ 2.3 billion in 215 (Figure 7.1, Figure 7.2). However, it should be highlighted tht more thn hlf of this funding is ccounted for by the Russin Federtion (Tble 7.2), reflecting extensive use of hospitliztion for ptients with MDR-TB. Given the still lrge detection gps for MDR-TB s well s gps between the numbers of cses detected nd strted on tretment (Chpter 4), much more funding is required for MDR-TB globlly nd in most of the high MDR-TB burden countries. A detiled brekdown of the funding estimted to be required for drug-susceptible TB, MDR-TB nd collbortive TB/HIV ctivities in 215, bsed on NTPs ssessments of their needs, is shown for the 36 high TB nd MDR-TB burden countries in Tble 7.2. Domestic funding for the TB-specific budgets of NTPs ccounts for the lrgest single shre of funding, followed by funding for inptient nd outptient cre (Figure 7.3). Since GLOBAL TUBERCULOSIS REPORT 215 n 89

n TABLE 7.1 123 low nd middle-income countries included in nlyses of TB finncing, by income group nd WHO region, 215 Afric LOW-INCOME (13% OF NOTIFIED CASES GLOBALLY IN 214) Benin, Burkin Fso, Burundi, Centrl Africn Republic, Chd, DR Congo, Eritre, Ethiopi, Gmbi, Guine, Guine-Bissu, Liberi, Mdgscr, Mlwi, Mli, Mozmbique, Niger, Rwnd, Sierr Leone, South Sudn, Togo, Ugnd, UR Tnzni, Zimbbwe LOWER-MIDDLE-INCOME (57% OF NOTIFIED CASES GLOBALLY IN 214) Cbo Verde, Cmeroon, Congo, Côte d Ivoire, Ghn, Keny, Lesotho, Muritni, Nigeri, So Tomé nd Principe, Senegl, Swzilnd, Zmbi Americs Hiti Bolivi, El Slvdor, Guteml, Guyn, Hondurs, Nicrgu Estern Mediterrnen Europe South-Est Asi Afghnistn, Somli Democrtic People s Republic of Kore, Nepl Djibouti, Egypt, Morocco, Pkistn, Sudn, Syri, West Bnk nd Gz Strip, Yemen Armeni, Georgi, Kyrgyzstn, Republic of Moldov, Tjikistn, Ukrine, Uzbekistn Bngldesh, Bhutn, Indi, Indonesi, Mynmr, Sri Lnk, Timor-Leste Western Pcific Cmbodi Kiribti, Lo People s Democrtic Republic, Micronesi (Federl Sttes of), Ppu New Guine, Philippines, Smo, Solomon Islnds, Vnutu, Viet Nm UPPER-MIDDLE-INCOME (25% OF NOTIFIED CASES GLOBALLY IN 214) Angol, Botswn, Gbon, Nmibi, South Afric Belize, Brzil, Colombi, Dominicn Republic, Ecudor, Jmic, Mexico, Pnm, Prguy, Peru, Surinme Irn (Islmic Republic of), Irq, Jordn, Lebnon, Tunisi Bosni nd Herzegovin, Bulgri, Kzkhstn, Montenegro, Romni, Serbi, The Former Yugoslv Republic of Mcedoni, Turkey BRICS (48% OF NOTIFIED CASES GLOBALLY IN 214) South Afric Brzil Russin Federtion 17 HIGH-BURDEN COUNTRIES EXCLUDING BRICS (33% OF NOTIFIED CASES GLOBALLY IN 214) DR Congo, Ethiopi, Keny, Mozmbique, Nigeri, Ugnd, UR Tnzni, Zimbbwe Afghnistn, Pkistn Mldives, Thilnd Indi Bngldesh, Indonesi, Mynmr, Thilnd Americn Smo, Chin, Fiji, Mlysi, Mrshll Islnds, Mongoli, Plu, Tong, Tuvlu Not included Comoros Albni, Algeri, Azerbijn, Belrus, Cost Ric, Cub, Dominic, Grend, Liby, Plu, Sint Luci, Sint Vincent nd the Grendines, Turkmenistn Chin Cmbodi, Philippines, Viet Nm 14 HIGH MDR-TB BURDEN COUNTRIES (NOT IN THE LIST OF 22 HIGH-BURDEN COUNTRIES) (2% OF NOTIFIED CASES GLOBALLY IN 214) Armeni,Bulgri, Estoni, Georgi, Kzkhstn, Kyrgyzstn, Ltvi, Republic of Moldov, Tjikistn, Ukrine, Uzbekistn Azerbijn, Belrus, Lithuni Anlyses focus primrily on low nd middle-income countries. Three high-income countries (Estoni, Ltvi nd the Russin Federtion) were included becuse they re in the list of 22 high-burden countries or the list of 27 high MDR-TB burden countries. Additionl countries included in trend nlyses of TB finncing compred with those included in previous globl reports re shown in bold. 9 n GLOBAL TUBERCULOSIS REPORT 215

n TABLE 7.2 TB budget reported by NTP by intervention re, nd estimted cost of inptient nd outptient cre for drug-susceptible (DS-TB) nd MDR-TB, 36 high TB or MDR-TB burden countries, 215 (current US$ millions) TB BUDGET REPORTED BY NTP RESOURCES REQUIRED FOR INPATIENT AND OUTPATIENT CARE TOTAL DS-TB MDR-TB TB/HIV DS-TB MDR-TB RESOURCES REQUIRED FOR TB CARE 22 HIGH-BURDEN COUNTRIES Afghnistn 15 13 1.3.1 6.7.2 22 Bngldesh 48 42 5.6.1 1..1 49 Brzil 77 65 9.4 2.3 47 1.9 126 Cmbodi 31 28 1.9.6 6.4 37 Chin 34 313 27 34 DR Congo 55 48 3.3 3.1 2.7 57 Ethiopi 82 57 19 5.6 8..3 91 Indi 261 179 78 4. 456 7 788 Indonesi 133 119 11 2.7 27.6 5.1 165 Keny 45 39.8 5.2 4.4.9 5 Mozmbique 29 18 6.4 4.3 3.7.3 33 Mynmr 36 23 9.5 4.4 3..5 4 Nigeri 228 156 54 17 8.5 3.8 24 Pkistn 5 33 17 3..2 53 Philippines 16 84 21.9 185 5.9 298 Russin Federtion,b 1 894 637 1 211 47 1 894 South Afric 248 129 61 58 99 363 71 Thilnd 32 27 5.2.1 7..1 39 Ugnd 24 21 2.1 1.1.6 25 UR Tnzni 67 53 9.6 4.5 2.4.3 7 Viet Nm 66 6 5.9.8 33 2.7 12 Zimbbwe 28 22 2.2 3.5.5 29 22 high-burden countries 3 895 2 166 1 563 165 91 455 5 261 REMAINING HIGH MDR-TB BURDEN COUNTRIES Armeni 4.2 4.2 3.7 2.1 1 Azerbijn 6.3 2.5 3.7 19 7.9 33 Belrus 15 1.9 13 <.1 22 29 66 Bulgri 15 15.2 11.6 27 Estoni.6.3.3 1.3 1.1 3.1 Georgi 17 8.6 8. 5.4 4.6 27 Kzkhstn 195 163 3 1.2 15 81 381 Kyrgyzstn 29 16 13 5.1 5. 39 Ltvi 1.6.2 1.4 11 2.6 15 Lithuni 7.4 11 18 Republic of Moldov 17 13 4.1.1 6.8 5.8 3 Tjikistn 25 16 7.7.7 5. 1.9 32 Ukrine 123 59 62 2.2 32 27 182 Uzbekistn 11 88 12 <.1 35 1 146 27 high MDR-TB burden countries 4 97 2 268 1 681 148 1 11 64 5 838 36 high-tb or high MDR-TB burden countries 4 445 2 555 1 72 17 1 18 644 6 268 Blnk cells indicte dt not reported. indictes vlues tht cnnot be clculted. No mount is shown for Chin nd the Russin Federtion becuse the NTP budgets reported by those countries include ll budgets for inptient nd outptient cre. b In the Russin Federtion, the stf f nd infrstructure reported for TB cre nd control were llocted to DS-TB (23%) nd MDR-TB (77%) by WHO bsed on the proportion of bed-dys used by DS-TB nd MDR-TB ptients. GLOBAL TUBERCULOSIS REPORT 215 n 91

Box 7.1 Methods used to compile, vlidte nd nlyze finncil dt reported to WHO WHO begn monitoring government nd interntionl donor finncing for TB in 22. All dt re stored in the WHO globl TB dtbse. The stndrd methods used to compile, review, vlidte nd nlyse these dt hve been described in detil elsewhere.,b This box provides summry. Ech yer, WHO requests ll low nd middle-income countries (nd the Russin Federtion, the only HBC tht is high-income country) to report the funding required 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 215 round of globl TB dt collection, the fiscl yers were 215 nd 214, respectively. Ctegories of expenditure for dignosis nd tretment of drug-susceptible TB were synthesized compred to those used 26 214, to simplify reporting. Six ctegories were used: lbortory infrstructure, equipment nd supplies; NTP stf f (centrl unit stf f nd subntionl TB stf f); drugs to tret drug-susceptible TB; progrmme costs; ptient support; nd opertionl reserch including surveys. The min chnge ws tht severl subctegories of progrmme costs were condensed into one ctegory (this mens tht trends cn still be ssessed bck to 26). Ctegories of expenditure used for MDR-TB remined the sme s those used since 26: second-line drugs, nd progrmmtic mngement of MDR-TB. Budgets nd expenditures for collbortive TB/ HIV ctivities were requested s one consolidted ctegory of expenditure, s in previous yers. Funding vilble from four mjor sources ws requested, lso s in previous yers: domestic funding excluding lons; externl lons, lso considered domestic funding; the Globl Fund; nd grnt finncing from sources other thn the Globl Fund. A simplifiction compred with previous yers ws tht only n overll brekdown of totl funding ws requested, s opposed to brekdown for ech ctegory of expenditure. Agin, this does not f fect bility to report trends in formt consistent with those published in pst reports. For highincome countries (except the Russin Federtion which is n HBC), only totls for both funding requirements nd expenditures were requested, without ny brekdown by ctegory of expenditure or source of funding, s in previous yers. As usul in 215, ll countries were sked to report on the utiliztion of inptient nd outptient cre required for tretment of people with drug-susceptible nd MDR-TB, on per ptient bsis (i.e. the verge number of dys spent in hospitl, nd the verge number of outptient visits to helth fcility). These dt re used in combintion with other informtion to estimte the finncil resources used for TB prevention, dignosis nd tretment tht re not reflected in TB-specific reports of funding requirements, vilble funding nd expenditures (further detils re provided below). Core methods used to review nd vlidte dt hve remined consistent since 22. They include: " Routine checks for plusibility nd consistency, including vlidtion checks tht re built into the online reporting system. Exmples of vlidtion checks re checks for implusibly lrge yer-to-yer chnges (for exmple 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 dif fer substntilly from prices quoted by the Globl TB Drug Fcility). " Discussions with country respondents to resolve queries. " Tringultion with other dt sources. One exmple is the detiled budgets prepred by NTPs tht re peer-reviewed by WHO s prt of ef forts to strengthen the budgeting of ntionl strtegic plns for TB cre nd control. Comprehensive nd robust budgets for ntionl strtegic plns re now n essentil requirement for funding pplictions to the Globl Fund, s prt of this gency s new funding model introduced in 213. Two tools promoted by WHO (the WHO TB plnning nd budgeting tool nd the OneHelth tool) c,d for estimting funding requirements llow mpping of detiled budgets to the line items used in the WHO TB dt collection form, nd comprisons with dt reported online. Tringultion is lso undertken with dt vilble from the Globl Fund, e USAID, f nd the Orgniztion for Economic Coopertion nd Development s Creditor Reporting System. In 215, for exmple, reported dt were compred with dt submitted to the Globl Fund s prt of the funding gp nlyses required for funding proposls nd follow-up nd djustments mde s pproprite. In 214 nd 215, dditionl elements of review nd vlidtion included fcilittion of communictions between focl points for Ntionl Helth Accounts nd NTP mngers, with the im of using expenditure dt generted from implementtion of the System of Helth Accounts 211 (tht llows expenditures to be reported by disese) for reporting of TB expenditures wherever vilble. In reviewing nd vlidting dt, prticulr ttention hs lwys been given to the 22 HBCs. A summry of dt vlidtion methods used for HBCs is provided in Tble B7.1. TB funding reported by NTPs usully does not include the finncil costs ssocited with the inptient nd outptient cre required during TB tretment (mong HBCs, the notble exceptions re Chin nd the Russin Federtion, since tretment is provided in TB-specific clinics or hospitls for which ermrked budgets nd funding exist). Since mny detiled costing studies in wide rnge of countries show tht these costs ccount for lrge shre of the cost of treting someone with TB, g nlyses of TB finncing undertken by WHO hve lwys included estimtes of the funding used for both inptient nd outptient cre. As in pst reports, WHO estimtes the funding used for inptient nd outptient cre of TB ptients by multiplying the number of outptient visits nd dys of inptient cre per ptient (reported by NTPs ech yer) by the cost per bed-dy nd clinic visits vilble from the WHO-CHOICE dtbse h nd then by the reported number of TB ptients notified or projected to be notified. This is done seprtely for drug-susceptible TB nd MDR-TB. For further three countries (Belrus, Burkin Fso nd the Democrtic Republic of the Congo), dt from recent Ntionl Helth Account (NHA) were used. i It is hoped tht in the ner future, NHA dt will be routinely vilble for mny more countries, including brekdown by source of funding (domestic vs interntionl) tht is currently not vilble for ny country. b c Floyd K, Pntoj A, Dye C. Finncing tuberculosis monitoring system. Bulletin of the World Helth Orgniztion; 27; 85:334 4. Floyd K, Fitzptrick C., Pntoj A nd Rviglione M. Domestic nd donor funding for tuberculosis cre nd control in low-income nd middleincome countries: n nlysis of trends 22 11, nd requirements to meet 215 trgets. The Lncet Globl Helth; 1: e15 15. Plnning nd budgeting for TB control ctivities. Genev, World Helth Orgniztion; 215. http://www.who.int/tb/dots/plnning_budgeting_ tool/en/ 92 n GLOBAL TUBERCULOSIS REPORT 215

TABLE B7.1 Methods used to review nd vlidte finncing dt reported by NTPs, high TB nd MDR-TB burden countries COUNTRY ROUTINE REAL-TIME CHECKS FOR PLAUSIBILITY AND INTERNAL CONSISTENCY (TRENDS OVER TIME), REVIEW AND FOLLOW-UP CHECKS BY WHO FINANCE DATA REVIEWERS, UPDATES/ CORRECTIONS ENCOURAGED REVIEW BY IN-COUNTRY WHO TB MEDICAL OFFICER NATIONAL TB STRATEGIC PLANNING AND BUDGETING AND ASSOCIATED ASSESSMENT OF SOURCES OF FUNDING USING WHO RECOMMENDED COSTING TOOLS b UNIT COST DATA AVAILABLE FROM INDEPENDENT ECONOMIC EVALUATION 22 HIGH TB BURDEN COUNTRIES Afghnistn yes yes yes (213) no Bngldesh yes yes yes (214) yes Brzil yes yes no yes Cmbodi yes yes yes (29) yes Chin yes yes no yes DR Congo yes yes yes (214) no Ethiopi yes sometimes yes (214) yes Indi yes yes yes (213) yes Indonesi yes yes yes (213) yes Keny yes yes yes (213) yes Mozmbique yes mostly yes (213) no Mynmr yes yes yes (211) no Nigeri yes yes yes (213) yes Pkistn yes yes yes (213) yes Philippines yes yes yes (211) yes Russin Federtion yes yes no yes South Afric yes yes yes (213) yes UR Tnzni yes yes no yes Thilnd yes yes yes (215) yes Ugnd yes yes yes (213) yes Viet Nm yes yes no yes Zimbbwe yes yes yes (213) yes REMAINING HIGH MDR-TB BURDEN COUNTRIES Armeni yes Wolfheze working group on finncing yes (21) no Azerbijn yes no no no Belrus yes Wolfheze working group on finncing no no Bulgri yes no no no Georgi yes no no no Kzkhstn yes no yes (213) no Kyrgyzstn yes yes yes (213) no Ltvi yes no no yes Lithuni no no no no Republic of Moldov yes no no no Tjikistn yes no no yes Ukrine yes yes yes (213) yes Uzbekistn yes no yes (211) no Source: GTB compiltion bsed on dt review process nd Lwrence Y. et l, 215. Dt for Lithuni hs never been reported to WHO. b The tools recommended by WHO re the OneHelth tool nd the WHO TB Plnning nd Budgeting tool. d e f Plnning nd budgeting for TB control ctivities s prt of sector wide ntionl strtegic helth plns nd policies. Genev, Inter-Agency working group; 215. Avilble t: http://www.who.int/choice/onehelthtool/en/ For exmple, dt vilble t http://web-pi.thegloblfund.org/odt/ were ccessed in My 215. FY 213 Congressionl Budget Justifiction for Foreign Opertions. Relesed Mrch nd April 212, USAID http://www.stte.gov/f/releses/ ib/fy213cbj/pdf/ g h i Lurence YV, Grif fiths UK, Vssll A. Costs to Helth Services nd the Ptient of Treting Tuberculosis: A Systemtic Literture Review. PhrmcoEconomics. 215:1 17. Choosing interventions tht re cost ef fective (WHO-CHOICE). Genev, World Helth Orgniztion; 28. Avilble t: http://www.who.int/ choice/cost-ef fectiveness/inputs/helth_service/en/ Ntionl Helth Accounts http://www.who.int/helth-ccounts/en/ GLOBAL TUBERCULOSIS REPORT 215 n 93

lmost ll (96%) of the funding estimted to be used for inptient nd outptient cre is ccounted for by middle- or high-income countries, it cn be ssumed tht virtully ll of this funding is from domestic sources (interntionl donor funding for inptient nd outptient cre is only likely to occur in low-income countries, vi generl budget support to the helth sector). Overll, 87% of the estimted funding of US$ 6.6 billion in 215 is from domestic sources. Interntionl donor funding for the TB-specific budgets of NTPs hs incresed since 26, reching US$.8 billion in 215. It is importnt to highlight tht the funding reported by NTPs does not cpture ll interntionl donor funding for TB; donor funding is lso provided to entities other thn NTPs, including interntionl nd ntionl governmentl nd nongovernmentl orgniztions. A more comprehensive nlysis of interntionl donor funding, bsed on donor reports to the Orgniztion for Economic Coopertion nd Development (OECD), is provided in Box 7.2. 1 It is lso importnt to emphsize tht the globl verge for the shre of funding provided from domestic sources concels enormous vrition mong individul countries, s well s country groups tht cn be defined bsed on TB burden, geogrphy, politicl/economic profile nd income level (Figure 7.4, Tble 7.3). Domestic funding domintes (93 94% of the totl funding vilble in 215) in three (not mutully exclusive) groups: BRICS, upper middle-income countries nd regions outside Afric nd Asi. In ddition to BRICS, only one HBC (Thilnd) hs consistently reported levels of domestic funding tht exceed contributions from interntionl donor funding in recent yers. In lower middle-income countries, domestic funding hs risen from US$.2 billion in 26 to over US$.5 billion in 215, but interntionl donor funding hs lso ssumed greter nd greter importnce, reching prity with domestic funding in 215. Most of the increse in lower middle-income countries hs been driven by grnts from the Globl Fund. Interntionl donor funding domintes in the group of 17 HBCs outside BRICS (73% of the totl funding vilble in 215) nd in low-income countries (8% of the totl funding vilble in 215). At the individul country level, it remins bsolutely criticl to funding for TB prevention, dignosis nd tretment in most of the 22 HBCs, nd in four HBCs (Afghnistn, Bngldesh, the Democrtic Republic of the Congo nd Mozmbique), 9% of vilble funding in 215 is from interntionl donor sources. 1 Out-of-pocket expenditures re lso not included in NTP reports. These re nlysed in more detil in section 7.5. 7.3 Funding gps reported by ntionl TB progrmmes, 26 215 Despite growth in funding from domestic nd interntionl donor sources, mny NTPs continue to be unble to mobilize ll the funding required for full implementtion of their ntionl strtegic plns (Figure 7.5). Funding gps (i.e. the dif ference between ssessments by NTPs of funding needs for TB prevention, dignosis nd tretment nd the ctul mount of funds mobilized) hve persisted nd in 215 mounted to totl of US$.8 billion. This is considerbly less thn the gp of US$ 1.4 billion tht exists between the US$ 8 billion estimted to be needed for full response to the TB epidemic in 215 (section 7.1) nd the US$ 6.6 billion vilble in 215 (section 7.2). The dif ference cn be explined by the fct tht ntionl strtegic plns for TB remin less mbitious thn the trgets set in the Globl Pln to Stop TB, 211 215 (section 7.1) in mny countries. Lower middle-income countries ccount for the lrgest reported funding gps (bout US$.5 billion in 215), of which US$.4 billion ws in five countries (Nigeri, Indonesi, Ukrine, Viet Nm nd the Philippines, in descending order). There my be dditionl cpcity to mobilize more domestic funding in these countries. Funding gps were reltively smll in upper middle-income countries in 215 (Figure 7.5), nd hve fllen in recent yers mostly explined by lrge reductions in the funding gps reported by the Russin Federtion nd Kzkhstn. These two countries reported no funding gps in 214 or 215. Funding gps reported by low-income countries fell between 214 nd 215, reflecting shif t of some countries from the low to middle-income country group between 214 nd 215. Geogrphiclly, the Africn Region hs by fr the lrgest funding gp: US$.4 billion in 215, equivlent to hlf of the globl totl. The lrgest gp ws reported by Nigeri (US$ 154 million, see Tble 7.3). Of the US$.8 billion funding gp reported by NTPs in 215, US$.64 billion is for drug-susceptible TB nd US$.14 billion is for MDR-TB. Reltive to totl funding needs, the funding gp is lrger for drug-susceptible TB. Domestic funding ccounts for lrger shre of the funding for MDR-TB compred with drug-susceptible TB, which is not surprising given tht most of the high MDR-TB burden countries re middle or high-income countries nd 14 of 27 re in the Europen Region. 7.4 Unit costs of tretment for drugsusceptible nd MDR-TB, 214 The cost per ptient treted for drug-susceptible nd MDR- TB could be estimted for 117 countries nd 9 countries, respectively. The nlysis of the cost per TB ptient with drug-susceptible TB ws limited to countries tht hd notified t lest 1 TB cses in 214. Estimtes of the unit cost of MDR-TB tretment were restricted to countries tht reported t lest 1 ptients on second-line tretment for MDR-TB. 94 n GLOBAL TUBERCULOSIS REPORT 215

n TABLE 7.3 TB budget reported by NTP, vilble funding from domestic nd interntionl donor sources, funding gp nd shre of budget provided by domestic nd interntionl donor funding, 36 high TB or MDR-TB burden countries, 215 (current US$ millions) TB BUDGET REPORTED BY NTP 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 (%) 22 HIGH-BURDEN COUNTRIES Afghnistn 15.9 1 8.1% 92% 4. Bngldesh 48.1 33.4% 1% 14 Brzil 77 55.6 99% 1.1% 21 Cmbodi 31 3.6 14 2% 8% 13 Chin 34 36 6 98% 2% 28 DR Congo 55 3. 27 1% 9% 24 Ethiopi 82 9.1 35 21% 79% 38 Indi 261 121 14 46% 54% Indonesi 133 18 27 39% 61% 88 Keny 45 12 13 48% 52% 2 Mozmbique 29 1.6 19 7.9% 92% 8.1 Mynmr 36 3.9 25 14% 86% 8 Nigeri 228 3 44 41% 59% 154 Pkistn 5 8.4 3 22% 78% 12 Philippines 16 25 42 37% 63% 4 Russin Federtion 1 894 1 893 1. 1% % South Afric 248 28 19 91% 8.6% 21 Thilnd 32 17 3.6 82% 18% 12 Ugnd 24 2.4 17 12% 88% 5.2 UR Tnzni 67 8.5 12 41% 59% 47 Viet Nm 66 6.7 12 37% 63% 48 Zimbbwe 28 2. 17 11% 89% 1 22 high-burden countries 3 895 2 735 546 83% 17% 614 FUNDING GAP REMAINING HIGH MDR-TB BURDEN COUNTRIES Armeni 4.2 3. 1.2 71% 29% Azerbijn 6.3 1.2 5.1 19% 81% Belrus 15 7.1 3.6 66% 34% 4.7 Bulgri 15 13 1.8 88% 12% Estoni.6.6 1% <1% Georgi 17 5.5 7.9 41% 59% 3.2 Kzkhstn 195 195 1% % Kyrgyzstn 29 11 18 37% 63% Ltvi 1.6 1.6 1% % Lithuni Republic of Moldov 17 1 7.1 59% 41% Tjikistn 25 6.9 13 35% 65% 5.1 Ukrine 123 5 23 68% 32% 5 Uzbekistn 11 86 14 86% 14% 27 high MDR-TB burden countries 4 97 3 23 536 85% 15% 538 36 high-tb or high MDR-TB burden countries 4 445 3 126 641 83% 17% 678 Blnk cells indicte dt not reported. indictes vlues tht cnnot be clculted. The funding gp reflects the nticipted gp for the yer t the time country reported dt in the 215 round of globl TB dt collection. GLOBAL TUBERCULOSIS REPORT 215 n 95

Box 7.2 Interntionl donor funding for TB prevention, dignosis nd tretment, bsed on donor reports to the Orgniztion for Economic Coopertion nd Development Interntionl donor funding provided for TB prevention, dignosis nd tretment is chnnelled to NTPs nd other recipients. The finncil dt reported to WHO by NTPs therefore understtes the totl mount of interntionl donor funding being provided ech yer. The creditor reporting system (CRS) of the Orgniztion for Economic Coopertion nd Development (OECD) is the most comprehensive source of informtion bout interntionl donor funding. Reports re provided by 31 multilterl orgniztions, FIGURE B7.2.1 Interntionl donor funding for TB prevention, dignosis nd tretment by source, 24 213 US$ millions 8 6 4 2 Other multilterls Other countries Globl Fund United Sttes 24 25 26 27 28 29 21 211 212 213 The increse between 212 nd 213 ws mostly ccounted for by Indi, which hd Globl Fund disbursement of US$ 11 million in 212 nd US$ 165 million in 213. 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). The OECD compiles dt on commitments nd disbursements from both governments nd multilterl orgniztions. Disbursement dt include both direct trnsfers to countries s well s the provision of goods nd services, such s in-kind trnsfers or technicl ssistnce. Dt on gross disbursements for TB (s opposed to commitments tht my not lwys be trnslted into ctul funding) were nlysed for 24 213. All funding coded s for TB (code 12263: tuberculosis control) ws included. It should be highlighted tht funding for TB tht flows between OECD countries is not recorded in the OECD dtbse. It is lso importnt to note tht in the OECD dtbse, government contributions to multilterl orgniztions re not ttributed to the government of origin but only to the multilterl orgniztion (for exmple, funding received by countries from Globl Fund grnts re ttributed to the Globl Fund, s opposed to the originl donor to the Globl Fund). Figure B7.2.1 shows tht interntionl donor funding for TB incresed from US$ 148 million in 24 to US$ 122 million in 213. Most of the funding tht ws provided 24 213 cme from the Globl Fund (72%), followed by the government of the United Sttes of Americ (14%). Remining funding for TB cme from other countries (8%) nd other multilterl orgniztions (6%), mong which the lrgest donors were the governments of Cnd (4%) nd the United Kingdom (3%). The Globl Fund hs consistently been the lrgest provider of interntionl donor funding for TB, including US$ 788 million in 213. Funding incresed stedily from 24 to 213 with the exception of drop from 21 to 211. Disbursements from the government of the United Sttes of Americ stedily incresed from 27 to 211 FIGURE B7.2.2 Interntionl donor funding for TB prevention, dignosis nd tretment by region, 24 213 US$ millions Afric 3 2 1 US$ millions Americ 4 3 2 1 25 26 27 28 29 21 211 212 213 25 26 27 28 29 21 211 212 213 US$ millions Asi Europe 5 5 4 4 3 3 2 2 1 1 25 26 27 28 29 21 211 212 213 25 26 27 28 29 21 211 212 213 US$ millions Globl Fund United Sttes Other countries Other multilterls 96 n GLOBAL TUBERCULOSIS REPORT 215

FIGURE B7.2.3 Interntionl donor funding for TB prevention, dignosis nd tretment to non-oecd countries, 211 213 (constnt 213 US$, million). Donors re listed on the lef t nd recipients of donor funding re listed on the right. The Globl Fund through which much donor funding is chnnelled, is shown in the middle. USA: $177 Asi: $ 13 Frnce, Germny nd the United Kingdom: $ 538 Afric: $ 899 Other countries: $ 657 Bill & Melind Gtes Foundtion: $ 77 Other multilterls: $ 91 Globl Fund: $ 1728 Americs: $ 14 Europe: $ 19 Oceni: $ 28 nd hve since levelled of f. However, it should lso be noted tht contributions from the government of the United Sttes of Americ cptured in the OECD dtbse re lower thn of ficil lloctions. In 213, the lloction for TB ws US$ 232 million nd in ddition more thn US$ 13 million ws llocted for TB/HIV vi the President s Emergency Pln for AIDS Relief (PEPFAR). The Globl Fund disbursed TB funding (in t lest one yer between 24 nd 213) in 15 of the 19 countries tht received ny TB donor ssistnce. The top recipients of funding, with totl mounts of over US$ 1 million ech during the yers 24 213, were (in descending order of the totl funding received): Chin, Indi, Indonesi, the Philippines, Bngldesh, Nigeri nd Pkistn. Collectively, these countries ccounted for over 58% of the TB cses notified in 214. Figure B7.2.2 shows tht Afric, Asi, nd Europe ll experienced mjor increses in disbursements between 212 nd 213 while mounts disbursed to the Americs remined reltively flt. The min drivers of these chnges between 212 nd 213 were incresed finncing from the Globl Fund for Zmbi (US$ 86 million in 213), Indi (US$ 165 million in 213), nd Ukrine (US$ 17 million in 213). Figure B7.2.3 shows the flow of interntionl donor funding for TB during the period 211 213. In this figure, mounts of funding flowing to the Globl Fund from countries nd other donors were estimted on the ssumption tht 18% of donor s totl contribution to the Globl Fund ws for TB, in line with the overll shre of Globl Fund finncing tht is used for TB. The Globl Fund publishes the mounts received from ech donor on its website. The four lrgest country donors (the United Sttes of Americ, Frnce, Germny nd the UK) re shown seprtely, s is the lrgest non-country donor (the Bill nd Melind Gtes Foundtion). The importnce of the United Sttes of Americ in the globl funding of TB is prticulrly evident in this presenttion of dt, since it ccounted for bout one third of contributions to the Globl Fund in ddition to funding provided vi bilterl chnnels. For comprison, the totl funding reported by countries to WHO mounted to 85% of this totl, US$ 669 million. GLOBAL TUBERCULOSIS REPORT 215 n 97

n FIGURE 7.4 Funding for TB prevention, dignosis nd tretment from domestic sources nd interntionl donors, 26 215, 9 country groups (constnt 215 US$ billions) 3. BRICS b. 17 HBCs excluding BRICS c. Rest of world.4 1 US$ billions US$ billions US$ billions.3.8 2.6.2.4 1.1.2 26 29 212 215 26 29 212 215 26 29 212 215 d. Low-income countries e. Lower-middle-income countries f. Upper-middle-income countries b.25.6 3.2.15.4 2.1.2 1.5 26 29 212 215 26 29 212 215 26 29 212 215 g. Afric h. Asi c i. Other regions d.4.6 3.3.4 2.2.2 1.1 26 29 212 215 26 29 212 215 26 29 212 215 Domestic Interntionl donors e Globl Fund only b c d e Rest of the world includes 11 countries tht re not in the list of 22 high TB burden or 27 high MDR-TB burden countries. The upper-middle-income ctegory includes three high-income countries tht re in the list of TB nd/or high MDR-TB burden countries: Estoni, Ltvi nd the Russin Federtion. Asi includes the WHO regions of South-Est Asi nd the Western Pcific. Other regions consists of three WHO regions: the Estern Mediterrnen Region, the Europen Region, nd the Region of the Americs. This includes the Globl Fund. Of the 36 countries tht re in the list of high TB burden or high MDR-TB countries, 35 could be included in the nlysis (the exception ws Lithuni). Anlyticl methods re summrized in Box 7.3. Unit cost estimtes for 214 re shown for drug-susceptible nd MDR-TB in Figure 7.6 nd Figure 7.7. 7.4.1 Drug-susceptible TB The cost per ptient treted for drug-susceptible TB ws generlly in the rnge US$ 1 US$ 1. In generl, pproximtely 8% of this cost ws ccounted for by reported NTP expenditures, with the reminder being inptient nd outptient cre. The cost per ptient treted ws typiclly higher, but still quite vried, in countries of the former Soviet Union, rnging from US$ 1 123 US$ 18 836. In these countries, lengthy hospitliztions ply more significnt role in the totl cost of cre, with dmissions lsting up to n verge of 75 dys nd ccounting for pproximtely 4 6% of the totl cost per ptient. However, there re some striking exmples of reductions in relince on hospitliztion. 98 n GLOBAL TUBERCULOSIS REPORT 215

Box 7.3 Methods used to estimte the cost per ptient treted for drug-susceptible nd MDR-TB Two min dt sources were used. The first ws the vlidted expenditure dt reported by NTPs tht re stored in the WHO globl TB dtbse. The second ws country-specific estimtes of the unit costs of bed-dys nd outptient visits vilble from WHO s CHOosing Interventions tht re Cost-Effective (WHO- CHOICE) model nd ssocited dtbse (mnged by the Helth Governnce nd Finncing deprtment). In few instnces when no expenditure dt could be reported, informtion bout the totl funding vilble ws used s proxy for expenditures. For few countries, WHO-CHOICE estimtes were replced with estimtes of unit costs obtined directly from recent studies or discussions with experts. Costs were clculted seprtely for drug-susceptible nd MDR- TB. In ech cse, the numertor ws the totl estimted cost of tretment, which hs two min prts: 1) the ntionl expenditures reported by the NTP; nd 2) the costs ssocited with the utiliztion of helth services by ptients with TB nd MDR-TB. As explined in Box 7.1, ntionl NTP expenditures re reported nnully to WHO using the online WHO globl TB dt collection system, nd then reviewed nd vlidted. Ctegories of expenditure considered s costs for MDR-TB were secondline drugs, nd ll other inputs/ctivities implemented for the progrmmtic mngement of MDR-TB. All other ctegories (with the exception of collbortive TB/HIV ctivities) were ssumed to be for drug-susceptible TB. For lmost ll countries, the totl costs ssocited with utiliztion of inptient nd outptient cre were clculted using informtion bout the typicl number of dys of inptient cre nd outptient visits required on per ptient bsis during tretment (reported seprtely for drug-susceptible nd MDR-TB by NTPs) combined with WHO-CHOICE unit cost estimtes, multiplied by the number of ptients treted in given yer (bsed on notifiction dt see Chpter 3 for drug-susceptible TB nd Chpter 4 for MDR-TB). Multiplying quntities of visits nd bed-dys by their price estimtes yields the totl estimted cost of inptient nd outptient services. For three countries (Belrus, Burkin Fso nd the Democrtic Republic of the Congo), TB inptient nd outptient expenditures vilble from Ntionl Helth Accounts were used in lieu of the estimted cost from this ingredients-bsed pproch. Unit costs were then clculted s the sum of 214 NTP expenditures nd totl costs for utiliztion of inptient nd outptient cre, divided by the reported number of ptients treted. Agin, this clcultion ws crried out seprtely for drugsusceptible nd MDR-TB. n FIGURE 7.5 Funding gps for TB prevention, dignosis nd tretment reported by countries, by income group nd WHO region, 26 215 (constnt 215 US$ millions) 6 Totl gp = US$.8 billion 5 Totl gp = US$.8 billion 5 4 US$ millions 4 3 2 US$ millions 3 2 1 1 26 27 28 29 21 211 212 213 214 215 26 27 28 29 21 211 212 213 214 215 Lower-middle-income countries Low-income countries Upper-middle-income countries Africn region Region of the Americs Estern Mediterrnen region Europen region South-Est Asi region Western Pcific region The upper-middle-income ctegory includes three high-income countries tht re in the list of TB nd/or high MDR-TB burden countries: Estoni, Ltvi nd the Russin Federtion. GLOBAL TUBERCULOSIS REPORT 215 n 99

n FIGURE 7.6 Estimted cost per ptient treted for drug-susceptible TB in 117 countries, 214 Cost per ptient treted (215 US$, log scle) 2 1 5 1 5 1 TB cselod (notified TB cses) 1 5 1 25 Ethiopi Cmbodi Zimbbwe Mozmbique Afghnistn Ugnd DR Congo UR Tnzni Bngldesh Pkistn Mynmr Philippines Viet Nm Nigeri Keny Indi Thilnd Indonesi Chin South Afric Russin Federtion Brzil WHO region Africn Americn Estern Mediterrnen Europen South-Est Asi Western Pcific 5 1 2 5 1 15 GDP per cpit (215 US$, log scle) Limited to countries with t lest 1 notified ptients in 214. n FIGURE 7.7 Estimted cost per ptient treted for MDR-TB in 9 countries, 214 Cost per ptient treted (215 US$, log scle) 5 2 1 5 1 MDR-TB cselod (notified cses) 2 7 5 1 DR Congo Ethiopi Tjikistn Kyrgyzstn Pkistn Indi Republic of Moldov Ukrine Mynmr Uzbekistn Bngldesh Nigeri Armeni Indonesi Philippines Viet Nm Georgi South Afric Russin Federtion Belrus Bulgri Chin Azerbijn WHO region Ltvi Estoni Kzkhstn Africn Americn Estern Mediterrnen Europen South-Est Asi Western Pcific 5 5 1 2 5 1 15 GDP per cpit (215 US$, log scle) Limited to countries with t lest 2 ptients on second-line tretment in 214. 1 n GLOBAL TUBERCULOSIS REPORT 215

Although not yet be reflected in nlyses for 214, the Russin Federtion reported hospitliztion of bout 65% of TB ptients with drug-susceptible TB in 215, compred with 93% in 214. Low-income countries spent on verge US$ 516 per TB ptient, while upper-middle-income or high-income countries invested n verge of US$ 5 558. In the 22 HBCs, the estimted cost per ptient treted for drug-susceptible TB in 214 rnged from US$ 74 in Pkistn to US$12 988 in the Russin Federtion. In ll of the 22 HBCs, the cost per ptient treted for drug-susceptible TB ws less thn gross domestic product (GDP) per cpit. Six countries Chin, Indi, South Afric, Indonesi, Bngldesh nd Pkistn, which together ccount for 58% of the globl TB burden hve costs per ptient treted tht re reltively low compred with their GDP per cpit. While the level of GDP per cpit clerly influences the cost of TB tretment, this shows tht the size of the totl ptient cselod is lso n importnt fctor (for exmple, when numbers of ptients treted re very lrge, economies of scle cn be relised). 7.4.2 MDR-TB For MDR-TB, the cost per ptient treted rnged from n verge of US$ 6 826 in low-income countries to n verge of US$ 21 265 in upper middle-income countries in 214. As for drug-susceptible TB, the cost per ptient treted for MDR-TB ws typiclly higher in countries of the former Soviet Union, rnging from US$ 2 935 in Uzbekistn to US$ 64 25 in Ltvi (where ll ptients with MDR-TB re hospitlized for n verge of 12 dys, t n estimted cost of US$ 262 per dy). This minly reflects greter relince on inptient cre, with dmissions lsting up to n verge of 24 dys per ptient nd ccounting for bout 6% of the totl cost of tretment. 7.5 Progress towrds UHC: insights from helth finncing dt UHC is defined s ccess for ll to essentil preventive nd tretment helth cre interventions, with finncil protection. 1 In finncing terms, the bsolute level of funding for helth cre must be high enough to ensure tht it is possible to provide essentil helth services to the whole popultion; dditionlly, the costs of using those services, once vilble, must not be prohibitive (using them should not result in finncil hrdship). Mndtory pre-pyment finncing mechnisms (such s txtion or socil insurnce schemes) need to form the core of domestic helth finncing. 2 There re three helth finncing indictors for which benchmrks required to chieve UHC hve been suggested nd for which recent estimtes re vilble for ll countries 1 World Helth Orgnistion, World Bnk Group. Monitoring progress towrds universl helth coverge t country nd globl levels. Frmework, mesures nd trgets. Genev: World Helth Orgniztion; 214 (WHO/ HIS/HIA/14.1). 2 World Helth Orgniztion. The World Helth Report 21. Helth systems finncing: the pth to universl coverge. Genev: World Helth Orgniztion; 21. to which the indictor pplies. Anlysis of dt (from the WHO Globl Helth Expenditure dtbse) for these three indictors cn therefore provide useful insights into country s progress towrds, or chievement of, UHC. The three indictors re: "" Totl government spending on helth s proportion of GDP: the suggested benchmrk is 5 6%; 3,4,5 "" Government nd donor-funded helth expenditure per cpit in low-income countries: the suggested benchmrk is US$ 86 (in 212 prices); 2 "" The shre of out-of-pocket expenditures (OOP) in totl helth expenditures: the suggested benchmrk is less thn 15%. 1,6,7 OOP expenditures re defined s direct pyments mde to helth cre providers by individuls t the time of service use, excluding prepyment for helth services (for exmple in the form of txes or specific insurnce premiums or contributions) nd, where possible, net of ny reimbursements to the individul who mde the pyment. 8 The level of OOP expenditures provides proxy mesure of the degree to which people lck finncil protection. 7.5.1 Government spending on helth s proportion of GDP The ltest dt on government helth expenditures (GHE) re for 213. 9 GHE ws less thn 6% of GDP in most countries in 213 (149/19, 78%), including ll of the 36 countries in the current lists of high TB burden nd/or MDR-TB burden countries (Figure 7.8). Among HBCs, those t the lowest end of the rnge were Bngldesh, Indonesi, Indi, Nigeri, Mynmr, Pkistn nd the Philippines (ll <1.5%); those closest to the 6% threshold were Brzil, South Afric nd Thilnd (ll t round 4.5%). Among WHO regions, the South-Est Asi Region hd the lowest levels of helth spending s proportion of GDP. There were 41 countries where government spending on helth exceeded 6% of GDP. Of these, only six were low or lower-middle income countries: Rwnd, Swzilnd, Lesotho, Smo, Kiribti nd Micronesi. 3 World Helth Orgniztion. The World Helth Report 21. Helth systems finncing: the pth to universl coverge. Genev: World Helth Orgniztion; 21. 4 McIntyre et l. Fiscl Spce for Domestic Funding of Helth nd Other Socil Services. London: Chthm House; 214. 5 World Helth Orgniztion nd Pn Americn Helth Orgniztion. Resolution CD53.R14 Strtegy for universl ccess to helth nd universl helth coverge. 53rd Directing Council, 66th Session of the Regionl Committee of WHO for the Americs. Wshington: World Helth Orgniztion nd Pn Americn Helth Orgniztion, 214. 6 Xu et l, Protecting Households from Ctstrophic Helth Spending, Helth Af firs 27; 26(4): 972 983. 7 Xu et l., Household Ctstrophic Helth Expenditure: A Multicountry Anlysis, The Lncet 23;362: 111 117. 8 World Helth Orgniztion nd World Bnk. First Globl Monitoring Report on Trcking Universl Helth Coverge, 215. http://www.who.int/ helthinfo/universl_helth_coverge/report/215/en/. 9 WHO Ntionl Helth Accounts dtbse, ccessed July 215 vi http:// pps.who.int/nh/dtbse cvv GLOBAL TUBERCULOSIS REPORT 215 n 11

n FIGURE 7.8 Government spending on helth, s percentge of gross domestic product (GDP), 213 Percentge of GDP <4% 4 5.9% 6 9.9% 1% No dt Not pplicble Dt for Bhrin nd Brzil re for 212. n FIGURE 7.9 Government spending on helth per cpit in low-income countries (shown in blue), 213. Middle nd high-income countries re shown in white. <US$ 5 US$ 5 9.9 US$ 1 19.9 US$ 2 29.9 US$ 3 44.9 US$ 45 6 No dt Not pplicble Countries re clssified s per the World Bnk income ctegories for 213. Avilble t: http://dt.worldbnk.org/bout/country-nd-lending-groups 12 n GLOBAL TUBERCULOSIS REPORT 215

n FIGURE 7.1 Out-of-pocket expenditures s percentge of totl helth expenditures, 213 Percentge 15% 16 29% 3 44% 45% No dt Not pplicble 7.5.2 Government spending on helth per cpit, low-income countries In 213, government spending on helth per cpit ws fr below the suggested benchmrk of US$ 86 per cpit in ll low-income countries (Figure 7.9). Most countries spent less thn US$ 2 per cpit. The countries tht were closest to the benchmrk were Rwnd (US$ 41 per cpit) nd Kyrgyzstn (US$ 51 per cpit). 7.5.3 Shre of out-of-pocket expenditures in totl helth expenditures In 213, OOP expenditures were less thn 15% of totl helth spending in 43 of 19 countries for which dt were vilble, including three HBCs: Mozmbique, Thilnd nd South Afric (Figure 7.1). At the other end of the scle, there were 49 countries where OOP expenditures ccounted for t lest 45% of totl helth expenditures, including ten HBCs: Bngldesh, Indi, Indonesi, Cmbodi, Nigeri, Mynmr, Pkistn, Philippines, Viet Nm nd the Russin Federtion. The globl verge in 213 ws 32%, smll reduction compred with 36% in 2. 1 The brekdown of totl helth expenditures by source of funding, including OOP expenditures, is shown for selected high TB burden nd high-income countries in Figure 7.11. n FIGURE 7.11 Totl helth expenditures by source of finncing in selected high TB burden nd high-income countries, 213 1 9 8 7 6 5 4 3 2 1 Percentge South Afric Brzil Chin Russin Federtion Indonesi Indi Nigeri Frnce United Kingdom Germny Netherlnds Cnd US Itly Privte expenditures, other Non-profit institutions serving households (e.g. NGOs) Out-of-pocket expenditures Voluntry pre-pyment Mndtory pre-pyment 1 World Helth Orgniztion nd World Bnk. First Globl Monitoring Report on Trcking Universl Helth Coverge, 215. http://www.who. int/helthinfo/universl_helth_coverge/report/215/en/. GLOBAL TUBERCULOSIS REPORT 215 n 13

7.5.4 Beyond finncil risk protection One of the three min trgets in the End TB Strtegy (216 235) is tht no TB ptients or their households should fce ctstrophic costs s result of TB disese (Chpter 1). This trget ws specificlly included becuse it is key mrker of finncil risk protection nd progress towrds UHC nd socil protection for TB-f fected households. 1 Ctstrophic cost is broder concept thn ctstrophic helth expenditure, since it includes not only direct expenditures on helth services but lso (1) non-medicl pyments (such s trnsporttion or lodging chrges) tht re directly relted to ccessing TB dignosis nd tretment nd (2) indirect costs such s income losses (for exmple, relted to time lost from work or loss of employment). The proportion of ptients nd their households tht experience ctstrophic costs cn be mesured using periodic surveys. To support such surveys, WHO estblished Tsk Force in 215. The min focus of the Tsk Force s work in 215 hs been to develop generic protocol nd ccompnying questionnires, 2 building on methods used in previous studies of ptient costs. 1 Uplekr M, Weil D, Lonnroth K, Jrmillo E, Lienhrdt C, Dis HM, et l. WHO s new End TB Strtegy. The Lncet. 215;385:1799-81. See in prticulr Pnel 2 in the supplementry ppendix. 2 Protocol for survey to determine direct nd indirect costs due to TB nd to estimte proportion of TB-f fected households experiencing ctstrophic costs Field testing version, 215. Avilble from the Globl TB Progrmme in WHO upon request. 14 n GLOBAL TUBERCULOSIS REPORT 215

CHAPTER 8 Reserch nd development Key fcts nd messges Intensified reserch nd development is one of the three pillrs of the WHO post-215 globl TB strtegy, nd will ply crucil role in ccelerting the reductions in TB incidence nd mortlity required to rech globl TB trgets by 235. Ef forts to develop new TB dignostics, drugs, nd vccines intensified in the pst decde, but considerble progress nd investment is still needed. The dignostic technology lndscpe continues to look promising lthough very few technologies re t dequtely dvnced stges for WHO evlution. Technologies under development include rpid tests to detect TB, drug resistnce, or TB nd drug resistnce combined. Those bsed on moleculr technologies such s nucleic cid mplifiction tests re the most dvnced. A new dignostic pltform clled the GeneXpert Omni is in development. This is intended for point-of-cre testing for TB nd rifmpicin-resistnt TB using existing Xpert MTB/RIF crtridges. This new pltform will be ssessed by WHO for equivlence to the current GeneXpert pltform in 216. A nextgenertion crtridge clled Xpert Ultr is lso in development, nd is expected to replce the Xpert MTB/RIF crtridge. The Xpert Ultr ssy will be ssessed in 216 in two stges, first s replcement for the current Xpert MTB/RIF ssy nd second s replcement for conventionl dignostic culture. In 215, three dignostic tests were reviewed by WHO: Determine TB LAM (liporbinomnnn), referred to s LF-LAM; nd two new generic versions of line probe ssys (LPAs) for first-line drugs. LF-LAM is not recommended for the dignosis of TB (pulmonry nd extrpulmonry), with the exception of people living with HIV who hve low CD4 counts or who re seriously ill. WHO will updte current policy recommendtions for the use of LPAs in erly 216. Two new drugs hve recently been recommended for the tretment of MDR-TB under specific conditions. The first, bedquiline, ws pproved by the US Food nd Drug Administrtion (FDA) in December 212 nd the second, delmnid, ws pproved by the Europen Medicines Agency in November 213. WHO issued interim guidnce on the use of these two drugs in the tretment of MDR-TB in June 213 nd October 214, respectively. Additionlly, there re eight new or repurposed nti-tb drugs in dvnced phses of clinicl development. For the first time in six yers, new nti-tb drug cndidte hs entered Phse I clinicl tril: TBA-354, nitroimidzole tht is prt of the sme clss of drugs s delmnid nd pretomnid. Results from three Phse III trils investigting four-month regimens for the tretment of drug-susceptible TB tht include fluoroquinolones were relesed in 214. These shorter regimens filed to show non-inferiority to the six-month stndrd of cre regimen currently recommended by WHO. Severl new regimens, including new nd/or re-purposed drugs, re now being tested in series of Phse II/III trils for the tretment of drug-susceptible nd/or drug-resistnt TB. Two recent observtionl studies of the ef fectiveness of shorter tretment regimens for ptients with MDR-TB in Niger nd Cmeroon hve shown tht 12-month tretment regimen ws ef fective nd well-tolerted in ptients not previously exposed to second-line drugs. There re 15 vccine cndidtes in clinicl trils. Results of Phse II ef ficcy dt to determine whether BCG nd/or H4:IC31 cn prevent infection, nd M72 cn prevent disese, s well s phse III dt of whether M.vcce cn prevent disese, will shortly be vilble. Mjor shif ts in TB vccine reserch nd development include the introduction of more stringent gting criteri/mechnisms for cndidte entry into nd progress in clinicl trils; vccine discovery tht explores induction of immunity beyond conventionl T cells; nd support of experimentl medicine studies for knowledge genertion nd to better connect dt from niml models nd humn studies. The gol of the End TB strtegy endorsed by the World Helth Assembly (WHA) in My 214 is to end the globl TB epidemic (Chpter 1). Despite mjor progress in TB prevention, dignosis nd tretment since the mid-199s (Chpters 2 7), reching this gol will require mjor technologicl brekthroughs from the reserch nd development pipeline by 225; these would mke possible mjor ccelertion in the rte t which TB incidence declines compred with historic levels. Criticl components include: the vilbility of f fordble short, ef fective nd well-tolerted tretments for ll forms of TB (ltent TB infection, drug-susceptible nd drug-resistnt TB disese); point-of-cre dignostic test with cpcity to identify resistnce to the most importnt nti-tb drugs; nd n effective post-exposure vccine. This is the fif th successive yer in which chpter on reserch nd development is included in the Globl tubercu- GLOBAL TUBERCULOSIS REPORT 215 n 15

n FIGURE 8.1 An overview of progress in the development of moleculr TB dignostics, August 215 FOR USE IN REFERENCE -LEVEL LABORATORIES n m2 RelTime MTB ssy, Abbott, USA n TruArry MDR-TB, Akkoni, USA n BioFilmChip MDR-TB, AutoGenomics, USA n MTBC-OCTA, AutoGenomics, USA n BD ProbeTec ET Direct TB ssy, BD, USA n TB drug resistnce rry, Cpitl Bio, Chin n AMTD test, Hologic Genprobe, USA n Cobs TqMn MTB test, Roche, Switzerlnd n Anyplex, Seegene, Kore n Mgicplex MTB, Seegene, Kore n TRC Rpid M.TB, Tosoh Bioscience, Jpn n MeltPro, Zeesn Biotech, Chin FOR USE IN INTERMEDIATE-LEVEL LABORATORIES n FluoroType MTB / FluoroType MTB RNA, Hin Lifesciences, Germny n icubte System, icubte, USA n AdvnSure, LG Life sciences, Republic of Kore n LPA NTM/MTB DR, Nipro, Jpn n veremtb, Veredus Lbortories, Singpore n SPEED-OLIGO, Vircell, Spin n MolecuTech REBA, YD Dignostics, Kore n LATE-PCR, Brndeis University, USA n GeneXpert XDR crtridge, Cepheid, USA n Xpert Ultr, Cepheid, USA n Enigm ML, Enigm Dignostics, UK FOR USE IN PERIPHERAL-LEVEL LABORATORIES n Alere Q, Alere, USA n TB-LAMP, Eiken, Jpn n B-SMART, LbCorp, USA n Genedrive MTB/RIF ID, Epistem, UK n HYDRA, Insilix Inc, USA n TBDx System, KGI, USA n Truelb/Truent MTB, Molbio/bigtec Dignostics, Indi n Svnn, NWGHF, USA n EsyNAT TB Dignostic kit, Ustr Biotechnologies, Chin n EOSCAPE-TB, Wve 8 Biosciences, USA n GenePOC test, GenePOC, Cnd n Xpert Omni, Cepheid, USA This is not n exhustive list of technologies in development. Those listed re the ones documented in publictions by UNITAID nd TAG: UNITAID. 214. Tuberculosis Dignostic Technology nd Mrket Lndscpe 3rd edition. Genev: World Helth Orgniztion. Avilble t: http://www. unitid.eu/imges/mrketdynmics/publictions/unitaid_tb_dignostics_lndscpe_3rd-edition.pdf Hrrington M. The tuberculosis dignostics pipeline in 215 Pipeline Report: HIV, Heptitis C Virus (HCV) nd Tuberculosis Drugs, Dignostics, Vccines, Preventive Technologies, Reserch Towrd Cure, nd Immune-Bsed nd Gene Therpies in Development. New York, Tretment Action Group, 215. Avilble t: http://www.pipelinereport.org/sites/g/files/g575521/f/2157/215%2pipeline%2report%2full.pdf losis report. The sttus of progress in the development of new TB dignostics, drugs nd vccines s of August 215 is summrized, bsed on recent publictions nd communictions with nd contributions from the secretrits of the relevnt Working Groups of the Stop TB Prtnership. 8.1 New dignostics for TB The End TB strtegy trgets set for 235 re to reduce the bsolute number of TB deths by 95% nd to reduce the TB incidence rte by 9%, compred with bseline of 215 (Chpter 1). To chieve these trgets, ntionl TB progrmmes (NTPs) first need to implement strtegies tht fully optimize the use of existing dignostic technologies. Reserch nd development is required so tht new rpid tests tht cn be used t the point of cre, nd tht ccelerte ccess to testing for drug susceptibility for ll bcteriologiclly-confirmed TB cses, become vilble. 8.1.1 An overview of the dignostics pipeline Although very few technologies re t n dvnced stge of evlution, the dignostic technology lndscpe continues to look promising. An overview of the dignostic pipeline for rpid moleculr tests in August 215 is shown in Figure 8.1. The list of technologies is not necessrily complete or exhustive, but does reflect technologies tht hve been documented in recent reports published by UNITAID 1 nd Tretment Action Group (TAG). 2 Tools using moleculr technologies such s nucleic cid mplifiction tests (NAATs) re the most dvnced. Technologies under development include tests to detect TB, drug resistnce, or TB nd drug resistnce combined. These include microrry-bsed multiplexing dignostic pltforms for the simultneous detection of lrge number of resistnce-conferring muttions. Unfortuntely, most tests under development re intended for use t the reference or intermedite lbortory level only, requiring dedicted infrstructure nd experienced stf f. There re t lest three technologies tht re commercilly vilble (Epistem Genedrive, Epistem, UK; Molbio Truelb, Molbio, Indi nd EASYNAT, Ustr, Chin) tht re intended for use t the microscopy level. However, to dte no multicentre evlution nd/or demonstrtion studies in different epidemiologicl setting hve been conducted. These re necessry to generte the performnce dt required by WHO to ssess nd produce recommendtions on these technologies (Figure 8.2). Evlution studies re expensive, nd therefore dditionl funding is urgently needed, both to expedite the progress of promising new technologies through the pipeline nd to conduct the necessry evlution studies. Priority should be given to tests tht re suitble for use t the lower levels of the helth system. The Foundtion for Innovtive New Dignostics (FIND) remins the led orgniztion conducting field evlutions of dif ferent 1 UNITAID. 214. Tuberculosis Dignostic Technology nd Mrket Lndscpe 3rd edition. Genev: World Helth Orgniztion. Avilble t: http://www.unitid.eu/imges/mrketdynmics/publictions/ UNITAID_TB_Dignostics_Lndscpe_3rd-edition.pdf 2 Hrrington M. The tuberculosis dignostics pipeline in 215 Pipeline Report: HIV, Heptitis C Virus (HCV) nd Tuberculosis Drugs, Dignostics, Vccines, Preventive Technologies, Reserch Towrd Cure, nd Immune- Bsed nd Gene Therpies in Development. New York, Tretment Action Group, 215. Avilble t: http://www.pipelinereport.org/sites/g/files/ g575521/f/2157/215%2pipeline%2report%2full.pdf 16 n GLOBAL TUBERCULOSIS REPORT 215

n FIGURE 8.2 The phses of TB dignostics development nd ssessment for WHO recommendtion using the GRADE (Grding of Recommendtions Assessment, Development nd Evlution) process PHASE 2 Evlution nd demonstrtion PHASE 3 WHO ssessment of the evidence using GRADE tbles PHASE 4 Phsed uptke nd collection of evidence for scle-up PHASE 1 Reserch nd development PHASE 5 Scle-up nd policy refinement technologies, but the enggement of other stkeholders nd dequte funding re urgently needed. A new dignostic pltform clled the GeneXpert Omni is in development. This is intended for point-of-cre testing for TB nd rifmpicin-resistnt TB using existing Xpert MTB/ RIF crtridges. The device is expected to be smller, lighter, nd less expensive thn other currently vilble pltforms for point-of-cre nucleic cid detection. The pltform will come with built-in four-hour bttery; n uxiliry bttery tht provides n dditionl 12 hours of run time is lso vilble. In 216, this new pltform will be ssessed by WHO for non-inferiority to the current GeneXpert pltform. Mjor gps still remin in the dignostic pipeline, nd slow progress in the evlution of technologies in the lte stges of development is the mjor brrier to these tools reching the mrket. There re insuf ficient tests under development for the dignosis of TB in children, ssessment of susceptibility to drugs tht my be prt of new tretment regimens, prediction of progression from ltent TB infection (LTBI) to ctive TB disese nd lterntives to TB culture for tretment monitoring. The development nd implementtion of such tests s well s incresing ccess to technologies lredy endorsed by WHO will be essentil to meet trgets outlined in the End TB Strtegy. 8.1.2 TB dignostic tests reviewed by WHO in 215 In 215, three dignostic tests were reviewed by WHO: Determine TB LAM (liporbinomnnn), referred to s LF-LAM, developed by Alere, USA; nd two new generic versions of line probe ssys (LPAs), one developed by the Nipro Corportion, Jpn nd the other by Hin Lifesciences. LF-LAM (Alere, USA) LF-LAM is lterl flow test tht hs been evluted in severl studies for the detection of ctive TB in people living with HIV who re severely immunocompromised. Evidence from systemtic review of the performnce chrcteristics of the ssy ws considered by Guideline Development Group convened by WHO in 215. This group recommended tht LF-LAM should not be used for the dignosis of TB (pulmonry nd extrpulmonry), with the exception of people living with HIV who hve low CD4 counts or who re seriously ill. More detils on these recommendtions re provided in Chpter 5. New generic versions of LPAs (Nipro Corportion, MTBDRplus version 2) For new versions of technologies tht WHO hs lredy recommended, WHO requires hed-to-hed comprison with the existing technology. If non-inferiority (tht is, their equivlence) in performnce cn be demonstrted, then WHO will recommend the new version. In 28, WHO endorsed the use of LPAs for the rpid detection of rifmpicin resistnce, beginning wht might be considered to be the moleculr revolution in detection of drug-resistnt TB. The evidence nd subsequent recommendtions for the utility of LPAs included n ssessment of the performnce of the GenoType MTBDRplus ssy, Hin Lifescience (Hin Version 1 ssy). This ssy incorportes rpob probes for rifmpicin resistnce detection s well s ktg probes nd inha probes for the determintion of isonizid resistnce. Hin Lifesciences hve subsequently developed n updted version of their MTBDRplus line probe ssy (Hin Version 2 ssy). GLOBAL TUBERCULOSIS REPORT 215 n 17

Nipro Corportion, Jpn hs developed n LPA tht is similr to tht of Hin Lifesciences, which ws registered in Jpn in 212 (Nipro ssy). This ssy llows for the detection of rifmpicin nd isonizid conferring muttions, the identifiction of M. tuberculosis complex nd the identifiction of some common nontuberculous mycobcteri including M. vium, M. intrcellulre nd M. knssii. In 214 nd 215, FIND coordinted multi-center, blinded cross-sectionl study of the dignostic ccurcy of these two tests, to compre their performnce ginst tht of the Hin Version 1 ssy. A composite reference stndrd including phenotypic drug susceptibility testing (DST) nd DNA sequencing ws used. The study ws divided into two distinct phses. Phse 1 ws designed to evlute the performnce of the newer ssys on wide rnge of clinicl isoltes nd Phse 2 to evlute their performnce on sputum specimens from ptients with pulmonry TB. The study demonstrted non-inferiority of the newer LPA ssy versions (Hin Version 2 nd Nipro) in comprison with the Hin Version 1 ssy; these ssys showed comprble performnce for the detection of M. tuberculosis nd rifmpicin resistnce conferring muttions in cid-fst bcilli smer-positive smples nd isoltes of M. tuberculosis. WHO will updte current policy recommendtions for the use of LPAs nd review new evidence bout the clinicl utility of the Hin Lifescience GenoType MTBDRsl ssy nd will ssess the role of sequencing in detecting resistnce to second-line drugs in 216. 8.1.3 Technologies scheduled for field evlution studies in 216 There re two technologies scheduled for field evlution in 216. Xpert Ultr, Cepheid A new version of the Xpert MTB/RIF ssy, clled Xpert Ultr, is in development. The im is to improve the sensitivity nd specificity of the current ssy in detection of TB nd rifmpicin resistnce, respectively. In 216, FIND will initite two-step evlution process. The first step is rpid noninferiority study tht will compre the new Xpert Ultr ssy with the current Xpert MTB/RIF ssy. If non-inferiority is demonstrted, the Xpert Ultr ssy will be recommended s replcement for the current Xpert MTB/RIF ssy. The second step will be multi-country evlution studies. It is nticipted tht these studies will demonstrte tht the Xpert Ultr ssy hs superior performnce (for exmple, bout 95% sensitivity in detecting smer-negtive, culturepositive TB from single sputum specimen). The Xpert Ultr ssy will be developed for use on the Omni pltform (described bove). Alere Q, Alere The Alere q TB dignostic system is being developed with funding support from the Bill & Melind Gtes Foundtion. It is rpid nd sensitive test for detection of TB, followed by n immedite reflex test for full nlysis of drug resistnce for people found to hve TB. A sputum smple is collected in cup tht is then screwed onto the test crtridge, which contins ll regents. The inoculted crtridge is subsequently plced into bttery-powered stnd-lone device tht llows for smple processing, DNA mplifiction, detection nd result interprettion nd reporting in pproximtely 2 minutes. This technology is mjor step towrds chieving universl DST for ll TB cses. Multi-centre evlution studies re plnned for 216 217. 8.1.4 Tests tht predict progression from ltent to ctive TB Most people with LTBI hve no signs nd symptoms of TB disese. People with LTBI re not infectious, but they re t risk for developing ctive disese nd becoming infectious. On verge, 5 15% of those infected will develop ctive TB during their lifetime, typiclly within the first 2 5 yers f ter the initil infection. Current tests for LTBI (i.e. interferon gmm relese ssys, IGRAs; nd the tuberculin skin test, TST) re immunity-bsed nd hve very limited bility to identify which individuls re likely to progress to ctive TB. They lso hve limited sensitivity in people with HIV infection, nd re not ble to dif ferentite between recent nd remote infection or to distinguish if person hs been re-infected if re-exposed. In My 215, WHO hosted meeting on behlf of FIND nd the New Dignostics Working Group of the Stop TB Prtnership to review set of miniml nd optiml performnce chrcteristics nd develop trget product profile (TPP) for biomrker-bsed test to predict the risk of progression to ctive TB from LTBI nd rule out ctive TB. The meeting ws ttended by representtives from the dignostic development industry, universities, clinicins nd technicl prtners. Following the meeting, the process to define the TPP for test for progression of LTBI hs continued longside the development of stndrdized study protocols tht could be used to evlute the performnce of such tests. 8.2 New drugs nd drug regimens to tret TB Much progress hs been mde during the lst ten yers in the tretment of TB. The body of knowledge bout the use of vrious drugs in combintion regimens, s well their potentil interction with ARVs nd the optimum timing of ART in the tretment of HIV-positive TB ptients, hs grown substntilly. However, TB tretment remins centred on the stndrd 6 month regimen of isonizid, rifmpicin, pyrzinmide nd ethmbutol. Ensuring dherence to tretment remins chllenge, nd drug-resistnt TB remins mjor thret to globl TB prevention, dignosis nd tretment (Chpter 4). This section provides n overview of the ltest sttus of the development of new TB drugs nd new TB tretment regimens. 18 n GLOBAL TUBERCULOSIS REPORT 215

n FIGURE 8.3 The development pipeline for new TB drugs, August 215 Discovery Preclinicl development Clinicl development Led optimiztion Preclinicl development Good Lbortory Prctice toxicity Phse I Phse II Phse III Cyclopeptides Dirylquinolines DprE Inhibitors InhA Inhibitor, Indzoles LeuRS Inhibitors, Ures Mcrolides, Azindoles Mycobcteril Gyrse Inhibitors Pyrzinmide Anlogs Ruthenium(II) Complexes Spectinmides SPR-113 Trnslocse-1 Inhibitors TBI-166 CPZEN-45 SQ69 SQ641 DC-159 PBTZ169 Q23 TBA-354 Sutezolid (PNU- 148) SQ19 Rifpentine for DS-TB AZD5847 Bedquiline- Pretomnid- Pyrzinmide Regimen Bedquiline (TMC- 27) with OBR b for MDR-TB Delmnid (OPC- 67683) with OBR b for MDR-TB Rifpentine for LTBI Pretomnid- Moxifloxcin- Pyrzinmide Regimen Chemicl clsses: fluoroquinolone, rifmycin, oxzolidinone, nitroimidzole, dirylquinoline, benzothizinone Detils for projects listed cn be found t http://www.newtbdrugs.org/pipeline.php nd ongoing projects without led compound series identified cn be viewed t http://www.newtbdrugs.org/pipeline-discovery.php b OBR = Optimized Bckground Regimen Source: Working Group on New TB Drugs, 215 www.newtbdrugs.org 8.2.1 The pipeline of new nd re-purposed nti-tb drugs The sttus of the pipeline for new nd repurposed nti-tb drugs in August 215 is shown in Figure 8.3. There re eight drugs in Phse I, Phse II or Phse III trils for the tretment of drug-susceptible, multidrug-resistnt TB (MDR-TB) or LTBI. Two of these compounds (AZD5847 nd Sutezolid) do not pper to hve progressed in the lst two yers. However, for the first time in six yers, new nti-tb drug cndidte hs entered Phse I clinicl tril: TBA-354, nitroimidzole tht is prt of the sme clss of drugs s delmnid nd pretomnid (formerly PA-824). 1 In ddition, more diversified fundmentl reserch is being conducted to better understnd the diversity of the metbolic stges of M. tuberculosis nd ssocited host responses, nd to identify novel trgets ginst which therpeutic chemicls cn be directed. This is importnt to ensure tht drugs re ef fective throughout the vrious stges of TB from cute disese through tretment of chronic bcteril crrige to cure. Rifpentine for drug-susceptible TB Investigtion of the potentil ef fectiveness of rifpentine in the tretment of drug-susceptible TB, is continuing bsed on the results of the TB Tril Consortium (TBTC) Study 29 tht showed comprble ef ficcy of dily rifpentine 1 CliniclTrils.gov [Internet]. Bethesd (MD): Ntionl Librry of Medicine (U.S.). 2. Identifier NCT2288481, A phse 1 study to evlute the sfety, tolerbility, nd phrmcokinetics of TBA-354 in helthy dult subjects; 214 November 7. https://clinicltrils.gov/ct2/ show/nct2288481 (1 mg/kg) nd rifmpicin (1 mg/kg) when provided long side stndrd doses of isonizid, ethmbutol nd pyrzinmide. The outcome of interest is culture conversion t two months in smer-positive pulmonry TB ptients. 2 A further study (Study 29X), imed t investigting the ef fect of vrious dosges of rifpentine (1, 15 or 2 mg/kg, given seven dys week with food supplements), showed tht the substitution of high-dose dily rifpentine for rifmpicin improved the ntimicrobil ctivity of combintion chemotherpy during the intensive phse of tretment, nd tht this ctivity ws driven by rifpentine exposure. 3 The observed sfety nd tolerbility combined with the high levels of ntimicrobil ctivity observed in the groups tht received higher doses of rifpentine provide support for the evlution of high-dose dily rifpentine-contining regimens of less thn six months durtion in Phse III clinicl trils. Rifmpicin Assessment of whether higher doses of rifmpicin could reduce tretment durtion for drug-susceptible TB hs continued. Results from the PnACEA MAMS-TB-1 tril presented t the Conference on Retroviruses nd Opportunistic Infections (CROI) in Mrch 215 showed tht dily dosing with 35 mg/kg of rifmpin (in ddition to stndrd doses of isonizid, ethmbutol, nd pyrzinmide) reduced the time 2 Dormn S et l. Substitution of Rifpentine for Rifmpin During Intensive Phse Tretment of Pulmonry Tuberculosis: Study 29 of the Tuberculosis Trils Consortium. J Infect Dis. 212, 26 (7): 13 14. 3 Dormn S et l. Dily Rifpentine for Tretment of Pulmonry Tuberculosis: A Rndomized, Dose-Rnging Tril. Am J Respir Crit Cre Med 215, 191; 333 343. GLOBAL TUBERCULOSIS REPORT 215 n 19

to stble culture conversion when mesured over 12 weeks on liquid medi, but not on solid medi, compred to the stndrd six month regimen. 1 In the sme tril, second rm in which 2 mg/kg of rifmpin + moxifloxcin ws provided showed non-significnt improvement in the time to culture conversion on liquid medi over 12 weeks, but no improvement when mesured using solid medi. Both rms ppered sfe nd well tolerted, but slightly higher percentge of ptients (14% versus 1%) experienced grde 3 dverse events compred with the control rm. There were potentilly higher rtes of heptic dverse events tht resulted in chnge of tretment in the 35 mg/kg rifmpin rm. Finl nlysis of results is underwy. Further reserch bout the sfety nd ef ficcy of higher dosges of rifmpicin, with or without moxifloxcin, nd its cpcity to shorten tretment, is needed. Fluoroquinolones The results from three Phse III trils of four-month combintion regimens for the tretment of drug-susceptible TB, ll of which included fluoroquinolone, were published in lte 214. These were: (i) the OFLOTUB tril, in which gtifloxcin ws substituted for ethmbutol; 2 (ii) the ReMOX tril, in which moxifloxcin ws substituted for either ethmbutol or isonizid; 3 nd (iii) the Rifquin tril, in which moxifloxcin ws substituted for isonizid in the intensive phse of tretment nd rifpentine ws used in the continution phse of tretment. 4 Disppointingly, ll of these trils showed tht the shortened regimen cnnot be recommended for the tretment of uncomplicted smer-positive pulmonry TB. Moreover, the inclusion of third-genertion fluoroquinolone s substitute for either ethmbutol or isonizid ws ssocited with higher risk of relpse compred with the stndrd regimen of six months. Bedquiline In December 212, bedquiline ws pproved by the US Food nd Drug Administrtion (FDA) for tretment of MDR-TB s prt of combintion therpy for dults with pulmonry TB when other lterntives re not vilble. The drug is being introduced in severl countries for the tretment of severe forms of MDR-TB (Chpter 4), following interim guidnce issued by WHO in 213. 5 1 Boeree M, Hoelscher M. High-dose rifmpin, SQ19 nd moxifloxcin for treting TB: the PnACEA MAMS-TB tril. Pper presented t: 22nd Conference on Retroviruses nd Opportunistic Infections; 215 Februry 23 26; Settle, WA. 2 Merle CS et l. A Four-Month Gtifloxcin-Contining Regimen for Treting Tuberculosis. N Engl J Med 214;371:1588 98. 3 Gillespie SH et l. Four-Month Moxifloxcin-Bsed Regimens for Drug-Sensitive Tuberculosis. N Engl J Med 214;371:1577 87. 4 Jindni A et l. High-Dose Rifpentine with Moxifloxcin for Pulmonry Tuberculosis. N Engl J Med 214;371:1599 68. 5 The use of bedquiline in the tretment of multidrug-resistnt tuberculosis: Interim policy guidnce. Genev: World Helth Orgniztion; 213 (WHO/ HTM/TB/213.6). Avilble t: http://pps.who.int/iris/ bitstrem/1665/84879/1/978924155482_eng.pdf The sfety nd ef ficcy of bedquiline in combintion with short MDR-TB regimens of six nd nine months durtion is currently being investigted s prt of the Phse III STREAM tril. These shorter regimens re being compred with the current stndrd of cre for MDR-TB recommended by WHO. Delmnid In November 213, conditionl mrketing uthoriztion for delmnid ws grnted by the Committee for Medicinl Products for Humn Use (CHMP) of the Europen Medicines Agency (EMA). Delmnid ws uthorized for use s prt of combintion regimen for pulmonry MDR-TB in dult ptients when n effective tretment regimen cnnot otherwise be composed for resons of resistnce or tolerbility. Interim guidnce on the use of delmnid ws issued by WHO in October 214. 6 Delmnid is currently being tested in Phse III clinicl tril, s n ddition to n optimized bckground regimen (OBR) for the tretment of MDR-TB. The tril is compring six months of tretment with delmnid plus the OBR with plcebo plus OBR. It is nticipted tht the tril will be completed in 216. Two other trils re evluting the use of delmnid in the tretment of children with MDR-TB. The first tril is 1-dy open lbel phrmcokinetic (PK) study of delmnid plus n OBR. Ptients who successfully complete this tril my then be enrolled in second, open-lbel study (Tril 242-12-233) to ssess the sfety, tolerbility, PK, nd ef ficcy of delmnid plus n OBR over six-month tretment period. These trils re scheduled for completion in 217. Pretomnid Pretomnid is nitroimidzole developed by the Globl Allince for TB drug development. It is being tested s prt of three potentil combintion regimens for the tretment of both drug-susceptible nd drug-resistnt TB (further detils re provided in section 8.2.2). SQ19 Preliminry results from the PnACEA MAMS-TB-1 tril presented t CROI in Mrch 215 showed tht there ws no benefit of including SQ19 insted of ethmbutol in stndrd therpy for drug-susceptible TB, in terms of time to culture conversion mesured over 12 weeks. 1 8.2.2 Trils of new regimens for the tretment of drug-susceptible nd/or drug-resistnt TB Besides individul compounds, new combintions of drugs re being tested in severl Phse II or Phse III trils. The NC-2 Phse IIb tril, conducted by the Globl Alli- 6 The use of delmnid in the tretment of multidrug-resistnt tuberculosis: Interim policy guidnce. Genev: World Helth Orgniztion; 214(WHO/ HTM/TB/214.23). Avilble t: http://pps.who.int/iris/ bitstrem/1665/137334/1/who_htm_tb_214.23_eng.pdf 11 n GLOBAL TUBERCULOSIS REPORT 215

nce for TB Drug Development (referred to in this text s TB Allince ) in South Afric nd the United Republic of Tnzni, investigted the ef ficcy, sfety nd tolerbility of the combintion of moxifloxcin + pretomnid + pyrzinmide (MPZ) f ter eight weeks of tretment in 27 dult ptients with newly dignosed drug-susceptible or smer-positive pulmonry MDR-TB. 1 Two doses of pretomnid were tested (1 mg nd 2 mg); the 26 MDR-TB ptients received only the higher dose. The primry endpoint ws the rte of chnge in colony forming units (CFUs) from sputum on solid culture over eight weeks. Results of this tril showed tht the MPZ regimen hd ctive bctericidl ctivity ginst both drug-susceptible nd MDR-TB over two months nd tht this bctericidl ctivity ws significntly greter thn tht of isonizid, rifmpicin, pyrzinmide nd ethmbutol (HRZE) therpy in ptients with drug-susceptible TB when the MP(2mg)Z regimen ws used. The frequency of dverse events ws similr to stndrd tretment in ll groups. The combintion of moxifloxcin, pretomnid, nd pyrzinmide thus ppered to be sfe, well-tolerted, nd showed superior bctericidl ctivity for tretment of drug-susceptible TB during the first eight weeks of tretment. On the bsis of the results from the Phse IIb tril, Phse III tril ws lunched in Februry 215. Known s the STAND tril, it will be implemented in 16 countries nd is prtilly rndomized clinicl tril. Tretments re ssigned to five prllel groups: P(1mg)-M-Z for 4 months for 35 ptients with drug-susceptible TB; P(2mg)-M-Z for four months for 35 ptients with drug-susceptible TB; P(2mg)-M-Z for six months for 35 ptients with drug-susceptible TB; HRZE for six months for 35 ptients with drug-susceptible TB; nd P(2mg)-M-Z for six months for 35 ptients with drug-resistnt TB. The NC-3 tril tested the 14 dy erly bctericidl ctivity (EBA) of vrious combintions of clofzimine, bedquiline, pretomnid nd pyrzinmide in ptients with drug-susceptible TB. 2 Following the results from this tril, Phse IIb tril, NC-5, hs been lunched. This is testing ll-orl combintion regimens tht include bedquiline (two dif ferent doses), pretomnid, nd pyrzinmide for ptients with drug-susceptible TB, nd these drugs in combintion with moxifloxcin for ptients with MDR-TB. The tril is mesuring the decline in CFUs over eight weeks, nd the time to positivity bsed on results from pooled sputum smpling every 16 hours. This study strted in October 214, nd results re expected in mid-216. The NiX-TB study, implemented by the TB Allince in South Afric, strted in April 215. It is investigting the sfe- 1 Dwson R et l. Ef ficiency nd sfety of the combintion of moxifloxcin, pretomnid (PA-824), nd pyrzinmide during the first 8 weeks of ntituberculosis tretment: phse 2b, open-lbel, prtly rndomised tril in ptients with drug-susceptible or drug-resistnt pulmonry tuberculosis. Lncet 215 2 Everitt D et l. 14 Dy EBA study of clofzimine lone nd in combintion. 44th Union World Conference on Lung Helth, Lte-breker session, Pris, 213 ty nd ef ficcy of six month combintion of bedquiline, pretomnid nd linezolid (ll compounds tht re new or to which there is little pre-existing resistnce due to limited use) for TB ptients with XDR-TB. The primry endpoint is the incidence of bcteriologic filure or relpse or clinicl filure, with follow-up for 24 months f ter the end of tretment. Alongside the Nix-TB study, the TB Allince is undertking study of the response to dif ferent doses of linezolid in ptients with drug-susceptible TB over two weeks. This study will inform dosing djustments tht my need to be mde for linezolid in the NiX-TB tril or other regimens tht include linezolid. There re two clinicl trils scheduled to strt round the end of 215. The first is clled the endtb tril. It is Phse III tril funded by UNITAID nd implemented by Prtners in Helth nd Médecins Sns Frontières. It will evlute five new ll-orl short regimens for the tretment of MDR- TB. These regimens contin one new nti-tb drug (either bedquiline or delmnid), moxifloxcin or levofloxcin, nd pyrzinmide plus linezolid or clofzimine or both, in vrious combintions. They will be compred with the current WHO stndrd of cre. Potentil sites include Georgi, Kzkhstn, Kyrgyzstn, Lesotho nd Peru. The second is the TB-PRACTECAL tril. This is rndomized, controlled, openlbel, Phse II/III dptive tril tht will evlute the sfety nd efficcy of six-month regimens tht contin bedquiline, pretomnid nd linezolid with or without moxifloxcin or clofzimine for the tretment of dults with MDR-TB or XDR-TB. The tril is funded by Médecins Sns Frontières nd will be conducted in Uzbekistn nd Swzilnd. In ddition to trils, two recent observtionl studies investigting the ef fectiveness of shorter tretment regimens for ptients with MDR-TB in Niger 3 nd Cmeroon 4 hve shown tht 12-month tretment regimen ws effective nd well-tolerted in ptients not previously exposed to second-line drugs. 8.2.3 Tretment of ltent TB infection (LTBI) Since the publiction of WHO guidelines on the tretment of LTBI in 215, 5 new evidence bout the benefits of isonizid preventive therpy (IPT) when provided in ddition to ntiretrovirl therpy (ART) to HIV-positive people with very high CD4 counts hs become vilble from the TEMPRANO ANRS 12136 tril. 6 This tril included 256 ptients in Côte 3 Piubello A, Hroun SH, Souleymne MB et l. High Cure Rte with Stndrdised Short-Course Multidrug-Resistnt Tuberculosis Tretment in Niger: No Relpses. Int J Tuberc Lung Dis 215;18:1188 94. 4 Kubn C, Noeske J, Rieder HL et l. High Ef fectiveness of 12-Month Regimen for MDR-TB Ptients in Cmeroon. The Interntionl Journl of Tuberculosis nd Lung Disese. Int J Tuberc Lung Dis 215;19: 517 24. 5 World Helth Orgniztion. Guidelines on the mngement of ltent tuberculosis infection. Genev: World Helth Orgniztion; 215. Avilble t: http://www.who.int/tb/publictions/ltbi_document_pge/ en/ 6 The TEMPRANO ANRS 12136 Study Group. A Tril of Erly Antiretrovirls nd Isonizid Preventive Therpy in Afric. N Engl J Med 215; 373:88 822. GLOBAL TUBERCULOSIS REPORT 215 n 111

n FIGURE 8.4 The development pipeline for new TB vccines, August 215 Phse I Phse II Phse IIb Phse III Ad5 Ag85A McMster, CnSino VPM 12 (rbcg) Mx Plnck, VPM, TBVI, SII M72 + AS1E b GSK, Aers M. Vcce c Anhui Zhifei Longcom ID93 + GLA-SE IDRI, Aers H1 + IC31 SSI, TBVI, EDCTP DAR-91 Drtmouth, Aers RUTI Archivel Frm, S.L TB / FLU-4L RIBSP H4: IC31 d SSI, Snofi-Psteur, Aers Crucell Ad35 / MVA85A* Crucell, Oxford, Aers ChAdOx1.85A / MVA85A* Birminghm, Oxford MVA85A / MVA85A (ID, Aerosol)* Oxford H56: IC31 SSI, Aers MTBVAC (Attenuted M.Tb) TBVI, Zrgoz, Biofbri n Virl Vector n Protein / Adjuvnt n Mycobcteril Whole Cell or Extrct * Experimentl medicine tools / pltforms Initil sfety nd ef ficcy to begin 215 b Ef ficcy dt likely vilble in 218 c Endpoint dt should be vilble in 216 d Prevention of infection dt likely vilble in 217 Sources: Aers, 215 www.ers.org; Working Group on New TB Vccines, 215 www.newtbvccines.org d Ivoire nd found tht IPT nd ART provided together hd higher ef ficcy in preventing TB disese thn ART lone. The study lso found lower rtes of severe illness when ART ws strted immeditely longside 6 months of IPT, compred with deferred ART nd no IPT. This ws true overll nd mong ptients with CD4 counts of 5 cells/mm 3. Study uthors lso highlighted tht isonizid cn be prescribed sfely when given erly in the course of HIV disese. 8.3 New vccines to prevent TB The slow decline in TB incidence globlly (Chpter 2) nd the persistent thret of MDR-TB both highlight the criticl need for new ef fective TB vccines. It is estimted tht t lest US$ 8 billion is required ech yer for TB dignosis nd tretment using currently vilble interventions (Chpter 7). A recent modelling study showed tht developing t lest one new TB vccine over the next 1 15 yers would cost bout US$.8 1 billion, pproximtely 1% of dignosis nd tretment costs, nd tht n dolescent nd dult vccine with 6% ef ficcy delivered to 2% of the popultion-trisk could vert s mny s 3 5 million new cses of TB by 25. 1 Recent modelling lso indictes tht trgeting dolescents will prevent morbidity nd mortlity in infnts nd young children, nd is more ef fective strtegy to protect 1 Aers, TB Vccine Reserch nd Development: A Business Cse for Investment. Rockville: Aers; 214. Avilble t: http://bit.ly/1eodjbj them from TB thn direct vccintion of infnts with similr vccine. 2 The potentil for n dult/dolescent vccine to hve meningful impct on the globl TB epidemic, compred with the limited impct of n infnt vccine, hs shif ted the focus of TB vccine development. The new prdigm emphsises the development of diverse pipeline of new TB vccine cndidtes tht trget the prevention of ctive TB in these older ge groups. Scientific dvnces hve lso enbled the pursuit of more sophisticted pproches to vccine design. The globl pipeline of TB vccine cndidtes in clinicl trils is more robust thn t ny previous period in history, now including recombinnt BCGs, ttenuted M. tuberculosis strins, recombinnt virl-vectored pltforms, protein/djuvnt combintions, nd mycobcteril extrcts. The sttus of the pipeline for new vccines in August 215 is shown in Figure 8.4. These vccines im either to prevent infection (pre-exposure) or to prevent primry progression to disese or rectivtion of ltent TB (post-exposure). Further detils re provided below. 2 White, R. Indirect ef fects in infnts on the force of TB disese from vccinting dolescents nd dults. London: TB Modelling Group, TB Centre, Centre for the Mthemticl Modelling of Infectious Diseses; 215. 112 n GLOBAL TUBERCULOSIS REPORT 215

8.3.1 Phse II nd Phse III clinicl trils There re currently eight vccines in Phse II or Phse III trils. M72/AS1E (mde by GlxoSmithKline (GSK)) is recombinnt fusion protein of the M. tuberculosis ntigens 32A nd 39A with the AS1E djuvnt. A lrge rndomized plcebo-controlled Phse IIb tril (NCT1755598, conducted by GSK nd Aers) is enrolling pulmonry TB-negtive, IGRApositive, HIV-negtive dults in Keny, South Afric nd Zmbi. The im is to enroll 356 dults; by July 215, 296 prticipnts hd been enrolled. The primry endpoint will be the protective ef ficcy of two doses of M72/AS1E ginst pulmonry TB disese. Secondry endpoints include sfety nd immunogenicity. Three vccines re protein subunits with djuvnts, initilly developed by the Sttens Serum Institute (SSI) in Copenhgen, Denmrk. These re: "" H1:IC31 is n djuvnted subunit vccine combining the M. tuberculosis ntigens Ag85B nd ESAT-6 with Vlnev s IC31 djuvnt. The H1:IC31 vccine ws the first TB vccine to commence clinicl development by SSI, nd Aers subsequently joined this ef fort. The H1:IC31 vccine hs been evluted in three Phse I trils, which showed the vccine to be sfe nd immunogenic in HIV-negtive dults who were either M. tuberculosis nïve, BCG vccinted or ltently infected, in low- nd high TB burden settings. A Phse II double-blind nd plcebo controlled tril in HIVpositive individuls with or without LTBI confirmed tht the vccine ws sfe nd immunogenic. 1 Recently, lrge Phse II tril investigting the influence of dose, schedule nd LTBI sttus on the immunogenicity of H1:IC31 in 24 dolescents in South Afric ws finlized; H1:IC31 ws the first TB vccine to be tested in lrge tril in this importnt trget popultion. A pper in which results will be published is in preprtion. In prllel, the H1:IC31 subunit vccine construct hs been improved with the ddition of third ntigen, Rv266c, becoming H56:IC31. Clinicl dt on H1:IC31 will support the further development of H56:IC31. No further clinicl trils with H1:IC31 re plnned. "" H4:IC31 is being developed s booster vccine to BCG with Snofi Psteur. The vccine cndidte contins fusion protein of Ag85B nd TB1.4 formulted with IC31 djuvnt. H4:IC31 is currently being evluted in Phse II studies in Africn infnts with Snofi nd SSI (nd lso with the Interntionl Mternl Peditric Adolescent AIDS Clinicl Trils Group (IMPAACT) network nd the HIV Vccine Trils Network (HVTN) in conjunction with NIAID). In ddition, the H4:IC31 cndidte is being ssessed in 1 Reither K, Ktsoulis L, Bettie T et l. Sfety nd Immunogenicity of H1/ IC31, n Adjuvnted TB Subunit Vccine, in HIV-Infected Adults with CD4+ Lymphocyte Counts Greter thn 35 cells/mm 3 : A Phse II, Multi-Centre, Double-Blind, Rndomized, Plcebo-Controlled Tril. PLoS ONE. 214;9(12):e11462. Phse II proof-of-concept study for its bility to prevent de novo infection with M. tuberculosis mong IGRA-negtive, HIV-uninfected South Africn dolescents t high risk of cquiring M. tuberculosis infection. An intensive immunogenicity study of H4:IC31 in South Africn dolescents is underwy. "" H56:IC31. This is n djuvnted subunit vccine tht combines three M. tuberculosis ntigens (Ag85B, ESAT-6, nd Rv266c) with Vlnev s IC31 djuvnt. It is being developed by SSI nd Aers. A Phse I study to evlute the sfety nd immunogenicity profile of H56:IC31 in HIVnegtive dults with nd without LTBI nd no history or evidence of TB disese hs been completed. Two Phse I studies re currently ongoing to determine the sfety nd immunogenicity profile of H56:IC31 in HIV-negtive, BCGvccinted dults with nd without LTBI nd in ptients who hve recently been treted for pulmonry TB disese, respectively. A study to determine the ef ficcy of H56:IC31 in preventing TB infection in LTBI negtive dolescents is plnned for 216. VPM 12, originlly developed t the Mx Plnck Institute of Infection Biology with further development by Vkzine Projekt Mngement, the Tuberculosis Vccine Inititive (TBVI), nd Serum Institute of Indi, is live recombinnt vccine. It hs been derived from the Prgue strin of BCG into which the listerolysin gene from Listeri monocytogenes hs been cloned, nd the urese gene deleted, to potentilly improve immunogenicity. A Phse II tril of this vccine hs been completed in South Afric. The Phse II tril (in plnning) will ssess the sfety nd immunogenicity of the vccine in HIV exposed nd unexposed newborns. RUTI is non-live nd polyntigenic vccine bsed on frgmented nd detoxified M. tuberculosis bcteri. The product is liposome suspension of the Drug Substnce with chrge excipient. RUTI is being developed by Archivel Frm s n immunotherpeutic vccine. A Phse II tril in South Afric ws completed recently nd other clinicl trils re in the plnning stges. MTBVAC is being developed by the University of Zrgos, Institut Psteur, BIOFABRI nd TBVI. It is live M. tuberculosis strin ttenuted vi deletions of the phop nd fdd26 genes. It is the first live ttenuted M. tuberculosis vccine to enter Phse I tril, which ws recently completed. The next tril will be Phse I/II tril mong dults in South Afric. The vccine is being developed both s BCG replcement vccine nd s potentil boost vccine in dolescents nd dults. M. Vcce is specified lyste developed by the phrmceuticl compny Anhui Zhifei Longcom Biologic Phrmcy Co., Ltd. nd licensed by the Chin Food nd Drug Administrtion s n immunotherpeutic gent to help shorten TB tretment for ptients with drug-susceptible TB. It is in Phse III tril to ssess its ef ficcy nd sfety in preventing TB disese in people with LTBI. The tril is being conducted in collbortion with the Gungxi Center for Disese Con- GLOBAL TUBERCULOSIS REPORT 215 n 113

trol nd Prevention in Chin. It is the lrgest TB vccine tril undertken in the lst decde, including 1 people ged 15 65 with PPD>15mm. The tril is scheduled to be completed by April 216. Of note, MVA85A, the ttenuted vccini virus-vectored vccine cndidte expressing Ag85A of M. tuberculosis designed t Oxford University s booster vccine for BCG vccinted infnts, hs now completed Phse II sfety nd immunogenicity study. 1 The study ws conducted in 65 BCG-vccinted, HIV-positive prticipnts in Senegl nd South Afric. As in the infnt study 2, the vccine ws well tolerted nd immunogenic, but no efficcy ginst M. tuberculosis infection or disese ws demonstrted (lthough the study ws not powered to detect n ef fect ginst disese). Current nd future clinicl pproches focus on evluting MVA85A delivered by erosol, lone or in prime-boost combintion with second virlly vectored vccine, ChAdOx1.85A (see below). 8.3.2 Phse I clinicl trils There re seven vccines in Phse I clinicl trils. ID93 + GLA-SE, developed by the Infectious Disese Reserch Institute (IDRI) in collbortion with Aers, comprises three M. tuberculosis immunodominnt ntigens (Rv268, Rv3619 nd Rv362), one M. tuberculosis ltencyssocited ntigen (Rv1813), nd the djuvnt GLA-SE. A Phse I tril in 6 dults in the United Sttes to ssess sfety nd immunogenicity ws recently completed. The vccine ws found to hve n cceptble sfety profile, nd T cell responses were seen t ll of the dose levels tht were studied. A further Phse I tril in South Afric is being conducted to describe the sfety nd immunogenicity profile of ID93 + GLA-SE in BCG-vccinted, QuntiFERON TB-Gold negtive nd positive helthy dults. A Phse II tril in South Afric, with the support of the Wellcome Trust, is evluting sfety nd immunogenicity in ptients tht hve recently completing tretment for pulmonry TB disese. A Phse IIb tril to ssess whether the vccine cn prevent recurrence of TB disese in ptients who hve recently nd successfully completed TB tretment is being plnned by IDRI nd South Africn collbortors in the sme popultion. Ad5 Ag85A is n denovirus serotype 5 vector expressing Ag85A. It hs been developed by McMster University with support from CnSino, Chinese biotechnology compny. Ad5Ag85A ws evluted in 24 helthy humn volunteers (both BCG-nïve nd previously BCG-immunized) for sfety nd immunogenicity following single intr-musculr injection in Phse I clinicl study completed t McMster 1 Ndiye BP, Thienemnn F, Ot M, et l. Sfety, immunogenicity, nd ef ficcy of the cndidte tuberculosis vccine MVA85A in helthy dults infected with HIV-1: rndomised, plcebo-controlled, phse 2 tril. Lncet Respir Med 215;3:19 2. 2 Tmeris MD, Htherill M, Lndry BS, et l. Sfety nd ef ficcy of MVA85A, new tuberculosis vccine, in infnts previously vccinted with BCG: rndomised plcebo-controlled phse 2b tril. Lncet 213;381:121 28 University, Cnd. Immuniztion of Ad5Ag85A ws sfe nd well-tolerted in both tril volunteer groups, with only rections t the injection site. Pre-existing Ad5 ntibodies did not pper to f fect the immune response. Ad5Ag85A ws immunogenic in both groups nd stimulted polyfunctionl T cell responses, but it more potently boosted both CD4+ nd CD8+ T cell immunity in previously BCG-vccinted volunteers compred with BCG-nïve individuls. DAR 91 is het-inctivted M. obuense. It hs been developed by investigtors t Drtmouth University, USA, nd mnufctured by Aers. Enrolment in Phse I sfety nd immunogenicity study in 6 BCG-vccinted, HIV-infected nd -uninfected individuls ws recently completed in the USA. The study remins blinded while subjects continue to be followed. No serious dverse events hve been reported nd plns re underwy to complete in-depth immunologic evlutions by the end of 215, using dt for the first people enrolled in the tril. TB/FLU-4L is recombinnt influenz vectored vccine cndidte developed by the Reserch Institute for Biologicl Sfety Problems nd the Reserch Institute on Influenz in the Russin Federtion, with support nd ssistnce from interntionl experts. The influenz virus strin A/Puerto Rico/8/34 (H1N1) ws used s prent strin for construction of n ttenuted repliction-deficient vector expressing M. tuberculosis ntigens Ag85A nd ESAT-6. It ws designed s mucosl boost vccine for infnts, dolescents nd dults. A Phse I tril in BCG-vccinted QuntiFERON TB- Gold negtive helthy dult volunteers using intrnsl dministrtion ws recently completed, nd Phse II tril is plnned. ChAdOx1.85A is simin denovirus expressing ntigen 85A tht ws developed t the University of Oxford. ChAdOX1.85A is being evluted in Phse I tril in BCGvccinted dults, both lone nd s prt of prime-boost strtegy with MVA85A. In this first-in-humns study, ChAdOx1.85A is being dministered intrmusculrly. Future plns include evlution of the erosol route of delivery of ChAdOx1.85A. Crucell Ad35/AERAS-42 nd MVA85A re now being tested in combintion, to try nd induce both CD4+ nd CD8+ T cells. One or two doses of Crucell Ad35 followed by dose of MVA85A is being compred with 3 doses of Crucell Ad35 in Phse I/II tril in dults in the United Kingdom. The tril is being implemented by Oxford University, Aers nd Crucell. MVA85A (Aerosol) is n erosolized MVA85A cndidte developed by Oxford tht recently underwent Phse I double-blind tril to compre the sfety nd immunogenicity of erosol-dministered nd intrdermlly dministered MVA85A in 24 BCG-vccinted dults in the United Kingdom. The study concluded tht erosol vccintion with MVA85A ppered to be sfe nd fesible vccintion tht produced stronger CD4+ T-cell response thn intrderml MVA85A. Further studies ssessing the erosol route re necessry. 114 n GLOBAL TUBERCULOSIS REPORT 215

8.3.3 Erly stge, trnsltionl reserch As documented bove, there is resonbly robust pipeline of vccine cndidtes, including those bsed on whole cell pproches, ntibody-inducing vccines nd nucleic cidbsed (DNA nd RNA) vccines. This my help to diversify the clinicl portfolio nd fill the scientific gps tht currently exist. To supplement existing ef forts, there is lso re-prioritized focus on erly stge, trnsltionl reserch. This will test hypotheses bout immunologicl mechnisms, delivery methods, nd cndidte biomrkers, nd help to broden preclinicl scientific pproches, ntigen selection strtegies, nd evlution strtegies, with the overll gol of ensuring tht more diverse pipeline of new TB vccine cndidtes cn move forwrd into clinicl trils. 1 Discussions bout relevnt clinicl endpoints, beyond immunologicl mesures tht indicte prevention of disese or infection, nd how these endpoints my be ssessed through biomrkers erly in clinicl trils or pre-cliniclly to select the most promising cndidte vccines/djuvnts, re lso underwy. 8.4 The End TB Strtegy: the criticl role of reserch nd development The End TB Strtegy includes Intensified Reserch nd Innovtion s one of three fundmentl pillrs (Chpter 1). This hs two essentil nd complementry components: (1) Discovery, development nd rpid uptke of new tools, interventions nd strtegies; nd (2) Reserch to optimize implementtion nd impct. The overll im of the pillr is tht intensified reserch will result in revolutionry new technologies, strtegies nd models of service delivery tht will trnsform the wy in which TB is dignosed, treted nd prevented. As high lighted t the beginning of this chpter, such chnges re necessry by 225, so tht the rte t which TB incidence flls cn be ccelerted beyond the best-ever historic performnce nd trgets tht correspond to ending the globl TB epidemic by 235 cn be chieved. A mssive increse in funding for reserch is required. This includes funding to crete or expnd reserch-enbling environments for the next genertion of scientists in low nd middle-income countries with the lrgest burden of TB, so tht they cn ply led role in reserch bsed on domestic investments, longside estblished globl expertise. Incresed domestic investments in reserch in countries with high burden of TB will be fcilitted by dvoccy from key plyers including ntionl public helth uthorities, reserchers, cre providers, nd civil society. It is lso importnt tht high-income countries nd their institutions, interntionl gencies nd philnthropic orgniztions increse their investments in TB reserch nd trining, in close collbortion with high-burden countries. Once new technologies nd innovtive pproches re developed, they need to be trnslted into policies nd prctices, nd then dpted to prticulr country contexts s pproprite. This will require expnded efforts to disseminte reserch results, prticulrly to policy mkers. To foster nd intensify high-qulity reserch t ntionl nd interntionl levels, WHO hs developed Globl Action Frmework for Reserch towrds TB Elimintion tht covers the period 216 225. This pln shows how to opertionlize Pillr 3 of the End TB Strtegy, including through the development of country-specific TB reserch strtegic plns, cpcity strengthening, nd development/reinforcement of networks t country level, nd through regulr meetings nd the development of interntionl networks for reserch, cpcity building nd dvoccy t globl nd regionl levels. 1 Brennn MJ nd Thole J, Eds. Tuberculosis vccines: A strtegic blueprint for the next decde. Tuberculosis. 212; 92: Supplement 1; S6 S13. GLOBAL TUBERCULOSIS REPORT 215 n 115

A N N E X 1 Access to the WHO globl TB dtbse

118 n GLOBAL TUBERCULOSIS REPORT 215

A.1 Dtbse contents The 215 globl TB report is bsed on dt collected nnully from countries nd territories, including 194 Member Sttes. These dt re stored in the globl TB dtbse. In 215, dt were collected on the following topics: TB cse notifictions nd tretment outcomes, including brekdowns by TB cse type, ge, sex nd HIV sttus; lbortory dignostic services; monitoring nd evlution, including surveillnce nd surveys specificlly relted to drug-resistnt TB; mngement of drug-resistnt TB; collbortive TB/HIV ctivities; TB infection control; enggement of ll public nd privte cre providers in TB control; community enggement; the budgets of ntionl TB control progrmmes (NTPs) in 215; utiliztion of generl helth services (hospitliztion nd outptient visits) during tretment in 215; nd NTP expenditures in 214. A shortened version of the online questionnire ws used for highincome countries (tht is, countries with gross ntionl income per cpit of US$ 12 736 in 214, s defined by the World Bnk) 1 nd/or low-incidence countries (defined s countries with n incidence rte of <2 cses per 1 popultion or <1 cses in totl). Countries reported dt using dedicted website (https://extrnet.who.int/tme), which ws opened for reporting in mid- Mrch. Countries in the Europen Union submitted notifiction nd tretment outcomes dt to the TESSy system mnged by the Europen Centre for Disese Prevention nd Control (ECDC). Dt from TESSy were uploded into the globl TB dtbse. Additionl dt bout the provision of isonizid preventive therpy (IPT) to people living with HIV nd ntiretrovirl therpy (ART) for HIV-positive TB ptients were collected by the Joint United Ntions Progrmme on HIV/AIDS (UNAIDS) nd the HIV deprtment in WHO. These dt were jointly vlidted by UNAIDS nd the WHO s Globl TB Progrmme nd HIV deprtment, nd uploded into the globl TB dtbse. Following review nd follow-up with countries, the dt used for the min prt of this report were those dt vilble on 6 August 215. The number of countries nd territories tht hd reported dt by 6 August 215 is shown in Tble A1.1. n TABLE A1.1 Reporting of dt in the 215 round of globl TB dt collection COUNTRIES AND TERRITORIES WHO MEMBER STATES WHO REGION OR SET OF COUNTRIES NUMBER NUMBER THAT REPORTED DATA NUMBER NUMBER THAT REPORTED DATA Africn Region 47 47 47 47 Estern Mediterrnen Region 22 21 21 2 Europen Region 54 46 53 46 Region of the Americs 46 45 35 34 South-Est Asi Region 11 11 11 11 Western Pcific Region 36 35 27 27 High-burden countries 22 22 22 22 World 216 25 194 185 Countries tht did not report by the dedline were mostly low-incidence countries in Western Europe. A.2 Accessing TB dt using the WHO Globl TB Progrmme website You cn find most of the dt held in the globl TB dtbse by going to www.who.int/tb/dt. This web pge gives you ccess to country profiles, comm-seprted vlue (CSV) dt files nd dt visulistions. A2.1 Country profiles Profiles cn be viewed nd downloded for ll 216 countries nd territories tht report TB dt to WHO ech yer, nd not just the 22 high burden countries shown in the printed version of the globl TB report. The profiles cn be generted on-demnd directly from the globl TB dtbse nd therefore my include updtes received fter publiction of the globl TB report. TB finncil profiles cn be viewed nd downloded for over 1 countries nd territories tht report detiled TB finncil dt to WHO. 1 http://dt.worldbnk.org/bout/country-clssifictions GLOBAL TUBERCULOSIS REPORT 215 n 119

n FIGURE A1.1 Interctive pge to view MDR-TB indictors by region or country nd yer 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 nd tretment outcomes, lbortory cpcity nd WHO estimtes of TB incidence, prevlence nd mortlity (Figure A1.1). A.3 Accessing TB dt using the WHO Globl Helth Observtory The WHO Globl Helth Observtory (GHO) t www.who.int/gho/ is WHO s portl, providing ccess to dt nd nlyses for monitoring the globl helth sitution. It includes dt repository. Key dt from WHO s globl TB dtbse cn be viewed, filtered, ggregted nd downloded from within the GHO Dt Repository t http://pps.who.int/gho/dt/node.min.1315 The GHO dt tble heders include links to vrible nd indictor definitions. The dt cn be downloded in mny formts, including s CSV nd Excel files (Figure A1.2). There is lso n Appliction Progrmme Interfce (API) for nlysts nd progrmmers to use GHO dt directly in their softwre pplictions. See http://pps.who.int/gho/dt/node.resources 12 n GLOBAL TUBERCULOSIS REPORT 215

n FIGURE A1.2 A dt tble in the GHO Dt Repository GLOBAL TUBERCULOSIS REPORT 215 n 121

A N N E X 2 Country profiles FOR 22 HIGH-BURDEN COUNTRIES

124 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

Afghnistn Popultion 214 32 million Estimtes of TB burden 214 NUMBER (thousnds) RATE (per 1 popultion) Mortlity (excludes HIV+TB) 14 (1 18) 44 (32 57) Mortlity (HIV+TB only).87 (.72.1).28 (.23.33) Prevlence (includes HIV+TB) 11 (56 18) 34 (178 555) Incidence (includes HIV+TB) 6 (53 67) 189 (167 212) Incidence (HIV+TB only).32 (.25.4) 1 (.8 1.3) Cse detection, ll forms (%) 53 (47 6) Estimtes of MDR-TB burden 214 NEW RETREATMENT % of TB cses with MDR-TB 3.2 (2.3 4.1) 17 (11 23) MDR-TB cses mong notified pulmonry TB cses 75 (54 96) 36 (24 49) TB cse notifictions 214 NEW b RELAPSE Pulmonry, bcteriologiclly confirmed 14 737 1 29 Pulmonry, cliniclly dignosed 8 573 Extrpulmonry 7 227 Totl new nd relpse 31 746 Previously treted, excluding relpses 966 Totl cses notified 32 712 Among 3 537 new cses: 4 454 (15%) cses ged under 15 yers; mle:femle rtio:.7 Reported cses of RR-/MDR-TB 214 NEW RETREATMENT TOTAL b Cses tested for RR-/MDR-TB 2 (<1%) 184 (8%) 186 Lbortory-confirmed RR-/MDR-TB cses 88 Ptients strted on MDR-TB tretment c 88 TB/HIV 214 NUMBER (%) TB ptients with known HIV sttus 1 443 (32) HIV-positive TB ptients 4 (<1) HIV-positive TB ptients on co-trimoxzole preventive therpy (CPT) HIV-positive TB ptients on ntiretrovirl therpy (ART) HIV-positive people screened for TB 142 HIV-positive people provided with IPT 7 Tretment success rte nd cohort size (%) COHORT New nd relpse cses registered in 213 (88) 3 57 Previously treted cses, excluding relpse, registered in 213 (74) 1 115 HIV-positive TB cses, ll types, registered in 213 RR-/MDR-TB cses strted on second-line tretment in 212 (71) 38 XDR-TB cses strted on second-line tretment in 212 Lbortories 214 Smer (per 1 popultion) 2.3 Culture (per 5 million popultion).5 Drug susceptibility testing (per 5 million popultion) Sites performing Xpert MTB/RIF 1 Is second-line drug susceptibility testing vilble? Yes, outside country Finncing TB control 215 Ntionl TB progrmme budget (US$ millions) 15 % Funded domesticlly 6% % Funded interntionlly 67% % Unfunded 27% Mortlity (excludes HIV+TB) (rte per 1 poultion per yer) Prevlence (rte per 1 poultion) Incidence (rte per 1 poultion per yer) Number of ptients Tretment success rte (%) 1 75 5 25 8 6 4 2 199 1995 2 25 21 2 15 1 5 199 1995 2 25 21 Notified (new nd relpse) Incidence Incidence (HIV+TB only) 1 8 6 4 2 23 25 27 29 211 213 HIV-positive TB ptients on CPT on ART 1 8 6 4 2 16 199 1995 2 25 21 1995 1997 1999 21 23 25 27 29 211 213 New Retretment New nd relpse Retretment excluding relpse HIV-positive RR-/MDR-TB XDR-TB Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b Includes cses with unknown previous TB tretment history. c Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. Totl budget (US$ millions) 12 8 4 211 212 213 214 215 Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 125

Bngldesh Popultion 214 159 million Estimtes of TB burden 214 NUMBER (thousnds) RATE (per 1 popultion) Mortlity (excludes HIV+TB) 81 (59 11) 51 (37 68) Mortlity (HIV+TB only).18 (.14.22).11 (.9.14) Prevlence (includes HIV+TB) 64 (34 1 ) 44 (211 659) Incidence (includes HIV+TB) 36 (32 41) 227 (2 256) Incidence (HIV+TB only).57 (.45.71).36 (.28.45) Cse detection, ll forms (%) 53 (47 6) Estimtes of MDR-TB burden 214 NEW RETREATMENT % of TB cses with MDR-TB 1.4 (.7 2.5) 29 (24 34) MDR-TB cses mong notified pulmonry TB cses 2 1 (1 3 7) 2 7 (2 2 3 2) TB cse notifictions 214 NEW b RELAPSE Pulmonry, bcteriologiclly confirmed 16 767 2 989 Pulmonry, cliniclly dignosed 42 832 863 Extrpulmonry 37 46 39 Totl new nd relpse 191 166 Previously treted, excluding relpses 5 631 Totl cses notified 196 797 Among 187 5 new cses: 6 262 (3%) cses ged under 15 yers; mle:femle rtio: 1.5 Reported cses of RR-/MDR-TB 214 NEW RETREATMENT TOTAL b Cses tested for RR-/MDR-TB 12 573 (12%) 4 959 (51%) 43 36 Lbortory-confirmed RR-/MDR-TB cses 994 Ptients strted on MDR-TB tretment c 945 TB/HIV 214 NUMBER (%) TB ptients with known HIV sttus 1 11 (<1) HIV-positive TB ptients 45 (4) HIV-positive TB ptients on co-trimoxzole preventive therpy (CPT) 45 (1) HIV-positive TB ptients on ntiretrovirl therpy (ART) 45 (1) HIV-positive people screened for TB 726 HIV-positive people provided with IPT Tretment success rte nd cohort size (%) COHORT New nd relpse cses registered in 213 (93) 184 77 Previously treted cses, excluding relpse, registered in 213 (86) 6 327 HIV-positive TB cses, ll types, registered in 213 (75) 68 RR-/MDR-TB cses strted on second-line tretment in 212 (72) 55 XDR-TB cses strted on second-line tretment in 212 (25) 4 Lbortories 214 Smer (per 1 popultion).7 Culture (per 5 million popultion) <.1 Drug susceptibility testing (per 5 million popultion) <.1 Sites performing Xpert MTB/RIF 38 Is second-line drug susceptibility testing vilble? Yes, in nd outside country Finncing TB control 215 Ntionl TB progrmme budget (US$ millions) 48 % Funded domesticlly <1% % Funded interntionlly 7% % Unfunded 3% Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. A joint ressessment of estimtes of TB disese burden will be undertken following completion of the ntionl TB prevlence survey. b Includes cses with unknown previous TB tretment history. c Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. Mortlity (excludes HIV+TB) (rte per 1 poultion per yer) Prevlence (rte per 1 poultion) Incidence (rte per 1 poultion per yer) Number of ptients Tretment success rte (%) Totl budget (US$ millions) 9 6 3 199 1995 2 25 21 75 5 25 199 1995 2 25 21 2 1 199 1995 2 25 21 Notified (new nd relpse) Incidence Incidence (HIV+TB only) 8 6 4 2 23 25 27 29 211 213 HIV-positive TB ptients on CPT on ART 1 8 6 4 2 1995 1997 1999 21 23 25 27 29 211 213 New Retretment New nd relpse Retretment excluding relpse HIV-positive RR-/MDR-TB XDR-TB 6 5 4 3 2 1 211 212 213 214 215 Funded domesticlly Funded interntionlly Unfunded 126 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

Brzil Popultion 214 26 million Estimtes of TB burden 214 NUMBER (thousnds) RATE (per 1 popultion) Mortlity (excludes HIV+TB) 5.3 (4.9 5.7) 2.6 (2.4 2.7) Mortlity (HIV+TB only) 2.4 (1.8 3.2) 1.2 (.87 1.6) Prevlence (includes HIV+TB) 11 (51 18) 52 (25 89) Incidence (includes HIV+TB) 9 (86 95) 44 (42 46) Incidence (HIV+TB only) 16 (14 17) 7.6 (6.9 8.4) Cse detection, ll forms (%) 82 (78 86) Estimtes of MDR-TB burden 214 NEW RETREATMENT % of TB cses with MDR-TB 1.4 (1 1.8) 7.5 (5.7 9.9) MDR-TB cses mong notified pulmonry TB cses 82 (59 1 1) 95 (72 1 3) TB cse notifictions 214 NEW b RELAPSE Pulmonry, bcteriologiclly confirmed 41 12 3 62 Pulmonry, cliniclly dignosed 17 81 1 488 Extrpulmonry 9 479 48 Mortlity (excludes HIV+TB) (rte per 1 poultion per yer) Prevlence (rte per 1 poultion) 6 4 2 199 1995 2 25 21 2 15 1 5 199 1995 2 25 21 Totl new nd relpse 73 97 Previously treted, excluding relpses 7 542 Totl cses notified 81 512 Among 73 97 new nd relpse cses: 2 368 (3%) cses ged under 15 yers; mle:femle rtio: 2.1 Reported cses of RR-/MDR-TB 214 NEW RETREATMENT TOTAL b Cses tested for RR-/MDR-TB 15 344 Lbortory-confirmed RR-/MDR-TB cses 72 Ptients strted on MDR-TB tretment c 72 TB/HIV 214 NUMBER (%) TB ptients with known HIV sttus 56 981 (7) HIV-positive TB ptients 9 578 (17) HIV-positive TB ptients on co-trimoxzole preventive therpy (CPT) HIV-positive TB ptients on ntiretrovirl therpy (ART) HIV-positive people screened for TB 37 54 HIV-positive people provided with IPT Tretment success rte nd cohort size (%) COHORT New nd relpse cses registered in 213 (72) 76 543 Previously treted cses, excluding relpse, registered in 213 (38) 6 945 HIV-positive TB cses, ll types, registered in 213 (46) 9 46 RR-/MDR-TB cses strted on second-line tretment in 212 (51) 825 XDR-TB cses strted on second-line tretment in 212 (25) 24 Lbortories 214 Smer (per 1 popultion) 1.6 Culture (per 5 million popultion) 7.9 Drug susceptibility testing (per 5 million popultion).6 Sites performing Xpert MTB/RIF 48 Is second-line drug susceptibility testing vilble? Yes, in country Finncing TB control 215 Ntionl TB progrmme budget (US$ millions) 77 % Funded domesticlly 72% % Funded interntionlly <1% % Unfunded 27% Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b Includes cses with unknown previous TB tretment history. c Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. Incidence (rte per 1 poultion per yer) Number of ptients Tretment success rte (%) Totl budget (US$ millions) 1 75 5 25 1 8 6 4 2 199 1995 2 25 21 Notified (new nd relpse) Incidence Incidence (HIV+TB only) 1 8 6 4 2 1 8 6 4 2 23 25 27 29 211 213 HIV-positive TB ptients on CPT on ART 1995 1997 1999 21 23 25 27 29 211 213 New Retretment New nd relpse Retretment excluding relpse HIV-positive RR-/MDR-TB XDR-TB 211 212 213 214 215 Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 127

Cmbodi Popultion 214 15 million Estimtes of TB burden 214 NUMBER (thousnds) RATE (per 1 popultion) Mortlity (excludes HIV+TB) 8.9 (6.3 12) 58 (41 78) Mortlity (HIV+TB only).82 (.63 1) 5.3 (4.1 6.7) Prevlence (includes HIV+TB) 1 (87 12) 668 (565 78) Incidence (includes HIV+TB) 6 (54 66) 39 (353 428) Incidence (HIV+TB only) 1.8 (1.6 2) 12 (1 13) Cse detection, ll forms (%) 72 (66 8) Estimtes of MDR-TB burden 214 NEW RETREATMENT % of TB cses with MDR-TB 1.4 (.7 2.5) 11 (4 22) MDR-TB cses mong notified pulmonry TB cses 33 (16 59) 2 (73 4) TB cse notifictions 214 NEW b RELAPSE Pulmonry, bcteriologiclly confirmed 12 168 445 Pulmonry, cliniclly dignosed 11 286 79 Extrpulmonry 18 31 141 Totl new nd relpse 43 59 Previously treted, excluding relpses 679 Totl cses notified 43 738 Among 43 59 new nd relpse cses: 12 5 (28%) cses ged under 15 yers; mle:femle rtio: 1.2 Reported cses of RR-/MDR-TB 214 NEW RETREATMENT TOTAL b Cses tested for RR-/MDR-TB 646 (5%) 1 329 (67%) 1 975 Lbortory-confirmed RR-/MDR-TB cses 11 Ptients strted on MDR-TB tretment c 11 TB/HIV 214 NUMBER (%) TB ptients with known HIV sttus 35 635 (81) HIV-positive TB ptients 953 (3) HIV-positive TB ptients on co-trimoxzole preventive therpy (CPT) 938 (98) HIV-positive TB ptients on ntiretrovirl therpy (ART) 938 (98) HIV-positive people screened for TB 3 54 HIV-positive people provided with IPT 91 Tretment success rte nd cohort size (%) COHORT New nd relpse cses registered in 213 (93) 35 536 Previously treted cses, excluding relpse, registered in 213 (9) 1 71 HIV-positive TB cses, ll types, registered in 213 RR-/MDR-TB cses strted on second-line tretment in 212 (79) 11 XDR-TB cses strted on second-line tretment in 212 Lbortories 214 Smer (per 1 popultion) 1.4 Culture (per 5 million popultion) 1.3 Drug susceptibility testing (per 5 million popultion) 1. Sites performing Xpert MTB/RIF 17 Is second-line drug susceptibility testing vilble? No Finncing TB control 215 Ntionl TB progrmme budget (US$ millions) 31 % Funded domesticlly 12% % Funded interntionlly 47% % Unfunded 42% Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b Includes cses with unknown previous TB tretment history. c Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. Mortlity (excludes HIV+TB) (rte per 1 poultion per yer) Prevlence (rte per 1 poultion) Incidence (rte per 1 poultion per yer) Number of ptients Tretment success rte (%) Totl budget (US$ millions) 2 1 25 2 15 1 5 6 4 2 6 5 4 3 2 1 199 1995 2 25 21 199 1995 2 25 21 199 1995 2 25 21 Notified (new nd relpse) Incidence Incidence (HIV+TB only) 1 9 8 7 6 4 3 2 1 23 25 27 29 211 213 HIV-positive TB ptients on CPT on ART 1995 1997 1999 21 23 25 27 29 211 213 New Retretment New nd relpse Retretment excluding relpse HIV-positive RR-/MDR-TB XDR-TB 211 212 213 214 215 Funded domesticlly Funded interntionlly Unfunded 128 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

Chin Popultion 214 1 369 million Estimtes of TB burden 214 NUMBER (thousnds) RATE (per 1 popultion) Mortlity (excludes HIV+TB) 38 (37 4) 2.8 (2.7 2.9) Mortlity (HIV+TB only).7 (.53.9).5 (.4.7) Prevlence (includes HIV+TB) 1 2 (1 1 1 4) 89 (78 12) Incidence (includes HIV+TB) 93 (86 1 ) 68 (63 73) Incidence (HIV+TB only) 13 (11 16).98 (.79 1.2) Cse detection, ll forms (%) 88 (82 95) Estimtes of MDR-TB burden 214 NEW RETREATMENT % of TB cses with MDR-TB 5.7 (4.5 7) 26 (22 3) MDR-TB cses mong notified pulmonry TB cses 43 (34 53 ) 8 2 (6 9 9 5) TB cse notifictions 214 NEW b RELAPSE Pulmonry, bcteriologiclly confirmed 235 74 25 125 Pulmonry, cliniclly dignosed 526 16 Extrpulmonry 32 348 Mortlity (excludes HIV+TB) (rte per 1 poultion per yer) Prevlence (rte per 1 poultion) 2 15 1 5 199 1995 2 25 21 2 15 1 5 199 1995 2 25 21 Totl new nd relpse 819 283 Previously treted, excluding relpses 6 872 Totl cses notified 826 155 Among 819 283 new nd relpse cses: 4 164 (<1%) cses ged under 15 yers; mle:femle rtio: 2.3 Reported cses of RR-/MDR-TB 214 NEW RETREATMENT TOTAL b Cses tested for RR-/MDR-TB 45 664 (19%) 17 21 (54%) 62 874 Lbortory-confirmed RR-/MDR-TB cses 5 87 Ptients strted on MDR-TB tretment c 2 846 TB/HIV 214 NUMBER (%) TB ptients with known HIV sttus 343 515 (42) HIV-positive TB ptients 5 39 (2) HIV-positive TB ptients on co-trimoxzole preventive therpy (CPT) HIV-positive TB ptients on ntiretrovirl therpy (ART) 3 675 (69) HIV-positive people screened for TB 423 254 HIV-positive people provided with IPT Tretment success rte nd cohort size (%) COHORT New nd relpse cses registered in 213 (95) 841 999 Previously treted cses, excluding relpse, registered in 213 (9) 7 847 HIV-positive TB cses, ll types, registered in 213 (82) 4 649 RR-/MDR-TB cses strted on second-line tretment in 212 (42) 1 96 XDR-TB cses strted on second-line tretment in 212 (13) 115 Lbortories 214 Smer (per 1 popultion).2 Culture (per 5 million popultion) 6.7 Drug susceptibility testing (per 5 million popultion) 1.5 Sites performing Xpert MTB/RIF 654 Is second-line drug susceptibility testing vilble? Yes, in country Finncing TB control 215 Ntionl TB progrmme budget (US$ millions) 34 % Funded domesticlly 9% % Funded interntionlly 2% % Unfunded 8% Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b Includes cses with unknown previous TB tretment history. c Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. Incidence (rte per 1 poultion per yer) Number of ptients Tretment success rte (%) Totl budget (US$ millions) 15 1 5 6 5 4 3 2 1 199 1995 2 25 21 Notified (new nd relpse) Incidence Incidence (HIV+TB only) 1 8 6 4 4 3 2 1 23 25 27 29 211 213 HIV-positive TB ptients on CPT on ART 2 1995 1997 1999 21 23 25 27 29 211 213 New Retretment New nd relpse Retretment excluding relpse HIV-positive RR-/MDR-TB XDR-TB 211 212 213 214 215 Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 129

Democrtic Republic of the Congo Popultion 214 75 million Estimtes of TB burden 214 NUMBER (thousnds) RATE (per 1 popultion) Mortlity (excludes HIV+TB) 52 (38 68) 69 (5 9) Mortlity (HIV+TB only) 6.3 (5 7.7) 8.4 (6.7 1) Prevlence (includes HIV+TB) 4 (21 64) 532 (282 859) Incidence (includes HIV+TB) 24 (22 27) 325 (295 356) Incidence (HIV+TB only) 34 (27 42) 45 (36 56) Cse detection, ll forms (%) 48 (43 52) Estimtes of MDR-TB burden 214 NEW RETREATMENT % of TB cses with MDR-TB 2.2 (.3 4.1) 11 (6.2 16) MDR-TB cses mong notified pulmonry TB cses 2 (27 3 7) 79 (45 1 1) TB cse notifictions 214 NEW b RELAPSE Pulmonry, bcteriologiclly confirmed 75 631 4 298 Pulmonry, cliniclly dignosed 13 494 1 892 Extrpulmonry 19 566 914 Totl new nd relpse 115 795 Previously treted, excluding relpses 1 99 Totl cses notified 116 894 Among 75 631 new cses: 3 438 (5%) cses ged under 15 yers; mle:femle rtio: 1.3 Reported cses of RR-/MDR-TB 214 NEW RETREATMENT TOTAL b Cses tested for RR-/MDR-TB 545 (<1%) 6 135 (75%) 6 817 Lbortory-confirmed RR-/MDR-TB cses 442 Ptients strted on MDR-TB tretment c 436 TB/HIV 214 NUMBER (%) TB ptients with known HIV sttus 53 285 (46) HIV-positive TB ptients 7 26 (14) HIV-positive TB ptients on co-trimoxzole preventive therpy (CPT) 5 671 (79) HIV-positive TB ptients on ntiretrovirl therpy (ART) 4 799 (67) HIV-positive people screened for TB 33 743 HIV-positive people provided with IPT Tretment success rte nd cohort size (%) COHORT New cses registered in 213 (87) 112 439 Previously treted cses registered in 213 (66) 1 164 HIV-positive TB cses, ll types, registered in 213 RR-/MDR-TB cses strted on second-line tretment in 212 (64) 134 XDR-TB cses strted on second-line tretment in 212 Lbortories 214 Smer (per 1 popultion) 2.1 Culture (per 5 million popultion).3 Drug susceptibility testing (per 5 million popultion).2 Sites performing Xpert MTB/RIF 39 Is second-line drug susceptibility testing vilble? Yes, in nd outside country Finncing TB control 215 Ntionl TB progrmme budget (US$ millions) 55 % Funded domesticlly 5% % Funded interntionlly 5% % Unfunded 44% Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b Includes cses with unknown previous TB tretment history. c Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. Mortlity (excludes HIV+TB) (rte per 1 poultion per yer) Prevlence (rte per 1 poultion) Incidence (rte per 1 poultion per yer) Number of ptients Tretment success rte (%) Totl budget (US$ millions) 125 1 75 5 25 75 5 25 3 2 1 8 6 4 2 199 1995 2 25 21 199 1995 2 25 21 Notified (new nd relpse) Incidence Incidence (HIV+TB only) 1 8 6 4 2 8 6 4 2 23 25 27 29 211 213 HIV-positive TB ptients on CPT on ART 199 1995 2 25 21 1995 1997 1999 21 23 25 27 29 211 213 New Retretment HIV-positive RR-/MDR-TB XDR-TB 211 212 213 214 215 Funded domesticlly Funded interntionlly Unfunded 13 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

Ethiopi Popultion 214 97 million Estimtes of TB burden 214 NUMBER (thousnds) RATE (per 1 popultion) Mortlity (excludes HIV+TB) 32 (22 43) 33 (23 44) Mortlity (HIV+TB only) 5.5 (4.4 6.8) 5.7 (4.6 7) Prevlence (includes HIV+TB) 19 (16 24) 2 (161 243) Incidence (includes HIV+TB) 2 (16 24) 27 (168 25) Incidence (HIV+TB only) 19 (15 23) 19 (15 24) Cse detection, ll forms (%) 6 (49 73) Estimtes of MDR-TB burden 214 NEW RETREATMENT % of TB cses with MDR-TB 1.6 (.86 2.8) 12 (5.6 21) MDR-TB cses mong notified pulmonry TB cses 1 3 (7 2 3) TB cse notifictions 214 NEW b Pulmonry, bcteriologiclly confirmed 4 87 Pulmonry, cliniclly dignosed 41 575 Extrpulmonry 37 93 RELAPSE Mortlity (excludes HIV+TB) (rte per 1 poultion per yer) Prevlence (rte per 1 poultion) 1 5 199 1995 2 25 21 6 4 2 199 1995 2 25 21 Totl new nd relpse 119 592 Previously treted, excluding relpses Totl cses notified 119 592 Among 119 592 new cses: 15 917 (13%) cses ged under 15 yers; mle:femle rtio: 1.2 Reported cses of RR-/MDR-TB 214 NEW RETREATMENT TOTAL b Cses tested for RR-/MDR-TB 2 45 (6%) 7 682 1 151 Lbortory-confirmed RR-/MDR-TB cses 53 Ptients strted on MDR-TB tretment c 557 TB/HIV 214 NUMBER (%) TB ptients with known HIV sttus 89 32 (75) HIV-positive TB ptients 8 67 (1) HIV-positive TB ptients on co-trimoxzole preventive therpy (CPT) d HIV-positive TB ptients on ntiretrovirl therpy (ART) d 3 396 (39) HIV-positive people screened for TB 341 534 HIV-positive people provided with IPT 1 385 Tretment success rte nd cohort size (%) COHORT New cses registered in 213 (89) 43 86 Previously treted cses registered in 213 HIV-positive TB cses, ll types, registered in 213 RR-/MDR-TB cses strted on second-line tretment in 212 (83) 271 XDR-TB cses strted on second-line tretment in 212 Lbortories 214 Smer (per 1 popultion) 3.1 Culture (per 5 million popultion).4 Drug susceptibility testing (per 5 million popultion).4 Sites performing Xpert MTB/RIF 28 Is second-line drug susceptibility testing vilble? Yes, in country Finncing TB control 215 Ntionl TB progrmme budget (US$ millions) 82 % Funded domesticlly 11% % Funded interntionlly 42% % Unfunded 47% Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b Includes cses with unknown previous TB tretment history. c Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. d ART nd IPT dt were missing for 3 of Ethiopi s 11 regions, which in previous yers hd ccounted for bout one third of the ntionl totls. In the 8 regions tht reported dt, 65% of HIV-positive TB ptients were on ART. Incidence (rte per 1 poultion per yer) Number of ptients Tretment success rte (%) Totl budget (US$ millions) 5 4 3 2 1 12 1 199 1995 2 25 21 Notified (new nd relpse) Incidence Incidence (HIV+TB only) 8 6 4 2 9 7 5 3 15 1 5 23 25 27 29 211 213 HIV-positive TB ptients on CPT on ART 1995 1997 1999 21 23 25 27 29 211 213 New Retretment HIV-positive RR-/MDR-TB XDR-TB 211 212 213 214 215 Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 131

Indi Popultion 214 1 295 million Estimtes of TB burden 214 NUMBER (thousnds) RATE (per 1 popultion) Mortlity (excludes HIV+TB) 22 (15 35) 17 (12 27) Mortlity (HIV+TB only) 31 (25 38) 2.4 (2 2.9) Prevlence (includes HIV+TB) 2 5 (1 7 3 5) 195 (131 271) Incidence (includes HIV+TB) 2 2 (2 2 3) 167 (156 179) Incidence (HIV+TB only) 11 (96 12) 8.3 (7.4 9.3) Cse detection, ll forms (%) 74 (7 8) Estimtes of MDR-TB burden 214 NEW RETREATMENT % of TB cses with MDR-TB 2.2 (1.9 2.6) 15 (11 19) MDR-TB cses mong notified pulmonry TB cses 24 (21 29 ) 47 (35 59 ) TB cse notifictions 214 NEW b RELAPSE Pulmonry, bcteriologiclly confirmed 754 268 124 679 Pulmonry, cliniclly dignosed 343 32 112 66 Extrpulmonry 275 52 Mortlity (excludes HIV+TB) (rte per 1 poultion per yer) Prevlence (rte per 1 poultion) 4 2 199 1995 2 25 21 4 3 2 1 199 1995 2 25 21 Totl new nd relpse 1 69 547 Previously treted, excluding relpses 74 368 Totl cses notified 1 683 915 Among 1 69 547 new nd relpse cses: 95 79 (6%) cses ged under 15 yers; mle:femle rtio: 1.9 Reported cses of RR-/MDR-TB 214 NEW RETREATMENT TOTAL b Cses tested for RR-/MDR-TB 12 795 (2%) 214 29 (69%) 255 897 Lbortory-confirmed RR-/MDR-TB cses 25 748 Ptients strted on MDR-TB tretment c 24 73 TB/HIV 214 NUMBER (%) TB ptients with known HIV sttus 1 34 712 (61) HIV-positive TB ptients 44 171 (4) HIV-positive TB ptients on co-trimoxzole preventive therpy (CPT) 41 66 (93) HIV-positive TB ptients on ntiretrovirl therpy (ART) 39 8 (9) HIV-positive people screened for TB 1 114 394 HIV-positive people provided with IPT Tretment success rte nd cohort size (%) COHORT New nd relpse cses registered in 213 (88) 1 243 95 Previously treted cses, excluding relpse, registered in 213 (66) 171 712 HIV-positive TB cses, ll types, registered in 213 (76) 44 27 RR-/MDR-TB cses strted on second-line tretment in 212 (46) 9 874 XDR-TB cses strted on second-line tretment in 212 (33) 91 Lbortories 214 Smer (per 1 popultion) 1. Culture (per 5 million popultion).3 Drug susceptibility testing (per 5 million popultion).2 Sites performing Xpert MTB/RIF 121 Is second-line drug susceptibility testing vilble? Yes, in country Finncing TB control 215 Ntionl TB progrmme budget (US$ millions) 261 % Funded domesticlly 46% % Funded interntionlly 54% % Unfunded % Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b Includes cses with unknown previous TB tretment history. c Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. Incidence (rte per 1 poultion per yer) Number of ptients Tretment success rte (%) Totl budget (US$ millions) 2 15 1 5 5 4 3 2 1 199 1995 2 25 21 Notified (new nd relpse) Incidence Incidence (HIV+TB only) 1 3 2 1 23 25 27 29 211 213 HIV-positive TB ptients on CPT on ART 8 6 4 2 1995 1997 1999 21 23 25 27 29 211 213 New Retretment New nd relpse Retretment excluding relpse HIV-positive RR-/MDR-TB XDR-TB 211 212 213 214 215 Funded domesticlly Funded interntionlly Unfunded 132 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

Indonesi Popultion 214 254 million Estimtes of TB burden 214 NUMBER (thousnds) RATE (per 1 popultion) Mortlity (excludes HIV+TB) 1 (66 15) 41 (26 59) Mortlity (HIV+TB only) 22 (13 32) 8.5 (5.2 13) Prevlence (includes HIV+TB) b 1 6 (1 3 2 ) 647 (513 797) Incidence (includes HIV+TB) 1 (7 1 4) 399 (274 546) Incidence (HIV+TB only) 63 (41 9) 25 (16 36) Cse detection, ll forms (%) 32 (23 46) Estimtes of MDR-TB burden 214 NEW RETREATMENT % of TB cses with MDR-TB 1.9 (1.4 2.5) 12 (8.1 17) MDR-TB cses mong notified pulmonry TB cses 5 6 (4 2 7 4) 1 1 (77 1 6) TB cse notifictions 214 NEW c RELAPSE Pulmonry, bcteriologiclly confirmed 193 321 6 449 Pulmonry, cliniclly dignosed 11 991 1 391 Extrpulmonry 19 653 1 Totl new nd relpse 322 86 Previously treted, excluding relpses 1 733 Totl cses notified 324 539 Among 322 86 new nd relpse cses: 23 17 (7%) cses ged under 15 yers; mle:femle rtio: 1.4 Reported cses of RR-/MDR-TB 214 NEW RETREATMENT TOTAL b Cses tested for RR-/MDR-TB 1 58 (<1%) 8 445 (88%) 9 53 Lbortory-confirmed RR-/MDR-TB cses 1 812 Ptients strted on MDR-TB tretment d 1 284 TB/HIV 214 NUMBER (%) TB ptients with known HIV sttus 15 74 (5) HIV-positive TB ptients 2 355 (16) HIV-positive TB ptients on co-trimoxzole preventive therpy (CPT) 963 (41) HIV-positive TB ptients on ntiretrovirl therpy (ART) 624 (26) HIV-positive people screened for TB HIV-positive people provided with IPT Tretment success rte nd cohort size (%) COHORT New nd relpse cses registered in 213 (88) 325 582 Previously treted cses, excluding relpse, registered in 213 (64) 1 521 HIV-positive TB cses, ll types, registered in 213 (49) 2 438 RR-/MDR-TB cses strted on second-line tretment in 212 (54) 432 XDR-TB cses strted on second-line tretment in 212 (64) 11 Lbortories 214 Smer (per 1 popultion) 2.2 Culture (per 5 million popultion).4 Drug susceptibility testing (per 5 million popultion).3 Sites performing Xpert MTB/RIF 41 Is second-line drug susceptibility testing vilble? Yes, in country Finncing TB control 215 Ntionl TB progrmme budget (US$ millions) 133 % Funded domesticlly 13% % Funded interntionlly 21% % Unfunded 66% Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b The prevlence rte of bcteriologiclly confirmed TB ws 531 (421 655) per 1 popultion; the prevlence rte of cliniclly dignosed TB (i.e. smer-negtive nd culturenegtive TB, including ll extr-pulmonry cses) ws 116 (91 143) per 1 popultion; the prevlence rte of extr-pulmonry TB ( subset of those in the cliniclly dignosed ctegory) ws 58 (43 75) per 1 popultion. c Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. Mortlity (excludes HIV+TB) (rte per 1 poultion per yer) Prevlence (rte per 1 poultion) Incidence (rte per 1 poultion per yer) Number of ptients Tretment success rte (%) Totl budget (US$ millions) 75 5 25 1 5 199 1995 2 25 21 6 4 2 3 2 1 199 1995 2 25 21 Notified (new nd relpse) Incidence Incidence (HIV+TB only) 1 8 6 4 2 15 1 23 25 27 29 211 213 HIV-positive TB ptients on CPT on ART 5 199 1995 2 25 21 1995 1997 1999 21 23 25 27 29 211 213 New Retretment New nd relpse Retretment excluding relpse HIV-positive RR-/MDR-TB XDR-TB 211 212 213 214 215 Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 133

Keny Popultion 214 45 million Estimtes of TB burden 214 NUMBER (thousnds) RATE (per 1 popultion) Mortlity (excludes HIV+TB) 9.4 (6.7 12) 21 (15 28) Mortlity (HIV+TB only) 8.1 (6.4 1) 18 (14 22) Prevlence (includes HIV+TB) 12 (64 19) 266 (142 427) Incidence (includes HIV+TB) 11 (11 11) 246 (24 252) Incidence (HIV+TB only) 4 (38 42) 89 (84 93) Cse detection, ll forms (%) 8 (78 82) Estimtes of MDR-TB burden 214 NEW RETREATMENT % of TB cses with MDR-TB 2.2 (.3 4.1) 14 (12 15) MDR-TB cses mong notified pulmonry TB cses 1 4 (2 2 7) 1 1 (93 1 2) TB cse notifictions 214 NEW b RELAPSE Pulmonry, bcteriologiclly confirmed 34 997 3 569 Pulmonry, cliniclly dignosed 3 872 2 947 Extrpulmonry 14 64 1 Mortlity (excludes HIV+TB) (rte per 1 poultion per yer) Prevlence (rte per 1 poultion) 3 2 1 199 1995 2 25 21 4 3 2 1 199 1995 2 25 21 Totl new nd relpse 88 25 Previously treted, excluding relpses 1 269 Totl cses notified 89 294 Among 89 294 new nd relpse cses: 8 448 (9%) cses ged under 15 yers; mle:femle rtio: 1.5 Reported cses of RR-/MDR-TB 214 NEW RETREATMENT TOTAL b Cses tested for RR-/MDR-TB 17 619 (5%) 7 436 (85%) 23 865 Lbortory-confirmed RR-/MDR-TB cses 644 Ptients strted on MDR-TB tretment c 544 TB/HIV 214 NUMBER (%) TB ptients with known HIV sttus 84 423 (95) HIV-positive TB ptients 3 2 (36) HIV-positive TB ptients on co-trimoxzole preventive therpy (CPT) 29 735 (99) HIV-positive TB ptients on ntiretrovirl therpy (ART) 26 142 (87) HIV-positive people screened for TB 426 12 HIV-positive people provided with IPT Tretment success rte nd cohort size (%) COHORT New cses registered in 213 (86) 81 255 Previously treted cses registered in 213 (78) 8 445 HIV-positive TB cses, ll types, registered in 213 (79) 31 755 RR-/MDR-TB cses strted on second-line tretment in 212 (83) 197 XDR-TB cses strted on second-line tretment in 212 Lbortories 214 Smer (per 1 popultion) 4.3 Culture (per 5 million popultion).3 Drug susceptibility testing (per 5 million popultion).3 Sites performing Xpert MTB/RIF 7 Is second-line drug susceptibility testing vilble? No Finncing TB control 215 Ntionl TB progrmme budget (US$ millions) 45 % Funded domesticlly 26% % Funded interntionlly 28% % Unfunded 45% Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b Includes cses with unknown previous TB tretment history. c Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. Incidence (rte per 1 poultion per yer) Number of ptients Tretment success rte (%) Totl budget (US$ millions) 2 6 5 4 3 2 1 199 1995 2 25 21 Notified (new nd relpse) Incidence Incidence (HIV+TB only) 1 23 25 27 29 211 213 HIV-positive TB ptients on CPT on ART 8 6 4 2 8 6 4 2 1995 1997 1999 21 23 25 27 29 211 213 New Retretment New nd relpse Retretment excluding relpse HIV-positive RR-/MDR-TB XDR-TB 211 212 213 214 215 Funded domesticlly Funded interntionlly Unfunded 134 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

Mozmbique Popultion 214 27 million Estimtes of TB burden 214 NUMBER (thousnds) RATE (per 1 popultion) Mortlity (excludes HIV+TB) 18 (12 26) 67 (44 96) Mortlity (HIV+TB only) 37 (29 45) 134 (16 165) Prevlence (includes HIV+TB) 15 (8 24) 554 (295 893) Incidence (includes HIV+TB) 15 (12 18) 551 (435 68) Incidence (HIV+TB only) 85 (65 11) 311 (237 395) Cse detection, ll forms (%) 39 (31 49) Estimtes of MDR-TB burden 214 NEW RETREATMENT % of TB cses with MDR-TB 3.5 (2.2 4.8) 11 ( 25) MDR-TB cses mong notified pulmonry TB cses 1 7 (1 1 2 3) 46 ( 1 ) TB cse notifictions 214 NEW c RELAPSE Pulmonry, bcteriologiclly confirmed 24 43 1 542 Pulmonry, cliniclly dignosed 23 455 2 7 Extrpulmonry 6 276 Totl new nd relpse 57 773 Previously treted, excluding relpses 497 Totl cses notified 58 27 Reported cses of RR-/MDR-TB 214 NEW RETREATMENT TOTAL b Cses tested for RR-/MDR-TB 886 (4%) 96 (22%) 3 716 Lbortory-confirmed RR-/MDR-TB cses 544 Ptients strted on MDR-TB tretment c 482 TB/HIV 214 NUMBER (%) TB ptients with known HIV sttus 55 943 (96) HIV-positive TB ptients 29 337 (52) HIV-positive TB ptients on co-trimoxzole preventive therpy (CPT) 27 54 (94) HIV-positive TB ptients on ntiretrovirl therpy (ART) 23 81 (81) HIV-positive people screened for TB 563 377 HIV-positive people provided with IPT 94 252 Tretment success rte nd cohort size (%) COHORT New cses registered in 213 d (88) 23 72 Previously treted cses registered in 213 HIV-positive TB cses, ll types, registered in 213 RR-/MDR-TB cses strted on second-line tretment in 212 (28) 214 XDR-TB cses strted on second-line tretment in 212 () 4 Lbortories 214 Smer (per 1 popultion) 1.2 Culture (per 5 million popultion).6 Drug susceptibility testing (per 5 million popultion).4 Sites performing Xpert MTB/RIF 24 Is second-line drug susceptibility testing vilble? Yes, in country Finncing TB control 215 Ntionl TB progrmme budget (US$ millions) 29 % Funded domesticlly 6% % Funded interntionlly 66% % Unfunded 28% Mortlity (excludes HIV+TB) (rte per 1 poultion per yer) Prevlence (rte per 1 poultion) Incidence (rte per 1 poultion per yer) Number of ptients Tretment success rte (%) 15 1 5 1 5 6 4 2 3 25 2 15 1 199 1995 2 25 21 199 1995 2 25 21 199 1995 2 25 21 Notified (new nd relpse) Incidence Incidence (HIV+TB only) 5 1 8 6 4 2 23 25 27 29 211 213 HIV-positive TB ptients on CPT on ART 1995 1997 1999 21 23 25 27 29 211 213 New Retretment HIV-positive RR-/MDR-TB XDR-TB 4 Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b Includes cses with unknown previous TB tretment history. c Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. d Tretment outcomes were vilble for new pulmonry bcteriologiclly confirmed cses only. Totl budget (US$ millions) 3 2 1 211 212 213 214 215 Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 135

Mynmr Popultion 214 53 million Estimtes of TB burden 214 NUMBER (thousnds) RATE (per 1 popultion) Mortlity (excludes HIV+TB) 28 (2 37) 53 (38 7) Mortlity (HIV+TB only) 4.1 (3.3 5.1) 7.7 (6.1 9.5) Prevlence (includes HIV+TB) 24 (19 31) 457 (352 575) Incidence (includes HIV+TB) 2 (18 22) 369 (334 46) Incidence (HIV+TB only) 19 (15 24) 36 (28 44) Cse detection, ll forms (%) 7 (64 78) Estimtes of MDR-TB burden 214 NEW RETREATMENT % of TB cses with MDR-TB 5 (3.1 6.8) 27 (15 39) MDR-TB cses mong notified pulmonry TB cses 5 6 (3 5 7 7) 3 4 (1 9 4 9) TB cse notifictions 214 NEW b RELAPSE Pulmonry, bcteriologiclly confirmed 42 68 5 276 Pulmonry, cliniclly dignosed 7 35 3 65 Extrpulmonry 16 18 45 Mortlity (excludes HIV+TB) (rte per 1 poultion per yer) Prevlence (rte per 1 poultion) 15 1 5 199 1995 2 25 21 1 5 199 1995 2 25 21 Totl new nd relpse 138 352 Previously treted, excluding relpses 3 65 Totl cses notified 141 957 Among 138 352 new nd relpse cses: 36 31 (26%) cses ged under 15 yers; mle:femle rtio: 1.6 Reported cses of RR-/MDR-TB 214 NEW RETREATMENT TOTAL b Cses tested for RR-/MDR-TB 1 295 (24%) 15 166 (117%) 26 24 Lbortory-confirmed RR-/MDR-TB cses 3 495 Ptients strted on MDR-TB tretment c 1 537 TB/HIV 214 NUMBER (%) TB ptients with known HIV sttus 56 133 (4) HIV-positive TB ptients 6 412 (11) HIV-positive TB ptients on co-trimoxzole preventive therpy (CPT) 4 666 (73) HIV-positive TB ptients on ntiretrovirl therpy (ART) 5 749 (9) HIV-positive people screened for TB 54 178 HIV-positive people provided with IPT 2 997 Tretment success rte nd cohort size (%) COHORT New cses registered in 213 (87) 135 614 Previously treted cses registered in 213 (71) 7 147 HIV-positive TB cses, ll types, registered in 213 RR-/MDR-TB cses strted on second-line tretment in 212 (79) 443 XDR-TB cses strted on second-line tretment in 212 Lbortories 214 Smer (per 1 popultion).9 Culture (per 5 million popultion).3 Drug susceptibility testing (per 5 million popultion).2 Sites performing Xpert MTB/RIF 38 Is second-line drug susceptibility testing vilble? Yes, outside country Finncing TB control 215 Ntionl TB progrmme budget (US$ millions) 36 % Funded domesticlly 11% % Funded interntionlly 67% % Unfunded 22% Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b Includes cses with unknown previous TB tretment history. c Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. Incidence (rte per 1 poultion per yer) Number of ptients Tretment success rte (%) Totl budget (US$ millions) 4 3 2 1 6 4 2 199 1995 2 25 21 Notified (new nd relpse) Incidence Incidence (HIV+TB only) 1 9 8 7 6 5 4 3 2 1 23 25 27 29 211 213 HIV-positive TB ptients on CPT on ART 1995 1997 1999 21 23 25 27 29 211 213 New Retretment HIV-positive RR-/MDR-TB XDR-TB 211 212 213 214 215 Funded domesticlly Funded interntionlly Unfunded 136 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

Nigeri Popultion 214 177 million Estimtes of TB burden 214 NUMBER (thousnds) RATE (per 1 popultion) Mortlity (excludes HIV+TB) 17 (91 28) 97 (51 156) Mortlity (HIV+TB only) 78 (53 11) 44 (3 61) Prevlence (includes HIV+TB) 59 (45 74) 33 (253 417) Incidence (includes HIV+TB) 57 (34 87) 322 (189 488) Incidence (HIV+TB only) 1 (59 16) 59 (33 92) Cse detection, ll forms (%) 15 (1 26) Estimtes of MDR-TB burden 214 NEW RETREATMENT % of TB cses with MDR-TB 2.9 (2.1 4) 14 (1 19) MDR-TB cses mong notified pulmonry TB cses 2 3 (1 7 3 2) 1 (75 1 4) TB cse notifictions 214 NEW c RELAPSE Pulmonry, bcteriologiclly confirmed 49 825 2 415 Pulmonry, cliniclly dignosed 29 46 Extrpulmonry 4 764 Mortlity (excludes HIV+TB) (rte per 1 poultion per yer) Prevlence (rte per 1 poultion) 15 1 5 199 1995 2 25 21 4 3 2 1 199 1995 2 25 21 Totl new nd relpse 86 464 Previously treted, excluding relpses 4 89 Totl cses notified 91 354 Among 91 354 new nd relpse cses: 5 463 (6%) cses ged under 15 yers; mle:femle rtio: 1.5 Reported cses of RR-/MDR-TB 214 NEW RETREATMENT TOTAL b Cses tested for RR-/MDR-TB 24 225 Lbortory-confirmed RR-/MDR-TB cses 798 Ptients strted on MDR-TB tretment c 423 TB/HIV 214 NUMBER (%) TB ptients with known HIV sttus 84 161 (92) HIV-positive TB ptients 16 66 (19) HIV-positive TB ptients on co-trimoxzole preventive therpy (CPT) 14 569 (91) HIV-positive TB ptients on ntiretrovirl therpy (ART) 11 997 (75) HIV-positive people screened for TB 335 357 HIV-positive people provided with IPT 26 383 Tretment success rte nd cohort size (%) COHORT New cses registered in 213 (86) 91 997 Previously treted cses registered in 213 (83) 8 44 HIV-positive TB cses, ll types, registered in 213 (8) 7 481 RR-/MDR-TB cses strted on second-line tretment in 212 (62) 154 XDR-TB cses strted on second-line tretment in 212 Lbortories 214 Smer (per 1 popultion) 1. Culture (per 5 million popultion).2 Drug susceptibility testing (per 5 million popultion).2 Sites performing Xpert MTB/RIF 96 Is second-line drug susceptibility testing vilble? Yes, in country Finncing TB control 215 Ntionl TB progrmme budget (US$ millions) 228 % Funded domesticlly 13% % Funded interntionlly 19% % Unfunded 68% Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b Includes cses with unknown previous TB tretment history. c Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. Incidence (rte per 1 poultion per yer) Number of ptients Tretment success rte (%) Totl budget (US$ millions) 5 4 3 2 1 2 15 1 199 1995 2 25 21 Notified (new nd relpse) Incidence Incidence (HIV+TB only) 5 1 8 6 4 2 24 16 8 23 25 27 29 211 213 HIV-positive TB ptients on CPT on ART 1995 1997 1999 21 23 25 27 29 211 213 New Retretment HIV-positive RR-/MDR-TB XDR-TB 211 212 213 214 215 Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 137

Pkistn Popultion 214 185 million Estimtes of TB burden 214 NUMBER (thousnds) RATE (per 1 popultion) Mortlity (excludes HIV+TB) 48 (11 11) 26 (6 61) Mortlity (HIV+TB only) 1.3 (.76 1.9).68 (.41 1) Prevlence (includes HIV+TB) 63 (53 74) 341 (285 42) Incidence (includes HIV+TB) 5 (37 65) 27 (21 35) Incidence (HIV+TB only) 6.4 (4.4 8.7) 3.4 (2.4 4.7) Cse detection, ll forms (%) 62 (48 83) Estimtes of MDR-TB burden 214 NEW RETREATMENT % of TB cses with MDR-TB 3.7 (2.5 5) 18 (13 23) MDR-TB cses mong notified pulmonry TB cses 9 (6 1 12 ) 2 9 (2 1 3 7) TB cse notifictions 214 NEW b RELAPSE Pulmonry, bcteriologiclly confirmed 122 537 7 42 Pulmonry, cliniclly dignosed 12 35 426 Extrpulmonry 57 463 221 Mortlity (excludes HIV+TB) (rte per 1 poultion per yer) Prevlence (rte per 1 poultion) 12 9 6 3 4 2 199 1995 2 25 21 199 1995 2 25 21 Totl new nd relpse 38 417 Previously treted, excluding relpses 8 16 Totl cses notified 316 577 Among 38 417 new nd relpse cses: 27 245 (9%) cses ged under 15 yers; mle:femle rtio: 1. Reported cses of RR-/MDR-TB 214 NEW RETREATMENT TOTAL b Cses tested for RR-/MDR-TB 361 (<1%) 11 685 (72%) 2 143 Lbortory-confirmed RR-/MDR-TB cses 3 243 Ptients strted on MDR-TB tretment c 2 662 TB/HIV 214 NUMBER (%) TB ptients with known HIV sttus 1 715 (3) HIV-positive TB ptients 9 (<1) HIV-positive TB ptients on co-trimoxzole preventive therpy (CPT) 9 (1) HIV-positive TB ptients on ntiretrovirl therpy (ART) 9 (1) HIV-positive people screened for TB HIV-positive people provided with IPT Tretment success rte nd cohort size (%) COHORT New nd relpse cses registered in 213 (93) 289 376 Previously treted cses, excluding relpse, registered in 213 (8) 7 217 HIV-positive TB cses, ll types, registered in 213 (81) 37 RR-/MDR-TB cses strted on second-line tretment in 212 (71) 858 XDR-TB cses strted on second-line tretment in 212 (32) 41 Lbortories 214 Smer (per 1 popultion).8 Culture (per 5 million popultion).3 Drug susceptibility testing (per 5 million popultion).1 Sites performing Xpert MTB/RIF 42 Is second-line drug susceptibility testing vilble? Yes, in country Finncing TB control 215 Ntionl TB progrmme budget (US$ millions) 5 % Funded domesticlly 17% % Funded interntionlly 6% % Unfunded 23% Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b Includes cses with unknown previous TB tretment history. c Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. Incidence (rte per 1 poultion per yer) Number of ptients Tretment success rte (%) Totl budget (US$ millions) 3 2 1 199 1995 2 25 21 Notified (new nd relpse) Incidence Incidence (HIV+TB only) 1 8 6 4 2 23 25 27 29 211 213 HIV-positive TB ptients on CPT on ART 1 8 6 4 2 1995 1997 1999 21 23 25 27 29 211 213 New Retretment New nd relpse Retretment excluding relpse HIV-positive RR-/MDR-TB XDR-TB 12 1 8 6 4 2 211 212 213 214 215 Funded domesticlly Funded interntionlly Unfunded 138 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

Philippines Popultion 214 99 million Estimtes of TB burden 214 NUMBER (thousnds) RATE (per 1 popultion) Mortlity (excludes HIV+TB) 1 (9 11) 1 (9.1 11) Mortlity (HIV+TB only).8 (.55.11).8 (.6.11) Prevlence (includes HIV+TB) 41 (36 47) 417 (367 471) Incidence (includes HIV+TB) 29 (25 32) 288 (254 324) Incidence (HIV+TB only) 2.5 (2 3.2) 2.6 (2 3.2) Cse detection, ll forms (%) 85 (76 97) Estimtes of MDR-TB burden 214 NEW RETREATMENT % of TB cses with MDR-TB 2 (1.4 2.7) 21 (16 29) MDR-TB cses mong notified pulmonry TB cses 4 6 (3 3 6 3) 6 5 (4 7 8 7) TB cse notifictions 214 NEW c RELAPSE Pulmonry, bcteriologiclly confirmed 92 991 6 277 Pulmonry, cliniclly dignosed 139 95 Extrpulmonry 4 161 Mortlity (excludes HIV+TB) (rte per 1 poultion per yer) Prevlence (rte per 1 poultion) 6 4 2 1 5 199 1995 2 25 21 199 1995 2 25 21 Totl new nd relpse 243 379 Previously treted, excluding relpses 24 57 Totl cses notified 267 436 Among 97 578 new nd relpse cses: 12 191 (12%) cses ged under 15 yers; mle:femle rtio: 1.8 Reported cses of RR-/MDR-TB 214 NEW RETREATMENT TOTAL b Cses tested for RR-/MDR-TB 4 415 (5%) 2 196 (67%) 27 287 Lbortory-confirmed RR-/MDR-TB cses 3 Ptients strted on MDR-TB tretment c 2 68 TB/HIV 214 NUMBER (%) TB ptients with known HIV sttus 53 354 (2) HIV-positive TB ptients 18 (<1) HIV-positive TB ptients on co-trimoxzole preventive therpy (CPT) 2 (19) HIV-positive TB ptients on ntiretrovirl therpy (ART) 53 (49) HIV-positive people screened for TB 5 995 HIV-positive people provided with IPT Tretment success rte nd cohort size (%) COHORT New nd relpse cses registered in 213 (9) 216 25 Previously treted cses, excluding relpse, registered in 213 (86) 2 924 HIV-positive TB cses, ll types, registered in 213 RR-/MDR-TB cses strted on second-line tretment in 212 (43) 1 798 XDR-TB cses strted on second-line tretment in 212 (1) 1 Lbortories 214 Smer (per 1 popultion) 2.6 Culture (per 5 million popultion) 1.1 Drug susceptibility testing (per 5 million popultion).2 Sites performing Xpert MTB/RIF 84 Is second-line drug susceptibility testing vilble? Yes, in country Finncing TB control 215 Ntionl TB progrmme budget (US$ millions) 16 % Funded domesticlly 23% % Funded interntionlly 39% % Unfunded 37% Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b Includes cses with unknown previous TB tretment history. c Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. Incidence (rte per 1 poultion per yer) Number of ptients Tretment success rte (%) Totl budget (US$ millions) 4 2 199 1995 2 25 21 Notified (new nd relpse) Incidence Incidence (HIV+TB only) 8 6 4 2 23 25 27 29 211 213 HIV-positive TB ptients on CPT on ART 1 8 6 4 2 1995 1997 1999 21 23 25 27 29 211 213 New Retretment New nd relpse Retretment excluding relpse HIV-positive RR-/MDR-TB XDR-TB 16 12 8 4 211 212 213 214 215 Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 139

Russin Federtion Popultion 214 143 million Estimtes of TB burden b 214 NUMBER (thousnds) RATE (per 1 popultion) Mortlity (excludes HIV+TB) 16 (15 16) 11 (11 11) Mortlity (HIV+TB only) 1.1 (.83 1.3).73 (.58.91) Prevlence (includes HIV+TB) 16 (7 27) 19 (49 192) Incidence (includes HIV+TB) 12 (11 13) 84 (76 93) Incidence (HIV+TB only) 5.5 (4.5 6.6) 3.8 (3.1 4.6) Cse detection, ll forms (%) 85 (77 94) Estimtes of MDR-TB burden b 214 NEW RETREATMENT % of TB cses with MDR-TB 19 (14 25) 49 (4 59) MDR-TB cses mong notified pulmonry TB cses 15 (11 19 ) 24 (19 29 ) TB cse notifictions 214 NEW c RELAPSE Pulmonry, bcteriologiclly confirmed 37 296 7 982 Pulmonry, cliniclly dignosed 4 894 6 753 Extrpulmonry 8 763 652 Totl new nd relpse 12 34 Previously treted, excluding relpses 33 828 Totl cses notified 136 168 Among 12 34 new nd relpse cses: 3 195 (3%) cses ged under 15 yers; mle:femle rtio: 2.3 Reported cses of RR-/MDR-TB 214 NEW RETREATMENT TOTAL b Cses tested for RR-/MDR-TB 31 25 (84%) 13 925 (28%) 45 175 Lbortory-confirmed RR-/MDR-TB cses 15 585 Ptients strted on MDR-TB tretment d 21 94 TB/HIV 214 NUMBER (%) TB ptients with known HIV sttus e 67 425 HIV-positive TB ptients 5 251 HIV-positive TB ptients on co-trimoxzole preventive therpy (CPT) HIV-positive TB ptients on ntiretrovirl therpy (ART) HIV-positive people screened for TB HIV-positive people provided with IPT Tretment success rte nd cohort size (%) COHORT New nd relpse cses registered in 213 (68) 83 31 Previously treted cses, excluding relpse, registered in 213 (39) 6 934 HIV-positive TB cses, ll types, registered in 213 RR-/MDR-TB cses strted on second-line tretment in 212 (4) 16 21 XDR-TB cses strted on second-line tretment in 212 (26) 1 318 Lbortories 214 Smer (per 1 popultion) 3.7 Culture (per 5 million popultion) 14.1 Drug susceptibility testing (per 5 million popultion) 1.4 Sites performing Xpert MTB/RIF 96 Is second-line drug susceptibility testing vilble? Yes, in country Finncing TB control 215 Ntionl TB progrmme budget (US$ millions) 1 894 % Funded domesticlly 1% % Funded interntionlly <1% % Unfunded % Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. 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 Includes cses with unknown previous TB tretment history. d Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. e The reported number of TB ptients with known HIV sttus is for new TB ptients in the civilin sector only. It ws not possible to clculte the percentge of ll TB ptients with known HIV sttus. Mortlity (excludes HIV+TB) (rte per 1 poultion per yer) Prevlence (rte per 1 poultion) Incidence (rte per 1 poultion per yer) Number of ptients Tretment success rte (%) Totl budget (US$ millions) 25 2 15 1 5 3 2 1 15 1 199 1995 2 25 21 5 8 6 4 2 199 1995 2 25 21 Notified (new nd relpse) Incidence Incidence (HIV+TB only) 1 2 15 1 5 23 25 27 29 211 213 HIV-positive TB ptients on CPT on ART 8 6 4 2 199 1995 2 25 21 1995 1997 1999 21 23 25 27 29 211 213 New Retretment New nd relpse Retretment excluding relpse HIV-positive RR-/MDR-TB XDR-TB 211 212 213 214 215 Funded domesticlly Funded interntionlly Unfunded 14 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

South Afric Popultion 214 54 million Estimtes of TB burden 214 NUMBER (thousnds) RATE (per 1 popultion) Mortlity (excludes HIV+TB) 24 (22 26) 44 (41 48) Mortlity (HIV+TB only) 72 (58 89) 134 (17 164) Prevlence (includes HIV+TB) 38 (21 59) 696 (39 1 88) Incidence (includes HIV+TB) 45 (4 51) 834 (737 936) Incidence (HIV+TB only) 27 (24 31) 59 (439 584) Cse detection, ll forms (%) 68 (61 77) Estimtes of MDR-TB burden 214 NEW RETREATMENT % of TB cses with MDR-TB 1.8 (1.4 2.3) 6.7 (5.4 8.2) MDR-TB cses mong notified pulmonry TB cses 4 7 (3 7 5 9) 1 5 (1 2 1 8) TB cse notifictions 214 NEW c RELAPSE Pulmonry, bcteriologiclly confirmed 155 473 7 43 Pulmonry, cliniclly dignosed 16 482 2 693 Extrpulmonry 33 522 566 Totl new nd relpse 36 166 Previously treted, excluding relpses 12 27 Totl cses notified 318 193 Among 36 166 new nd relpse cses: 31 977 (1%) cses ged under 15 yers; mle:femle rtio: 1.3 Reported cses of RR-/MDR-TB 214 NEW RETREATMENT TOTAL b Cses tested for RR-/MDR-TB 218 231 Lbortory-confirmed RR-/MDR-TB cses 18 734 Ptients strted on MDR-TB tretment c 11 538 TB/HIV 214 NUMBER (%) TB ptients with known HIV sttus 295 136 (93) HIV-positive TB ptients 179 756 (61) HIV-positive TB ptients on co-trimoxzole preventive therpy (CPT) 155 17 (86) HIV-positive TB ptients on ntiretrovirl therpy (ART) 141 755 (79) HIV-positive people screened for TB 1 148 477 HIV-positive people provided with IPT 551 787 Tretment success rte nd cohort size (%) COHORT New nd relpse cses registered in 213 (78) 321 87 Previously treted cses, excluding relpse, registered in 213 (69) 18 292 HIV-positive TB cses, ll types, registered in 213 (76) 191 189 RR-/MDR-TB cses strted on second-line tretment in 212 (49) 8 84 XDR-TB cses strted on second-line tretment in 212 (2) 67 Lbortories 214 Smer (per 1 popultion).4 Culture (per 5 million popultion) 1.1 Drug susceptibility testing (per 5 million popultion) 1.1 Sites performing Xpert MTB/RIF 27 Is second-line drug susceptibility testing vilble? Yes, in country Finncing TB control 215 Ntionl TB progrmme budget (US$ millions) 248 % Funded domesticlly 84% % Funded interntionlly 8% % Unfunded 8% Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b Includes cses with unknown previous TB tretment history. c Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. Mortlity (excludes HIV+TB) (rte per 1 poultion per yer) Prevlence (rte per 1 poultion) Incidence (rte per 1 poultion per yer) Number of ptients Tretment success rte (%) Totl budget (US$ millions) 75 5 25 1 5 9 6 3 25 2 15 1 5 1 8 6 4 2 5 4 3 2 1 199 1995 2 25 21 199 1995 2 25 21 199 1995 2 25 21 Notified (new nd relpse) Incidence (HIV+TB only) Incidence 23 25 27 29 211 213 HIV-positive TB ptients on CPT on ART 1995 1997 1999 21 23 25 27 29 211 213 New Retretment New nd relpse Retretment excluding relpse HIV-positive RR-/MDR-TB XDR-TB 211 212 213 214 215 Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 141

Thilnd Popultion 214 68 million Estimtes of TB burden 214 NUMBER (thousnds) RATE (per 1 popultion) Mortlity (excludes HIV+TB) 7.4 (3.9 12) 11 (5.7 18) Mortlity (HIV+TB only) 4.5 (2.3 7.4) 6.6 (3.4 11) Prevlence (includes HIV+TB) 16 (11 22) 236 (161 326) Incidence (includes HIV+TB) 12 (61 19) 171 (9 276) Incidence (HIV+TB only) 15 (7.8 24) 22 (12 36) Cse detection, ll forms (%) 59 (36 11) Estimtes of MDR-TB burden 214 NEW RETREATMENT % of TB cses with MDR-TB 2 (1.4 2.8) 19 (14 25) MDR-TB cses mong notified pulmonry TB cses 1 1 (78 1 6) 1 1 (8 1 5) TB cse notifictions 214 NEW b RELAPSE Pulmonry, bcteriologiclly confirmed 34 394 1 969 Pulmonry, cliniclly dignosed 21 115 Extrpulmonry 1 244 Mortlity (excludes HIV+TB) (rte per 1 poultion per yer) Prevlence (rte per 1 poultion) 4 3 2 1 199 1995 2 25 21 5 4 3 2 1 199 1995 2 25 21 Totl new nd relpse 67 722 Previously treted, excluding relpses 3 896 Totl cses notified 71 618 Among 34 394 new cses: 119 (<1%) cses ged under 15 yers; mle:femle rtio: 2.5 Reported cses of RR-/MDR-TB 214 NEW RETREATMENT TOTAL b Cses tested for RR-/MDR-TB 4 37 (13%) 2 29 (38%) 9 58 Lbortory-confirmed RR-/MDR-TB cses 56 Ptients strted on MDR-TB tretment c TB/HIV 214 NUMBER (%) TB ptients with known HIV sttus 5 67 (71) HIV-positive TB ptients 6 831 (13) HIV-positive TB ptients on co-trimoxzole preventive therpy (CPT) 4 359 (64) HIV-positive TB ptients on ntiretrovirl therpy (ART) 4 691 (69) HIV-positive people screened for TB HIV-positive people provided with IPT Tretment success rte nd cohort size (%) COHORT New nd relpse cses registered in 213 (81) 65 867 Previously treted cses, excluding relpse, registered in 213 (66) 1 812 HIV-positive TB cses, ll types, registered in 213 (67) 7 665 RR-/MDR-TB cses strted on second-line tretment in 212 XDR-TB cses strted on second-line tretment in 212 Lbortories 214 Smer (per 1 popultion) 1.3 Culture (per 5 million popultion) 3.9 Drug susceptibility testing (per 5 million popultion) 1.5 Sites performing Xpert MTB/RIF 14 Is second-line drug susceptibility testing vilble? Yes, in country Finncing TB control 215 Ntionl TB progrmme budget (US$ millions) 32 % Funded domesticlly 52% % Funded interntionlly 11% % Unfunded 37% Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b Includes cses with unknown previous TB tretment history. c Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. Incidence (rte per 1 poultion per yer) Number of ptients Tretment success rte (%) Totl budget (US$ millions) 4 3 2 1 1 8 6 4 199 1995 2 25 21 Notified (new nd relpse) Incidence Incidence (HIV+TB only) 2 1 9 8 7 6 5 4 5 4 3 2 1 23 25 27 29 211 213 HIV-positive TB ptients on CPT on ART 1995 1997 1999 21 23 25 27 29 211 213 New Retretment New nd relpse Retretment excluding relpse HIV-positive RR-/MDR-TB XDR-TB 211 212 213 214 215 Funded domesticlly Funded interntionlly Unfunded 142 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

Ugnd Popultion 214 38 million Estimtes of TB burden 214 NUMBER (thousnds) RATE (per 1 popultion) Mortlity (excludes HIV+TB) 4.5 (3.2 6.1) 12 (8.4 16) Mortlity (HIV+TB only) 6.4 (5 8.1) 17 (13 21) Prevlence (includes HIV+TB) 6 (33 95) 159 (87 253) Incidence (includes HIV+TB) 61 (53 69) 161 (141 183) Incidence (HIV+TB only) 28 (24 32) 73 (63 84) Cse detection, ll forms (%) 72 (64 83) Estimtes of MDR-TB burden 214 NEW RETREATMENT % of TB cses with MDR-TB 1.4 (.6 2.2) 12 (6.8 19) MDR-TB cses mong notified pulmonry TB cses 53 (23 83) 48 (27 77) TB cse notifictions 214 NEW c RELAPSE Pulmonry, bcteriologiclly confirmed 26 79 1 499 Pulmonry, cliniclly dignosed 11 854 468 Extrpulmonry 4 18 17 Mortlity (excludes HIV+TB) (rte per 1 poultion per yer) Prevlence (rte per 1 poultion) 75 5 25 199 1995 2 25 21 8 6 4 2 199 1995 2 25 21 Totl new nd relpse 44 187 Previously treted, excluding relpses 1 984 Totl cses notified 46 171 Among 44 187 new nd relpse cses: 3 316 (8%) cses ged under 15 yers; mle:femle rtio: 1.8 Reported cses of RR-/MDR-TB 214 NEW RETREATMENT TOTAL b Cses tested for RR-/MDR-TB 1 958 (8%) 737 (18%) 3 569 Lbortory-confirmed RR-/MDR-TB cses 255 Ptients strted on MDR-TB tretment c 213 TB/HIV 214 NUMBER (%) TB ptients with known HIV sttus 43 883 (95) HIV-positive TB ptients 19 612 (45) HIV-positive TB ptients on co-trimoxzole preventive therpy (CPT) 19 211 (98) HIV-positive TB ptients on ntiretrovirl therpy (ART) 15 877 (81) HIV-positive people screened for TB 729 268 HIV-positive people provided with IPT Tretment success rte nd cohort size (%) COHORT New nd relpse cses registered in 213 (75) 44 65 Previously treted cses, excluding relpse, registered in 213 (67) 2 572 HIV-positive TB cses, ll types, registered in 213 (73) 16 762 RR-/MDR-TB cses strted on second-line tretment in 212 (8) 41 XDR-TB cses strted on second-line tretment in 212 Lbortories 214 Smer (per 1 popultion) 3.6 Culture (per 5 million popultion).7 Drug susceptibility testing (per 5 million popultion).7 Sites performing Xpert MTB/RIF 74 Is second-line drug susceptibility testing vilble? Yes, in country Finncing TB control 215 Ntionl TB progrmme budget (US$ millions) 24 % Funded domesticlly 1% % Funded interntionlly 69% % Unfunded 21% Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b Includes cses with unknown previous TB tretment history. c Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. Incidence (rte per 1 poultion per yer) Number of ptients Tretment success rte (%) Totl budget (US$ millions) 8 6 4 2 25 2 15 1 199 1995 2 25 21 Notified (new nd relpse) Incidence Incidence (HIV+TB only) 5 1 8 6 4 2 4 3 2 1 23 25 27 29 211 213 HIV-positive TB ptients on CPT on ART 1995 1997 1999 21 23 25 27 29 211 213 New Retretment New nd relpse Retretment excluding relpse HIV-positive RR-/MDR-TB XDR-TB 211 212 213 214 215 Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 143

United Republic of Tnzni Popultion 214 52 million Estimtes of TB burden 214 NUMBER (thousnds) RATE (per 1 popultion) Mortlity (excludes HIV+TB) 3 (13 54) 58 (26 14) Mortlity (HIV+TB only) 28 (15 43) 53 (3 84) Prevlence (includes HIV+TB) 27 (11 51) 528 (215 979) Incidence (includes HIV+TB) 17 (8 29) 327 (155 561) Incidence (HIV+TB only) 62 (29 11) 12 (56 28) Cse detection, ll forms (%) 36 (21 77) Estimtes of MDR-TB burden 214 NEW RETREATMENT % of TB cses with MDR-TB 1.1 (.5 2) 3.1 (.9 7.9) MDR-TB cses mong notified pulmonry TB cses 52 (23 94) 8 (23 2) TB cse notifictions 214 NEW b RELAPSE Pulmonry, bcteriologiclly confirmed 23 583 1 8 Pulmonry, cliniclly dignosed 23 38 Extrpulmonry 13 6 Totl new nd relpse 61 571 Previously treted, excluding relpses 1 58 Totl cses notified 63 151 Among 61 571 new nd relpse cses: 6 463 (1%) cses ged under 15 yers; mle:femle rtio: 1.5 Reported cses of RR-/MDR-TB 214 NEW RETREATMENT TOTAL b Cses tested for RR-/MDR-TB 9 56 (4%) 882 (34%) 35 923 Lbortory-confirmed RR-/MDR-TB cses 516 Ptients strted on MDR-TB tretment c 143 TB/HIV 214 NUMBER (%) TB ptients with known HIV sttus 57 612 (91) HIV-positive TB ptients 2 55 (35) HIV-positive TB ptients on co-trimoxzole preventive therpy (CPT) 19 388 (97) HIV-positive TB ptients on ntiretrovirl therpy (ART) 16 564 (83) HIV-positive people screened for TB 525 713 HIV-positive people provided with IPT 23 124 Tretment success rte nd cohort size (%) COHORT New nd relpse cses registered in 213 (91) 64 53 Previously treted cses, excluding relpse, registered in 213 (79) 1 679 HIV-positive TB cses, ll types, registered in 213 (72) 2 32 RR-/MDR-TB cses strted on second-line tretment in 212 (73) 45 XDR-TB cses strted on second-line tretment in 212 Lbortories 214 Smer (per 1 popultion) 1.8 Culture (per 5 million popultion).4 Drug susceptibility testing (per 5 million popultion) <.1 Sites performing Xpert MTB/RIF 59 Is second-line drug susceptibility testing vilble? Yes, in country Finncing TB control 215 Ntionl TB progrmme budget (US$ millions) 67 % Funded domesticlly % Funded interntionlly % Unfunded 1% Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b Includes cses with unknown previous TB tretment history. c Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. Mortlity (excludes HIV+TB) (rte per 1 poultion per yer) Prevlence (rte per 1 poultion) Incidence (rte per 1 poultion per yer) Number of ptients Tretment success rte (%) Totl budget (US$ millions) 15 1 5 15 1 5 8 6 4 2 25 2 15 1 199 1995 2 25 21 199 1995 2 25 21 Notified (new nd relpse) Incidence Incidence (HIV+TB only) 5 199 1995 2 25 21 1 8 6 4 2 23 25 27 29 211 213 HIV-positive TB ptients on CPT on ART 9 8 7 6 1995 1997 1999 21 23 25 27 29 211 213 New Retretment New nd relpse Retretment excluding relpse HIV-positive RR-/MDR-TB XDR-TB 211 212 213 214 215 Funded domesticlly Funded interntionlly Unfunded 144 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

Viet Nm Popultion 214 92 million Estimtes of TB burden 214 NUMBER (thousnds) RATE (per 1 popultion) Mortlity (excludes HIV+TB) 17 (11 23) 18 (12 25) Mortlity (HIV+TB only) 1.9 (1.3 2.5) 2 (1.4 2.7) Prevlence (includes HIV+TB) 18 (76 33) 198 (83 362) Incidence (includes HIV+TB) 13 (11 15) 14 (116 167) Incidence (HIV+TB only) 7 (5.7 8.5) 7.6 (6.1 9.2) Cse detection, ll forms (%) 77 (65 94) Estimtes of MDR-TB burden 214 NEW RETREATMENT % of TB cses with MDR-TB 4 (2.5 5.4) 23 (17 3) MDR-TB cses mong notified pulmonry TB cses 3 (1 9 4 1) 2 1 (1 5 2 6) TB cse notifictions 214 NEW c RELAPSE Pulmonry, bcteriologiclly confirmed 49 938 7 114 Pulmonry, cliniclly dignosed 25 179 Extrpulmonry 18 118 Mortlity (excludes HIV+TB) (rte per 1 poultion per yer) Prevlence (rte per 1 poultion) 6 4 2 199 1995 2 25 21 75 5 25 199 1995 2 25 21 Totl new nd relpse 1 349 Previously treted, excluding relpses 1 738 Totl cses notified 12 87 Among 49 929 new cses: 144 (<1%) cses ged under 15 yers; mle:femle rtio: 3. Reported cses of RR-/MDR-TB 214 NEW RETREATMENT TOTAL b Cses tested for RR-/MDR-TB 2 756 (6%) 8 511 (96%) 13 829 Lbortory-confirmed RR-/MDR-TB cses 2 198 Ptients strted on MDR-TB tretment c 1 532 TB/HIV 214 NUMBER (%) TB ptients with known HIV sttus 74 92 (73) HIV-positive TB ptients 3 875 (5) HIV-positive TB ptients on co-trimoxzole preventive therpy (CPT) 2 936 (76) HIV-positive TB ptients on ntiretrovirl therpy (ART) 2 827 (73) HIV-positive people screened for TB 9 592 HIV-positive people provided with IPT Tretment success rte nd cohort size (%) COHORT New nd relpse cses registered in 213 (89) 12 196 Previously treted cses, excluding relpse, registered in 213 HIV-positive TB cses, ll types, registered in 213 (71) 4 453 RR-/MDR-TB cses strted on second-line tretment in 212 (71) 713 XDR-TB cses strted on second-line tretment in 212 Lbortories 214 Smer (per 1 popultion) 1.1 Culture (per 5 million popultion) 1.2 Drug susceptibility testing (per 5 million popultion).1 Sites performing Xpert MTB/RIF 3 Is second-line drug susceptibility testing vilble? Yes, in nd outside country Finncing TB control 215 Ntionl TB progrmme budget (US$ millions) 66 % Funded domesticlly 1% % Funded interntionlly 17% % Unfunded 72% Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b Includes cses with unknown previous TB tretment history. c Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. Incidence (rte per 1 poultion per yer) Number of ptients Tretment success rte (%) Totl budget (US$ millions) 3 2 1 6 4 2 199 1995 2 25 21 Notified (new nd relpse) Incidence Incidence (HIV+TB only) 1 8 6 4 2 23 25 27 29 211 213 HIV-positive TB ptients on CPT on ART 8 6 4 2 1995 1997 1999 21 23 25 27 29 211 213 New Retretment New nd relpse Retretment excluding relpse HIV-positive RR-/MDR-TB XDR-TB 211 212 213 214 215 Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 145

Zimbbwe Popultion 214 15 million Estimtes of TB burden 214 NUMBER (thousnds) RATE (per 1 popultion) Mortlity (excludes HIV+TB) 2.3 (1.4 3.4) 15 (9.5 22) Mortlity (HIV+TB only) 5.2 (3.2 7.8) 34 (21 51) Prevlence (includes HIV+TB) 44 (24 71) 292 (158 465) Incidence (includes HIV+TB) 42 (29 58) 278 (193 379) Incidence (HIV+TB only) 25 (17 35) 167 (114 229) Cse detection, ll forms (%) 7 (51 1) Estimtes of MDR-TB burden 214 NEW RETREATMENT % of TB cses with MDR-TB 2.2 (.3 4.1) 11 (6.2 16) MDR-TB cses mong notified pulmonry TB cses 54 (73 1 ) 41 (23 59) TB cse notifictions 214 NEW b RELAPSE Pulmonry, bcteriologiclly confirmed 11 224 1 369 Pulmonry, cliniclly dignosed 13 151 Extrpulmonry 3 99 Mortlity (excludes HIV+TB) (rte per 1 poultion per yer) Prevlence (rte per 1 poultion) 6 4 2 199 1995 2 25 21 6 4 2 199 1995 2 25 21 Totl new nd relpse 29 653 Previously treted, excluding relpses 2 363 Totl cses notified 32 16 Among 29 653 new nd relpse cses: 2 29 (8%) cses ged under 15 yers; mle:femle rtio: 1.3 Reported cses of RR-/MDR-TB 214 NEW RETREATMENT TOTAL b Cses tested for RR-/MDR-TB 341 (3%) 237 (6%) 7 585 Lbortory-confirmed RR-/MDR-TB cses 412 Ptients strted on MDR-TB tretment c 381 TB/HIV 214 NUMBER (%) TB ptients with known HIV sttus 28 58 (89) HIV-positive TB ptients 19 29 (68) HIV-positive TB ptients on co-trimoxzole preventive therpy (CPT) 18 2 (94) HIV-positive TB ptients on ntiretrovirl therpy (ART) 16 522 (86) HIV-positive people screened for TB 133 997 HIV-positive people provided with IPT 3 42 Tretment success rte nd cohort size (%) COHORT New cses registered in 213 (8) 35 278 Previously treted cses registered in 213 HIV-positive TB cses, ll types, registered in 213 RR-/MDR-TB cses strted on second-line tretment in 212 (75) 234 XDR-TB cses strted on second-line tretment in 212 Lbortories 214 Smer (per 1 popultion) 1.4 Culture (per 5 million popultion).7 Drug susceptibility testing (per 5 million popultion).7 Sites performing Xpert MTB/RIF 62 Is second-line drug susceptibility testing vilble? Yes, in nd outside country Finncing TB control 215 Ntionl TB progrmme budget (US$ millions) 28 % Funded domesticlly 7% % Funded interntionlly 59% % Unfunded 34% Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b Includes cses with unknown previous TB tretment history. c Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. Incidence (rte per 1 poultion per yer) Number of ptients Tretment success rte (%) Totl budget (US$ millions) 8 6 4 2 4 3 2 1 199 1995 2 25 21 Notified (new nd relpse) Incidence Incidence (HIV+TB only) 1 8 6 4 2 5 4 3 2 1 23 25 27 29 211 213 HIV-positive TB ptients on CPT on ART 1995 1997 1999 21 23 25 27 29 211 213 New Retretment HIV-positive RR-/MDR-TB XDR-TB 211 212 213 214 215 Funded domesticlly Funded interntionlly Unfunded 146 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

A N N E X 3 Regionl profiles FOR 6 WHO REGIONS Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b Includes cses with unknown previous TB tretment history. c Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 147

148 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

WHO Africn Region Popultion 214 963 million WHO MEMBER STATES 47 Estimtes of TB burden 214 NUMBER (thousnds) RATE (per 1 popultion) Mortlity (excludes HIV+TB) 45 (35 56) 46 (36 58) Mortlity (HIV+TB only) 31 (27 35) 32 (28 36) Prevlence (includes HIV+TB) 3 2 (2 8 3 6) 33 (288 375) Incidence (includes HIV+TB) 2 7 (2 4 3 ) 281 (25 313) Incidence (HIV+TB only) 87 (79 95) 9 (82 99) Cse detection, ll forms (%) 48 (43 54) Estimtes of MDR-TB burden 214 NEW RETREATMENT % of TB cses with MDR-TB 2.1 (.5 3.7) 11 (6.7 16) MDR-TB cses mong notified pulmonry TB cses 22 (5 2 38 ) 11 (6 2 15 ) TB cse notifictions 214 NEW b RELAPSE Pulmonry, bcteriologiclly confirmed 635 56 39 782 Pulmonry, cliniclly dignosed 399 155 11 217 Extrpulmonry 212 57 3 81 Totl new nd relpse 1 3 852 Previously treted, excluding relpses 41 548 Totl cses notified 1 342 4 Among 1 54 331 reported new nd relpse c cses disggregted by ge, 9 523 (8.6%) cses were ged < 15 yers Among 1 56 629 reported new nd relpse c cses disggregted by sex, mle:femle rtio = 1.4 Reported cses of RR-/MDR-TB 214 NEW RETREATMENT TOTAL b Cses tested for RR-/MDR-TB 4 94 (6.4%) 31 952 (33%) 367 223 Lbortory-confirmed RR-/MDR-TB cses 25 531 Ptients strted on MDR-TB tretment d 17 352 TB/HIV 214 NUMBER (%) e TB ptients with known HIV sttus 1 64 385 79 HIV-positive TB ptients 415 657 39 HIV-positive TB ptients on co-trimoxzole preventive therpy (CPT) 36 15 89 HIV-positive TB ptients on ntiretrovirl therpy (ART) 317 773 77 HIV-positive people screened for TB 5 166 166 HIV-positive people provided with IPT 875 886 Tretment success rte nd cohort size (%) COHORT New nd relpse c cses registered in 213 79 1 165 7 Previously treted cses, excluding relpse, registered in 213 7 7 144 HIV-positive TB cses, ll types, registered in 213 7 326 597 RR-/MDR-TB cses strted on second-line tretment in 212 53 1 246 XDR-TB cses strted on second-line tretment in 212 2 618 Lbortories 214 Smer (per 1 popultion) 1 28 out of 44 Culture (per 5 million popultion) 1 15 out of 44 Drug susceptibility testing (per 5 million popultion) 1 1 out of 44 NUMBER OF MEMBER STATES f Finncing TB control (low- nd middle-income countries) f,g 215 Ntionl TB progrmme budget (US$ millions) 1 8 % Funded domesticlly 34 % Funded interntionlly 29 % Unfunded 37 Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b Includes cses with unknown previous TB tretment history. c Some countries reported on new cses only. d Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. e Clcultions exclude countries with missing numertors or denomintors. f Dt re not collected from ll Member Sttes. g Finncing indictors exclude funding for generl helthcre services provided outside NTPs. Mortlity (excludes HIV+TB) (rte per 1 poultion per yer) Prevlence (rte per 1 poultion) Incidence (rte per 1 poultion per yer) Number of TB ptients (thousnds) Tretment success rte (%) Totl budget (US$ millions constnt 215) 6 4 2 4 3 2 1 4 3 2 1 1 8 6 4 2 15 1 199 1995 2 25 21 5 4 3 2 1 5 199 1995 2 25 21 199 1995 2 25 21 Notified (new nd relpse) Incidence (HIV+TB only) Incidence 24 26 28 21 212 214 HIV-positive TB ptients on CPT on ART 1995 1997 1999 21 23 25 27 29 211 213 New, or new nd relpse Retretment, or retretment excluding relpse HIV-positive RR-/MDR-TB XDR-TB 21 211 212 213 214 215 Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 149

WHO/PAHO Region of the Americs Popultion 214 982 million WHO MEMBER STATES 35 OTHER COUNTRIES AND TERRITORIES 11 Estimtes of TB burden 214 NUMBER (thousnds) RATE (per 1 popultion) Mortlity (excludes HIV+TB) 17 (16 18) 1.7 (1.6 1.8) Mortlity (HIV+TB only) 6 (5 7).61 (.53.69) Prevlence (includes HIV+TB) 35 (27 44) 36 (28 45) Incidence (includes HIV+TB) 28 (27 29) 28 (27 29) Incidence (HIV+TB only) 36 (34 38) 3.7 (3.5 3.9) Cse detection, ll forms (%) 77 (75 81) Estimtes of MDR-TB burden 214 NEW RETREATMENT % of TB cses with MDR-TB 2.4 (1.3 3.5) 11 (6.5 16) MDR-TB cses mong notified pulmonry TB cses 4 (2 2 5 9) 3 (1 7 4 2) TB cse notifictions 214 NEW b RELAPSE Pulmonry, bcteriologiclly confirmed 127 864 1 193 Pulmonry, cliniclly dignosed 4 746 2 918 Extrpulmonry 32 51 1 21 Totl new nd relpse 215 243 Previously treted, excluding relpses 13 233 Totl cses notified 228 476 Among 28 839 reported new nd relpse c cses disggregted by ge, 1 489 (5.%) cses were ged < 15 yers Among 21 774 reported new nd relpse c cses disggregted by sex, mle:femle rtio = 1.7 Reported cses of RR-/MDR-TB 214 NEW RETREATMENT TOTAL b Cses tested for RR-/MDR-TB 3 531 (24%) 8 724 (32%) 6 468 Lbortory-confirmed RR-/MDR-TB cses 3 745 Ptients strted on MDR-TB tretment d 3 568 TB/HIV 214 NUMBER (%) e TB ptients with known HIV sttus 169 141 74 HIV-positive TB ptients 21 913 13 HIV-positive TB ptients on co-trimoxzole preventive therpy (CPT) 5 719 52 HIV-positive TB ptients on ntiretrovirl therpy (ART) 7 29 63 HIV-positive people screened for TB 56 856 HIV-positive people provided with IPT 28 556 Tretment success rte nd cohort size (%) COHORT New nd relpse c cses registered in 213 75 2 726 Previously treted cses, excluding relpse, registered in 213 48 14 753 HIV-positive TB cses, ll types, registered in 213 53 19 816 RR-/MDR-TB cses strted on second-line tretment in 212 57 2 866 XDR-TB cses strted on second-line tretment in 212 3 67 Lbortories 214 Smer (per 1 popultion) 1 19 out of 23 Culture (per 5 million popultion) 1 2 out of 23 Drug susceptibility testing (per 5 million popultion) 1 6 out of 23 NUMBER OF MEMBER STATES f Finncing TB control (low- nd middle-income countries) f,g 215 Ntionl TB progrmme budget (US$ millions) 285 % Funded domesticlly 71 % Funded interntionlly 7.3 % Unfunded 22 Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b Includes cses with unknown previous TB tretment history. c Some countries reported on new cses only. d Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. e Clcultions exclude countries with missing numertors or denomintors. f Dt re not collected from ll Member Sttes. g Finncing indictors exclude funding for generl helthcre services provided outside NTPs. Mortlity (excludes HIV+TB) (rte per 1 poultion per yer) Prevlence (rte per 1 poultion) Incidence (rte per 1 poultion per yer) Number of TB ptients (thousnds) Tretment success rte (%) Totl budget (US$ millions constnt 215) 6 4 2 1 75 5 25 6 4 2 25 2 15 1 5 1 8 6 4 2 4 3 2 1 199 1995 2 25 21 199 1995 2 25 21 199 1995 2 25 21 Notified (new nd relpse) Incidence (HIV+TB only) Incidence 24 26 28 21 212 214 HIV-positive TB ptients on CPT on ART 1995 1997 1999 21 23 25 27 29 211 213 New, or new nd relpse Retretment, or retretment excluding relpse HIV-positive RR-/MDR-TB XDR-TB 21 211 212 213 214 215 Funded domesticlly Funded interntionlly Unfunded 15 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

WHO Estern Mediterrnen Region Popultion 214 636 million WHO MEMBER STATES 21 OTHER COUNTRIES AND TERRITORIES 1 Estimtes of TB burden 214 NUMBER (thousnds) RATE (per 1 popultion) Mortlity (excludes HIV+TB) 88 (43 15) 14 (6.8 23) Mortlity (HIV+TB only) 3 (3 4).51 (.41.62) Prevlence (includes HIV+TB) 1 (88 1 2) 16 (139 183) Incidence (includes HIV+TB) 74 (61 89) 117 (96 14) Incidence (HIV+TB only) 12 (1 15) 1.9 (1.6 2.3) Cse detection, ll forms (%) 61 (51 75) Estimtes of MDR-TB burden 214 NEW RETREATMENT % of TB cses with MDR-TB 3.2 (2.3 4.1) 18 (12 25) MDR-TB cses mong notified pulmonry TB cses 11 (7 7 14 ) 4 7 (3 6 4) TB cse notifictions 214 NEW b RELAPSE Pulmonry, bcteriologiclly confirmed 183 63 12 368 Pulmonry, cliniclly dignosed 151 696 866 Extrpulmonry 13 959 87 Totl new nd relpse 453 393 Previously treted, excluding relpses 12 284 Totl cses notified 465 677 Among 441 71 reported new nd relpse c cses disggregted by ge, 42 28 (9.5%) cses were ged < 15 yers Among 449 16 reported new nd relpse c cses disggregted by sex, mle:femle rtio = 1. Reported cses of RR-/MDR-TB 214 NEW RETREATMENT TOTAL b Cses tested for RR-/MDR-TB 8 44 (4.6%) 13 73 (52%) 3 519 Lbortory-confirmed RR-/MDR-TB cses 4 348 Ptients strted on MDR-TB tretment d 3 423 TB/HIV 214 NUMBER (%) e TB ptients with known HIV sttus 67 624 15 HIV-positive TB ptients 1 629 2.4 HIV-positive TB ptients on co-trimoxzole preventive therpy (CPT) 686 67 HIV-positive TB ptients on ntiretrovirl therpy (ART) 943 63 HIV-positive people screened for TB 14 775 HIV-positive people provided with IPT 478 Tretment success rte nd cohort size (%) COHORT New nd relpse c cses registered in 213 91 431 622 Previously treted cses, excluding relpse, registered in 213 76 11 281 HIV-positive TB cses, ll types, registered in 213 6 681 RR-/MDR-TB cses strted on second-line tretment in 212 65 1 271 XDR-TB cses strted on second-line tretment in 212 33 43 Lbortories 214 Smer (per 1 popultion) 1 3 out of 15 Culture (per 5 million popultion) 1 9 out of 15 Drug susceptibility testing (per 5 million popultion) 1 4 out of 15 NUMBER OF MEMBER STATES f Finncing TB control (low- nd middle-income countries) f,g 215 Ntionl TB progrmme budget (US$ millions) 183 % Funded domesticlly 46 % Funded interntionlly 43 % Unfunded 11 Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b Includes cses with unknown previous TB tretment history. c Some countries reported on new cses only. d Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. e Clcultions exclude countries with missing numertors or denomintors. f Dt re not collected from ll Member Sttes. g Finncing indictors exclude funding for generl helthcre services provided outside NTPs. Mortlity (excludes HIV+TB) (rte per 1 poultion per yer) Prevlence (rte per 1 poultion) Incidence (rte per 1 poultion per yer) Number of TB ptients (thousnds) Tretment success rte (%) Totl budget (US$ millions constnt 215) 4 3 2 1 199 1995 2 25 21 2 1 15 1 5 2. 1.5 1..5 1 8 6 4 2 2 1 199 1995 2 25 21 199 1995 2 25 21 Notified (new nd relpse) Incidence (HIV+TB only) Incidence 24 26 28 21 212 214 HIV-positive TB ptients on CPT on ART 1995 1997 1999 21 23 25 27 29 211 213 New, or new nd relpse Retretment, or retretment excluding relpse HIV-positive RR-/MDR-TB XDR-TB 21 211 212 213 214 215 Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 151

WHO Europen Region Popultion 214 97 million WHO MEMBER STATES 53 OTHER COUNTRIES AND TERRITORIES 1 Estimtes of TB burden 214 NUMBER (thousnds) RATE (per 1 popultion) Mortlity (excludes HIV+TB) 33 (33 34) 3.7 (3.6 3.8) Mortlity (HIV+TB only) 3 (3 4).35 (.3.4) Prevlence (includes HIV+TB) 44 (33 56) 48 (36 61) Incidence (includes HIV+TB) 34 (32 35) 37 (35 39) Incidence (HIV+TB only) 2 (18 21) 2.2 (2 2.4) Cse detection, ll forms (%) 79 (75 83) Estimtes of MDR-TB burden 214 NEW RETREATMENT % of TB cses with MDR-TB 15 (1 19) 48 (43 53) MDR-TB cses mong notified pulmonry TB cses 28 (2 37 ) 44 (39 48 ) TB cse notifictions 214 NEW b RELAPSE Pulmonry, bcteriologiclly confirmed 112 416 23 935 Pulmonry, cliniclly dignosed 76 759 11 483 Extrpulmonry 39 175 2 29 Mortlity (excludes HIV+TB) (rte per 1 poultion per yer) Prevlence (rte per 1 poultion) 8 6 4 2 199 1995 2 25 21 1 5 199 1995 2 25 21 Totl new nd relpse 266 58 Previously treted, excluding relpses 55 363 Totl cses notified 321 421 Among 26 844 reported new nd relpse c cses disggregted by ge, 9 898 (3.8%) cses were ged < 15 yers Among 261 563 reported new nd relpse c cses disggregted by sex, mle:femle rtio = 2. Reported cses of RR-/MDR-TB 214 NEW RETREATMENT TOTAL b Cses tested for RR-/MDR-TB 18 569 (97%) 48 234 (52%) 161 22 Lbortory-confirmed RR-/MDR-TB cses 42 293 Ptients strted on MDR-TB tretment d 49 74 TB/HIV 214 NUMBER (%) e TB ptients with known HIV sttus 199 81 62 HIV-positive TB ptients 16 63 8.2 HIV-positive TB ptients on co-trimoxzole preventive therpy (CPT) 5 452 53 HIV-positive TB ptients on ntiretrovirl therpy (ART) 6 279 58 HIV-positive people screened for TB 37 266 HIV-positive people provided with IPT 21 14 Tretment success rte nd cohort size (%) COHORT New nd relpse c cses registered in 213 75 24 741 Previously treted cses, excluding relpse, registered in 213 58 3 125 HIV-positive TB cses, ll types, registered in 213 47 9 54 RR-/MDR-TB cses strted on second-line tretment in 212 49 37 638 XDR-TB cses strted on second-line tretment in 212 26 1 563 Lbortories 214 Smer (per 1 popultion) 1 1 out of 53 Culture (per 5 million popultion) 1 44 out of 53 Drug susceptibility testing (per 5 million popultion) 1 39 out of 53 NUMBER OF MEMBER STATES f Finncing TB control (low- nd middle-income countries) f,g 215 Ntionl TB progrmme budget (US$ millions) 2 513 % Funded domesticlly 93 % Funded interntionlly 4.1 % Unfunded 2.5 Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b Includes cses with unknown previous TB tretment history. c Some countries reported on new cses only. d Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. e Clcultions exclude countries with missing numertors or denomintors. f Dt re not collected from ll Member Sttes. g Finncing indictors exclude funding for generl helthcre services provided outside NTPs. Incidence (rte per 1 poultion per yer) Number of TB ptients (thousnds) Tretment success rte (%) Totl budget (US$ millions constnt 215) 6 4 2 2 15 1 5 1 8 6 4 2 3 2 1 199 1995 2 25 21 Notified (new nd relpse) Incidence (HIV+TB only) Incidence 24 26 28 21 212 214 HIV-positive TB ptients on CPT on ART 1995 1997 1999 21 23 25 27 29 211 213 New, or new nd relpse Retretment, or retretment excluding relpse HIV-positive RR-/MDR-TB XDR-TB 21 211 212 213 214 215 Funded domesticlly Funded interntionlly Unfunded 152 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

WHO South-Est Asi Region Popultion 214 1 96 million WHO MEMBER STATES 11 Estimtes of TB burden 214 NUMBER (thousnds) RATE (per 1 popultion) Mortlity (excludes HIV+TB) 46 (35 57) 24 (19 3) Mortlity (HIV+TB only) 62 (51 74) 3.3 (2.7 3.9) Prevlence (includes HIV+TB) 5 4 (4 4 6 5) 286 (233 343) Incidence (includes HIV+TB) 4 (3 7 4 4) 211 (192 232) Incidence (HIV+TB only) 21 (18 24) 11 (9.4 12) Cse detection, ll forms (%) 62 (56 68) Estimtes of MDR-TB burden 214 NEW RETREATMENT % of TB cses with MDR-TB 2.2 (1.9 2.6) 16 (14 17) MDR-TB cses mong notified pulmonry TB cses 4 (35 47 ) 59 (52 65 ) TB cse notifictions 214 NEW b RELAPSE Pulmonry, bcteriologiclly confirmed 1 188 654 152 498 Pulmonry, cliniclly dignosed 632 418 117 97 Extrpulmonry 389 819 715 Totl new nd relpse 2 482 74 Previously treted, excluding relpses 98 531 Totl cses notified 2 58 65 Among 2 416 375 reported new nd relpse c cses disggregted by ge, 168 31 (7.%) cses were ged < 15 yers Among 2 435 769 reported new nd relpse c cses disggregted by sex, mle:femle rtio = 1.8 Reported cses of RR-/MDR-TB 214 NEW RETREATMENT TOTAL b Cses tested for RR-/MDR-TB 45 56 (3.8%) 247 336 (67%) 35 871 Lbortory-confirmed RR-/MDR-TB cses 33 264 Ptients strted on MDR-TB tretment d 28 536 TB/HIV 214 NUMBER (%) e TB ptients with known HIV sttus 1 171 258 45 HIV-positive TB ptients 6 235 5.1 HIV-positive TB ptients on co-trimoxzole preventive therpy (CPT) 51 141 85 HIV-positive TB ptients on ntiretrovirl therpy (ART) 51 231 85 HIV-positive people screened for TB 1 183 7 HIV-positive people provided with IPT 3 49 Tretment success rte nd cohort size (%) COHORT New nd relpse c cses registered in 213 88 2 1 58 Previously treted cses, excluding relpse, registered in 213 67 196 439 HIV-positive TB cses, ll types, registered in 213 74 54 235 RR-/MDR-TB cses strted on second-line tretment in 212 49 11 566 XDR-TB cses strted on second-line tretment in 212 37 18 Lbortories 214 Smer (per 1 popultion) 1 9 out of 11 Culture (per 5 million popultion) 1 3 out of 11 Drug susceptibility testing (per 5 million popultion) 1 2 out of 11 NUMBER OF MEMBER STATES f Finncing TB control (low- nd middle-income countries) f,g 215 Ntionl TB progrmme budget (US$ millions) 559 % Funded domesticlly 33 % Funded interntionlly 45 % Unfunded 22 Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b Includes cses with unknown previous TB tretment history. c Some countries reported on new cses only. d Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. e Clcultions exclude countries with missing numertors or denomintors. f Dt re not collected from ll Member Sttes. g Finncing indictors exclude funding for generl helthcre services provided outside NTPs. Mortlity (excludes HIV+TB) (rte per 1 poultion per yer) Prevlence (rte per 1 poultion) Incidence (rte per 1 poultion per yer) Number of TB ptients (thousnds) Tretment success rte (%) Totl budget (US$ millions constnt 215) 4 2 6 4 2 2 1 6 4 2 1 8 6 4 2 6 4 2 199 1995 2 25 21 199 1995 2 25 21 199 1995 2 25 21 Notified (new nd relpse) Incidence (HIV+TB only) Incidence 24 26 28 21 212 214 HIV-positive TB ptients on CPT on ART 1995 1997 1999 21 23 25 27 29 211 213 New, or new nd relpse Retretment, or retretment excluding relpse HIV-positive RR-/MDR-TB XDR-TB 21 211 212 213 214 215 Funded domesticlly Funded interntionlly Unfunded Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 153

WHO Western Pcific Region Popultion 214 1 845 million WHO MEMBER STATES 27 OTHER COUNTRIES AND TERRITORIES 9 Estimtes of TB burden 214 NUMBER (thousnds) RATE (per 1 popultion) Mortlity (excludes HIV+TB) 88 (81 95) 4.8 (4.4 5.1) Mortlity (HIV+TB only) 5 (4 6).27 (.23.31) Prevlence (includes HIV+TB) 2 1 (1 9 2 4) 116 (14 128) Incidence (includes HIV+TB) 1 6 (1 5 1 6) 85 (8 89) Incidence (HIV+TB only) 31 (28 35) 1.7 (1.5 1.9) Cse detection, ll forms (%) 85 (81 9) Estimtes of MDR-TB burden 214 NEW RETREATMENT % of TB cses with MDR-TB 4.4 (2.5 6.3) 22 (18 25) MDR-TB cses mong notified pulmonry TB cses 52 (3 75 ) 19 (16 22 ) TB cse notifictions 214 NEW b RELAPSE Pulmonry, bcteriologiclly confirmed 449 845 44 354 Pulmonry, cliniclly dignosed 734 179 3 37 Extrpulmonry 13 85 1 316 Mortlity (excludes HIV+TB) (rte per 1 poultion per yer) Prevlence (rte per 1 poultion) 25 2 15 1 5 199 1995 2 25 21 3 2 1 199 1995 2 25 21 Totl new nd relpse 1 335 816 Previously treted, excluding relpses 39 756 Totl cses notified 1 375 572 Among 1 1 525 reported new nd relpse c cses disggregted by ge, 37 273 (3.4%) cses were ged < 15 yers Among 1 112 985 reported new nd relpse c cses disggregted by sex, mle:femle rtio = 2.1 Reported cses of RR-/MDR-TB 214 NEW RETREATMENT TOTAL b Cses tested for RR-/MDR-TB 92 81 (21%) 54 56 (62%) 164 449 Lbortory-confirmed RR-/MDR-TB cses 13 437 Ptients strted on MDR-TB tretment d 8 85 TB/HIV 214 NUMBER (%) e TB ptients with known HIV sttus 552 4 4 HIV-positive TB ptients 12 657 2.3 HIV-positive TB ptients on co-trimoxzole preventive therpy (CPT) 4 271 59 HIV-positive TB ptients on ntiretrovirl therpy (ART) 8 453 68 HIV-positive people screened for TB 528 464 HIV-positive people provided with IPT 3 68 Tretment success rte nd cohort size (%) COHORT New nd relpse c cses registered in 213 92 1 298 42 Previously treted cses, excluding relpse, registered in 213 81 18 523 HIV-positive TB cses, ll types, registered in 213 73 1 756 RR-/MDR-TB cses strted on second-line tretment in 212 51 6 176 XDR-TB cses strted on second-line tretment in 212 29 286 Lbortories 214 Smer (per 1 popultion) 1 13 out of 16 Culture (per 5 million popultion) 1 1 out of 16 Drug susceptibility testing (per 5 million popultion) 1 5 out of 16 NUMBER OF MEMBER STATES f Finncing TB control (low- nd middle-income countries) f,g 215 Ntionl TB progrmme budget (US$ millions) 63 % Funded domesticlly 63 % Funded interntionlly 16 % Unfunded 22 Dt re s reported to WHO. Estimtes of TB nd MDR-TB burden re produced by WHO in consulttion with countries. Rnges represent uncertinty intervls. b Includes cses with unknown previous TB tretment history. c Some countries reported on new cses only. d Includes ptients dignosed before 214 nd ptients who were not lbortory-confirmed s hving RR-/MDR-TB. e Clcultions exclude countries with missing numertors or denomintors. f Dt re not collected from ll Member Sttes. g Finncing indictors exclude funding for generl helthcre services provided outside NTPs. Incidence (rte per 1 poultion per yer) Number of TB ptients (thousnds) Tretment success rte (%) Totl budget (US$ millions constnt 215) 15 1 5 199 1995 2 25 21 Notified (new nd relpse) Incidence Incidence (HIV+TB only) 16 12 8 4 24 26 28 21 212 214 HIV-positive TB ptients on CPT on ART 1 8 6 4 2 6 4 2 1995 1997 1999 21 23 25 27 29 211 213 New, or new nd relpse Retretment, or retretment excluding relpse HIV-positive RR-/MDR-TB XDR-TB 21 211 212 213 214 215 Funded domesticlly Funded interntionlly Unfunded 154 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

A N N E X 4 Key TB indictors FOR INDIVIDUAL COUNTRIES AND TERRITORIES, WHO REGIONS AND THE WORLD

Contents Tble A4.1 TB incidence estimtes, notifiction nd cse detection rtes, ll forms of TB cse, 214 158 Tble A4.2 Estimtes of TB mortlity, 214 162 Tble A4.3 TB cse notifictions, 214 166 Tble A4.4 Notified new nd relpse TB cses by ge nd sex, 214 17 Tble A4.5 Tretment outcomes by TB cse type, 213, nd tretment outcomes for RR-/MDR-TB cses, 212 177 Tble A4.6 Mesured percentge of TB cses with MDR-TB, most recent yer vilble 181 Tble A4.7 Tble A4.8 Drug susceptibility testing for TB cses, estimted MDR-TB mong notified TB cses, RR-/MDR-TB cses detected, nd enrolments on MDR-TB tretment, 214 HIV testing for TB ptients, provision of CPT nd ART to HIV-positive TB ptients, nd initition of IPT for people newly enrolled in HIV cre, 214 185 189 Estimtes of mortlity, prevlence nd incidence 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 http://www.who.int/tb/publictions/globl_report/. Estimted numbers re shown rounded to two significnt figures. Estimted rtes re shown rounded to three significnt figures unless the vlue is under 1, in which cse rtes re shown rounded to two significnt figures. Dt source Dt shown in this file were tken from the WHO globl TB dtbse on 7 October 215. Dt shown in the min prt of the report were tken from the dtbse on 6 August 215. As result, dt in this nnex my dif fer slightly from those in the min prt of the report. Downlodble dt This nnex is provided s reference for looking up figures s nd 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 www.who.int/tb/ dt/. See Annex 1 for more detils. Country notes Bngldesh A joint ressessment of estimtes of TB disese burden will be undertken following completion of the ntionl TB prevlence survey which ws lunched in Mrch 215. Cribben Islnds Dt collection from Cribben Islnds tht re not Member Sttes of WHO ws resumed in 211 f ter brek of few yers. This includes Arub, Curço, Puerto Rico nd Sint Mrten, which re Associte Members of the Pn Americn Helth Orgniztion, plus the territories of Anguill, Bermud, Bonire, Sint Eusttius nd Sb, British Virgin Islnds, Cymn Islnds, Montserrt nd Turks nd Cicos Islnds. Dt re not currently independently collected from the US Virgin Islnds. Denmrk Dt for Denmrk exclude Greenlnd. Europen Union/ Europen Economic Are countries Notifiction nd tretment outcome dt for Europen Union nd Europen Economic Are countries re provisionl. Frnce Dt from Frnce include dt from 5 overses deprtments (French Guin, Gudeloupe, Mrtinique, Myotte nd Ré union) nd exclude French territories of the Pcific. Russin Federtion UN Popultion Division estimtes re lower thn the popultion registered by the Federl Stte Sttistics Service of the Russin Federtion. The reported number of TB ptients with known HIV sttus (Tble A4.8) is for new TB ptients in the civilin sector only. It ws not possible to clculte the percentge of ll TB ptients with known HIV sttus. United Sttes of Americ In ddition to the 51 reporting res, the USA includes territories tht report seprtely to WHO. The dt for these territories re not included in the dt reported by the USA. Definitions of cse types nd outcomes do not exctly mtch those used by WHO. GLOBAL TUBERCULOSIS REPORT 215 n 157

TABLE A4.1 TB incidence estimtes, notifiction nd cse detection rtes, ll forms of TB cse, 214 Incidence (including HIV) Incidence (HIV-positive) Notified cses b Cse detection Popultion (millions) Number (thousnds) Rte Number (thousnds) Rte Number Rte Percent Afghnistn 32 6 (53 67) 189 (167 212).32 (.25.4) 1 (.8 1.3) 31 746 1 53 (47 6) Albni 3.54 (.46.63) 19 (16 22) <.1 (<.1 <.1).12 (<.1.15) 48 14 75 (65 88) Algeri 39 31 (25 37) 78 (64 94).2 (.15.26).52 (.39.67) 22 517 58 74 (62 9) Americn Smo < 1 <.1 (<.1 <.1) 7 (5.6 8.6) ( <.1) <.1 (<.1 <.1) Andorr < 1 <.1 (<.1 <.1) 9.2 (8.1 1) 6 8.2 89 (79 1) Angol 24 9 (58 13) 37 (24 529) 23 (14 34) 95 (58 141) 53 552 221 6 (42 92) Anguill < 1 <.1 (<.1 <.1) 23 (19 27) 1 6.9 31 (26 37) Antigu nd Brbud < 1 <.1 (<.1 <.1) 7.6 (6.6 8.6) <.1 (<.1 <.1) 2.5 (1.8 3.3) 3 3.3 44 (39 5) Argentin 43 1 (9.1 12) 24 (21 27).74 (.58.92) 1.7 (1.3 2.1) 9 195 21 89 (78 1) Armeni 3 1.4 (1.2 1.5) 45 (4 5).8 (.71.9) 2.7 (2.4 3.) 1 329 44 98 (88 11) Arub < 1.11 (<.1.13) 11 (9.6 12) 2 1.9 18 (16 2) Austrli 24 1.5 (1.3 1.7) 6.4 (5.6 7.2).26 (.23.3).11 (.1.13) 1 33 5.6 88 (78 1) Austri 9.66 (.58.75) 7.8 (6.8 8.8).22 (.17.28).26 (.2.33) 564 6.6 85 (75 97) Azerbijn 1 7.4 (6.5 8.3) 77 (68 86).13 (.11.15) 1.4 (1.2 1.6) 5 788 6 78 (7 89) Bhms < 1.45 (.4.51) 12 (1 13).14 (.12.16) 3.7 (3.2 4.2) 5 13 11 (98 13) Bhrin 1.2 (.17.22) 14 (13 16) <.1 (<.1.11).68 (.57.8) Bngldesh 159 36 (32 41) 227 (2 256).57 (.45.71).36 (.28.45) 191 166 12 53 (47 6) Brbdos < 1 <.1 (<.1 <.1).91 (.8 1.) <.1 (<.1 <.1).91 (.8 1.) 5 1.8 19 (17 22) Belrus 1 5.5 (4.7 6.4) 58 (5 67).31 (.26.37) 3.3 (2.8 3.8) 3 858 41 7 (6 81) Belgium 11 1 (.88 1.1) 9 (7.8 1).72 (.61.85).65 (.54.76) 886 7.9 88 (78 1) Belize < 1.13 (.12.14) 37 (34 41).24 (.2.29) 6.9 (5.7 8.2) 72 2 55 (5 6) Benin 11 6.5 (5.3 7.9) 61 (5 74) 1 (.82 1.3) 9.7 (7.7 12) 3 886 37 6 (49 73) Bermud < 1 Bhutn < 1 1.3 (1.1 1.4) 164 (148 181).91 (.72.11) 12 (9.4 15) 1 66 139 85 (77 94) Bolivi (Plurintionl Stte of) 11 13 (11 14) 12 (16 135).51 (.4.63) 4.8 (3.8 6.) 8 79 76 64 (57 72) Bonire, Sint Eusttius nd Sb < 1 Bosni nd Herzegovin 4 1.6 (1.2 2.1) 42 (31 55) <.1 (<.1 <.1) <.1 (<.1.1) 1 196 31 75 (57 1) Botswn 2 8.5 (8. 9.1) 385 (361 41) 4.5 (4.1 5.) 24 (183 227) 6 19 271 7 (66 75) Brzil 26 9 (86 95) 44 (42 46) 16 (14 17) 7.6 (6.9 8.4) 73 97 36 82 (78 86) British Virgin Islnds < 1 <.1 (<.1 <.1) 1.7 (1.5 1.9) Brunei Drusslm < 1.26 (.23.29) 62 (54 7) <.1 (<.1 <.1) <.1 (<.1 <.1) 198 47 77 (68 88) Bulgri 7 1.9 (1.8 2.1) 27 (24 29) <.1 (<.1 <.1) <.1 (<.1 <.1) 1 825 25 95 (87 1) Burkin Fso 18 9.4 (8.5 1) 54 (48 59) 1.2 (1. 1.3) 6.6 (5.7 7.4) 5 546 32 59 (53 65) Burundi 11 14 (13 15) 126 (116 136) 1.9 (1.6 2.1) 17 (15 2) 7 226 67 53 (49 58) Cbo Verde < 1.71 (.63.8) 138 (122 156).66 (.55.78) 13 (11 15) 274 53 39 (34 44) Cmbodi 15 6 (54 66) 39 (353 428) 1.8 (1.6 2.) 12 (1 13) 43 59 281 72 (66 8) Cmeroon 23 5 (44 56) 22 (195 247) 2 (17 23) 88 (75 13) 26 38 114 52 (46 59) Cnd 36 1.9 (1.6 2.1) 5.2 (4.6 5.9).1 (.79.13).29 (.22.36) Cymn Islnds < 1 <.1 (<.1 <.1) 7 (6.1 7.9) <.1 (<.1 <.1).28 (<.1.62) Centrl Africn Republic 5 18 (16 2) 375 (333 42) 7.6 (5.9 9.4) 157 (124 195) 1 186 212 57 (5 64) Chd 14 22 (19 24) 159 (141 179) 6 (4.7 7.4) 44 (35 55) 11 973 88 55 (49 62) Chile 18 2.8 (2.4 3.2) 16 (14 18).13 (.1.16).73 (.57.91) 2 383 13 85 (75 97) Chin 1 369 93 (86 1 ) 68 (63 73) 13 (11 16).98 (.79 1.2) 819 283 6 88 (82 95) Chin, Hong Kong SAR 7 5.4 (4.7 6.1) 74 (65 84).32 (.28.37).45 (.38.52) 4 759 66 89 (79 1) Chin, Mco SAR < 1.48 (.42.54) 82 (72 93) <.1 (<.1 <.1) 1.3 (1.2 1.5) 394 68 83 (73 94) Colombi 48 16 (14 17) 33 (29 37) 3.4 (2.9 3.9) 7.1 (6.1 8.2) 11 875 25 76 (68 86) Comoros < 1.27 (.22.32) 35 (28 41) <.1 (<.1.1) 1.1 (.88 1.3) 148 19 56 (47 68) Congo 5 17 (15 19) 381 (335 43) 5.5 (4.3 6.9) 122 (96 152) 1 17 222 58 (52 66) Cook Islnds < 1 <.1 (<.1 <.1) 12 (11 14) 2 9.7 79 (7 9) Cost Ric 5.53 (.47.6) 11 (9.8 13).54 (.47.61) 1.1 (.99 1.3) 463 9.7 87 (77 99) Croti 4.53 (.46.59) 12 (11 14) <.1 (<.1 <.1) <.1 (<.1.12) 496 12 94 (83 11) Cub 11 1.1 (.92 1.2) 9.4 (8.1 11).11 (.93.13).97 (.82 1.1) 729 6.4 68 (6 79) Curço < 1 <.1 (<.1 <.1) 3.7 (3.2 4.2) <.1 (<.1 <.1) 3.7 (2.9 4.6) 5 3.2 87 (77 99) Cyprus 1.61 (.54.69) 5.3 (4.6 6.) <.1 (<.1 <.1) <.1 (<.1 <.1) 39 3.4 64 (56 73) Czech Republic 11.49 (.43.55) 4.6 (4.1 5.2) <.1 (<.1 <.1) <.1 (<.1 <.1) 474 4.5 97 (86 11) Côte d'ivoire 22 36 (33 4) 165 (15 179) 8.5 (7.5 9.6) 39 (34 43) 23 275 15 64 (59 7) Democrtic People's Republic of Kore 25 11 (1 12) 442 (412 473).31 (.25.38) 1.2 (.99 1.5) 13 45 412 93 (87 1) Democrtic Republic of the Congo 75 24 (22 27) 325 (295 356) 34 (27 42) 45 (36 56) 115 795 155 48 (43 52) Denmrk 6.4 (.35.45) 7.1 (6.2 8.).12 (<.1.15).22 (.17.27) 293 5.2 73 (65 84) Djibouti < 1 5.4 (4.8 6.1) 619 (547 696).54 (.44.65) 62 (51 74) 2 22 253 41 (36 46) Dominic < 1 <.1 (<.1 <.1).71 (.62.8) 1 1.4 19 (17 22) Dominicn Republic 1 6.2 (5.5 7.) 6 (53 68) 1.7 (1.4 1.9) 16 (14 19) 4 45 42 71 (63 8) Ecudor 16 8.6 (6.3 11) 54 (39 71) 1.1 (.82 1.5) 7.2 (5.2 9.6) 5 157 32 6 (46 82) Egypt 9 13 (12 15) 15 (13 16).35 (.28.44) <.1 (<.1 <.1) 7 177 8 54 (49 6) Rtes re per 1 popultion. b New cses, relpse cses nd cses for which the tretment history is unknown. 158 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

TABLE A4.1 TB incidence estimtes, notifiction nd cse detection rtes, ll forms of TB cse, 214 Popultion (millions) Incidence (including HIV) Number (thousnds) Rte Incidence (HIV-positive) Number (thousnds) Notified cses b Cse detection Rte Number Rte Percent El Slvdor 6 2.5 (2.3 2.7) 41 (38 45).24 (.22.26) 3.9 (3.6 4.3) 2 26 36 87 (8 95) Equtoril Guine < 1 1.3 (1.2 1.5) 162 (142 184).67 (.52.84) 82 (64 12) 1 166 142 88 (77 1) Eritre 5 4 (2.9 5.2) 78 (57 13).25 (.18.34) 4.9 (3.5 6.6) 2 391 47 6 (46 82) Estoni 1.27 (.24.3) 2 (18 23).24 (.21.27) 1.8 (1.6 2.1) 236 18 88 (78 1) Ethiopi 97 2 (16 24) 27 (168 25) 19 (15 23) 19 (15 24) 119 592 123 6 (49 73) Fiji < 1.59 (.48.72) 67 (55 81).27 (.22.34) 3.1 (2.5 3.8) 378 43 64 (53 78) Finlnd 5.31 (.27.35) 5.6 (4.9 6.4) <.1 (<.1 <.1).1 (<.1.13) 252 4.6 82 (72 93) Frnce 64 5.6 (5.3 6.) 8.7 (8.2 9.3).34 (.28.42).53 (.43.65) 4 535 7.1 81 (76 86) French Polynesi < 1.61 (.54.69) 22 (19 25) 56 2 91 (81 1) Gbon 2 7.5 (6.6 8.4) 444 (393 497).53 (.46.61) 32 (27 36) 5 68 332 75 (67 84) Gmbi 2 3.4 (2.8 4.) 174 (145 26).78 (.64.93) 4 (33 48) 2 552 132 76 (64 91) Georgi 4 4.3 (4. 4.6) 16 (99 114).16 (.13.19) 3.9 (3.2 4.8) 3 2 79 75 (7 8) Germny 81 5 (4.3 5.6) 6.2 (5.4 7.).12 (.95.15).15 (.12.19) 4 328 5.4 87 (77 1) Ghn 27 44 (21 75) 165 (8 281) 11 (5.2 19) 42 (2 72) 14 668 55 33 (19 69) Greece 11.53 (.46.6) 4.8 (4.2 5.4).16 (.12.19).14 (.11.18) 484 4.4 92 (81 1) Greenlnd < 1.11 (.97.13) 197 (173 223) Grend < 1 <.1 (<.1 <.1) 1.3 (1. 1.5) <.1 (<.1 <.1).11 (<.1.14) Gum < 1.67 (.59.76) 4 (35 45) <.1 (<.1 <.1) <.1 (<.1 <.1) 56 33 83 (74 95) Guteml 16 9.2 (8.1 1) 57 (51 64).84 (.7 1.) 5.3 (4.3 6.3) 3 163 2 34 (31 39) Guine 12 22 (19 24) 177 (156 199) 4.7 (3.9 5.5) 38 (32 45) 11 734 96 54 (48 61) Guine-Bissu 2 6.6 (4.7 8.9) 369 (261 495) 2.9 (2. 4.) 162 (11 224) 2 282 127 34 (26 49) Guyn < 1.79 (.7.89) 13 (91 116).17 (.14.2) 22 (19 26) 545 71 69 (62 78) Hiti 11 21 (19 24) 2 (177 225) 3.7 (3.2 4.3) 35 (31 41) 15 86 15 75 (66 85) Hondurs 8 3.4 (3. 3.9) 43 (38 48).34 (.3.39) 4.3 (3.8 4.9) 2 82 35 82 (73 93) Hungry 1 1.2 (1. 1.3) 12 (11 14).11 (<.1.14).11 (<.1.14) 799 8.1 67 (59 77) Icelnd < 1.11 (<.1.12) 3.3 (2.9 3.8) <.1 (<.1 <.1) ( ) 8 2.4 74 (65 84) Indi 1 295 2 2 (2 2 3) 167 (156 179) 11 (96 12) 8.3 (7.4 9.3) 1 69 547 124 74 (7 8) Indonesi 254 1 (7 1 4) 399 (274 546) 63 (41 9) 25 (16 36) 322 86 127 32 (23 46) Irn (Islmic Republic of) 78 17 (14 2) 22 (18 26).4 (.3.52).51 (.38.66) 1 191 13 6 (5 74) Irq 35 15 (13 17) 43 (38 49) <.1 (<.1 <.1) <.1 (<.1 <.1) 8 268 23 54 (48 62) Irelnd 5.35 (.3.39) 7.4 (6.5 8.4).15 (.11.18).31 (.24.39) 297 6.4 85 (75 97) Isrel 8.46 (.4.52) 5.8 (5.1 6.6).32 (.28.37).41 (.36.46) 368 4.6 8 (71 91) Itly 6 3.6 (3.1 4.1) 6 (5.2 6.8).24 (.19.3).4 (.31.5) Jmic 3.13 (.11.16) 4.7 (3.8 5.7).29 (.23.36) 1.1 (.84 1.3) 86 3.1 66 (55 81) Jpn 127 23 (2 26) 18 (16 21).99 (.83.12) <.1 (<.1 <.1) 19 615 15 84 (75 96) Jordn 7.41 (.36.46) 5.5 (4.9 6.2) <.1 (<.1 <.1) <.1 ( <.1) 385 5.2 94 (84 11) Kzkhstn 17 17 (11 25) 99 (64 141).59 (.38.84) 3.4 (2.2 4.8) 15 244 88 89 (62 14) Keny 45 11 (11 11) 246 (24 252) 4 (38 42) 89 (84 93) 88 25 196 8 (78 82) Kiribti < 1.55 (.45.66) 497 (46 597) <.1 (<.1 <.1) 1.7 (1.3 2.1) 414 375 75 (63 92) Kuwit 4.8 (.7.91) 21 (19 24) <.1 (<.1 <.1).14 (.11.17) 734 2 92 (81 1) Kyrgyzstn 6 8.3 (7.3 9.3) 142 (126 16).18 (.16.2) 3.1 (2.7 3.5) 6 39 19 77 (68 87) Lo People's Democrtic Republic 7 13 (9.5 16) 189 (141 244).5 (.34.68) 7.4 (5.1 1) 4 264 64 34 (26 45) Ltvi 2.98 (.91 1.) 49 (46 53).21 (.19.24) 11 (9.4 12) 738 37 76 (71 81) Lebnon 6.92 (.8 1.1) 16 (14 19).11 (.96.13) 2 (1.7 2.2) 673 12 73 (64 84) Lesotho 2 18 (13 24) 852 (612 1 13) 12 (8.5 16) 578 (45 781) 8 84 419 49 (37 69) Liberi 4 14 (12 15) 38 (273 346) 2.1 (1.7 2.7) 49 (38 61) 2 72 61 2 (18 23) Liby 6 2.5 (2.1 3.) 4 (33 48).1 (.8.12) 1.6 (1.3 2.) 1 153 18 46 (39 56) Lithuni 3 1.8 (1.7 2.) 62 (57 68).57 (.5.64) 2 (1.7 2.2) 1 481 51 82 (75 89) Luxembourg < 1.37 (.32.41) 6.6 (5.8 7.5) <.1 (<.1 <.1).49 (.38.61) 24 4.3 65 (58 75) Mdgscr 24 55 (49 62) 235 (27 264) 2.2 (1.7 2.8) 9.5 (7.4 12) 28 466 121 51 (46 58) Mlwi 17 38 (2 61) 227 (122 365) 19 (1 31) 115 (6 186) 16 267 97 43 (27 8) Mlysi 3 31 (25 37) 13 (83 124) 2.2 (1.8 2.6) 7.3 (5.9 8.8) 24 54 8 78 (65 96) Mldives < 1.15 (.13.17) 41 (36 47) <.1 (<.1 <.1) <.1 (<.1.11) 131 37 89 (78 1) Mli 17 9.8 (9.5 1) 58 (56 59).71 (.64.78) 4.1 (3.8 4.5) 5 89 34 59 (57 61) Mlt < 1.52 (.45.58) 12 (11 14) <.1 (<.1 <.1).52 (.37.69) 45 11 87 (77 1) Mrshll Islnds < 1.18 (.14.21) 335 (274 42) <.1 (<.1 <.1).68 (.5.88) 142 268 8 (67 98) Muritni 4 4.4 (3.2 5.9) 111 (79 148).41 (.27.57) 1 (6.8 14) 2 42 61 55 (41 77) Muritius 1.28 (.24.31) 22 (19 24).42 (.36.48) 3.3 (2.8 3.8) 126 9.9 46 (41 52) Mexico 125 26 (23 29) 21 (19 23) 2.1 (1.9 2.4) 1.7 (1.5 1.9) 21 196 17 81 (72 91) Micronesi (Federted Sttes of) < 1.2 (.9.36) 195 (87 347) 188 181 92 (52 21) Monco < 1 <.1 (<.1 <.1) 2.2 (1.9 2.5) Mongoli 3 5 (4.3 5.6) 17 (149 193).11 (<.1.12).37 (.31.42) 4 483 154 9 (8 1) Montenegro < 1.13 (.11.15) 21 (18 24) <.1 (<.1 <.1) <.1 (<.1 <.1) 113 18 87 (77 99) Montserrt < 1 Rtes re per 1 popultion. b New cses, relpse cses nd cses for which the tretment history is unknown. Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 159

TABLE A4.1 TB incidence estimtes, notifiction nd cse detection rtes, ll forms of TB cse, 214 Popultion (millions) Incidence (including HIV) Number (thousnds) Rte Incidence (HIV-positive) Number (thousnds) Notified cses b Cse detection Rte Number Rte Percent Morocco 34 36 (33 39) 16 (97 115).77 (.61.94) 2.3 (1.8 2.8) 29 843 88 83 (77 91) Mozmbique 27 15 (12 18) 551 (435 68) 85 (65 11) 311 (237 395) 57 773 212 39 (31 49) Mynmr 53 2 (18 22) 369 (334 46) 19 (15 24) 36 (28 44) 138 352 259 7 (64 78) Nmibi 2 13 (12 15) 561 (492 635) 5.6 (4.8 6.5) 232 (198 269) 8 972 373 67 (59 76) Nuru < 1 <.1 (<.1 <.1) 73 (64 83) 8 79 11 (95 12) Nepl 28 44 (39 5) 158 (139 178) 1.5 (1.2 1.9) 5.4 (4.2 6.7) 35 277 125 79 (71 9) Netherlnds 17.97 (.85 1.1) 5.8 (5.1 6.5).52 (.43.61).31 (.26.36) 814 4.8 84 (74 95) New Cledoni < 1.38 (.34.43) 15 (13 17) 29 11 76 (67 86) New Zelnd 4.33 (.29.38) 7.4 (6.5 8.4) <.1 (<.1 <.1) <.1 (<.1 <.1) 297 6.6 89 (79 1) Nicrgu 6 3.5 (3.2 3.8) 58 (53 63).14 (.11.17) 2.3 (1.8 2.8) 2 632 44 76 (7 82) Niger 19 19 (17 21) 98 (87 11) 1.5 (1.3 1.8) 7.9 (6.6 9.3) 1 851 57 58 (51 65) Nigeri 177 57 (34 87) 322 (189 488) 1 (59 16) 59 (33 92) 86 464 49 15 (1 26) Niue < 1 Northern Mrin Islnds < 1.33 (.29.38) 61 (53 69) <.1 (<.1 <.1).21 (.16.26) 26 48 78 (69 89) Norwy 5.42 (.37.47) 8.1 (7.1 9.2).12 (<.1.14).23 (.18.28) 33 5.9 73 (64 83) Omn 4.41 (.36.46) 9.6 (8.4 11) <.1 (<.1 <.1).11 (<.1.12) 358 8.5 88 (78 1) Pkistn 185 5 (37 65) 27 (21 35) 6.4 (4.4 8.7) 3.4 (2.4 4.7) 38 417 167 62 (48 83) Plu < 1 <.1 (<.1 <.1) 42 (36 47) <.1 (<.1 <.1) <.1 (<.1 <.1) 14 66 16 (14 18) Pnm 4 1.8 (1.5 2.2) 46 (38 56).18 (.14.21) 4.6 (3.7 5.5) 1 457 38 81 (68 1) Ppu New Guine 7 31 (23 41) 417 (34 547) 3.5 (2.4 4.8) 47 (32 64) 26 17 351 84 (64 12) Prguy 7 2.8 (2.7 3.) 43 (41 45).29 (.27.32) 4.5 (4.1 4.9) 2 246 34 8 (76 84) Peru 31 37 (3 45) 12 (98 145) 2.5 (2. 3.1) 8.1 (6.5 9.9) 3 8 97 81 (67 99) Philippines 99 29 (25 32) 288 (254 324) 2.5 (2. 3.2) 2.6 (2. 3.2) 243 379 245 85 (76 97) Polnd 39 8 (7. 9.) 21 (18 23).1 (.81.13).27 (.21.34) 6 539 17 82 (73 94) Portugl 1 2.6 (2.3 2.9) 25 (22 28).37 (.31.43) 3.5 (3. 4.1) 2 169 21 84 (74 96) Puerto Rico 4.51 (.45.58) 1.4 (1.2 1.6) <.1 (<.1 <.1).2 (.17.23) 44 1.2 86 (76 99) Qtr 2.63 (.55.72) 29 (26 33) <.1 (<.1 <.1) <.1 (<.1 <.1) 465 21 74 (65 84) Republic of Kore 5 43 (41 46) 86 (81 91).19 (.15.23).37 (.3.45) 4 19 8 93 (88 99) Republic of Moldov 4 6.2 (5.5 7.) 153 (135 172).5 (.43.58) 12 (11 14) 4 58 1 65 (58 74) Romni 2 16 (14 18) 81 (71 91).51 (.44.59) 2.6 (2.2 3.) 14 861 76 94 (83 11) Russin Federtion 143 12 (11 13) 84 (76 93) 5.5 (4.5 6.6) 3.8 (3.1 4.6) 12 34 71 85 (77 94) Rwnd 11 7.1 (6.1 8.2) 63 (54 72) 1.8 (1.5 2.1) 16 (14 18) 5 761 51 81 (71 94) Sint Kitts nd Nevis < 1 <.1 (<.1 <.1) 7.2 (6.3 8.1) ( ) <.1 (<.1 <.1) 7 13 18 (16 2) Sint Luci < 1.17 (.15.19) 9.1 (8. 1) <.1 (<.1 <.1) 1.4 (1.2 1.6) 6 3.3 36 (32 41) Sint Vincent nd the Grendines < 1.26 (.22.31) 24 (2 29) <.1 (<.1.11) 8.4 (6.7 1) 5 4.6 19 (16 23) Smo < 1.37 (.3.45) 19 (16 23) 23 12 62 (51 77) Sn Mrino < 1 <.1 (<.1 <.1) 1.6 (1.4 1.8) So Tome nd Principe < 1.18 (.16.2) 97 (85 19).38 (.33.42) 2 (18 23) 158 85 87 (78 99) Sudi Arbi 31 3.9 (3.4 4.4) 12 (11 14).13 (.11.16).43 (.36.5) 3 248 11 84 (75 96) Senegl 15 2 (18 23) 138 (122 154) 1.5 (1.3 1.8) 1 (8.9 12) 13 332 91 66 (59 75) Serbi 9 2.1 (1.8 2.4) 24 (21 27).17 (.13.21).19 (.15.24) 1 818 2 87 (77 99) Seychelles < 1.25 (.22.28) 26 (23 29) <.1 (<.1 <.1).76 (.59.95) 13 14 52 (46 6) Sierr Leone 6 2 (15 25) 31 (235 394) 2.3 (1.7 3.) 37 (28 47) 12 477 198 64 (5 84) Singpore 6 2.7 (2.4 3.1) 49 (43 56).75 (.65.86) 1.4 (1.2 1.6) 2 171 39 8 (71 92) Sint Mrten (Dutch prt) < 1 Slovki 5.36 (.32.41) 6.7 (5.9 7.6) <.1 (<.1 <.1) <.1 (<.1 <.1) 32 5.9 88 (78 1) Sloveni 2.16 (.14.18) 7.7 (6.7 8.7) <.1 (<.1 <.1) <.1 (<.1 <.1) 142 6.9 89 (79 1) Solomon Islnds < 1.49 (.41.59) 86 (71 12) 345 6 7 (59 85) Somli 11 29 (25 32) 274 (242 38) 2.2 (1.7 2.7) 21 (16 26) 12 93 123 45 (4 51) South Afric 54 45 (4 51) 834 (737 936) 27 (24 31) 59 (439 584) 36 166 567 68 (61 77) South Sudn 12 17 (14 21) 146 (121 173) 2.9 (2.3 3.6) 25 (2 3) 8 335 7 48 (4 58) Spin 46 5.5 (4.8 6.2) 12 (1 13).31 (.27.37).68 (.58.79) 4 818 1 88 (77 1) Sri Lnk 21 13 (12 15) 65 (57 73).53 (.41.66).26 (.2.32) 9 35 45 69 (62 79) Sudn 39 37 (2 58) 94 (52 148) 1.2 (.65 2.) 3.2 (1.7 5.1) 19 266 49 52 (33 95) Surinme < 1.2 (.17.25) 38 (31 46).64 (.52.77) 12 (9.6 14) 149 28 73 (61 89) Swzilnd 1 9.3 (6.8 12) 733 (533 963) 5.9 (4.2 7.9) 464 (33 619) 5 583 44 6 (46 83) Sweden 1.72 (.63.82) 7.5 (6.5 8.4).24 (.18.3).24 (.19.3) 635 6.5 88 (77 1) Switzerlnd 8.52 (.45.59) 6.3 (5.5 7.1).37 (.29.47).46 (.36.57) 423 5.2 82 (72 93) Syrin Arb Republic 19 3.1 (2.6 3.7) 17 (14 2) <.1 (<.1 <.1) <.1 (<.1 <.1) 3 481 19 11 (94 13) Tjikistn 8 7.6 (6.7 8.5) 91 (8 13).23 (.2.27) 2.8 (2.4 3.2) 5 87 7 77 (68 87) Thilnd 68 12 (61 19) 171 (9 276) 15 (7.8 24) 22 (12 36) 67 722 1 59 (36 11) The Former Yugoslv Republic of Mcedoni 2.32 (.28.36) 15 (13 17) <.1 (<.1 <.1) <.1 (<.1 <.1) 284 14 9 (79 1) Timor-Leste 1 5.8 (4.8 6.9) 498 (411 594).57 (.42.73) 4.9 (3.7 6.3) 3 657 316 63 (53 77) Rtes re per 1 popultion. b New cses, relpse cses nd cses for which the tretment history is unknown. 16 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

TABLE A4.1 TB incidence estimtes, notifiction nd cse detection rtes, ll forms of TB cse, 214 Popultion (millions) Incidence (including HIV) Number (thousnds) Rte Incidence (HIV-positive) Number (thousnds) Notified cses b Cse detection Rte Number Rte Percent Togo 7 4.1 (3.4 5.) 58 (47 7).83 (.67 1.) 12 (9.4 14) 2 525 35 61 (51 75) Tokelu < 1 Tong < 1.15 (.12.18) 14 (11 17) <.1 (<.1 <.1) <.1 (<.1 <.1) 13 12 88 (73 11) Trinidd nd Tobgo 1.29 (.26.33) 22 (19 24).71 (.62.81) 5.3 (4.6 6.) 251 19 86 (76 98) Tunisi 11 3.7 (3.4 4.) 33 (31 36).23 (.18.28).2 (.16.25) 3 134 28 84 (77 92) Turkey 78 14 (12 16) 18 (16 21).45 (.35.57) <.1 (<.1 <.1) 13 18 17 93 (82 11) Turkmenistn 5 3.4 (2.7 4.1) 64 (52 78) 2 57 48 76 (62 94) Turks nd Cicos Islnds < 1 <.1 (<.1 <.1) 1 (8.8 11) <.1 (<.1 <.1) 5 (4. 6.1) 1 3 3 (26 34) Tuvlu < 1.19 (.15.23) 19 (154 228) 15 152 8 (66 98) US Virgin Islnds < 1 <.1 (<.1 <.1) 7.7 (6.8 8.7) Ugnd 38 61 (53 69) 161 (141 183) 28 (24 32) 73 (63 84) 44 187 117 72 (64 83) Ukrine 45 43 (38 48) 94 (83 16) 8.1 (7. 9.3) 18 (16 21) 31 71 7 75 (66 84) United Arb Emirtes 9.14 (.1.19) 1.6 (1.1 2.1) <.1 (<.1 <.1) <.1 (<.1 <.1) 6.66 42 (32 58) United Kingdom of Gret Britin nd Northern Irelnd 64 7.8 (7.3 8.4) 12 (11 13).39 (.31.47).6 (.49.74) 6 622 1 84 (79 9) United Republic of Tnzni 52 17 (8 29) 327 (155 561) 62 (29 11) 12 (56 28) 61 571 119 36 (21 77) United Sttes of Americ 319 9.9 (8.7 11) 3.1 (2.7 3.5).6 (.52.68).19 (.16.21) 8 949 2.8 9 (8 1) Uruguy 3 1 (.91 1.2) 3 (27 34).16 (.14.18) 4.7 (4. 5.3) 862 25 83 (73 95) Uzbekistn 29 24 (18 31) 82 (61 17).83 (.61 1.1) 2.8 (2.1 3.6) 18 345 62 76 (58 1) Vnutu < 1.16 (.13.19) 63 (52 74) 112 43 69 (58 84) Venezuel (Bolivrin Republic of) 31 7.3 (6.4 8.3) 24 (21 27).7 (.6.81) 2.3 (2. 2.6) 6 392 21 87 (77 99) Viet Nm 92 13 (11 15) 14 (116 167) 7 (5.7 8.5) 7.6 (6.1 9.2) 1 349 19 77 (65 94) Wllis nd Futun Islnds < 1 <.1 (<.1 <.1) 3.7 (3.2 4.2) West Bnk nd Gz Strip 5.26 (.23.3) 5.8 (5.1 6.6) <.1 (<.1 <.1) <.1 ( <.1) 43.95 16 (14 19) Yemen 26 13 (11 14) 48 (42 54).8 (.62.1).31 (.24.38) 9 628 37 77 (68 88) Zmbi 16 64 (44 88) 46 (279 557) 38 (25 52) 239 (162 331) 37 931 241 59 (43 86) Zimbbwe 15 42 (29 58) 278 (193 379) 25 (17 35) 167 (114 229) 29 653 194 7 (51 1) WHO regions Africn Region 963 2 7 (2 4 3 ) 281 (25 313) 87 (79 95) 9 (82 99) 1 3 852 135 48 (43 54) Region of the Americs 982 28 (27 29) 28 (27 29) 36 (34 38) 3.7 (3.5 3.9) 215 226 22 77 (75 81) Estern Mediterrnen Region 636 74 (61 89) 117 (96 14) 12 (1 15) 1.9 (1.6 2.3) 453 393 71 61 (51 75) Europen Region 97 34 (32 35) 37 (35 39) 2 (18 21) 2.2 (2. 2.4) 273 381 3 81 (78 86) South-Est Asi Region 1 96 4 (3 7 4 4) 211 (192 232) 21 (18 24) 11 (9.4 12) 2 482 74 13 62 (56 68) Western Pcific Region 1 845 1 6 (1 5 1 6) 85 (8 89) 31 (28 35) 1.7 (1.5 1.9) 1 335 816 72 85 (81 9) Globl 7 239 9 6 (9 1 1 ) 133 (126 141) 1 2 (1 1 1 3) 16 (15 17) 6 6 742 84 63 (6 66) Rtes re per 1 popultion. b New cses, relpse cses nd cses for which the tretment history is unknown. Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 161

TABLE A4.2 Estimtes of TB mortlity, 214. Deths from TB mong HIV-positive people re of ficilly clssified s deths cused by HIV/AIDS in the Interntionl clssifiction of diseses. Popultion (millions) Mortlity (HIV-negtive people) Number (thousnds) Rte Mortlity (HIV-positive people) Number (thousnds) Rte Mortlity (HIV-negtive nd HIV-positive people) b Number (thousnds) Afghnistn 32 14 (1 18) 44 (32 57).87 (.72.1).28 (.23.33) 14 (1 18) 44 (32 58) Albni 3.17 (.12.23).58 (.4.79) <.1 (<.1 <.1) <.1 (<.1 <.1).19 (.14.25).65 (.47.85) Algeri 39 4.4 (3.1 6.1) 11 (7.9 16).46 (.19.85).12 (<.1.22) 4.5 (3.1 6.1) 12 (8. 16) Americn Smo < 1 <.1 (<.1 <.1).52 (.31.8) <.1 (<.1 <.1).52 (.31.8) Andorr < 1 <.1 (<.1 <.1).76 (.47 1.1) <.1 (<.1 <.1).76 (.47 1.1) Angol 24 13 (7.5 19) 52 (31 79) 3.5 (1.5 6.2) 14 (6.2 26) 16 (1 23) 67 (43 95) Anguill < 1 Antigu nd Brbud < 1 <.1 (<.1 <.1) 3.8 (3.4 4.4) <.1 (<.1 <.1) 3.8 (3.4 4.4) Argentin 43.61 (.58.63) 1.4 (1.4 1.5).58 (.23.11).13 (<.1.25).67 (.62.72) 1.5 (1.4 1.7) Armeni 3.14 (.12.16) 4.7 (3.9 5.5).12 (<.1.16).4 (.29.53).15 (.13.18) 5.1 (4.3 5.9) Arub < 1 <.1 (<.1 <.1).9 (.56 1.3) <.1 (<.1 <.1).9 (.56 1.3) Austrli 24.42 (.42.42).18 (.18.18) <.1 (<.1 <.1) <.1 (<.1 <.1).47 (.45.49).2 (.19.21) Austri 9.55 (.54.56).65 (.64.66) <.1 (<.1 <.1) <.1 ( <.1).56 (.55.57).66 (.64.67) Azerbijn 1.41 (.37.45).42 (.38.47).28 (.21.36).29 (.21.38).69 (.6.78).72 (.63.81) Bhms < 1 <.1 (<.1 <.1).63 (.6.65) <.1 (<.1 <.1).78 (.52 1.1) <.1 (<.1 <.1) 1.4 (1.1 1.7) Bhrin 1 <.1 (<.1 <.1).42 (.36.47) <.1 (<.1 <.1).42 (.36.47) Bngldesh 159 81 (59 11) 51 (37 68).18 (.14.22).11 (<.1.14) 82 (59 11) 51 (37 68) Brbdos < 1 <.1 (<.1 <.1) ( ) <.1 (<.1 <.1) ( ) Belrus 1.73 (.68.79) 7.7 (7.1 8.3).8 (.64.98).84 (.67 1.).81 (.75.87) 8.5 (7.9 9.2) Belgium 11.31 (.3.32).28 (.27.29).1 (<.1.14) <.1 (<.1.13).41 (.37.46).37 (.33.41) Belize < 1 <.1 (<.1 <.1) 1.8 (1.8 1.8) <.1 (<.1 <.1) 2 (1.4 2.6).13 (.11.15) 3.8 (3.2 4.4) Benin 11 1 (.72 1.4) 9.8 (6.8 13).31 (.24.4) 3 (2.2 3.8) 1.4 (1. 1.7) 13 (9.6 16) Bermud < 1 Bhutn < 1.72 (.39.12) 9.5 (5.1 15) <.1 (<.1 <.1).13 (<.1.29).73 (.4.12) 9.6 (5.2 15) Bolivi (Plurintionl Stte of) 11.33 (.21.48) 3.1 (2. 4.5).13 (.11.16) 1.2 (1. 1.5).46 (.33.61) 4.4 (3.1 5.8) Bonire, Sint Eusttius nd Sb < 1 Bosni nd Herzegovin 4.15 (.13.16) 3.8 (3.5 4.2).15 (.13.16) 3.8 (3.5 4.2) Botswn 2.62 (.44.82) 28 (2 37) 1 (.8 1.3) 47 (36 59) 1.7 (1.4 2.) 75 (61 9) Brzil 26 5.3 (4.9 5.7) 2.6 (2.4 2.7) 2.4 (1.8 3.2) 1.2 (.87 1.6) 7.7 (7. 8.5) 3.8 (3.4 4.1) British Virgin Islnds < 1 <.1 (<.1 <.1) 5 (5. 5.1) <.1 (<.1 <.1) 5 (5. 5.1) Brunei Drusslm < 1.15 (.14.16) 3.6 (3.3 3.9).15 (.14.16) 3.6 (3.3 3.9) Bulgri 7.15 (.15.16) 2.1 (2.1 2.2).15 (.15.16) 2.1 (2.1 2.2) Burkin Fso 18 1.6 (1.2 2.1) 9.1 (6.6 12).47 (.39.56) 2.7 (2.2 3.2) 2.1 (1.6 2.6) 12 (9.2 15) Burundi 11 2.5 (1.8 3.3) 23 (17 3).69 (.57.82) 6.4 (5.3 7.5) 3.2 (2.5 4.) 3 (23 37) Cbo Verde < 1.16 (.11.21) 31 (22 41).26 (.22.31) 5.1 (4.2 6.).18 (.14.24) 36 (27 46) Cmbodi 15 8.9 (6.3 12) 58 (41 78).82 (.63 1.) 5.3 (4.1 6.7) 9.7 (7.1 13) 64 (46 83) Cmeroon 23 7.1 (5.1 9.4) 31 (22 41) 7.6 (6.3 9.2) 34 (28 4) 15 (12 17) 65 (54 77) Cnd 36.82 (.81.82).23 (.23.23).16 (<.1.25) <.1 (<.1 <.1).98 (.9.11).27 (.25.3) Cymn Islnds < 1 Centrl Africn Republic 5 2.3 (1.6 3.1) 48 (34 65) 3.1 (2.2 4.1) 64 (46 86) 5.4 (4.3 6.7) 113 (89 14) Chd 14 3.1 (2.2 4.1) 23 (16 3) 2.1 (1.4 3.) 15 (1 22) 5.2 (4.1 6.5) 38 (3 48) Chile 18.29 (.28.29) 1.6 (1.6 1.6) <.1 (<.1 <.1) <.1 (<.1 <.1).29 (.29.3) 1.6 (1.6 1.7) Chin 1 369 38 (37 4) 2.8 (2.7 2.9).7 (.53.9) <.1 (<.1 <.1) 39 (37 4) 2.8 (2.7 2.9) Chin, Hong Kong SAR 7.18 (.18.18) 2.5 (2.4 2.5).18 (.18.18) 2.5 (2.4 2.5) Chin, Mco SAR < 1.23 (.22.24) 4 (3.9 4.1).23 (.22.24) 4 (3.9 4.1) Colombi 48.73 (.71.75) 1.5 (1.5 1.6).4 (.3.51).84 (.64 1.1) 1.1 (1. 1.2) 2.4 (2.1 2.6) Comoros < 1.58 (.41.78) 7.5 (5.3 1).58 (.41.78) 7.5 (5.3 1) Congo 5 2.1 (1.5 2.8) 46 (32 61) 2.5 (2.1 3.) 55 (46 66) 4.6 (3.8 5.4) 11 (84 119) Cook Islnds < 1 <.1 (<.1 <.1) 1.8 (1.3 2.4) <.1 (<.1 <.1) 1.8 (1.3 2.4) Cost Ric 5.39 (.37.41).83 (.78.87) <.1 (<.1 <.1).15 (.11.19).46 (.43.49).97 (.91 1.) Croti 4.46 (.45.46) 1.1 (1.1 1.1).46 (.45.46) 1.1 (1.1 1.1) Cub 11.29 (.29.29).25 (.25.26) <.1 (<.1 <.1) <.1 (<.1 <.1).36 (.34.38).32 (.3.33) Curço < 1 ( <.1) ( <.1) ( ) ( ) Cyprus 1 <.1 (<.1 <.1).42 (.37.46) <.1 (<.1 <.1).42 (.37.46) Czech Republic 11.6 (.59.6).56 (.56.57).6 (.59.6).56 (.56.57) Côte d'ivoire 22 4.8 (3.5 6.3) 22 (16 29) 2.4 (1.9 2.9) 11 (8.7 13) 7.2 (5.8 8.8) 32 (26 4) Democrtic People's Republic of Kore 25 5 (2. 9.3) 2 (7.9 37).21 (.15.28) <.1 (<.1.11) 5 (2. 9.3) 2 (8. 37) Democrtic Republic of the Congo 75 52 (38 68) 69 (5 9) 6.3 (5. 7.7) 8.4 (6.7 1) 58 (44 74) 77 (58 99) Denmrk 6.24 (.23.25).42 (.4.45) <.1 (<.1 <.1) <.1 (<.1 <.1).25 (.24.26).44 (.42.46) Djibouti < 1 1.1 (.76 1.4) 12 (87 159).14 (.12.17) 16 (13 19) 1.2 (.9 1.5) 137 (13 175) Dominic < 1 <.1 (<.1 <.1) 2.7 (2.6 2.7) <.1 (<.1 <.1) 2.7 (2.6 2.7) Dominicn Republic 1.41 (.22.65) 3.9 (2.2 6.2).19 (.15.24) 1.8 (1.4 2.3).6 (.4.84) 5.8 (3.9 8.) Rte Rtes re per 1 popultion. b All clcultions re mde before numbers re rounded. 162 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

TABLE A4.2 Estimtes of TB mortlity, 214. Deths from TB mong HIV-positive people re of ficilly clssified s deths cused by HIV/AIDS in the Interntionl clssifiction of diseses. Popultion (millions) Mortlity (HIV-negtive people) Number (thousnds) Rte Mortlity (HIV-positive people) Number (thousnds) Rte Mortlity (HIV-negtive nd HIV-positive people) b Number (thousnds) Ecudor 16.47 (.39.56) 2.9 (2.4 3.5).31 (.23.4) 1.9 (1.5 2.5).78 (.66.9) 4.9 (4.2 5.7) Egypt 9.22 (.2.25).25 (.22.27).43 (.35.51) <.1 (<.1 <.1).27 (.24.29).3 (.27.32) El Slvdor 6.12 (.89.15) 1.9 (1.5 2.5).31 (.22.41).51 (.36.68).15 (.12.18) 2.4 (1.9 3.) Equtoril Guine < 1.54 (.33.81) 6.6 (4. 9.9).49 (.33.69) 6 (4. 8.4).1 (.76.14) 13 (9.2 17) Eritre 5.71 (.46 1.) 14 (9. 2).1 (.58.15) 2 (1.1 3.).81 (.55 1.1) 16 (11 22) Estoni 1.27 (.27.27) 2.1 (2. 2.1) <.1 (<.1 <.1).3 (.2.43).31 (.3.33) 2.4 (2.3 2.5) Ethiopi 97 32 (22 43) 33 (23 44) 5.5 (4.4 6.8) 5.7 (4.6 7.) 37 (27 48) 38 (28 5) Fiji < 1.41 (.41.42) 4.7 (4.6 4.8) <.1 (<.1 <.1).56 (.45.69).46 (.45.48) 5.2 (5.1 5.4) Finlnd 5.11 (.11.11).19 (.19.19).11 (.11.11).19 (.19.19) Frnce 64.37 (.36.39).58 (.56.61).62 (.34.99).1 (<.1.15).43 (.4.47).68 (.62.74) French Polynesi < 1 <.1 (<.1 <.1) 1.8 (1.1 2.6) <.1 (<.1 <.1) 1.8 (1.1 2.6) Gbon 2.94 (.66 1.3) 55 (39 75).3 (.24.37) 18 (14 22) 1.2 (.95 1.6) 73 (56 93) Gmbi 2.35 (.24.47) 18 (12 25).14 (.1.18) 7.2 (5.4 9.3).49 (.37.62) 25 (19 32) Georgi 4.27 (.2.34) 6.6 (5.1 8.3).17 (.1.25).42 (.26.63).28 (.22.35) 7 (5.5 8.7) Germny 81.33 (.32.33).4 (.4.41).11 (<.1.15) <.1 (<.1 <.1).34 (.33.34).42 (.41.43) Ghn 27 9.7 (4.4 17) 36 (16 64) 4.2 (2.3 6.5) 16 (8.8 24) 14 (7.9 21) 52 (3 8) Greece 11.11 (.11.12) 1 (.96 1.1) <.1 (<.1 <.1) <.1 (<.1 <.1).12 (.11.12) 1 (.98 1.1) Greenlnd < 1 <.1 (<.1.13) 16 (1 24) <.1 (<.1.13) 16 (1 24) Grend < 1 <.1 (<.1 <.1).44 (.43.44) <.1 (<.1 <.1).44 (.43.44) Gum < 1 <.1 (<.1 <.1) 3.3 (2.1 4.8) <.1 (<.1 <.1) 3.3 (2.1 4.8) Guteml 16.26 (.24.28) 1.6 (1.5 1.7).54 (.46.63) 3.4 (2.9 3.9).8 (.72.89) 5 (4.5 5.5) Guine 12 3.6 (2.6 4.8) 29 (21 39) 1.5 (1.2 1.8) 12 (1 15) 5.1 (4. 6.3) 42 (33 51) Guine-Bissu 2 1.1 (.7 1.7) 63 (39 93) 1.5 (1.1 1.9) 81 (6 14) 2.6 (2. 3.3) 144 (111 181) Guyn < 1.16 (.14.17) 21 (18 23).42 (.33.52) 5.5 (4.3 6.8).2 (.18.22) 26 (24 29) Hiti 11 2.1 (1.5 2.9) 2 (14 27).77 (.61.95) 7.3 (5.8 9.) 2.9 (2.2 3.7) 27 (21 35) Hondurs 8.75 (.75.76).95 (.94.95).46 (.34.6).58 (.43.75).12 (.11.13) 1.5 (1.4 1.7) Hungry 1.69 (.69.69).7 (.7.7) <.1 (<.1 <.1) <.1 ( <.1).7 (.69.71).71 (.7.72) Icelnd < 1 <.1 (<.1 <.1).28 (.28.28) <.1 (<.1 <.1).28 (.28.28) Indi 1 295 22 (15 35) 17 (12 27) 31 (25 38) 2.4 (2. 2.9) 25 (17 36) 2 (13 28) Indonesi 254 1 (66 15) 41 (26 59) 22 (13 32) 8.5 (5.2 13) 13 (86 17) 49 (34 67) Irn (Islmic Republic of) 78 2.7 (1.9 3.7) 3.5 (2.4 4.7).11 (.7.15).14 (<.1.19) 2.8 (2. 3.8) 3.6 (2.5 4.9) Irq 35.79 (.16 3.) 2.2 (<.1 8.6).79 (.16 3.) 2.2 (<.1 8.6) Irelnd 5.2 (.2.2).43 (.43.43).2 (.2.21).43 (.42.45) Isrel 8.14 (.13.14).17 (.17.18) <.1 (<.1 <.1) <.1 (<.1 <.1).16 (.15.17).2 (.19.21) Itly 6.26 (.26.26).44 (.43.44).31 (.19.46) <.1 (<.1 <.1).29 (.28.31).49 (.46.51) Jmic 3 <.1 (<.1.1).31 (.26.38) <.1 (<.1.11).32 (.25.41).18 (.15.21).64 (.54.74) Jpn 127 2.2 (2.1 2.3) 1.8 (1.7 1.8).1 (<.1.17) <.1 ( <.1) 2.2 (2.2 2.3) 1.8 (1.7 1.8) Jordn 7.25 (.24.25).33 (.33.34).25 (.24.25).33 (.33.34) Kzkhstn 17 1.5 (1.2 1.8) 8.6 (7. 1).37 (<.1.11).21 (<.1.64) 1.5 (1.2 1.9) 8.8 (7.1 11) Keny 45 9.4 (6.7 12) 21 (15 28) 8.1 (6.4 1) 18 (14 22) 17 (14 21) 39 (32 47) Kiribti < 1.54 (.44.65) 49 (4 59).54 (.44.65) 49 (4 59) Kuwit 4 <.1 (<.1 <.1).16 (.16.17) <.1 (<.1 <.1).16 (.16.17) Kyrgyzstn 6.65 (.63.67) 11 (11 12).55 (.42.7).94 (.71 1.2).71 (.69.73) 12 (12 13) Lo People's Democrtic Republic 7 3.7 (2.4 5.2) 55 (36 78).28 (.21.35) 4.1 (3.2 5.2) 3.9 (2.6 5.5) 59 (4 82) Ltvi 2.54 (.53.55) 2.7 (2.7 2.8).19 (.14.24).96 (.72 1.2).73 (.68.78) 3.7 (3.4 3.9) Lebnon 6.89 (.61.12) 1.6 (1.1 2.2).89 (.61.12) 1.6 (1.1 2.2) Lesotho 2 1.4 (.81 2.1) 64 (38 97) 4.9 (3.4 6.6) 231 (16 315) 6.2 (4.6 8.1) 296 (218 384) Liberi 4 3 (2.2 4.) 68 (49 9).33 (.28.39) 7.5 (6.3 8.8) 3.3 (2.5 4.3) 76 (57 98) Liby 6.61 (.43.82) 9.7 (6.8 13).61 (.43.82) 9.7 (6.8 13) Lithuni 3.22 (.22.22) 7.7 (7.6 7.7).2 (.15.25).69 (.53.86).24 (.24.25) 8.3 (8.2 8.5) Luxembourg < 1 <.1 (<.1 <.1).16 (.15.16) <.1 (<.1 <.1).16 (.15.16) Mdgscr 24 12 (8.7 16) 51 (37 68).48 (.39.58) 2 (1.7 2.4) 13 (9.2 16) 53 (39 7) Mlwi 17 2.8 (1.6 4.4) 17 (9.7 26) 7 (4.1 11) 42 (25 64) 9.8 (6.6 14) 59 (4 82) Mlysi 3 2.4 (1.3 3.7) 8 (4.5 12).62 (.38.93) 2.1 (1.3 3.1) 3 (1.9 4.3) 1 (6.4 15) Mldives < 1 <.1 (<.1.1) 2.3 (1.9 2.8) <.1 (<.1.1) 2.3 (1.9 2.8) Mli 17 1.8 (1.3 2.4) 11 (7.9 14).4 (.3.52) 2.4 (1.8 3.) 2.2 (1.7 2.8) 13 (1 16) Mlt < 1 <.1 (<.1 <.1).26 (.26.26) <.1 (<.1 <.1).26 (.26.26) Mrshll Islnds < 1.2 (.14.28) 38 (26 53).2 (.14.28) 38 (26 53) Muritni 4.89 (.57 1.3) 22 (14 32).26 (.2.33).65 (.5.83).91 (.59 1.3) 23 (15 33) Muritius 1.16 (.16.17) 1.3 (1.3 1.3).1 (<.1.14).79 (.54 1.1).26 (.23.3) 2.1 (1.8 2.4) Mexico 125 2.1 (2.1 2.1) 1.7 (1.7 1.7).31 (.24.38).24 (.19.3) 2.4 (2.3 2.5) 1.9 (1.9 2.) Micronesi (Federted Sttes of) < 1.17 (<.1.28) 16 (7.6 27).17 (<.1.28) 16 (7.6 27) Rte Rtes re per 1 popultion. b All clcultions re mde before numbers re rounded. Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 163

TABLE A4.2 Estimtes of TB mortlity, 214. Deths from TB mong HIV-positive people re of ficilly clssified s deths cused by HIV/AIDS in the Interntionl clssifiction of diseses. Popultion (millions) Mortlity (HIV-negtive people) Number (thousnds) Rte Mortlity (HIV-positive people) Number (thousnds) Rte Mortlity (HIV-negtive nd HIV-positive people) b Number (thousnds) Monco < 1 <.1 (<.1 <.1).18 (.11.26) <.1 (<.1 <.1).18 (.11.26) Mongoli 3.64 (.59.7) 2.2 (2. 2.4) <.1 (<.1 <.1) <.1 (<.1 <.1).66 (.61.72) 2.3 (2.1 2.5) Montenegro < 1 <.1 (<.1 <.1).58 (.56.6) <.1 (<.1 <.1).58 (.56.6) Montserrt < 1 <.1 (<.1 <.1) 21 (2 21) <.1 (<.1 <.1) 21 (2 21) Morocco 34 2.7 (.22 11) 7.9 (<.1 33).12 (.66.18).34 (.19.54) 2.8 (.33 11) 8.2 (.1 33) Mozmbique 27 18 (12 26) 67 (44 96) 37 (29 45) 134 (16 165) 55 (25 97) 21 (9 355) Mynmr 53 28 (2 37) 53 (38 7) 4.1 (3.3 5.1) 7.7 (6.1 9.5) 32 (24 41) 6 (45 77) Nmibi 2 1.5 (1.1 2.) 63 (45 83) 1.5 (1.2 1.9) 64 (51 79) 3 (2.5 3.6) 127 (14 152) Nuru < 1 <.1 (<.1 <.1) 6 (3.8 8.8) <.1 (<.1 <.1) 6 (3.8 8.8) Nepl 28 4.9 (3.4 6.7) 17 (12 24).38 (.28.5) 1.4 (1. 1.8) 5.3 (3.7 7.1) 19 (13 25) Netherlnds 17.22 (.21.22).13 (.13.13) <.1 (<.1 <.1) <.1 (<.1 <.1).27 (.24.29).16 (.14.17) New Cledoni < 1 <.1 (<.1 <.1) 1.2 (.76 1.8) <.1 (<.1 <.1) 1.2 (.76 1.8) New Zelnd 4 <.1 (<.1 <.1).13 (.13.13) <.1 (<.1 <.1).13 (.12.15) Nicrgu 6.21 (.16.26) 3.4 (2.7 4.3).22 (.17.28).37 (.28.47).23 (.18.28) 3.8 (3. 4.7) Niger 19 3.4 (2.4 4.5) 18 (13 23).47 (.39.56) 2.5 (2. 2.9) 3.8 (2.9 4.9) 2 (15 26) Nigeri 177 17 (91 28) 97 (51 156) 78 (53 11) 44 (3 61) 25 (16 36) 141 (91 21) Niue < 1 Northern Mrin Islnds < 1 <.1 (<.1 <.1) 5 (3.1 7.3) <.1 (<.1 <.1) 5 (3.1 7.3) Norwy 5 <.1 (<.1 <.1).15 (.14.15) <.1 (<.1 <.1).15 (.14.16) Omn 4.24 (.15.35).56 (.36.82) <.1 (<.1 <.1) <.1 (<.1 <.1).25 (.16.36).59 (.38.84) Pkistn 185 48 (11 11) 26 (6. 61) 1.3 (.76 1.9).68 (.41 1.) 5 (12 11) 27 (6.5 61) Plu < 1 <.1 (<.1 <.1) 1.2 (.25 3.) <.1 (<.1 <.1) 1.2 (.25 3.) Pnm 4.21 (.2.23) 5.5 (5.1 5.9).46 (.34.6) 1.2 (.87 1.6).26 (.24.28) 6.7 (6.2 7.2) Ppu New Guine 7 3 (1.9 4.3) 4 (25 58).54 (.33.8) 7.2 (4.4 11) 3.5 (2.4 4.9) 47 (32 65) Prguy 7.19 (.16.23) 2.9 (2.4 3.5).53 (.42.65).81 (.64 1.).25 (.21.28) 3.7 (3.2 4.3) Peru 31 2.2 (1.8 2.7) 7.2 (5.7 8.8).25 (.18.34).81 (.57 1.1) 2.5 (2. 3.) 8 (6.5 9.6) Philippines 99 1 (9. 11) 1 (9.1 11).8 (.55.11) <.1 (<.1.11) 1 (9.1 11) 1 (9.2 12) Polnd 39.53 (.51.55) 1.4 (1.3 1.4).16 (.1.23) <.1 (<.1 <.1).54 (.53.56) 1.4 (1.4 1.5) Portugl 1.12 (.12.13) 1.2 (1.1 1.3).38 (.23.57).37 (.22.54).16 (.15.18) 1.6 (1.4 1.7) Puerto Rico 4 <.1 (<.1 <.1).19 (.19.19) <.1 (<.1 <.1).19 (.19.19) Qtr 2 <.1 (<.1 <.1).15 (<.1.23) <.1 (<.1 <.1).15 (<.1.23) Republic of Kore 5 1.9 (1.8 2.1) 3.8 (3.6 4.1) <.1 (<.1.13) <.1 (<.1 <.1) 1.9 (1.8 2.1) 3.8 (3.6 4.1) Republic of Moldov 4.32 (.3.34) 7.8 (7.4 8.3).11 (.89.14) 2.7 (2.2 3.3).43 (.4.46) 11 (9.9 11) Romni 2 1.1 (1.1 1.1) 5.5 (5.5 5.5).54 (.35.77).27 (.18.39) 1.1 (1.1 1.2) 5.8 (5.7 5.9) Russin Federtion 143 16 (15 16) 11 (11 11) 1.1 (.83 1.3).73 (.58.91) 17 (16 18) 12 (11 12) Rwnd 11.73 (.51.99) 6.4 (4.5 8.7).31 (.21.42) 2.7 (1.8 3.7) 1 (.79 1.3) 9.1 (7. 12) Sint Kitts nd Nevis < 1 <.1 (<.1 <.1) 2.7 (2.3 3.1) <.1 (<.1 <.1) 2.7 (2.3 3.1) Sint Luci < 1 <.1 (<.1 <.1) 2.4 (2.3 2.5) <.1 (<.1 <.1) 2.4 (2.3 2.5) Sint Vincent nd the Grendines < 1 <.1 (<.1 <.1) 1 (1. 1.1) <.1 (<.1 <.1) 1 (1. 1.1) Smo < 1 <.1 (<.1 <.1) 3.4 (2.4 4.6) <.1 (<.1 <.1) 3.4 (2.4 4.6) Sn Mrino < 1 So Tome nd Principe < 1.14 (<.1.19) 7.3 (4.8 1) <.1 (<.1.1) 2.7 (.86 5.5).19 (.12.26) 1 (6.7 14) Sudi Arbi 31.65 (.21 1.4) 2.1 (.67 4.4).65 (.21 1.4) 2.1 (.67 4.4) Senegl 15 3.1 (2.2 4.1) 21 (15 28).43 (.34.52) 2.9 (2.3 3.6) 3.5 (2.7 4.6) 24 (18 31) Serbi 9.12 (.11.13) 1.4 (1.3 1.5).12 (.11.13) 1.4 (1.3 1.5) Seychelles < 1 Sierr Leone 6 2.8 (1.9 3.9) 45 (3 62).7 (.47.98) 11 (7.4 16) 3.5 (2.5 4.7) 56 (4 74) Singpore 6.57 (.48.68) 1 (.87 1.2).13 (<.1.18).24 (.17.32).7 (.6.82) 1.3 (1.1 1.5) Sint Mrten (Dutch prt) < 1 Slovki 5.25 (.24.25).45 (.45.46).25 (.24.25).45 (.45.46) Sloveni 2.16 (.16.16).76 (.75.76).16 (.16.16).76 (.75.76) Solomon Islnds < 1.76 (.53.1) 13 (9.3 18).76 (.53.1) 13 (9.3 18) Somli 11 7 (5.1 9.3) 67 (48 88).44 (.34.56) 4.2 (3.2 5.3) 7.5 (5.5 9.7) 71 (52 92) South Afric 54 24 (22 26) 44 (41 48) 72 (58 89) 134 (17 164) 96 (81 11) 178 (151 29) South Sudn 12 3.4 (2.4 4.7) 29 (2 39) 3.4 (2.4 4.7) 29 (2 39) Spin 46.23 (.23.24).5 (.5.51).61 (.36.93).13 (<.1.2).29 (.27.32).64 (.57.7) Sri Lnk 21 1.3 (1. 1.6) 6.1 (4.8 7.6).14 (.1.18) <.1 (<.1 <.1) 1.3 (1. 1.6) 6.2 (4.9 7.7) Sudn 39 8.3 (4.3 14) 21 (11 34) 1 (.67 1.4) 2.5 (1.7 3.6) 9.3 (5.2 15) 24 (13 37) Surinme < 1.11 (.11.12) 2.1 (2. 2.2).11 (<.1.14) 2 (1.5 2.7).22 (.19.26) 4.1 (3.6 4.7) Swzilnd 1.65 (.4.95) 51 (32 75) 1.7 (1.2 2.4) 135 (91 187) 2.4 (1.7 3.1) 186 (137 243) Sweden 1.25 (.25.26).26 (.26.27) <.1 (<.1 <.1) <.1 (<.1 <.1).27 (.27.28).28 (.27.29) Switzerlnd 8.1 (.1.1).12 (.12.13) <.1 (<.1 <.1) <.1 (<.1 <.1).12 (.11.13).15 (.13.16) Rte Rtes re per 1 popultion. b All clcultions re mde before numbers re rounded. 164 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

TABLE A4.2 Estimtes of TB mortlity, 214. Deths from TB mong HIV-positive people re of ficilly clssified s deths cused by HIV/AIDS in the Interntionl clssifiction of diseses. Popultion (millions) Mortlity (HIV-negtive people) Number (thousnds) Rte Mortlity (HIV-positive people) Number (thousnds) Rte Mortlity (HIV-negtive nd HIV-positive people) b Number (thousnds) Syrin Arb Republic 19.12 (.1.13) <.1 (<.1 <.1).12 (.1.13) <.1 (<.1 <.1) Tjikistn 8.27 (.2.36) 3.3 (2.4 4.4).55 (.39.74).66 (.47.89).33 (.25.42) 3.9 (3. 5.) Thilnd 68 7.4 (3.9 12) 11 (5.7 18) 4.5 (2.3 7.4) 6.6 (3.4 11) 12 (7.5 17) 18 (11 26) The Former Yugoslv Republic of Mcedoni 2.49 (.48.5) 2.3 (2.3 2.4).49 (.48.5) 2.3 (2.3 2.4) Timor-Leste 1 1.1 (.76 1.5) 94 (66 126) 1.1 (.76 1.5) 94 (66 126) Togo 7.63 (.44.85) 8.8 (6.1 12).3 (.23.38) 4.2 (3.3 5.3).93 (.72 1.2) 13 (1 16) Tokelu < 1 Tong < 1 <.1 (<.1 <.1) 2.1 (1.4 2.9) <.1 (<.1 <.1) 2.1 (1.4 2.9) Trinidd nd Tobgo 1.27 (.24.29) 2 (1.8 2.2).12 (<.1.15).89 (.69 1.1).39 (.35.42) 2.8 (2.6 3.1) Tunisi 11.23 (.47.54) 2 (.42 4.9) <.1 (<.1.1) <.1 (<.1 <.1).23 (.52.55) 2.1 (.47 4.9) Turkey 78.47 (.4.55).61 (.52.7) <.1 (<.1.12) <.1 (<.1 <.1).48 (.41.55).62 (.53.72) Turkmenistn 5.18 (.15.21) 3.4 (2.9 4.).18 (.15.21) 3.4 (2.9 4.) Turks nd Cicos Islnds < 1 <.1 (<.1 <.1).75 (.72.77) <.1 (<.1 <.1).75 (.72.77) Tuvlu < 1 <.1 (<.1 <.1) 14 (8.3 21) <.1 (<.1 <.1) 14 (8.3 21) US Virgin Islnds < 1 <.1 (<.1 <.1).98 (.96.99) <.1 (<.1 <.1).98 (.96.99) Ugnd 38 4.5 (3.2 6.1) 12 (8.4 16) 6.4 (5. 8.1) 17 (13 21) 11 (8.9 13) 29 (24 35) Ukrine 45 5.7 (5.6 5.8) 13 (13 13) 1.2 (.82 1.6) 2.7 (1.8 3.7) 6.9 (6.5 7.4) 15 (14 16) United Arb Emirtes 9.29 (.24.35).32 (.26.38).29 (.24.35).32 (.26.38) United Kingdom of Gret Britin nd Northern Irelnd 64.3 (.29.3).46 (.45.46).13 (<.1.24) <.1 (<.1 <.1).31 (.3.32).48 (.46.49) United Republic of Tnzni 52 3 (13 54) 58 (26 14) 28 (15 43) 53 (3 84) 58 (36 85) 112 (69 164) United Sttes of Americ 319.46 (.45.47).14 (.14.15).11 (.54.19) <.1 (<.1 <.1).57 (.51.65).18 (.16.2) Uruguy 3.57 (.54.6) 1.7 (1.6 1.7).24 (.17.32).7 (.51.92).81 (.73.89) 2.4 (2.1 2.6) Uzbekistn 29 2.7 (2.3 3.1) 9.1 (8. 1).16 (.12.2).54 (.42.69) 2.9 (2.5 3.2) 9.7 (8.5 11) Vnutu < 1.2 (.14.28) 7.9 (5.4 11).2 (.14.28) 7.9 (5.4 11) Venezuel (Bolivrin Republic of) 31.54 (.54.55) 1.8 (1.8 1.8).12 (.83.17).4 (.27.55).67 (.62.71) 2.2 (2. 2.3) Viet Nm 92 17 (11 23) 18 (12 25) 1.9 (1.3 2.5) 2 (1.4 2.7) 19 (13 25) 2 (14 27) Wllis nd Futun Islnds < 1 <.1 (<.1 <.1).3 (.19.44) <.1 (<.1 <.1).3 (.19.44) West Bnk nd Gz Strip 5 <.1 (<.1 <.1).17 (.17.18) <.1 (<.1 <.1) <.1 (<.1 <.1) <.1 (<.1 <.1).2 (.19.21) Yemen 26 1.1 (.74 1.6) 4.4 (2.8 6.2).25 (.19.31).1 (<.1.12) 1.2 (.76 1.7) 4.4 (2.9 6.3) Zmbi 16 5.1 (3.1 7.5) 32 (2 48) 11 (7.4 16) 72 (47 12) 16 (12 22) 14 (76 137) Zimbbwe 15 2.3 (1.4 3.4) 15 (9.5 22) 5.2 (3.2 7.8) 34 (21 51) 7.6 (5.2 1) 5 (34 68) WHO regions Africn Region 963 45 (35 56) 46 (36 58) 31 (27 35) 32 (28 36) 75 (65 87) 78 (67 9) Region of the Americs 982 17 (16 18) 1.7 (1.6 1.8) 6 (5.2 6.8).61 (.53.69) 23 (22 24) 2.3 (2.2 2.5) Estern Mediterrnen Region 636 88 (43 15) 14 (6.8 23) 3.2 (2.6 4.).51 (.41.62) 91 (46 15) 14 (7.2 24) Europen Region 97 33 (33 34) 3.7 (3.6 3.8) 3.2 (2.7 3.7).35 (.3.4) 37 (36 38) 4 (3.9 4.1) South-Est Asi Region 1 96 46 (35 57) 24 (19 3) 62 (51 74) 3.3 (2.7 3.9) 52 (41 63) 27 (22 33) Western Pcific Region 1 845 88 (81 95) 4.8 (4.4 5.1) 4.9 (4.2 5.7).27 (.23.31) 93 (86 1) 5 (4.6 5.4) Globl 7 239 1 1 (97 1 3) 16 (13 18) 39 (35 43) 5.3 (4.8 5.9) 1 5 (1 4 1 7) 21 (19 23) Rte Rtes re per 1 popultion. b All clcultions re mde before numbers re rounded. Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 165

TABLE A4.3 TB cse notifictions, 214 New nd relpse Bcteriologiclly confirmed New cses Pulmonry Cliniclly dignosed Bcteriologiclly confirmed Relpses Pulmonry Cliniclly dignosed Extrpulmonry Extrpulmonry Previously treted, excluding relpse Afghnistn 31 746 14 737 8 573 7 227 1 29 966 Albni 48 159 83 145 16 2 3 Algeri 22 517 7 26 1 239 13 78 364 198 Americn Smo Andorr 6 3 2 1 Angol 53 552 22 46 25 262 3 562 2 682 1 654 Anguill 1 1 Antigu nd Brbud 3 2 1 Argentin 9 195 5 249 2 218 1 255 319 17 47 843 Armeni 1 329 356 434 249 49 147 94 13 Arub 2 2 Austrli 1 33 721 78 474 42 1 14 13 Austri 564 388 58 14 9 3 2 18 Azerbijn 5 788 1 877 1 678 829 95 359 14 1 751 Bhms 5 25 2 1 2 2 Bhrin Bngldesh 191 166 16 767 42 832 37 46 2 989 863 39 5 631 Brbdos 5 3 1 1 Belrus 3 858 2 45 872 31 615 6 1 416 Belgium 886 531 97 258 73 Belize 72 33 29 8 2 15 Benin 3 886 3 79 313 359 135 91 Bermud Bhutn 1 66 454 91 466 55 16 Bolivi (Plurintionl Stte of) 8 79 5 476 449 1 642 428 32 52 122 Bonire, Sint Eusttius nd Sb Bosni nd Herzegovin 1 196 613 328 147 59 43 6 Botswn 6 19 2 218 1 819 1 8 439 43 132 Brzil 73 97 41 12 17 81 9 479 3 62 1 488 48 7 542 British Virgin Islnds Brunei Drusslm 198 15 6 35 5 2 Bulgri 1 825 8 369 481 95 5 3 47 Burkin Fso 5 546 3 722 815 683 217 19 246 Burundi 7 226 4 265 653 2 12 26 83 Cbo Verde 274 172 41 52 9 18 Cmbodi 43 59 12 168 11 286 18 31 445 79 141 679 Cmeroon 26 38 15 41 5 472 4 6 1 96 479 Cnd Cymn Islnds Centrl Africn Republic 1 186 5 16 3 12 1 685 383 Chd 11 973 5 724 4 257 1 499 493 332 Chile 2 383 1 481 237 467 158 15 25 57 Chin 819 283 235 74 526 16 32 348 25 125 6 872 Chin, Hong Kong SAR 4 759 2 435 952 917 297 94 64 25 Chin, Mco SAR 394 25 55 6 21 4 4 Colombi 11 875 7 73 1 949 2 289 415 117 32 56 Comoros 148 83 29 32 4 2 Congo 1 17 3 876 3 479 2 466 196 177 Cook Islnds 2 1 1 Cost Ric 463 38 7 63 1 3 6 Croti 496 346 74 41 3 3 2 1 Cub 729 467 13 8 41 7 4 13 Curço 5 4 1 Cyprus 39 31 3 4 1 2 Czech Republic 474 326 81 67 4 Côte d'ivoire 23 275 14 233 2 91 5 243 898 475 Democrtic People's Republic of Kore 13 45 34 622 41 423 18 587 8 413 7 245 Democrtic Republic of the Congo 115 795 75 631 13 494 19 566 4 298 1 892 914 1 99 Denmrk 293 2 26 67 27 Djibouti 2 22 1 69 986 165 7 Includes cses for which the tretment history is unknown. 166 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

TABLE A4.3 TB cse notifictions, 214 New nd relpse Pulmonry Bcteriologiclly confirmed New cses Cliniclly dignosed Bcteriologiclly confirmed Relpses Pulmonry Cliniclly dignosed Extrpulmonry Extrpulmonry Previously treted, excluding relpse Dominic 1 1 Dominicn Republic 4 45 2 63 926 483 3 64 2 2 Ecudor 5 157 3 649 341 913 254 195 Egypt 7 177 3 697 886 2 285 39 29 El Slvdor 2 26 1 564 215 291 134 2 14 Equtoril Guine 1 166 7 28 142 41 3 47 Eritre 2 391 771 714 774 86 34 12 34 Estoni 236 163 29 13 22 7 2 1 Ethiopi 119 592 4 87 41 575 37 93 Fiji 378 15 131 19 4 24 5 7 Finlnd 252 156 3 6 4 1 1 7 Frnce 4 535 2 515 79 1 23 31 French Polynesi 56 37 8 11 3 Gbon 5 68 2 184 2 754 448 222 691 Gmbi 2 552 1 475 787 29 81 31 Georgi 3 2 1 797 349 661 36 44 43 65 Germny 4 328 2 621 55 1 15 9 24 28 16 Ghn 14 668 7 682 5 364 1 181 441 68 Greece 484 354 51 79 35 Greenlnd Grend Gum 56 31 21 3 1 Guteml 3 163 2 13 55 352 132 15 11 61 Guine 11 734 6 449 2 334 2 478 473 Guine-Bissu 2 282 1 544 62 93 43 6 Guyn 545 284 153 58 19 31 13 Hiti 15 86 9 747 3 521 1 541 641 281 75 157 Hondurs 2 82 1 81 38 46 18 22 22 Hungry 799 313 414 26 11 34 1 52 Icelnd 8 3 2 2 1 Indi 1 69 547 754 268 343 32 275 52 124 679 112 66 74 368 Indonesi 322 86 193 321 11 991 19 653 6 449 1 391 1 1 733 Irn (Islmic Republic of) 1 191 5 61 1 251 2 869 339 69 62 24 Irq 8 268 2 563 2 3 3 69 297 193 116 73 Irelnd 297 149 35 113 19 Isrel 368 21 62 99 4 2 Itly Jmic 86 34 44 6 2 Jpn 19 615 12 12 2 61 4 255 797 171 211 Jordn 385 117 11 161 6 2 Kzkhstn 15 244 8 26 1 883 1 571 2 414 1 5 3 474 Keny 88 25 34 997 3 872 14 64 3 569 2 947 1 1 269 Kiribti 414 151 198 55 1 18 Kuwit 734 319 177 237 1 Kyrgyzstn 6 39 1 849 2 47 1 624 51 1 33 Lo People's Democrtic Republic 4 264 2 973 685 48 198 86 Ltvi 738 487 97 53 91 9 1 23 Lebnon 673 36 12 238 9 1 Lesotho 8 84 2 619 4 312 1 363 519 27 1 16 Liberi 2 72 1 73 957 42 24 Liby 1 153 526 232 384 11 32 Lithuni 1 481 949 255 19 16 8 126 Luxembourg 24 12 4 8 Mdgscr 28 466 18 825 2 93 5 658 1 562 328 47 Mlwi 16 267 5 564 5 589 4 567 547 1 456 Mlysi 24 54 14 99 5 743 3 55 749 3 18 657 Mldives 131 9 41 Mli 5 89 3 84 632 1 28 165 167 Mlt 45 2 13 12 1 Mrshll Islnds 142 53 46 37 4 1 1 11 Includes cses for which the tretment history is unknown. Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 167

TABLE A4.3 TB cse notifictions, 214 New nd relpse Pulmonry Bcteriologiclly confirmed New cses Cliniclly dignosed Bcteriologiclly confirmed Relpses Pulmonry Cliniclly dignosed Extrpulmonry Extrpulmonry Previously treted, excluding relpse Muritni 2 42 1 364 35 588 118 18 Muritius 126 114 1 2 1 Mexico 21 196 13 177 3 6 3 892 779 192 96 685 Micronesi (Federted Sttes of) 188 36 126 26 1 Monco Mongoli 4 483 1 791 676 1 75 241 24 46 288 Montenegro 113 63 27 13 7 2 1 Montserrt Morocco 29 843 12 32 2 436 13 397 1 189 97 422 881 Mozmbique 57 773 24 43 23 455 6 276 1 542 2 7 497 Mynmr 138 352 42 68 7 35 16 18 5 276 3 65 45 3 65 Nmibi 8 972 4 335 2 35 1 469 1 133 91 Nuru 8 5 2 1 Nepl 35 277 15 947 8 445 8 583 2 32 1 748 Netherlnds 814 354 87 363 5 1 4 9 New Cledoni 29 12 3 12 2 New Zelnd 297 16 19 111 4 3 5 Nicrgu 2 632 1 447 717 338 13 27 Niger 1 851 7 73 1 698 1 71 37 251 Nigeri 86 464 49 825 29 46 4 764 2 415 4 89 Niue Northern Mrin Islnds 26 19 6 1 Norwy 33 241 31 31 22 Omn 358 234 116 7 1 Pkistn 38 417 122 537 12 35 57 463 7 42 426 221 8 16 Plu 14 7 4 3 Pnm 1 457 713 353 284 5 38 19 71 Ppu New Guine 26 17 3 84 1 716 11 46 28 2 397 Prguy 2 246 1 37 459 28 163 42 4 169 Peru 3 8 17 823 4 24 5 348 2 128 366 139 1 453 Philippines 243 379 92 991 139 95 4 161 6 277 24 57 Polnd 6 539 4 216 1 476 374 337 125 11 159 Portugl 2 169 1 257 219 595 71 11 16 57 Puerto Rico 44 39 5 Qtr 465 15 5 31 Republic of Kore 4 19 18 784 9 35 6 987 2 75 1 665 699 2 898 Republic of Moldov 4 58 1 774 1 157 343 477 276 31 578 Romni 14 861 7 874 2 421 2 29 1 899 356 12 1 45 Russin Federtion 12 34 37 296 4 894 8 763 7 982 6 753 652 33 828 Rwnd 5 761 4 3 554 857 347 263 Sint Kitts nd Nevis 7 1 6 Sint Luci 6 5 1 Sint Vincent nd the Grendines 5 4 1 1 Smo 23 9 1 3 1 Sn Mrino So Tome nd Principe 158 7 5 2 9 9 Sudi Arbi 3 248 1 942 412 789 93 4 8 88 Senegl 13 332 9 278 1 514 1 653 653 234 315 Serbi 1 818 92 432 351 81 44 8 14 Serbi (without Kosovo) 984 666 113 124 59 14 14 Kosovo 834 236 319 227 22 3 Seychelles 13 7 1 5 Sierr Leone 12 477 7 453 4 239 59 276 244 Singpore 2 171 1 56 649 313 93 42 18 Sint Mrten (Dutch prt) Slovki 32 155 77 57 21 5 5 16 Sloveni 142 89 9 39 5 2 Solomon Islnds 345 145 79 111 8 2 1 Somli 12 93 6 248 3 378 2 813 372 7 22 227 South Afric 36 166 155 473 16 482 33 522 7 43 2 693 566 12 27 Includes cses for which the tretment history is unknown. 168 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

TABLE A4.3 TB cse notifictions, 214 New nd relpse Pulmonry Bcteriologiclly confirmed New cses Cliniclly dignosed Bcteriologiclly confirmed Relpses Pulmonry Cliniclly dignosed Extrpulmonry Extrpulmonry Previously treted, excluding relpse South Sudn 8 335 3 565 2 887 1 624 259 521 Spin 4 818 2 843 673 1 32 23 Sri Lnk 9 35 4 345 1 962 2 71 288 168 Sudn 19 266 6 16 7 934 4 571 655 1 126 Surinme 149 1 16 26 4 2 1 9 Swzilnd 5 583 2 54 1 66 765 322 35 33 Sweden 635 313 44 27 4 4 35 Switzerlnd 423 272 3 121 5 Syrin Arb Republic 3 481 1 161 441 1 796 55 6 22 95 Tjikistn 5 87 2 432 1 162 1 423 54 139 111 453 Thilnd 67 722 34 394 21 115 1 244 1 969 3 896 The Former Yugoslv Republic of Mcedoni 284 167 31 64 19 3 1 Timor-Leste 3 657 1 838 1 222 519 78 121 Togo 2 525 1 899 177 339 11 52 Tokelu Tong 13 8 5 Trinidd nd Tobgo 251 128 88 25 5 5 42 Tunisi 3 134 1 52 214 1 834 34 39 Turkey 13 18 5 799 1 897 4 557 568 119 168 27 Turkmenistn 2 57 1 944 415 173 38 317 Turks nd Cicos Islnds 1 1 2 Tuvlu 15 8 6 1 US Virgin Islnds Ugnd 44 187 26 79 11 854 4 18 1 499 468 17 1 984 Ukrine 31 71 14 242 9 296 2 596 4 566 8 21 8 61 United Arb Emirtes 6 37 3 16 3 1 1 United Kingdom of Gret Britin nd Northern Irelnd 6 622 2 672 872 3 78 455 United Republic of Tnzni 61 571 23 583 23 38 13 6 1 8 1 58 United Sttes of Americ 8 949 5 838 1 234 1 877 458 Uruguy 862 536 18 83 5 12 1 26 Uzbekistn 18 345 4 44 6 261 4 514 1 89 1 92 265 4 459 Vnutu 112 38 22 51 1 Venezuel (Bolivrin Republic of) 6 392 3 526 1 458 1 79 243 8 6 223 Viet Nm 1 349 49 938 25 179 18 118 7 114 1 738 Wllis nd Futun Islnds West Bnk nd Gz Strip 43 14 18 8 3 Yemen 9 628 2 912 3 135 3 39 191 65 Zmbi 37 931 12 7 15 568 8 584 1 79 4 785 Zimbbwe 29 653 11 224 13 151 3 99 1 369 2 363 WHO regions Africn Region 1 3 852 635 56 399 155 212 57 39 782 11 217 3 81 41 47 Region of the Americs 215 226 127 844 4 751 32 5 1 192 2 918 1 21 13 234 Estern Mediterrnen Region 453 393 183 63 151 696 13 959 12 368 866 874 12 284 Europen Region 273 381 116 599 78 17 4 857 23 956 11 58 2 291 55 889 South-Est Asi Region 2 482 74 1 188 654 632 418 389 819 152 498 117 97 715 98 531 Western Pcific Region 1 335 816 449 845 734 179 13 85 44 354 3 37 1 316 39 756 Globl 6 6 742 2 72 132 2 36 369 882 277 283 15 147 516 9 298 261 11 Includes cses for which the tretment history is unknown. Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 169

TABLE A4.4 Notified new nd relpse TB cses by ge nd sex, 214 * New cses only. Notified cses by ge (Number) Notified cses by ge group (rte per 1 popultion) 14 > 15 Unknown 4 5 14 15 24 25 34 35 44 45 54 55 64 > 65 Afghnistn* Femle 2 283 11 89 3 921 34 33 Mle 2 171 6 966 3 36 41 24 Albni Femle 8 13 3.5 2.8 1 8.2 7.3 12 12 15 Mle 13 257 4.3 4.7 19 22 17 2 28 28 Algeri* Femle 46 2 649 23 18 13 13 19 33 Mle 26 4 46 28 33 28 23 26 33 Americn Smo Femle Mle Andorr Femle Mle 6 35 18 49 Angol Femle 514 8 649 1.3 14 111 163 162 141 17 97 Mle 395 12 488 1.6 1 136 253 262 241 186 16 Anguill Femle 1 91 Mle Antigu nd Brbud Femle 3 13 15 27 Mle Argentin Femle 41 3 454 24 7.7 7.6 27 26 2 16 19 13 Mle 435 4 824 48 8.1 7.7 33 35 28 29 31 28 Armeni Femle 11 36.99 6.1 24 22 22 28 3 12 Mle 21 991 9.1 5.9 51 76 94 18 136 83 Arub Femle 2 35 Mle Austrli Femle 25 598 1.5 1 5.6 12 7 4.5 3.3 4.2 Mle 28 679 1.5 1.1 6.2 9.5 6.2 4.7 6.8 9 Austri Femle 8 19 1.5 1.3 6.1 8.2 4.2 3.6 5.2 4.2 Mle 6 359.49 1.2 13 11 9.4 8.7 7.2 12 Azerbijn* Femle 6 1 13 2.4 8.7 39 31 21 25 29 2 Mle 119 3 17 6.1 14 12 78 84 85 79 61 Bhms Femle 1 23 7.1 9.2 13 18 19 15 17 Mle 1 25 3.8 18 13 26 24 6 7.8 Bhrin Femle Mle Bngldesh* Femle 3 369 7 547 4.8 19 13 113 119 156 225 145 Mle 2 893 11 196 7.2 14 91 137 155 249 491 526 Brbdos* Femle 1 1 5.5 5.4 Mle 3 11 6.2 Belrus Femle 8 1 38.71 1.3 2 34 32 19 14 23 Mle 16 2 796 2 2.1 22 71 14 11 9 52 Belgium Femle 32 287 5.7 2.3 8.5 11 7.6 3.7 3.4 3.8 Mle 29 538 4.2 2.4 11 18 15 7.9 9.5 11 Belize Femle 2 23 5.2 2.7 27 23 26 23 46 Mle 3 44 7.7 14 36 29 7 44 12 Benin* Femle 39 1 64 25 5 4 31 25 26 Mle 21 1 955 27 75 95 96 78 85 Bermud Femle Mle Bhutn Femle 24 57 18 26 298 225 127 9 115 17 Mle 32 53 23 33 214 135 118 151 177 247 Bolivi (Plurintionl Stte of)* Femle 189 2 76 6.9 13 87 76 52 52 86 119 Mle 25 4 413 8.1 13 127 13 86 123 164 219 Bonire, Sint Eusttius nd Sb Femle Mle Bosni nd Herzegovin Femle 2 49 1.2 26 1 21 15 23 73 Mle 13 691 3.3 5.6 27 2 31 44 52 87 Botswn Femle 23 2 324 8 44 19 344 419 352 278 314 Mle 216 3 274 11 31 158 37 628 697 627 964 Brzil Femle 1 95 23 113 5.6 4.2 27 31 29 28 28 28 Mle 1 273 48 489 7.6 4.1 45 66 66 72 76 67 British Virgin Islnds Femle Mle Brunei Drusslm Femle 1 77 3.2 2 46 6 32 53 186 Mle 12 3 63 61 67 95 339 Bulgri Femle 64 519 9 15 14 13 18 2 13 17 Mle 81 1 161 19 14 2 36 42 51 44 37 Burkin Fso* Femle 33 1 72.52 1 11 24 25 33 37 37 Mle 22 2 595.13.8 17 63 86 91 94 129 17 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

TABLE A4.4 Notified new nd relpse TB cses by ge nd sex, 214 Notified cses by ge (Number) Notified cses by ge group (rte per 1 popultion) 14 > 15 Unknown 4 5 14 15 24 25 34 35 44 45 54 55 64 > 65 Burundi* Femle 247 2 249 11 9.5 49 7 17 18 79 9 Mle 281 4 243 13 1 58 146 221 253 25 29 Cbo Verde* Femle 5 57 3.8 8.1 26 33 43 23 35 28 Mle 6 197 11 5.9 67 7 24 191 6 1 Cmbodi Femle 5 289 14 663 136 269 96 152 256 366 584 854 Mle 6 761 16 346 215 35 94 16 384 543 865 1 34 Cmeroon Femle Mle Cnd Femle Mle Cymn Islnds Femle Mle Centrl Africn Republic* Femle 17 2 42 17 179 193 142 99 43 Mle 99 2 637 93 225 299 275 166 85 Chd Femle 431 3 853 14 13 55 122 15 176 169 112 Mle 55 7 139 2 14 77 219 32 375 36 39 Chile Femle 23 822 5 1 1.4 5.9 9.3 11 11 16 18 Mle 3 1 492 11 2 1.4 9.4 18 17 22 27 51 Chin Femle 2 1 248 755.25 2.7 47 4 33 36 52 73 Mle 2 154 566 364.47 2.4 76 65 69 93 14 24 Chin, Hong Kong SAR Femle 8 1 732 2.4 1.6 36 44 4 4 49 95 Mle 12 3 7 1.1 3.8 36 45 52 64 115 293 Chin, Mco SAR Femle 2 131 9.8 41 7 33 39 43 77 Mle 2 259 9.1 7 7 67 111 195 185 Colombi Femle 298 4 223 8.3 3.7 17 23 2 18 27 45 Mle 292 7 62 7.4 3.7 25 36 3 41 57 1 Comoros Femle 55 2 29 26 26 18 26 Mle 88 27 51 33 49 32 51 Congo* Femle 68 1 465 2.7 9.9 112 131 126 1 9 62 Mle 35 2 38 1.3 5.1 118 241 248 182 143 81 Cook Islnds Femle Mle 2 129 164 Cost Ric Femle 15 142 4.1 2.3 4.2 5.9 9.6 7.2 8.5 14 Mle 11 295 2.8 1.6 6.7 13 14 2 28 29 Croti Femle 187 5.1 8.6 6.6 5.7 9.9 17 Mle 3 36.92.92 7.3 9.7 13 24 21 3 Cub Femle 8 163.69.96 3.2 3.8 3 3.3 3.8 3.7 Mle 7 551.98.6 5.8 11 15 13 14 9.3 Curço Femle 1 7.6 Mle 4 12 11 21 Cyprus Femle 18 3.6 5.4 7.5 4.2 1.3 Mle 21 4.4 8.5 3.4 2.7 4.6 Czech Republic Femle 2 146.38.2 1.5 2.5 2.2 2.2 2.7 6.1 Mle 3 323.71.19 2.1 5 5.9 11 9.9 1 Côte d'ivoire* Femle 217 5 12.95 6.8 59 11 11 74 8 86 Mle 169 8 727.78 5.2 72 196 185 141 119 11 Democrtic People's Republic of Kore* Femle 2 521 33 374 44 121 238 45 456 395 33 115 Mle 3 11 55 627 49 144 367 632 739 671 667 377 Democrtic Republic of the Congo* Femle 1 856 3 748 126 1.3 17 9 171 21 21 27 118 Mle 1 582 41 153 166 1.4 14 97 215 31 33 323 236 Denmrk Femle 4 116 2.1.31 3.9 9 8.3 4.7 3.2 2.1 Mle 5 168 1.3.88 4.2 12 6.4 11 7.3 3.6 Djibouti* Femle 27 348 6 26 119 136 126 11 77 93 Mle 24 67 1.9 24 18 34 247 211 28 161 Dominic Femle Mle 1 23 Dominicn Republic Femle 17 839 479.77 1.3 22 26 26 2 19 19 Mle 3 1 677 1 363.74 2.5 36 6 58 45 42 33 Ecudor Femle 111 1 816 4.5 5.1 29 33 28 28 34 5 Mle 113 3 117 3.5 5.4 44 6 48 6 64 81 Egypt* Femle 189 2 644.6 1.8 4.4 8.7 14 11 12 5.7 Mle 24 3 795.88 2 6.7 1 16 2 2 12 El Slvdor* Femle 11 677 11 13 13 21 25 38 42 55 Mle 72 1 22 6.3 9.3 42 81 59 47 59 95 Equtoril Guine Femle 27 416 8 22 153 219 253 133 125 7 Mle 31 55 9.5 25 125 258 358 219 213 74 * New cses only. Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 171

TABLE A4.4 Notified new nd relpse TB cses by ge nd sex, 214 Notified cses by ge (Number) Notified cses by ge group (rte per 1 popultion) 14 > 15 Unknown 4 5 14 15 24 25 34 35 44 45 54 55 64 > 65 Eritre Femle 138 958 13 13 36 57 74 13 19 133 Mle 168 1 127 17 14 52 51 91 116 129 313 Estoni Femle 72 4.3 16 17 8.9 11 12 Mle 1 163 1.4 8.1 2 41 52 52 18 Ethiopi* Femle 7 438 46 876 21 46 Mle 8 479 56 799 35 45 Fiji Femle 19 123 12 17 39 46 38 28 28 63 Mle 26 21 24 17 24 61 57 16 95 114 Finlnd Femle 5 19 2.69 2.5 6.8 1.9 2.7 2.9 8.2 Mle 3 135.64.66 3.9 4.8 4.5 2.1 4.9 14 Frnce Femle 135 1 597 3.5 1.8 6.6 9.5 6.5 4.3 3.4 5.6 Mle 135 2 645 3.3 1.7 9.1 15 12 8.8 8.5 1 French Polynesi Femle 1 25 9.6 21 14 1 28 57 29 Mle 1 29 9.1 8 23 29 1 23 19 Gbon Femle 211 2 19 55 75 281 435 552 517 552 385 Mle 252 2 955 57 93 365 572 63 799 743 518 Gmbi Femle Mle Georgi Femle 61 1 11 24 86 93 52 42 28 36 Mle 68 2 71 13 22 94 159 151 16 142 85 Germny Femle 67 1 522 1 1.8 1.1 4.6 5.9 4.5 3 3 4.7 Mle 79 2 653 1.9 1.3 12 9.3 7.7 5.6 5.9 7.7 Ghn Femle 341 4 826 6.4 6.9 26 54 71 8 8 122 Mle 372 9 129 7.2 6.8 34 84 169 27 23 262 Greece Femle 4 142 1.1.19 2.2 4.2 2.2 2.1.72 4.8 Mle 5 328 3 1.1.37 5 9.3 7.1 5.5 7.3 8.2 Greenlnd Femle Mle Grend Femle Mle Gum Femle 4 25 28 15 35 28 19 78 14 Mle 3 24 14 13 6.8 17 55 53 38 93 Guteml Femle 141 1 215 15 21 22 35 4 29 Mle 143 1 664 2 31 38 5 6 65 Guine* Femle 198 3 18 34 16 17 152 131 131 Mle 212 7 671 86 243 316 321 32 356 Guine-Bissu Femle 44 823 1 16 9.7 11 181 225 161 126 92 Mle 64 1 348 2 18 17 126 331 348 34 289 23 Guyn Femle 5 146 6.2 25 78 62 56 81 65 Mle 6 388 7.4 53 174 213 184 166 158 Hiti Femle 86 6 632 62 41 187 229 197 152 153 13 Mle 835 7 479 7 32 176 27 259 213 191 195 Hondurs Femle 58 1 17 5.2 4.3 22 35 37 5 63 7 Mle 69 1 676 6.2 4.8 34 57 64 84 92 155 Hungry Femle 2 35.42 5 4.8 6.5 7.6 7.3 8.3 Mle 2 49.4 3.3 6.2 7.5 2 22 17 Icelnd Femle 3 4.3 4.4 4.6 Mle 5 8.2 4.2 4.7 4.7 Indi Femle 5 943 53 218 12 36 131 124 16 98 11 81 Mle 44 766 1 1 62 14 26 143 171 229 281 317 35 Indonesi Femle 11 81 122 592 41 27 121 131 124 151 179 114 Mle 12 89 177 44 44 27 122 175 173 233 319 296 Irn (Islmic Republic of) Femle 24 4 77 1.8 2.6 1 8.1 11 13 27 82 Mle 146 5 71 2.2 1.2 7.2 13 15 15 24 69 Irq Femle 323 3 988 2.5 5.9 28 29 27 46 85 11 Mle 262 3 695 3.6 3.4 18 28 35 51 8 119 Irelnd Femle 3 132.95 5 1 5.6 6.3 7.2 8.1 Mle 4 158 1.2 6.3 9.7 8.5 7.2 6.9 14 Isrel Femle 14 12 2.8.45 2.8 5.6 3.3 4.7 2.6 5.5 Mle 17 217 3.8.14 4.8 14 6.1 5.4 6 9.4 Itly Femle Mle Jmic Femle 4 16 3.44.38 2.2.55 4.5 1.8 Mle 4 62 1.9.84 3.6 8.3 3.6 5.7 13 4.3 Jpn Femle 26 7 584.35.31 5.5 8.3 5.9 6.5 6.8 27 Mle 23 11 982.29.26 6.3 8.8 8.7 11 18 55 * New cses only. 172 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

TABLE A4.4 Notified new nd relpse TB cses by ge nd sex, 214 Notified cses by ge (Number) Notified cses by ge group (rte per 1 popultion) 14 > 15 Unknown 4 5 14 15 24 25 34 35 44 45 54 55 64 > 65 Jordn Femle 14 168.63 1.3 4.3 9.7 6.9 5.3 13 1 Mle 16 187.4 1.6 5 8.6 6.4 7 14 16 Kzkhstn Femle 235 5 792 6.4 14 13 119 84 6 53 64 Mle 217 9 6.6 11 115 146 18 165 165 124 Keny Femle 4 69 31 36 51 39 158 288 37 271 2 249 Mle 4 379 49 81 59 38 195 431 561 558 399 483 Kiribti Femle 52 147 165 345 275 417 391 485 495 536 Mle 43 172 185 237 399 189 633 715 963 87 Kuwit Femle 2 325.83 15 42 24 15 13 29 Mle 7 4 2.3 1.2 12 24 25 34 24 31 Kyrgyzstn* Femle 22 2 414 9.7 32 142 13 88 7 113 151 Mle 236 3 28 1 36 142 138 163 164 196 177 Lo People's Democrtic Republic Femle 47 1 58 2.9 4.7 2 49 66 115 162 22 Mle 26 2 581 1.6 2.5 27 67 129 241 342 445 Ltvi Femle 15 197 11 11 17 38 33 26 15 8.1 Mle 26 5 24 14 38 74 8 96 68 31 Lebnon Femle 34 366 6.1 4.5 19 29 14 6.2 9.8 9.2 Mle 22 251 5.5 2.2 8.1 13 16 9.9 14 11 Lesotho Femle 196 3 543 56 64 45 255 677 917 79 46 357 Mle 172 4 83 7 54 39 156 692 1 38 1 77 1 4 1 2 Liberi* Femle 25 531 4.3 2 62 57 47 33 38 Mle 21 1 126 1.1 2.8 49 99 114 113 71 25 Liby Femle 42 413 3.1 5.5 16 19 16 21 25 25 Mle 27 671 1.8 3.4 19 35 37 28 25 4 Lithuni Femle 14 445 1.4 9.9 21 48 39 37 27 28 Mle 8 1 14 2.6 4.3 25 61 127 123 126 82 Luxembourg Femle 1 12 4.8 6.9 Mle 14 8.4 4.9 12 2.2 3.1 5.9 Mdgscr* Femle Mle Mlwi Femle 858 5 716 24 22 57 15 26 186 143 127 Mle 969 8 724 3 23 55 229 341 321 274 273 Mlysi Femle 354 8 434 7.9 1 62 7 69 72 99 119 Mle 337 14 929 12 7.7 71 97 139 172 227 266 Mldives Femle 1 49 11 27 34 27 13 18 75 173 Mle 4 68 16 3.2 19 42 23 57 121 238 Mli Femle 37 1 216 68 14 36 32 34 34 35 Mle 32 2 519 1 234 23 62 69 94 113 12 Mlt Femle 12 11 27 3.3 3.7 2.3 Mle 33 64 29 1 7.2 5.7 Mrshll Islnds Femle 1 3 2 191 134 177 275 49 6 Mle 1 25 18 11 158 98 22 185 Muritni Femle 67 695 12 3.4 12 45 57 65 64 86 74 Mle 75 1 559 23 5.3 12 78 128 12 157 24 345 Muritius Femle 39 8 13 5.3 4.3 8.2 6 Mle 87 13 22 19 22 16 1 Mexico Femle 381 7 71 1.8 2.4 12 14 14 21 26 28 Mle 47 12 698 3.1 1.9 15 23 27 38 43 56 Micronesi (Federted Sttes of) Femle 19 73 125 12 16 227 189 3 23 373 Mle 18 77 184 55 226 232 272 188 263 51 Monco Femle Mle Mongoli Femle 193 1 733 37 56 222 198 15 11 127 151 Mle 196 2 361 38 55 238 214 222 238 274 22 Montenegro Femle 47 14 16 14 14 17 31 Mle 66 18 15 26 24 28 54 Montserrt Femle Mle Morocco* Femle 1 74 1 422 11 31 13 83 68 67 74 88 Mle 1 2 15 637 12 27 134 157 123 14 114 134 Mozmbique Femle Mle Mynmr Femle 15 56 36 727 17 299 168 127 178 162 22 253 33 Mle 2 795 65 26 47 383 228 147 317 384 449 54 656 Nmibi* Femle 431 3 241 135 75 269 517 543 378 356 459 Mle 446 4 724 151 7 234 772 1 3 942 739 969 * New cses only. Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 173

TABLE A4.4 Notified new nd relpse TB cses by ge nd sex, 214 Notified cses by ge (Number) Notified cses by ge group (rte per 1 popultion) 14 > 15 Unknown 4 5 14 15 24 25 34 35 44 45 54 55 64 > 65 Nuru Femle 6 11 279 536 Mle 2 273 Nepl* Femle 181 4 973 7 427.36 5.5 43 42 46 61 78 6 Mle 164 1 629 11 93.34 4.7 69 1 116 156 224 26 Netherlnds Femle 21 29 1.4 1.6 5.1 8.1 4 3.6 2.3 2.6 Mle 27 476 1.8 1.9 6.7 11 8.1 5 5 6.2 New Cledoni Femle 1 9.7 5.5 5.9 8.2 37 Mle 3 16 2 5.1 4.7 21 5.3 23 48 New Zelnd Femle 1 114 4 1.4 5.8 11 8.1 4.6 4.5 3.4 Mle 9 164 3.8.98 9.1 13 1 6.2 7.1 11 Nicrgu* Femle 19 63 26 28 26 3 3 32 Mle 1 815 27 36 47 53 57 56 Niger* Femle 46 1 733.2 1.5 17 42 45 53 53 57 Mle 5 5 244.2 1.6 47 163 145 12 126 183 Nigeri Femle 2 683 33 863 5.6 7.9 4 86 86 81 73 83 Mle 2 78 52 28 6.3 7.3 43 119 144 144 136 166 Niue Femle Mle Northern Mrin Islnds Femle 1 21 52 57 33 95 116 Mle 16 2 25 32 92 224 346 Norwy Femle 7 127.66 2 7.2 16 9.2 2.3 2 1.1 Mle 6 163.62 1.6 12 17 7.8 4.1 1.6 2.9 Omn Femle 4 149 2.2 11 17 14 17 17 18 Mle 4 21.51 1.1 6.5 6.2 7.2 15 15 41 Pkistn Femle 15 32 14 12 32 58 217 21 238 264 33 294 Mle 12 213 141 52 33 38 166 181 225 297 415 386 Plu* Femle 3 53 74 15 Mle 1 1 46 132 245 79 348 179 Pnm Femle 62 482 23 6.2 35 38 31 32 31 37 Mle 53 86 16 6.5 42 73 59 75 58 71 Ppu New Guine* Femle Mle Unknown 6 959 19 3 Prguy Femle 9 612 1 13 7.2 23 27 23 31 32 4 Mle 97 1 442 4 15 6.9 4 61 6 73 11 93 Peru* Femle 766 9 548 15 19 16 86 62 76 7 14 Mle 793 16 268 14 2 179 146 129 16 129 19 Philippines Femle 5 74 14 486 14 494 48 31 29 38 44 57 61 6 Mle 6 451 32 479 23 928 52 32 53 78 16 144 162 148 Polnd Femle 33 2 57 1.2 1.2 6 8.1 9.4 11 13 21 Mle 37 4 412 1.3 1.2 5.6 12 23 43 46 43 Portugl Femle 18 791 3.2 2.2 15 25 17 15 13 16 Mle 25 1 334 1 4.8 2.7 18 25 37 42 32 33 Puerto Rico Femle 11.36.38.38.79.46 1.7 Mle 33.35 1.2.83 4.1 5.6 3.6 Qtr Femle 5 79 6.4 1.1 16 25 15 14 5.6 12 Mle 1 375 5 1.5 24 3 23 23 25 36 Republic of Kore Femle 94 16 287 1.4 3.4 44 66 5 49 61 178 Mle 83 23 474 2.1 2.3 52 68 73 18 14 281 Republic of Moldov Femle 53 1 99 13 19 52 73 86 6 52 37 Mle 61 2 845 27 14 65 159 247 279 192 14 Romni Femle 329 4 481 22 22 81 72 49 41 34 46 Mle 31 9 741 24 18 11 11 129 158 138 95 Russin Federtion Femle 1 635 29 28 157 12 15 45 77 65 36 26 22 Mle 1 56 69 153 555 12 14 59 157 197 142 13 54 Rwnd Femle 168 1 762 41 49 61 55 54 51 Mle 17 3 661 47 115 167 25 238 225 Sint Kitts nd Nevis Femle 2 27 29 Mle 5 3 175 Sint Luci Femle 2 8.3 13 Mle 4 16 8.7 14 Sint Vincent nd the Grendines Femle Mle 5 11 13 14 22 28 Smo Femle 2 8 8.4 4.4 17 18 1 18 18 Mle 1 12 7.8 5.1 8.2 28 22 34 7 Sn Mrino Femle * New cses only. Mle 174 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

TABLE A4.4 Notified new nd relpse TB cses by ge nd sex, 214 Notified cses by ge (Number) Notified cses by ge group (rte per 1 popultion) 14 > 15 Unknown 4 5 14 15 24 25 34 35 44 45 54 55 64 > 65 So Tome nd Principe Femle 4 51 14 8 44 66 93 21 175 29 Mle 7 96 14 2 49 146 245 396 379 425 Sudi Arbi Femle 42 988.77 1.1 11 13 5.9 9.2 14 23 Mle 61 2 157 1.2 1.4 15 21 12 14 21 44 Senegl* Femle 11 2 632.72 4.8 Mle 15 6 44 1.2 4.5 Serbi Femle 19 793 1.4 1.6 21 21 21 15 14 29 Mle 22 984.86 1.5 22 19 25 3 29 38 Seychelles Femle 6 27 14 15 23 26 Mle 7 25 15 46 74 Sierr Leone Femle 63 2 683.6 7 12 169 194 159 15 127 Mle 72 4 635.8 8 134 28 376 419 292 267 Singpore Femle 7 767.77 2 17 63 32 2 25 39 Mle 1 1 387 5.1.97 24 51 4 5 8 152 Sint Mrten (Dutch prt)* Femle Mle Slovki Femle 26 16 14 2.7 4.3 1.9 3.9 3 4.4 8.6 Mle 18 17 8.9 1.8 2.6 2.7 7.5 12 11 13 Sloveni Femle 6 2 4.4 3.5 2.6 7.5 15 Mle 3 79 3.5 1 8 6.3 7 9.4 22 Solomon Islnds Femle 32 138 28 3 61 17 44 11 173 52 Mle 3 145 4 17 8 75 45 14 191 13 Somli Femle 1 21 3 924 62 41 99 147 158 155 152 257 Mle 1 582 6 196 92 45 167 223 23 255 33 498 South Afric Femle 15 727 116 441 369 112 46 798 845 597 395 324 Mle 16 25 157 748 393 11 295 92 1 44 1 14 1 8 764 South Sudn* Femle Mle Spin Femle 136 1 777 5.9 3.2 1 13 9.8 7.1 5.5 7.8 Mle 161 2 735 2 7.5 3.2 1 15 14 14 14 17 Sri Lnk Femle 159 2 95 7.1 5.8 31 3 29 41 48 44 Mle 154 5 717 6.9 5.5 29 55 64 18 128 127 Sudn* Femle 943 6 336 226 13 11 Mle 1 29 1 123 429 14 15 Surinme Femle 5 43 8.6 6.3 18 31 28 27 4.7 9.5 Mle 2 99 8 17 46 52 13 66 26 Swzilnd Femle 25 2 251 131 91 289 815 981 565 337 384 Mle 252 2 83 13 91 174 83 1 61 1 28 1 13 79 Sweden Femle 26 277 1.1 4.4 9.7 16 8 4.1 3.9 2.7 Mle 27 35 1 4.4 13 15 8.5 4.9 1.9 3.7 Switzerlnd* Femle 7 15.49 1.5 4.3 7.2 5.4 3.1 2.6 3.2 Mle 4 262.93.49 14 9.8 9 5.1 4.3 5.1 Syrin Arb Republic Femle 172 1 271 14 5.9 4.7 21 22 19 22 23 28 Mle 225 1 755 44 11 4 21 33 31 32 37 42 Tjikistn Femle 15 2 445 6.7 13 78 96 66 82 132 19 Mle 184 3 28 12 13 16 123 99 97 124 164 Thilnd* Femle 62 9 662 Mle 57 24 613 The Former Yugoslv Republic of Mcedoni Femle 7 96 3.6 4.2 11 19 7.4 6.2 8.3 14 Mle 12 169 14 3.2 15 17 13 29 25 23 Timor-Leste* Femle 21 1 457 Mle 189 1 732 Togo Femle 45 884.88 4.3 23 55 51 48 45 57 Mle 35 1 561.87 3.2 27 74 119 152 127 17 Tokelu Femle Mle Tong Femle 7 3 15 63 28 Mle 6 19 17 17 Trinidd nd Tobgo Femle 5 67 4.2 3.3 4.3 15 9.5 18 14 13 Mle 4 175 4.1 2.1 9.5 29 32 55 47 32 Tunisi Femle 13 1 463 1.7 12 26 36 29 34 42 39 Mle 92 1 476 1.2 1 23 37 36 37 41 51 Turkey Femle 266 5 316 2.2 3 16 16 13 16 2 33 Mle 284 7 242 2.3 3 16 2 22 32 41 49 Turkmenistn* Femle Mle * New cses only. Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 175

TABLE A4.4 Notified new nd relpse TB cses by ge nd sex, 214 Notified cses by ge (Number) Notified cses by ge group (rte per 1 popultion) 14 > 15 Unknown 4 5 14 15 24 25 34 35 44 45 54 55 64 > 65 Turks nd Cicos Islnds Femle Mle 1 35 Tuvlu Femle 8 226 298 163 371 273 Mle 7 15 145 177 813 342 US Virgin Islnds Femle Mle Ugnd Femle 1 66 14 169 2 16 84 189 197 22 136 127 Mle 1 71 26 72 23 16 86 324 483 53 387 37 Ukrine Femle 254 8 924 8.2 7.8 4 7 64 38 24 25 Mle 278 22 245 8.7 7.9 52 145 29 163 13 57 United Arb Emirtes Femle 3 24.42.54 1.9.8 2.9 2 Mle 4 29 1.2.25.37.25.1.33 2.7 13 United Kingdom of Gret Britin nd Northern Irelnd Femle 133 2 581 1.8 2.7 9.2 16 11 7.3 7 7.1 Mle 141 3 767 2.7 2.2 11 23 19 12 11 11 United Republic of Tnzni Femle 2 972 21 895 33 21 61 159 234 225 219 228 Mle 3 491 33 213 35 26 72 224 363 411 388 467 United Sttes of Americ Femle 224 3 193 1.4.46 1.8 3 2.5 2.1 2.2 3 Mle 231 5 298 1.3.48 2.4 3.6 3.7 4.1 5 6.4 Uruguy Femle 24 25 12 4.1 23 25 15 13 13 16 Mle 33 555 13 6.7 28 59 48 5 46 33 Uzbekistn Femle 758 6 961 9.2 24 36 56 56 68 16 149 Mle 1 155 9 471 16 34 47 74 15 128 159 187 Vnutu Femle 7 42 3 6.9 25 57 49 81 47 94 Mle 8 55 28 9.5 46 57 35 86 155 151 Venezuel (Bolivrin Republic of) Femle 197 2 379 6.4 3.7 17 22 18 18 28 34 Mle 218 3 598 6.3 4.1 25 29 28 35 48 64 Viet Nm* Femle 76 12 518.22 1 23 31 24 28 49 77 Mle 68 37 267.27.81 35 76 11 154 189 25 Wllis nd Futun Islnds* Femle Mle West Bnk nd Gz Strip Femle 1 13.18.62.61.45 1.3 2.4 4.3 Mle 29.99.6 2.2 4 6.4 9.5 Yemen Femle 497 4 394 15 38 53 7 82 81 94 Mle 525 4 212 15 3 48 62 99 88 134 Zmbi Femle 1 294 13 24 36 36 16 391 471 417 277 239 Mle 1 432 2 472 43 37 148 61 895 714 556 526 Zimbbwe Femle 1 123 11 64 43 31 15 291 455 37 291 286 Mle 1 167 15 723 48 3 99 374 719 652 523 523 WHO regions Africn Region Femle 43 928 389 667 83 32 21 98 215 237 28 17 164 Mle 46 595 574 141 1 495 35 2 98 29 41 394 338 324 Region of the Americs Femle 5 112 71 991 59 5.4 4.3 21 23 19 17 17 18 Mle 5 377 126 342 1 426 6.1 4.1 31 4 36 35 36 38 Estern Mediterrnen Region Femle 22 195 194 95 4 161 15 26 94 81 89 12 124 128 Mle 19 833 24 948 3 784 16 18 77 76 85 111 153 18 Europen Region Femle 4 834 86 6 158 5.6 7.1 25 37 28 19 17 17 Mle 5 425 171 825 561 6.5 7.3 33 64 71 59 5 3 South-Est Asi Region Femle 84 57 786 56 7 444 24 37 126 127 116 119 128 97 Mle 84 253 1 462 9 11 95 27 32 136 176 224 279 336 329 Western Pcific Region Femle 14 19 33 42 14 494 7.5 9.6 43 4 34 37 52 7 Mle 16 295 714 27 23 928 8.8 9.3 67 65 71 95 134 182 Unknown 6 959 19 3 Globl Femle 174 145 1 857 911 27 569 17 21 75 82 71 64 66 59 Mle 177 778 3 253 472 43 144 19 18 85 115 133 144 162 16 Unknown 6 959 19 3 * New cses only. 176 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

TABLE A4.5 Tretment outcomes by TB cse type, 213 nd tretment outcomes for RR-/MDR-TB cses, 212 Cohort (Number) New nd relpse, 213 Previously treted, excluding relpse, 213 Lost to Not Success Filed Died follow-up evluted Cohort Success Cohort (%) (%) (%) (%) (%) (Number) (%) (Number) Afghnistn 3 57 88 1 1 2 8 1 115 74 38 71 Albni 472 88 1 2 4 5 2 5 Algeri 7 2 91 2 3 3 13 59 Americn Smo Andorr 5 6 2 2 1 1 Angol 6 87 23 1 1 8 67 6 844 39 24 445 Anguill Antigu nd Brbud* 9 67 22 11 4 75 Argentin 8 474 51 5 8 36 782 4 554 32 89 34 Armeni 1 251 81 1 5 11 2 18 78 38 66 115 44 Arub Austrli 1 264 85 4 1 9 6 83 26 77 16 75 Austri 617 72 8 14 6 16 62 2 6 Azerbijn* 4 294 82 5 2 8 3 2 652 73 373 6 Bhms 33 76 12 9 3 1 4 1 1 Bhrin Bngldesh 184 77 93 4 1 1 6 327 86 68 75 55 72 Brbdos* 4 1 2 1 Belrus 3 34 87 4 6 1 2 222 71 138 65 2 59 54 Belgium 878 79 6 1 5 72 72 35 71 18 61 Belize 121 36 14 12 39 3 67 25 12 Benin* 3 254 89 3 6 2 242 9 8 75 Bermud Bhutn 1 8 91 4 4 1 35 6 1 1 Bolivi (Plurintionl Stte of)* 7 657 85 1 5 5 4 561 77 43 67 Bonire, Sint Eusttius nd Sb Bosni nd Herzegovin 1 261 82 2 8 1 7 7 43 Botswn 7 254 73 1 8 3 16 124 6 4 83 71 63 7 Brzil 76 543 72 8 1 1 6 945 38 9 46 46 825 51 British Virgin Islnds* 1 1 Brunei Drusslm 212 73 8 2 Bulgri 1 93 85 1 9 4 1 2 5 4 75 44 66 Burkin Fso* 5 125 8 3 1 5 2 4 75 68 71 26 58 Burundi 7 547 91 1 6 2 8 84 977 87 36 92 Cbo Verde 32 88 1 1 8 2 12 42 24 83 Cmbodi 35 536 93 1 2 1 3 1 71 9 11 79 Cmeroon* 15 12 82 1 6 7 3 1 634 71 76 92 Cnd Cymn Islnds 5 8 2 1 Centrl Africn Republic* 4 4 7 1 5 17 6 514 62 1 972 62 16 81 Chd* 9 127 74 1 4 17 3 722 53 Chile 2 41 47 6 5 42 38 5 187 13 9 56 Chin 841 999 95 1 1 3 7 847 9 4 649 82 1 96 42 Chin, Hong Kong SAR 4 6 67 16 3 14 29 31 21 62 24 62 Chin, Mco SAR 433 82 7 1 1 3 67 4 1 7 86 Colombi 11 92 71 1 9 8 11 78 42 1 489 45 99 48 Comoros* 67 94 1 3 1 3 67 4 5 Congo Cook Islnds* 2 5 5 1 1 Cost Ric 42 88 6 5 6 5 42 69 Croti 516 44 13 1 42 6 17 Cub 747 84 1 1 5 18 28 58 57 6 67 Curço 2 1 Cyprus 4 5 5 45 Czech Republic 468 69 21 7 4 29 83 3 33 Côte d'ivoire* 23 796 8 2 11 6 2 1 53 64 Democrtic People's Republic of Kore 97 665 92 3 3 2 1 7 247 83 5 86 Democrtic Republic of the Congo* 112 439 87 1 4 3 5 1 164 66 134 64 Denmrk 329 59 1 3 1 37 25 48 7 43 Djibouti 1 383 75 1 1 13 1 Dominic 3 1 2 1 1 1 Dominicn Republic 2 898 83 3 5 8 1 162 51 263 65 1 72 * Relpses included in the previously treted cohort. All clcultions re mde before numbers re rounded, so the totl of ll outcomes my not lwys pper s 1%. HIV-positive TB, 213 RR-/MDR-TB, 212 Success (%) Cohort (Number) Success (%) Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 177

TABLE A4.5 Tretment outcomes by TB cse type, 213 nd tretment outcomes for RR-/MDR-TB cses, 212 Cohort (Number) Previously treted, excluding relpse, New nd relpse, 213 213 Lost to Not Success Filed Died follow-up evluted Cohort Success Cohort Success Cohort (%) (%) (%) (%) (%) (Number) (%) (Number) (%) (Number) HIV-positive TB, 213 RR-/MDR-TB, 212 Ecudor 5 277 75 2 5 6 12 197 53 243 54 Egypt 7 876 86 1 3 4 5 37 72 7 29 52 63 El Slvdor 2 176 93 5 2 17 76 23 69 1 1 Equtoril Guine 1 152 62 2 7 3 59 53 259 57 Eritre 2 862 89 1 6 3 2 17 77 147 79 1 1 Estoni 226 87 9 3 1 6 29 66 5 76 Ethiopi* 43 86 89 3 2 5 271 83 Fiji 248 77 1 8 7 6 14 64 4 75 Finlnd 265 53 12 35 6 17 Success (%) Frnce French Polynesi* 44 93 5 2 8 88 Gbon 3 861 55 1 1 35 8 628 41 Gmbi* 1 431 86 2 5 3 4 Georgi 3 98 8 2 3 1 5 779 69 31 68 623 48 Germny 4 29 67 11 3 19 192 6 6 47 Ghn 15 43 85 1 1 3 563 77 2 737 73 2 1 Greece Greenlnd Grend 1 1 Gum 48 92 6 2 Guteml* 2 978 84 1 7 8 1 36 67 243 62 39 69 Guine 11 313 79 6 5 5 5 1 959 75 15 8 Guine-Bissu 2 236 77 1 9 4 9 22 5 4 Guyn 68 67 2 11 19 1 16 47 139 63 Hiti* 16 557 81 1 5 1 3 483 75 2 857 71 62 76 Hondurs* 1 924 89 1 6 4 185 81 263 72 5 4 Hungry 1 3 74 11 6 9 5 6 9 33 Icelnd 11 91 9 Indi 1 243 95 88 1 4 6 1 171 712 66 44 27 76 14 51 46 Indonesi 325 582 88 2 5 4 1 521 64 2 438 49 432 54 Irn (Islmic Republic of) 1 884 87 2 8 2 1 35 82 284 66 62 48 Irq 8 554 88 1 3 2 7 329 79 66 47 Irelnd 346 59 5 2 34 26 62 8 12 4 1 Isrel 35 84 6 4 6 14 71 13 92 Itly Jmic 14 77 3 8 12 16 81 Jpn* 15 941 54 17 7 23 1 8 46 3 4 Jordn 327 88 2 3 5 1 22 86 12 5 Kzkhstn 14 456 89 3 5 2 1 464 63 34 59 7 213 73 Keny* 81 255 86 6 5 3 8 445 78 31 755 79 197 83 Kiribti 394 86 8 5 1 16 88 Kuwit 73 82 1 4 13 4 75 Kyrgyzstn* 5 658 85 1 4 5 4 1 13 76 775 63 Lo People's Democrtic Republic 3 937 87 1 7 3 2 46 5 13 38 Ltvi 84 83 9 6 1 21 81 79 67 9 63 Lebnon 689 71 1 5 23 4 5 7 86 Lesotho* 9 119 7 1 14 8 6 1 619 62 7 683 66 146 64 Liberi 3 534 4 1 4 9 46 14 64 795 52 Liby 1 345 59 1 36 3 71 2 52 27 Lithuni 1 392 8 1 1 7 3 57 37 21 43 219 41 Luxembourg 38 3 97 Mdgscr* 24 182 82 1 5 9 4 2 243 75 Mlwi 17 779 82 1 1 2 6 19 63 Mlysi 23 346 76 9 5 11 654 46 1 51 51 74 3 Mldives 113 84 4 1 12 4 75 2 5 Mli 5 81 74 2 8 9 7 191 76 12 67 Mlt 49 76 2 6 16 Mrshll Islnds 153 89 6 5 1 1 1 4 75 Muritni 2 137 71 1 3 1 15 2 58 71 1 Muritius 13 88 5 5 2 23 65 Mexico 2 78 8 1 8 6 4 638 55 1 23 48 133 74 Micronesi (Federted Sttes of) 129 91 1 4 1 4 5 2 5 1 * Relpses included in the previously treted cohort. All clcultions re mde before numbers re rounded, so the totl of ll outcomes my not lwys pper s 1%. 178 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

TABLE A4.5 Tretment outcomes by TB cse type, 213 nd tretment outcomes for RR-/MDR-TB cses, 212 Cohort (Number) Previously treted, excluding relpse, New nd relpse, 213 213 Lost to Not Success Filed Died follow-up evluted Cohort Success Cohort Success Cohort (%) (%) (%) (%) (%) (Number) (%) (Number) (%) (Number) HIV-positive TB, 213 RR-/MDR-TB, 212 Success (%) Monco Mongoli 4 22 89 4 2 3 2 395 79 5 6 179 61 Montenegro* 119 87 8 3 2 1 2 1 1 1 Montserrt Morocco 29 144 89 1 2 8 77 66 7 33 Mozmbique* 23 72 88 1 6 3 2 214 28 Mynmr* 135 614 87 2 4 5 1 7 147 71 443 79 Nmibi* 8 418 86 2 6 4 1 2 192 71 4 343 81 28 68 Nuru 3 67 33 Nepl 33 877 91 1 3 2 3 456 74 238 76 Netherlnds 816 88 3 2 6 12 75 17 76 11 73 New Cledoni* 47 6 4 1 1 New Zelnd 269 84 7 2 7 5 8 4 25 Nicrgu* 1 438 84 2 3 8 2 72 69 1 9 Niger* 1 795 79 1 6 9 4 635 73 43 86 Nigeri* 91 997 86 1 6 5 2 8 44 83 7 481 8 154 62 Niue Northern Mrin Islnds 33 82 3 3 3 9 1 1 Norwy 357 89 1 2 1 8 38 79 8 75 6 33 Omn 33 96 4 5 1 6 83 Pkistn 289 376 93 1 1 4 1 7 217 8 37 81 858 71 Plu* 8 88 12 1 Pnm 1 456 8 1 7 12 92 48 222 68 12 42 Ppu New Guine* 3 617 67 3 4 17 1 587 57 85 55 Prguy 2 254 68 1 8 5 19 162 48 181 34 7 57 Peru* 17 265 79 1 4 6 1 2 82 59 1 16 57 1 122 6 Philippines 216 25 9 1 2 4 3 2 924 86 1 798 43 Polnd 7 11 59 9 8 24 199 42 31 13 Portugl 2 336 74 7 3 17 52 56 249 54 19 47 Puerto Rico* 49 73 22 2 2 1 6 1 Qtr 469 85 14 Republic of Kore 4 794 82 7 6 4 3 257 74 1 212 6 Republic of Moldov 3 889 8 3 9 7 1 357 39 247 52 856 59 Romni 15 188 85 2 7 6 925 45 25 58 638 34 Russin Federtion 83 31 68 9 9 7 7 6 934 39 16 21 4 Rwnd 5 71 85 2 1 2 1 278 75 1 448 76 58 98 Sint Kitts nd Nevis Sint Luci* 16 1 Sint Vincent nd the Grendines* Smo 23 83 13 4 1 Sn Mrino So Tome nd Principe 147 73 5 13 7 1 3 6 5 8 Sudi Arbi 3 435 56 5 15 24 127 39 77 17 2 25 Senegl 13 18 87 1 5 5 2 329 74 826 44 29 76 Serbi 1 427 78 1 8 7 6 49 69 19 84 6 5 Seychelles 24 79 17 4 1 1 Sierr Leone* 7 795 87 1 3 5 4 324 71 Singpore 2 142 77 9 1 14 8 75 51 86 22 55 Sint Mrten (Dutch prt)* 2 1 2 1 Slovki 395 94 1 4 1 2 3 67 1 Sloveni 139 77 19 4 1 1 Solomon Islnds 361 94 1 5 8 1 Somli 12 994 86 1 4 2 7 312 43 195 69 South Afric 321 87 78 7 6 8 18 292 69 191 189 76 8 84 49 South Sudn 7 24 72 1 4 12 12 559 58 71 62 Spin 5 29 75 4 2 298 67 283 58 Sri Lnk 9 1 85 1 6 5 4 167 62 37 24 8 88 Sudn 17 396 82 1 4 1 3 514 71 52 62 Surinme 136 77 1 1 4 5 2 31 65 Swzilnd 7 191 75 3 14 5 3 538 66 5 773 71 Sweden 597 9 4 1 5 34 82 12 83 Switzerlnd * Relpses included in the previously treted cohort. All clcultions re mde before numbers re rounded, so the totl of ll outcomes my not lwys pper s 1%. Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 179

TABLE A4.5 Tretment outcomes by TB cse type, 213 nd tretment outcomes for RR-/MDR-TB cses, 212 Cohort (Number) Previously treted, excluding relpse, New nd relpse, 213 213 Lost to Not Success Filed Died follow-up evluted Cohort Success Cohort Success Cohort (%) (%) (%) (%) (%) (Number) (%) (Number) (%) (Number) HIV-positive TB, 213 RR-/MDR-TB, 212 Syrin Arb Republic 2 739 8 1 2 17 1 112 75 1 1 7 Tjikistn 5 263 88 3 5 4 1 812 82 122 66 535 66 Thilnd 65 867 81 1 7 5 6 1 812 66 7 665 67 Success (%) The Former Yugoslv Republic of Mcedoni 317 91 7 2 5 1 3 67 Timor-Leste 3 718 84 2 11 3 11 91 4 75 Togo 2 644 88 1 6 3 1 5 82 18 3 1 Tokelu Tong 1 9 1 Trinidd nd Tobgo 25 62 1 15 15 6 3 33 56 34 Tunisi 3 32 91 1 2 2 4 35 86 17 1 15 73 Turkey 13 17 86 5 3 6 239 38 32 53 291 66 Turkmenistn* 3 46 72 4 4 3 17 629 26 Turks nd Cicos Islnds 2 1 Tuvlu 18 78 11 11 2 1 US Virgin Islnds Ugnd 44 65 75 1 8 12 4 2 572 67 16 762 73 41 8 Ukrine 29 726 71 9 1 9 1 9 149 55 7 553 44 5 556 34 United Arb Emirtes 81 75 11 14 3 67 2 5 2 5 United Kingdom of Gret Britin nd Northern Irelnd 7 293 82 5 5 9 496 75 78 54 United Republic of Tnzni 64 53 91 6 1 2 1 679 79 2 32 72 45 73 United Sttes of Americ* 8 89 83 1 6 1 9 448 78 552 75 27 59 Uruguy 878 79 13 8 18 67 119 61 1 1 Uzbekistn 17 373 83 3 5 5 3 4 34 78 1 491 49 Vnutu 123 85 4 7 3 Venezuel (Bolivrin Republic of) 6 481 81 6 11 1 237 59 581 8 21 52 Viet Nm 12 196 89 1 3 7 4 453 71 713 71 Wllis nd Futun Islnds* 2 1 West Bnk nd Gz Strip 33 91 3 3 3 Yemen 1 325 9 2 4 4 42 62 Zmbi 39 899 85 5 4 5 4 984 8 1 27 Zimbbwe* 35 278 8 1 1 3 6 234 75 WHO regions Africn Region 1 165 7 79 1 6 5 9 7 144 7 326 597 7 1 246 53 Region of the Americs 2 742 75 1 7 8 9 14 753 48 19 816 53 2 866 57 Estern Mediterrnen Region 431 622 91 1 2 4 3 11 281 76 681 6 1 271 65 Europen Region 243 828 76 5 7 6 6 3 35 58 9 529 47 37 71 49 South-Est Asi Region 2 1 58 88 1 4 5 2 196 439 67 54 235 74 15 743 48 Western Pcific Region 1 298 42 92 1 2 2 4 18 523 81 1 756 73 6 176 51 Globl 5 44 172 86 1 4 4 4 341 445 67 421 614 69 74 3 5 * Relpses included in the previously treted cohort. All clcultions re mde before numbers re rounded, so the totl of ll outcomes my not lwys pper s 1%. 18 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

TABLE A4.6 Mesured percentge of TB cses with MDR-TB, most recent yer vilble New TB cses Previously treted TB cses Yer Source Coverge Percentge Yer Source Coverge Percentge Afghnistn Albni 212 Surveillnce Ntionl.58 (<.1 3.2) 212 Surveillnce Ntionl ( 22) Algeri 22 Survey Ntionl 1.4 (.6 2.7) 22 Survey Ntionl 9.1 (1.1 29) Americn Smo Andorr 214 Surveillnce Ntionl ( 71) 214 Surveillnce Ntionl ( 98) Angol Anguill Antigu nd Brbud Argentin 25 Survey Ntionl 2.2 (1.2 3.6) 25 Survey Ntionl 15 (9.8 23) Armeni 27 Survey Ntionl 9.4 (7. 12) 27 Survey Ntionl 43 (38 49) Arub Austrli 214 Surveillnce Ntionl 1.7 (.86 3.) 214 Surveillnce Ntionl 1 (2.8 24) Austri 214 Surveillnce Ntionl 2.7 (1.1 5.5) 214 Surveillnce Ntionl 37 (16 62) Azerbijn 213 Survey Ntionl 13 (1 16) 213 Survey Ntionl 28 (22 34) Bhms 212 Surveillnce Ntionl 3.7 (<.1 19) 213 Surveillnce Ntionl ( 71) Bhrin 212 Surveillnce Ntionl 1.9 (.39 5.4) 212 Surveillnce Ntionl 1 (2.5 1) Bngldesh 211 Survey Ntionl 1.4 (.7 2.5) 211 Survey Ntionl 29 (24 34) Brbdos 214 Surveillnce Ntionl ( 71) 214 Surveillnce Ntionl ( ) Belrus 214 Surveillnce Ntionl 34 (32 36) 214 Surveillnce Ntionl 69 (66 72) Belgium 213 Surveillnce Ntionl 1.8 (.71 3.6) 213 Surveillnce Ntionl 2.4 (<.1 13) Belize 213 Surveillnce Ntionl 1 (29 1) Benin 21 Survey Ntionl.5 (.1 2.) 214 Surveillnce Ntionl 4.8 (2.1 9.3) Bermud 212 Surveillnce Ntionl ( 84) 212 Surveillnce Ntionl ( ) Bhutn 211 Survey Ntionl 35 (21 52) Bolivi (Plurintionl Stte of) 214 Surveillnce Ntionl 1 (7.7 13) Bonire, Sint Eusttius nd Sb 211 Surveillnce Ntionl 1 (2.5 1) Bosni nd Herzegovin 213 Surveillnce Ntionl (.57) 213 Surveillnce Ntionl 1.6 (<.1 8.5) Botswn 28 Survey Ntionl 2.5 (1.5 3.5) 28 Survey Ntionl 6.6 (2.4 11) Brzil 28 Survey Sub-ntionl 1.4 (1. 1.8) 28 Survey Sub-ntionl 7.5 (5.7 9.9) British Virgin Islnds Brunei Drusslm 214 Surveillnce Ntionl.88 (<.1 4.8) 214 Surveillnce Ntionl ( 52) Bulgri 212 Surveillnce Ntionl 2.3 (1.3 3.8) 212 Surveillnce Ntionl 23 (17 31) Burkin Fso Burundi Cbo Verde Cmbodi 27 Survey Ntionl 1.4 (.7 2.5) 27 Survey Ntionl 11 (4. 22) Cmeroon Cnd 213 Surveillnce Ntionl 1.4 (.7 2.4) 213 Surveillnce Ntionl 4.6 (.96 13) Cymn Islnds 213 Surveillnce Ntionl ( 71) 213 Surveillnce Ntionl ( ) Centrl Africn Republic 29 Survey Sub-ntionl.4 ( 2.5) Chd Chile 214 Surveillnce Ntionl 1.2 (.68 2.1) 214 Surveillnce Ntionl.56 (<.1 3.1) Chin 27 Survey Ntionl 5.7 (4.5 7.) 27 Survey Ntionl 26 (22 3) Chin, Hong Kong SAR 212 Surveillnce Ntionl.97 (.59 1.5) 212 Surveillnce Ntionl 2.6 (.95 5.5) Chin, Mco SAR 214 Surveillnce Ntionl 1.7 (.48 4.4) 214 Surveillnce Ntionl 19 (5.4 42) Colombi 25 Survey Ntionl 2.4 (1.6 3.6) 212 Surveillnce Ntionl 13 (9.6 17) Comoros Congo Cook Islnds 213 Surveillnce Ntionl ( 98) 213 Surveillnce Ntionl ( ) Cost Ric 26 Survey Ntionl 1.5 (.42 3.8) 212 Surveillnce Ntionl 4.5 (.12 23) Croti 214 Surveillnce Ntionl ( 1.3) 214 Surveillnce Ntionl 6.9 (.85 23) Cub 212 Surveillnce Ntionl.74 (<.1 2.7) 214 Surveillnce Ntionl 4.2 (.51 14) Curço 214 Surveillnce Ntionl ( 6) 214 Surveillnce Ntionl ( ) Cyprus 213 Surveillnce Ntionl ( 15) 213 Surveillnce Ntionl 1 (2.5 1) Czech Republic 213 Surveillnce Ntionl ( 1.3) 213 Surveillnce Ntionl ( 31) Côte d'ivoire 26 Survey Ntionl 2.5 (1.1 4.9) Democrtic People's Republic of Kore 214 Survey Sub-ntionl 1.9 (.8 3.9) 214 Survey Sub-ntionl 15 (8.8 24) Democrtic Republic of the Congo Denmrk 213 Surveillnce Ntionl.51 (<.1 2.8) 213 Surveillnce Ntionl 5 (.13 25) Empty rows indicte n bsence of high-qulity survey or surveillnce dt. In the bsence of high-qulity ntionl dt, high-qulity sub-ntionl dt re used. Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 181

TABLE A4.6 Mesured percentge of TB cses with MDR-TB, most recent yer vilble New TB cses Previously treted TB cses Yer Source Coverge Percentge Yer Source Coverge Percentge Djibouti Dominic 213 Surveillnce Ntionl ( ) 213 Surveillnce Ntionl ( ) Dominicn Republic Ecudor 22 Survey Ntionl 4.9 (3.5 6.7) 212 Surveillnce Ntionl 26 (23 29) Egypt 211 Survey Ntionl 3.4 (1.9 4.9) 213 Surveillnce Ntionl 15 (12 18) El Slvdor 21 Survey Ntionl.33 (<.1 1.2) 214 Surveillnce Ntionl ( 4.3) Equtoril Guine Eritre Estoni 214 Surveillnce Ntionl 19 (14 27) 214 Surveillnce Ntionl 62 (42 79) Ethiopi 25 Survey Ntionl 1.6 (.86 2.8) 25 Survey Ntionl 12 (5.6 21) Fiji 26 Surveillnce Ntionl ( 8.2) 26 Surveillnce Ntionl ( 98) Finlnd 214 Surveillnce Ntionl 2.7 (.73 6.7) 214 Surveillnce Ntionl 2 (.51 72) Frnce 29 Surveillnce Ntionl.45 (.24.77) 29 Surveillnce Ntionl 13 (7.4 21) French Polynesi 214 Surveillnce Ntionl ( 13) 214 Surveillnce Ntionl ( 98) Gbon Gmbi 2 Survey Ntionl.48 (<.1 2.6) 2 Survey Ntionl ( 18) Georgi 214 Surveillnce Ntionl 12 (1 13) 214 Surveillnce Ntionl 39 (35 44) Germny 214 Surveillnce Ntionl 2.9 (1.3 5.7) 214 Surveillnce Ntionl 17 (11 25) Ghn Greece 21 Surveillnce Ntionl 1.5 (<.1 8.) 21 Surveillnce Ntionl 9.1 (.23 41) Greenlnd Grend Gum 212 Surveillnce Ntionl ( 11) 212 Surveillnce Ntionl ( ) Guteml 22 Survey Ntionl 3 (1.8 4.6) 22 Survey Ntionl 26 (2 34) Guine Guine-Bissu Guyn Hiti Hondurs 24 Survey Ntionl 1.8 (.76 3.4) 24 Survey Ntionl 12 (5.8 22) Hungry 21 Surveillnce Ntionl 2.5 (1.3 4.3) 21 Surveillnce Ntionl 8.1 (3.3 16) Icelnd 214 Surveillnce Ntionl ( 71) 214 Surveillnce Ntionl ( 98) 21, Indi 24, 26, Multiple surveys 2.2 (1.9 2.6) 26, 29 Multiple surveys 15 (11 19) 29 Indonesi 24, 26, 21 Multiple surveys 1.9 (1.4 2.5) 26, 21 Multiple surveys 12 (8.1 17) Irn (Islmic Republic of) 214 Survey Ntionl.8 (.3 1.4) 214 Survey Ntionl 12 (6.2 19) Irq 213 Survey Ntionl 1.1 (.3 1.8) 213 Survey Ntionl 2 (13 27) Irelnd 214 Surveillnce Ntionl 1.6 (.2 5.8) 214 Surveillnce Ntionl ( 26) Isrel 214 Surveillnce Ntionl 6.6 (3.5 11) 214 Surveillnce Ntionl 5 (6.8 93) Itly 212 Surveillnce Ntionl 2.6 (1.4 4.6) 213 Surveillnce Ntionl 4.2 (1.7 8.4) Jmic 213 Surveillnce Ntionl 2.4 (<.1 13) 213 Surveillnce Ntionl ( ) Jpn 22 Surveillnce Ntionl.7 (.42 1.1) 22 Surveillnce Ntionl 9.8 (7.1 13) Jordn 29 Surveillnce Ntionl 6.3 (2.4 13) 29 Surveillnce Ntionl 29 (3.7 71) Kzkhstn 213 Surveillnce Ntionl 26 (25 27) 213 Surveillnce Ntionl 58 (57 59) Keny 214 Surveillnce Ntionl 14 (12 15) Kiribti Kuwit 214 Surveillnce Ntionl 2.2 (.89 4.5) 214 Surveillnce Ntionl ( 98) Kyrgyzstn 211 Survey Ntionl 26 (23 31) 213 Surveillnce Ntionl 55 (52 58) Lo People's Democrtic Republic Ltvi 214 Surveillnce Ntionl 8.2 (5.8 11) 214 Surveillnce Ntionl 3 (21 4) Lebnon 23 Survey Ntionl 1 (.13 3.8) 213 Surveillnce Ntionl 29 (3.7 71) Lesotho 214 Survey Ntionl 3.2 (2.2 4.1) 214 Survey Ntionl 7.3 (4.2 1) Liberi Liby Lithuni 214 Surveillnce Ntionl 14 (12 16) 214 Surveillnce Ntionl 49 (43 55) Luxembourg 214 Surveillnce Ntionl ( ) 214 Surveillnce Ntionl ( ) Mdgscr 27 Survey Ntionl.49 (.13 1.3) 27 Survey Ntionl 3.9 (.48 13) Mlwi 211 Survey Ntionl.42 (.14.97) 211 Survey Ntionl 4.8 (3.2 6.9) 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. 182 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

TABLE A4.6 Mesured percentge of TB cses with MDR-TB, most recent yer vilble New TB cses Previously treted TB cses Yer Source Coverge Percentge Yer Source Coverge Percentge Mlysi 214 Surveillnce Ntionl.4 (.24.63) 214 Surveillnce Ntionl 1.1 (.24 3.3) Mldives Mli Mlt 212 Surveillnce Ntionl ( 25) 214 Surveillnce Ntionl ( 98) Mrshll Islnds 214 Surveillnce Ntionl ( 8.) 214 Surveillnce Ntionl ( 41) Muritni Muritius 214 Surveillnce Ntionl ( 3.2) 214 Surveillnce Ntionl 33 (.84 91) Mexico 29 Survey Ntionl 2.4 (2.1 2.8) 29 Survey Ntionl 6.5 (5.1 7.8) Micronesi (Federted Sttes of) Monco Mongoli 27 Survey Ntionl 1.4 (.7 2.5) 213 Surveillnce Ntionl 34 (29 38) Montenegro 214 Surveillnce Ntionl ( 5.7) 214 Surveillnce Ntionl 4 (5.3 85) Montserrt Morocco 214 Survey Ntionl 1 (.3 1.7) 214 Survey Ntionl 8.7 (4.8 13) Mozmbique 27 Survey Ntionl 3.5 (2.2 4.8) 27 Survey Ntionl 11 ( 25) Mynmr 213 Survey Ntionl 5 (3.1 6.8) 213 Survey Ntionl 27 (15 39) Nmibi 28 Survey Ntionl 3.8 (2.7 5.1) 28 Survey Ntionl 16 (13 21) Nuru Nepl 211 Survey Ntionl 2.2 (1.3 3.8) 211 Survey Ntionl 15 (1 23) Netherlnds 214 Surveillnce Ntionl.92 (.19 2.7) 214 Surveillnce Ntionl 13 (.32 53) New Cledoni 214 Surveillnce Ntionl ( 28) 214 Surveillnce Ntionl ( 84) New Zelnd 212 Surveillnce Ntionl.9 (.11 3.2) 212 Surveillnce Ntionl 17 (2.1 48) Nicrgu 26 Survey Ntionl.63 (<.1 2.2) 21 Surveillnce Ntionl 11 (6.2 17) Niger Nigeri 21 Survey Ntionl 2.9 (2.1 4.) 21 Survey Ntionl 14 (1 19) Niue Northern Mrin Islnds 214 Surveillnce Ntionl 5.3 (.13 26) 214 Surveillnce Ntionl ( 98) Norwy 213 Surveillnce Ntionl 2.2 (.61 5.6) 213 Surveillnce Ntionl 5.9 (.15 29) Omn 214 Surveillnce Ntionl 2.6 (.96 5.6) 214 Surveillnce Ntionl ( 41) Pkistn 213 Survey Ntionl 3.7 (2.5 5.) 213 Survey Ntionl 18 (13 23) Plu 213 Surveillnce Ntionl ( 41) 213 Surveillnce Ntionl ( ) Pnm Ppu New Guine 214 Survey Sub-ntionl 2.7 (1.1 4.3) 214 Survey Sub-ntionl 19 (8.5 3) Prguy 28 Survey Ntionl.3 ( 1.7) 28 Survey Ntionl 15 (6.1 28) Peru 214 Surveillnce Ntionl 5.3 (4.9 5.7) 214 Surveillnce Ntionl 2 (19 22) Philippines 212 Survey Ntionl 2 (1.4 2.7) 212 Survey Ntionl 21 (16 29) Polnd 214 Surveillnce Ntionl.44 (.26.7) 214 Surveillnce Ntionl 4.4 (2.6 6.8) Portugl 212 Surveillnce Ntionl.98 (.51 1.7) 212 Surveillnce Ntionl 4.9 (1.6 11) Puerto Rico 214 Surveillnce Ntionl ( 9.3) 214 Surveillnce Ntionl ( ) Qtr 214 Surveillnce Ntionl 1.3 (.16 4.7) Republic of Kore 24 Survey Ntionl 2.7 (2.1 3.4) 24 Survey Ntionl 14 (1 19) Republic of Moldov 212 Surveillnce Ntionl 24 (21 26) 212 Surveillnce Ntionl 62 (59 65) Romni 24 Survey Ntionl 2.8 (1.8 4.2) 24 Survey Ntionl 11 (8. 15) Russin Federtion 213 Oblsts 19 (14 25) 213 Oblsts 49 (4 59) Rwnd 214 Surveillnce Ntionl 2.2 (1.4 3.2) 214 Surveillnce Ntionl 5.1 (1.7 11) Sint Kitts nd Nevis Sint Luci 213 Surveillnce Ntionl ( ) 213 Surveillnce Ntionl ( ) Sint Vincent nd the Grendines 214 Surveillnce Ntionl ( ) Smo 213 Surveillnce Ntionl ( 28) 213 Surveillnce Ntionl ( ) Sn Mrino So Tome nd Principe 212 Surveillnce Ntionl 88 (47 1) Sudi Arbi 21 Survey Ntionl 1.8 (1.4 2.4) 21 Survey Ntionl 16 (12 21) Senegl 214 Survey Ntionl.4 (.8) 214 Survey Ntionl 16 (9.3 23) Serbi 213 Surveillnce Ntionl.85 (.31 1.8) 213 Surveillnce Ntionl 4.7 (1.3 11) Seychelles 214 Surveillnce Ntionl ( 41) 214 Surveillnce Ntionl ( ) Sierr Leone Singpore 214 Surveillnce Ntionl 1.1 (.54 1.9) 214 Surveillnce Ntionl 1.3 (<.1 7.1) Sint Mrten (Dutch prt) Slovki 212 Surveillnce Ntionl ( 2.6) 212 Surveillnce Ntionl 3.7 (<.1 19) Empty rows indicte n bsence of high-qulity survey or surveillnce dt. In the bsence of high-qulity ntionl dt, high-qulity sub-ntionl dt re used. Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 183

TABLE A4.6 Mesured percentge of TB cses with MDR-TB, most recent yer vilble New TB cses Previously treted TB cses Yer Source Coverge Percentge Yer Source Coverge Percentge Sloveni 214 Surveillnce Ntionl ( 4.1) 214 Surveillnce Ntionl ( 41) Solomon Islnds 214 Surveillnce Ntionl ( ) Somli 211 Survey Ntionl 5.2 (2.7 7.7) 211 Survey Ntionl 41 (23 58) South Afric 22 Survey Ntionl 1.8 (1.4 2.3) 22 Survey Ntionl 6.7 (5.4 8.2) South Sudn Spin 21, 25 Multiple surveys.22 (<.1.8) 21, 25 Multiple surveys 7.1 (3.3 13) Sri Lnk 26 Survey Ntionl.18 (.99) 213 Surveillnce Ntionl.58 (<.1 2.1) Sudn Surinme Swzilnd 29 Survey Ntionl 7.7 (4.8 11) 29 Survey Ntionl 34 (28 39) Sweden 214 Surveillnce Ntionl 3 (1.4 5.6) 214 Surveillnce Ntionl 11 (1.3 33) Switzerlnd 214 Surveillnce Ntionl 3.1 (1. 7.) 214 Surveillnce Ntionl 14 (4. 33) Syrin Arb Republic 23 Survey Ntionl 6.2 (3.9 9.3) 211 Surveillnce Ntionl 31 (21 44) Tjikistn 214 Surveillnce Ntionl 8.1 (6.9 9.4) 214 Surveillnce Ntionl 52 (47 57) Thilnd 212 Survey Ntionl 2 (1.4 2.8) 212 Survey Ntionl 19 (14 25) The Former Yugoslv Republic of Mcedoni 214 Surveillnce Ntionl 1.4 (.17 4.9) 214 Surveillnce Ntionl ( 2) Timor-Leste Togo 213 Surveillnce Ntionl 26 (15 4) Tokelu Tong Trinidd nd Tobgo Tunisi 212 Survey Ntionl.8 ( 1.7) 212 Survey Ntionl 12 (4.5 19) Turkey 213 Surveillnce Ntionl 2.5 (2.1 3.) 213 Surveillnce Ntionl 18 (15 21) Turkmenistn 213 Survey Ntionl 14 (11 17) 213 Survey Ntionl 38 (3 45) Turks nd Cicos Islnds Tuvlu US Virgin Islnds Ugnd 211 Survey Ntionl 1.4 (.6 2.2) 211 Survey Ntionl 12 (6.8 19) Ukrine 214 Survey Ntionl 22 (2 24) 214 Survey Ntionl 56 (5 61) United Arb Emirtes 213 Surveillnce Ntionl ( 52) United Kingdom of Gret Britin nd Northern Irelnd 214 Surveillnce Ntionl 1.2 (.81 1.7) 214 Surveillnce Ntionl 3.6 (1.3 7.7) United Republic of Tnzni 27 Survey Ntionl 1.1 (.5 2.) 27 Survey Ntionl 3.1 (.9 7.9) United Sttes of Americ 214 Surveillnce Ntionl 1.1 (.84 1.4) 214 Surveillnce Ntionl 7.4 (4.7 11) Uruguy 212 Surveillnce Ntionl (.79) 212 Surveillnce Ntionl 2.4 (<.1 13) Uzbekistn 211 Survey Ntionl 23 (18 29) 211 Survey Ntionl 62 (52 71) Vnutu 26 Surveillnce Ntionl ( 12) Venezuel (Bolivrin Republic of) Viet Nm 212 Survey Ntionl 4 (2.5 5.4) 212 Survey Ntionl 23 (17 3) Wllis nd Futun Islnds West Bnk nd Gz Strip Yemen 211 Survey Ntionl 1.7 (.5 3.) 211 Survey Ntionl 15 (8.1 22) Zmbi 28 Survey Ntionl.3 (<.1 1.2) 28 Survey Ntionl 8.1 (4.1 14) Zimbbwe Empty rows indicte n bsence of high-qulity survey or surveillnce dt. In the bsence of high-qulity ntionl dt, high-qulity sub-ntionl dt re used. 184 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

TABLE A4.7 Drug susceptibility testing for TB cses, estimted MDR-TB mong notified TB cses, RR-/MDR-TB cses detected, nd enrolments on MDR-TB tretment, 214 Confirmed new TB cses tested for RR-/MDR-TB Notified previously treted TB cses tested for RR-/MDR-TB Estimted MDR-TB mong Confirmed RR-/MDR-TB cses Cses enrolled on MDR-TB tretment (Number) (%) b (Number) (%) b notified pulmonry cses (Number) (% of estimted) c (Number)(% of notified) d Afghnistn 2 <.1 184 8.5 1 1 (85 1 4) 88 8 88 1 Albni 21 13 8 38 1 ( 4.) 3 >1 Algeri 59 7.1 178 32 17 (53 29) 65 38 56 86 Americn Smo Andorr 4 >1 1 1 ( ) 2 Angol 29.13 278 6.4 1 5 (63 2 5) 37 2 614 >1 Anguill 1 1 ( ) Antigu nd Brbud ( ) Argentin 1 894 36 546 41 36 (24 48) 114 32 78 68 Armeni 343 96 5 17 16 (14 19) 111 69 12 >1 Arub ( ) 2 Austrli 954 >1 55 79 19 (1 29) 24 >1 23 96 Austri 314 81 2 62 23 (12 34) 5 >1 3 6 Azerbijn 2 59 >1 3 91 >1 1 3 (1 1 1 5) 1 7 77 814 81 Bhms 21 84 2 5 2 ( 5.) Bhrin Bngldesh 12 573 12 4 959 51 4 8 (3 4 6 2) 994 21 945 95 Brbdos 3 1 ( 3.) Belrus 1 99 97 877 84 1 7 (1 6 1 8) 1 282 75 1 93 >1 Belgium 56 95 53 73 13 (4. 22) 12 92 1 83 Belize 2 6.1 2 12 19 (18 19) 1 Benin 81 2.6 185 82 28 ( 6) 25 89 16 64 Bermud ( ) Bhutn 38 84 44 62 37 (26 48) 61 >1 122 >1 Bolivi (Plurintionl Stte of) 238 4.3 51 8 21 (12 29) 11 52 55 5 Bonire, Sint Eusttius nd Sb ( ) Bosni nd Herzegovin 613 1 59 55 2 ( 5.) 4 >1 3 75 Botswn 1.45 62 6.4 16 (1 21) 41 26 73 >1 Brzil 1 8 (1 4 2 1) 72 39 72 1 British Virgin Islnds ( ) Brunei Drusslm 126 84 7 1 1 ( 4.) 1 1 1 1 Bulgri 639 8 11 45 72 (53 91) 44 61 29 66 Burkin Fso 6.16 273 48 17 (74 28) 53 31 34 64 Burundi 289 6.8 6 21 14 (42 24) 48 34 49 >1 Cbo Verde 8 (4. 13) 5 62 5 1 Cmbodi 646 5.3 1 329 67 52 (26 79) 11 21 11 1 Cmeroon 5 <.1 866 55 63 (22 1 ) 126 2 91 72 Cnd Cymn Islnds ( ) Centrl Africn Republic 92 1.8 74 ( 18) 4 54 21 52 Chd 217 26 31 (12 5) 22 7.1 12 55 Chile 1 127 76 179 7 23 (11 34) 23 1 1 43 Chin 45 664 19 17 21 54 52 (42 61 ) 5 87 11 2 846 49 Chin, Hong Kong SAR 2 328 96 277 58 44 (27 6) 34 77 22 65 Chin, Mco SAR 26 >1 23 79 1 (3. 17) 8 8 7 88 Colombi 3 484 49 535 48 36 (26 45) 187 52 173 93 Comoros 3 (1. 5.) Congo 477 >1 2 (57 35) 24 12 Cook Islnds ( 2.) Cost Ric 1 5.3 7 ( 13) 1 14 1 1 Croti 274 79 29 81 2 ( 6.) 2 1 3 >1 Cub 31 66 56 86 7 ( 14) 1 >1 1 1 Curço 4 1 ( 3.) Cyprus 17 55 1 33 3 (3. 3.) Czech Republic 323 99 18 45 ( ) 8 5 62 Côte d'ivoire 658 48 58 (25 9) 471 81 313 66 Democrtic People's Republic of Kore 81.23 364 2.3 3 8 (2 2 5 5) 197 5.2 212 >1 Democrtic Republic of the Congo 545.72 6 135 75 2 8 (98 4 5) 442 16 436 99 Bcteriologiclly confirmed pulmonry or extrpulmonry cses. b My be > 1% due to testing of extrpulmonry cses or indequte linkges between lbortory nd clinicl registers. c My be > 1% due to denomintor only including pulmonry MDR-TB cses, or if estimtes of MDR-TB re too low. d My be > 1% due to enrolment of cses without lbortory confirmtion of RR-/MDR-TB, or cses detected in previous clendr yers. Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 185

TABLE A4.7 Drug susceptibility testing for TB cses, estimted MDR-TB mong notified TB cses, RR-/MDR-TB cses detected, nd enrolments on MDR-TB tretment, 214 Confirmed new TB cses tested for RR-/MDR-TB Notified previously treted TB cses tested for RR-/MDR-TB (Number) (%) b (Number) (%) b Estimted MDR-TB mong notified pulmonry cses Confirmed RR-/MDR-TB cses Denmrk 197 98 18 67 3 ( 6.) 1 33 Cses enrolled on MDR-TB tretment (Number) (% of estimted) c (Number)(% of notified) d Djibouti 218 2 28 16 48 (2 75) 11 >1 6 55 Dominic 1 ( ) Dominicn Republic 24 9.1 176 31 15 (95 21) 93 62 127 >1 Ecudor 1 16 28 72 >1 31 (25 38) 451 >1 179 4 Egypt 45 1.2 358 6 25 (18 32) 86 34 72 84 El Slvdor 846 54 123 82 6 ( 16) 15 >1 15 1 Equtoril Guine 2.29 5 5.5 28 (2 36) 7 25 4 57 Eritre 52 (21 82) 22 42 24 >1 Estoni 175 >1 29 71 62 (48 75) 5 81 48 96 Ethiopi 2 45 6 7 682 1 3 (7 2 3) 53 39 557 >1 Fiji 12 11 3 7.5 ( ) 1 Finlnd 212 >1 5 38 7 (1. 14) 8 >1 9 >1 Frnce 3 358 >1 332 >1 56 (34 77) 111 >1 111 1 French Polynesi 31 84 1 33 ( ) Gbon 58 2.7 2.22 21 (1 31) 59 28 Gmbi 96 86 11 ( 41) 15 >1 9 6 Georgi 1 7 95 634 61 64 (59 7) 441 69 51 >1 Germny 273 1 127 42 14 (74 21) 9 64 Ghn 328 4.3 1 471 >1 4 (16 64) 93 23 14 15 Greece 12 34 12 34 9 ( 22) 4 44 Greenlnd Grend ( ) Gum 34 >1 1 1 ( ) 1 1 1 Guteml 353 17 151 69 13 (95 17) 62 48 42 68 Guine 114 1.8 181 38 23 (8 38) 15 46 124 >1 Guine-Bissu 83 5.4 58 >1 45 (11 79) 25 56 17 68 Guyn 6 2.1 41 27 28 (18 38) 4 14 4 1 Hiti 91 7.9 45 (26 64) 91 2 91 1 Hondurs 117 6.5 97 43 63 (3 96) 12 19 12 1 Hungry 339 >1 34 35 26 (14 37) 11 42 9 82 Icelnd 6 >1 1 1 ( ) Indi 12 795 1.7 214 29 69 71 (57 85 ) 25 748 36 24 73 93 Indonesi 1 58.55 8 445 88 6 8 (5 2 8 4) 1 812 27 1 284 71 Irn (Islmic Republic of) 1 135 2 237 35 13 (79 18) 48 37 53 >1 Irq 986 38 25 37 16 (11 21) 196 >1 58 3 Irelnd 173 >1 13 68 3 ( 7.) 2 67 2 1 Isrel 257 >1 4 67 2 (11 3) 17 85 17 1 Itly 1 178 221 93 Jmic 34 1 2 1 2 ( 6.) Jpn 7 861 65 481 41 19 (14 25) 81 43 56 69 Jordn 72 62 4 15 21 (7. 35) 9 43 9 1 Kzkhstn 9 597 >1 6 377 >1 4 9 (4 8 5 ) 5 877 >1 7 315 >1 Keny 17 619 5 7 436 85 2 5 (1 2 3 8) 644 26 544 84 Kiribti 22 79 22 (15 29) Kuwit 733 >1 1 1 11 (3. 19) 9 82 9 1 Kyrgyzstn 2 (1 8 2 1) 1 267 63 1 157 91 Lo People's Democrtic Republic 671 23 68 24 23 (16 3) 24 1 25 >1 Ltvi 483 99 17 86 84 (66 1) 71 85 7 99 Lebnon 299 98 4 >1 1 ( 2) 1 1 5 5 Lesotho 461 18 79 5.1 34 (26 42) 148 44 152 >1 Liberi 4 (12 68) Liby 31 (24 39) Lithuni 968 >1 294 1 3 (27 34) 279 93 271 97 Luxembourg 16 >1 ( ) 2 2 1 Mdgscr 492 21 2 (5. 38) 27 14 11 41 Mlwi 4.72 615 31 14 (86 2) 16 76 64 6 Mlysi 5 171 37 298 16 99 (57 14) 319 >1 6 19 Bcteriologiclly confirmed pulmonry or extrpulmonry cses. b My be > 1% due to testing of extrpulmonry cses or indequte linkges between lbortory nd clinicl registers. c My be > 1% due to denomintor only including pulmonry MDR-TB cses, or if estimtes of MDR-TB re too low. d My be > 1% due to enrolment of cses without lbortory confirmtion of RR-/MDR-TB, or cses detected in previous clendr yers. 186 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

TABLE A4.7 Drug susceptibility testing for TB cses, estimted MDR-TB mong notified TB cses, RR-/MDR-TB cses detected, nd enrolments on MDR-TB tretment, 214 Confirmed new TB cses tested for RR-/MDR-TB Notified previously treted TB cses tested for RR-/MDR-TB (Number) (%) b (Number) (%) b Estimted MDR-TB mong notified pulmonry cses Confirmed RR-/MDR-TB cses Cses enrolled on MDR-TB tretment (Number) (% of estimted) c (Number)(% of notified) d Mldives 3 3.3 2 2 (2. 2.) Mli 294 7.7 12 3.6 13 (51 21) 4 31 33 82 Mlt 24 >1 1 1 ( ) Mrshll Islnds 82 >1 7 41 ( ) Muritni 8.59 52 (21 84) 8 15 11 >1 Muritius 114 1 3 1 1 ( 3.) 1 1 1 1 Mexico 42.32 1 282 73 5 (44 56) 21 4 26 >1 Micronesi (Federted Sttes of) 63 >1 8 (4. 11) 1 12 Monco Mongoli 1 43 58 1 664 >1 22 (19 25) 318 >1 294 92 Montenegro 63 1 5 5 4 ( 8.) 2 5 2 1 Montserrt ( ) Morocco 424 3.4 358 14 34 (21 47) 115 34 123 >1 Mozmbique 886 3.6 96 22 2 1 (1 3 2 9) 544 26 482 89 Mynmr 1 295 24 15 166 >1 9 (6 5 12 ) 3 495 39 1 537 44 Nmibi 58 (47 69) 35 6 327 93 Nuru ( ) Nepl 2 292 14 1 71 26 1 2 (77 1 5) 46 34 349 86 Netherlnds 463 >1 11 58 6 ( 12) 7 >1 6 86 New Cledoni 11 92 2 1 ( ) New Zelnd 3 ( 6.) Nicrgu 9.62 68 2 5 (21 78) 19 38 2 >1 Niger 1 <.1 86 14 26 (97 41) 46 18 47 >1 Nigeri 3 3 (2 5 4 2) 798 24 423 53 Niue ( ) Northern Mrin Islnds 19 1 4 >1 1 ( 4.) 1 1 Norwy 213 88 16 73 7 (1. 14) 8 >1 Omn 271 >1 8 1 6 (1. 11) 8 >1 8 1 Pkistn 361.29 11 685 72 12 (8 8 15 ) 3 243 27 2 662 82 Plu 6 86 ( 5.) 1 1 1 Pnm 158 22 46 26 45 (28 61) 31 69 2 65 Ppu New Guine 89 (54 1 2) 32 36 32 1 Prguy 38 22 149 39 6 (18 1) 11 18 13 >1 Peru 12 949 73 3 375 83 2 (1 9 2 1) 1 463 73 1 671 >1 Philippines 4 415 4.7 2 196 67 11 (8 6 13 ) 3 27 2 68 89 Polnd 4 16 95 42 66 52 (35 69) 49 94 Portugl 822 65 76 49 21 (11 31) 26 >1 22 85 Puerto Rico 4 >1 ( 4.) Qtr 465 >1 2 ( 7.) 2 1 2 1 Republic of Kore 19 412 >1 4 299 54 1 8 (1 4 2 1) 1 172 65 856 73 Republic of Moldov 1 764 99 831 61 1 5 (1 4 1 6) 925 62 93 >1 Romni 5 751 73 2 171 64 65 (49 81) 578 89 648 >1 Russin Federtion 31 25 84 13 925 28 39 (33 45 ) 15 585 4 21 94 >1 Rwnd 1 449 36 172 28 13 (83 18) 82 63 81 99 Sint Kitts nd Nevis ( ) Sint Luci 6 >1 ( ) Sint Vincent nd the Grendines 4 1 1 1 ( ) Smo 1 >1 ( ) Sn Mrino So Tome nd Principe 5 7.1 2 11 18 (13 22) 2 11 2 1 Sudi Arbi 1 91 56 82 42 72 (58 86) 67 93 51 76 Senegl 3 694 4 1 335 >1 24 (15 33) 7 29 49 7 Serbi 63 7 54 37 18 (7. 29) 14 78 13 93 Seychelles 7 1 ( 3.) Sierr Leone 29 (93 48) Singpore 1 217 >1 93 61 2 (9. 32) 16 8 16 1 Sint Mrten (Dutch prt) ( ) Slovki 156 >1 38 81 2 ( 5.) 7 >1 2 29 Bcteriologiclly confirmed pulmonry or extrpulmonry cses. b My be > 1% due to testing of extrpulmonry cses or indequte linkges between lbortory nd clinicl registers. c My be > 1% due to denomintor only including pulmonry MDR-TB cses, or if estimtes of MDR-TB re too low. d My be > 1% due to enrolment of cses without lbortory confirmtion of RR-/MDR-TB, or cses detected in previous clendr yers. Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 187

TABLE A4.7 Drug susceptibility testing for TB cses, estimted MDR-TB mong notified TB cses, RR-/MDR-TB cses detected, nd enrolments on MDR-TB tretment, 214 Confirmed new TB cses tested for RR-/MDR-TB Notified previously treted TB cses tested for RR-/MDR-TB (Number) (%) b (Number) (%) b Estimted MDR-TB mong notified pulmonry cses Confirmed RR-/MDR-TB cses Cses enrolled on MDR-TB tretment (Number) (% of estimted) c (Number)(% of notified) d Sloveni 122 >1 7 1 ( ) Solomon Islnds 9 6.2 2 18 1 (6. 14) Somli 21.34 2 29 77 (51 1 ) 176 23 76 43 South Afric 6 2 (5 1 7 3) 18 734 >1 11 538 62 South Sudn 56 7.2 23 (95 36) 6 2.6 Spin 1 492 52 11 48 24 (9. 39) 39 >1 Sri Lnk 1 29 28 669 >1 14 ( 45) 42 >1 11 26 Sudn 24.39 13 5.8 54 (23 86) 82 15 74 9 Surinme 88 88 13 81 5 (3. 6.) 9 >1 Swzilnd 44 (32 56) 358 81 38 >1 Sweden 498 >1 23 53 15 (6. 24) 18 >1 15 83 Switzerlnd 231 85 35 7 16 (6. 27) 17 >1 Syrin Arb Republic 226 19 57 32 15 (1 19) 31 21 8 26 Tjikistn 2 432 1 8 64 88 (81 95) 92 >1 84 89 Thilnd 4 37 13 2 29 38 2 2 (1 7 2 7) 56 23 The Former Yugoslv Republic of Mcedoni 154 92 18 78 3 ( 6.) 3 1 3 1 Timor-Leste 198 99 99 (87 11) 3 3 3 1 Togo 1 <.1 18 11 77 (39 12) 9 12 1 11 Tokelu ( ) Tong 1 ( 1.) Trinidd nd Tobgo 43 34 15 29 1 (8. 12) 1 Tunisi 1 9 96 43 59 19 (7. 3) 14 74 14 1 Turkey 4 866 84 63 56 36 (32 41) 349 97 257 74 Turkmenistn 31 16 162 31 45 (39 52) 21 47 21 1 Turks nd Cicos Islnds ( ) Tuvlu 1 (1. 1.) US Virgin Islnds Ugnd 1 958 7.5 737 18 1 (62 1 4) 255 26 213 84 Ukrine 13 833 97 9 77 69 13 (12 14 ) 7 735 6 8 21 >1 United Arb Emirtes 26 7 3 6 1 ( 1.) 1 1 1 1 United Kingdom of Gret Britin nd Northern Irelnd 3 82 >1 29 46 59 (39 79) 63 >1 6 95 United Republic of Tnzni 9 56 4 882 34 6 (24 95) 516 86 143 28 United Sttes of Americ 6 557 >1 322 7 11 (88 14) 18 98 17 99 Uruguy 37 69 35 39 2 ( 6.) 2 1 2 1 Uzbekistn 11 956 >1 5 888 77 7 (6 1 7 9) 4 955 71 3 665 74 Vnutu ( ) Venezuel (Bolivrin Republic of) 266 7.5 186 34 15 (11 2) 26 17 26 1 Viet Nm 2 756 5.5 8 511 96 5 1 (3 9 6 3) 2 198 43 1 532 7 Wllis nd Futun Islnds ( ) West Bnk nd Gz Strip 2 (1. 2.) Yemen 996 34 62 24 14 (65 22) 53 38 5 94 Zmbi 61 (26 96) Zimbbwe 341 3 237 6.4 94 (43 1 5) 412 44 381 92 WHO regions Africn Region 4 94 6.4 31 952 33 32 (15 49 ) 25 654 8 17 352 68 Region of the Americs 3 537 24 8 724 32 7 (4 7 9 3) 3 745 54 3 568 95 Estern Mediterrnen Region 8 44 4.6 13 73 52 15 (12 19 ) 4 348 29 3 423 79 Europen Region 111 21 95 48 463 52 73 (63 83 ) 42 341 58 49 144 >1 South-Est Asi Region 45 56 3.8 247 336 67 99 (9 11 ) 33 264 34 28 536 86 Western Pcific Region 92 81 21 54 553 62 71 (47 94 ) 13 437 19 8 85 66 Globl 328 759 12 44 731 58 3 (22 37 ) 122 789 41 11 873 9 Bcteriologiclly confirmed pulmonry or extrpulmonry cses. b My be > 1% due to testing of extrpulmonry cses or indequte linkges between lbortory nd clinicl registers. c My be > 1% due to denomintor only including pulmonry MDR-TB cses, or if estimtes of MDR-TB re too low. d My be > 1% due to enrolment of cses without lbortory confirmtion of RR-/MDR-TB, or cses detected in previous clendr yers. 188 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

TABLE A4.8 HIV testing for TB ptients, provision of CPT nd ART to HIV-positive TB ptients, nd initition of IPT for people newly enrolled in HIV cre, 214 Totl TB ptients notified CPT = Cotrimoxzole preventive therpy. b ART = Anti-retrovirl therpy. c Initition of isonizid preventive therpy (IPT) for people newly enrolled in HIV cre. (Number) (%) (Number) (%) (Number) (%) (Number) (%) Afghnistn 32 712 1 443 32 4 <.1 7 Albni 48 41 1 2 4.9 2 1 2 1 Algeri 22 715 TB ptients with known HIV sttus HIV-positve TB ptients HIV-positive TB ptients on CPT HIV-positive TB ptients on ART b HIV-positive people provided IPT c Americn Smo Andorr 6 Angol 55 26 27 699 5 2 827 1 2 827 1 Anguill 1 1 1 1 1 1 1 1 1 Antigu nd Brbud 3 3 1 1 33 1 1 1 1 1 Argentin 1 38 1 58 16 447 28 Armeni 1 342 1 342 1 84 6.3 54 64 54 64 Arub 2 Austrli 1 343 1 69 8 17 1.6 Austri 582 Azerbijn 7 539 7 4 93 148 2.1 11 68 296 Bhms 5 28 56 1 36 4 4 8 8 Bhrin Bngldesh 196 797 1 11.56 45 4.1 45 1 45 1 Brbdos 5 2 4 2 1 2 1 Belrus 4 274 4 274 1 271 6.3 271 1 191 7 539 Belgium 959 497 52 38 7.6 Belize 87 63 72 25 4 25 1 25 1 Benin 3 977 3 828 96 Bermud Bhutn 1 82 73 65 7 1 7 1 Bolivi (Plurintionl Stte of) 8 21 6 34 77 262 4.1 125 48 177 68 Bonire, Sint Eusttius nd Sb Bosni nd Herzegovin 1 196 194 16 2 Botswn 6 19 5 496 91 3 28 6 3 132 95 2 546 78 Brzil 81 512 56 981 7 9 578 17 British Virgin Islnds Brunei Drusslm 198 198 1 Bulgri 1 872 1 377 74 3.22 31 Burkin Fso 5 792 5 553 96 656 12 641 98 564 86 Burundi 7 39 6 654 91 91 14 873 97 611 68 Cbo Verde 292 29 99 27 9.3 24 89 25 93 214 Cmbodi 43 738 35 635 81 953 2.7 938 98 938 98 91 Cmeroon 26 517 23 6 87 8 565 37 7 679 9 5 955 7 Cnd Cymn Islnds Centrl Africn Republic 1 186 5 21 51 1 781 34 Chd 12 35 6 636 54 1 291 19 721 56 Chile 2 44 1 213 5 213 18 66 31 Chin 826 155 343 515 42 5 39 1.5 3 675 69 Chin, Hong Kong SAR 4 784 3 345 7 23.69 Chin, Mco SAR 394 355 9 6 1.7 4 67 5 83 Colombi 12 435 9 994 8 2 143 21 91 42 816 38 Comoros 15 1.67 1 1 1 1 1 1 1 Congo 1 194 1 313 13 386 29 14 27 94 24 Cook Islnds 2 Cost Ric 469 442 94 41 9.3 41 1 41 1 Croti 497 Cub 742 736 99 87 12 4 4.6 72 83 1 3 Curço 5 5 1 1 2 1 1 1 1 Cyprus 41 Czech Republic 514 146 28 3 2.1 Côte d'ivoire 23 75 22 18 93 5 292 24 1 259 24 1 95 21 Democrtic People's Republic of Kore 11 29 Democrtic Republic of the Congo 116 894 53 285 46 7 26 14 5 671 79 4 799 67 Denmrk 32 Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 189

TABLE A4.8 HIV testing for TB ptients, provision of CPT nd ART to HIV-positive TB ptients, nd initition of IPT for people newly enrolled in HIV cre, 214 Totl TB ptients notified TB ptients with known HIV sttus HIV-positve TB ptients HIV-positive TB ptients on CPT HIV-positive TB ptients on ART b (Number) (%) (Number) (%) (Number) (%) (Number) (%) Djibouti 2 227 1 877 84 16 8.5 19 68 Dominic 1 HIV-positive people provided IPT c Dominicn Republic 4 65 3 377 73 782 23 37 47 667 85 945 Ecudor 5 352 4 729 88 637 13 637 1 287 Egypt 7 467 1 69 23 12.71 12 1 12 1 El Slvdor 2 22 2 173 98 23 9.3 171 84 17 84 1 946 Equtoril Guine 1 213 732 6 293 4 266 91 Eritre 2 425 2 311 95 14 6.1 14 74 115 82 Estoni 246 238 97 24 1 19 79 Ethiopi 119 592 89 32 75 8 67 9.7 3 396 39 1 385 Fiji 385 281 73 11 3.9 11 1 11 1 1 Finlnd 259 2 Frnce 4 845 French Polynesi 59 12 2 Gbon 6 299 2 54 4 648 26 511 79 511 79 Gmbi 2 583 2 169 84 429 2 381 89 25 48 Georgi 3 85 2 591 67 57 2.2 56 98 56 98 16 Germny 4 488 Ghn 15 276 11 83 77 2 858 24 1 91 67 1 14 39 Greece 519 Greenlnd Grend Gum 56 55 98 Guteml 3 224 2 782 86 245 8.8 228 93 228 93 Guine 11 734 7 383 63 1 815 25 1 768 97 1 353 75 Guine-Bissu 2 288 1 51 66 561 37 282 5 149 27 448 Guyn 648 587 91 148 25 135 91 13 7 44 Hiti 15 963 13 968 88 2 588 19 1 63 63 1 396 54 22 38 Hondurs 2 82 2 479 88 256 1 23 79 21 82 249 Hungry 851 Icelnd 8 7 88 Indi 1 683 915 1 34 712 61 44 171 4.3 41 66 93 39 8 9 Indonesi 324 539 15 74 4.6 2 355 16 963 41 624 26 Irn (Islmic Republic of) 1 395 3 9 29 272 9 55 2 1 37 181 Irq 8 341 3 925 47 Irelnd 316 84 27 15 18 7 47 Isrel 368 367 1 25 6.8 Itly Jmic 86 79 92 19 24 18 95 Jpn 19 615 1 672 8.5 45 2.7 Jordn 45 379 94 Kzkhstn 15 718 15 435 98 625 4 487 78 472 76 85 Keny 89 294 84 423 95 3 2 36 29 735 99 26 142 87 Kiribti 432 223 52 1.45 1 1 1 1 Kuwit 734 393 54 1.25 1 1 1 1 Kyrgyzstn 7 423 221 118 53 112 51 95 Lo People's Democrtic Republic 4 35 3 39 78 715 Ltvi 761 488 64 95 19 48 51 55 58 Lebnon 683 289 42 6 2.1 6 1 6 1 1 Lesotho 9 856 9 145 93 6 6 72 6 6 1 4 866 74 Liberi 2 726 2 81 1 42 14 214 53 112 28 Liby 1 185 1 142 96 54 4.7 Lithuni 1 67 1 135 71 36 3.2 Luxembourg 24 Mdgscr 28 936 6 66 23 98 1.5 98 1 Mlwi 17 723 16 445 93 8 844 54 7 995 9 8 162 92 135 13 Mlysi 24 711 21 698 88 1 468 6.8 19 7.4 453 31 2 63 Mldives 131 13 99 Mli 5 976 2 563 43 367 14 265 72 367 1 CPT = Cotrimoxzole preventive therpy. b ART = Anti-retrovirl therpy. c Initition of isonizid preventive therpy (IPT) for people newly enrolled in HIV cre. 19 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt

TABLE A4.8 HIV testing for TB ptients, provision of CPT nd ART to HIV-positive TB ptients, nd initition of IPT for people newly enrolled in HIV cre, 214 Totl TB ptients notified TB ptients with known HIV sttus HIV-positve TB ptients Mlt 46 35 76 6 17 HIV-positive TB ptients on CPT HIV-positive TB ptients on ART b (Number) (%) (Number) (%) (Number) (%) (Number) (%) Mrshll Islnds 153 95 62 Muritni 2 438 Muritius 127 122 96 15 12 15 1 15 1 HIV-positive people provided IPT c Mexico 21 881 18 547 85 1 287 6.9 9 7 755 59 487 Micronesi (Federted Sttes of) 189 117 62 Monco Mongoli 4 771 3 498 73 8.23 6 75 6 75 Montenegro 113 94 83 Montserrt Morocco 3 724 14 413 47 351 2.4 351 1 351 1 Mozmbique 58 27 55 943 96 29 337 52 27 54 94 23 81 81 94 252 Mynmr 141 957 56 133 4 6 412 11 4 666 73 2 319 36 2 997 Nmibi 9 882 9 88 92 3 994 44 3 94 99 3 36 84 Nuru 8 Nepl 37 25 3 254 8.8 369 11 273 74 43 Netherlnds 823 424 52 23 5.4 New Cledoni 29 13 45 New Zelnd 32 22 73 2.91 Nicrgu 2 839 2 185 77 78 13 Niger 11 12 7 56 64 485 6.9 76 16 111 23 Nigeri 91 354 84 161 92 16 66 19 14 569 91 11 997 75 26 383 Niue Northern Mrin Islnds 26 26 1 Norwy 325 Omn 358 358 1 3.84 3 1 3 1 Pkistn 316 577 1 715 3.4 9.84 9 1 9 1 Plu 14 11 79 Pnm 1 528 1 52 99 123 8.1 117 95 Ppu New Guine 28 567 7 218 25 781 11 246 31 484 62 Prguy 2 415 1 899 79 189 1 114 6 165 87 Peru 31 461 23 28 74 1 385 5.9 578 42 913 66 1 126 Philippines 267 436 53 354 2 18.2 2 19 53 49 Polnd 6 698 13.19 Portugl 2 226 1 432 64 221 15 Puerto Rico 44 39 89 6 15 2 33 2 33 Qtr 465 46 99 Republic of Kore 43 88 Republic of Moldov 4 636 4 426 95 338 7.6 14 41 Romni 15 96 1 927 69 312 2.9 281 9 278 89 158 Russin Federtion 136 168 67 425 5 251 Rwnd 6 24 5 944 99 1 497 25 1 473 98 1 297 87 Sint Kitts nd Nevis 7 4 57 1 25 1 1 1 1 Sint Luci 6 6 1 1 17 1 1 1 1 Sint Vincent nd the Grendines 6 3 Smo 23 Sn Mrino So Tome nd Principe 158 158 1 28 18 28 1 28 1 Sudi Arbi 3 336 1 781 53 63 3.5 Senegl 13 647 11 35 83 831 7.4 791 95 78 85 1 332 Serbi 1 832 127 6.9 8 6.3 8 1 Seychelles 13 13 1 1 7.7 1 1 Sierr Leone 12 721 11 48 87 1 35 12 816 63 887 68 1 339 Singpore 2 171 1 827 84 5 2.7 Sint Mrten (Dutch prt) Slovki 336 38 92 Sloveni 144 11 76 Solomon Islnds 346 45 13 Somli 13 13 7 714 59 248 3.2 166 67 111 45 226 CPT = Cotrimoxzole preventive therpy. b ART = Anti-retrovirl therpy. c Initition of isonizid preventive therpy (IPT) for people newly enrolled in HIV cre. Dt for ll yers cn be downloded from www.who.int/tb/dt GLOBAL TUBERCULOSIS REPORT 215 n 191

TABLE A4.8 HIV testing for TB ptients, provision of CPT nd ART to HIV-positive TB ptients, nd initition of IPT for people newly enrolled in HIV cre, 214 Totl TB ptients notified TB ptients with known HIV sttus HIV-positve TB ptients HIV-positive TB ptients on CPT HIV-positive TB ptients on ART b (Number) (%) (Number) (%) (Number) (%) (Number) (%) HIV-positive people provided IPT c South Afric 318 193 295 136 93 179 756 61 155 17 86 141 755 79 551 787 South Sudn 8 856 5 892 67 752 13 713 95 463 62 Spin 5 48 3 191 63 233 7.3 Sri Lnk 9 473 7 418 78 21.28 18 86 18 86 9 Sudn 2 392 5 51 27 329 6 147 45 Surinme 158 154 97 44 29 27 61 32 73 Swzilnd 5 616 5 43 97 3 972 73 3 94 98 3 123 79 1 188 Sweden 67 Switzerlnd 473 Syrin Arb Republic 3 576 Tjikistn 6 26 5 656 9 161 2.8 156 97 128 8 28 Thilnd 71 618 5 67 71 6 831 13 4 359 64 4 691 69 The Former Yugoslv Republic of Mcedoni 285 171 6 1.58 1 1 1 1 1 Timor-Leste 3 778 2 54 54 24 1.2 24 1 24 1 Togo 2 577 2 511 97 523 21 465 89 396 76 Tokelu Tong 13 13 1 Trinidd nd Tobgo 293 289 99 71 25 17 24 4 56 Tunisi 3 173 2 317 73 12.52 12 1 54 Turkey 13 378 9 344 7 45.48 13 29 28 62 Turkmenistn 2 887 Turks nd Cicos Islnds 3 1 33 1 1 1 1 1 1 Tuvlu 15 15 1 US Virgin Islnds Ugnd 46 171 43 883 95 19 612 45 19 211 98 15 877 81 Ukrine 4 32 39 57 97 7 64 2 3 35 44 4 273 56 16 263 United Arb Emirtes 61 42 69 2 4.8 2 1 1 5 United Kingdom of Gret Britin nd Northern Irelnd 7 77 5 552 78 United Republic of Tnzni 63 151 57 612 91 2 55 35 19 388 97 16 564 83 23 124 United Sttes of Americ 9 47 8 217 87 54 6.1 Uruguy 888 89 91 132 16 73 55 68 52 Uzbekistn 22 84 22 347 98 78 3.5 615 79 354 45 2 438 Vnutu 112 48 43 Venezuel (Bolivrin Republic of) 6 615 4 613 7 482 1 166 34 398 83 Viet Nm 12 87 74 92 73 3 875 5.2 2 936 76 2 827 73 Wllis nd Futun Islnds West Bnk nd Gz Strip 43 43 1 Yemen 9 693 1 133 12 22 1.9 Zmbi 42 716 39 763 93 24 198 61 21 929 91 17 611 73 Zimbbwe 32 16 28 58 89 19 29 68 18 2 94 16 522 86 3 42 WHO regions Africn Region 1 342 259 1 64 31 79 415 657 39 36 15 89 317 773 77 875 886 Region of the Americs 228 46 169 125 74 21 915 13 5 72 52 7 132 63 28 556 Estern Mediterrnen Region 465 677 67 624 15 1 629 2.4 686 67 943 63 478 Europen Region 329 27 25 859 63 16 445 8.2 5 452 53 6 279 58 21 14 South-Est Asi Region 2 58 65 1 171 258 45 6 235 5.1 51 141 85 47 81 79 3 49 Western Pcific Region 1 375 572 552 4 4 12 657 2.3 4 271 59 8 453 68 3 68 Globl 6 321 843 3 23 216 51 528 538 16 427 285 87 388 381 77 932 663 CPT = Cotrimoxzole preventive therpy. b ART = Anti-retrovirl therpy. c Initition of isonizid preventive therpy (IPT) for people newly enrolled in HIV cre. 192 n GLOBAL TUBERCULOSIS REPORT 215 Dt for ll yers cn be downloded from www.who.int/tb/dt