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GLOBAL

TUBERCULOSIS
REPORT

2017

GLOBAL
TUBERCULOSIS
REPORT
2017

Global tuberculosis report 2017

ISBN 978-92-4-156551-6

© World Health Organization 2017

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Designed by minimum graphics
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WHO/HTM/TB/2017.23

Contents

Abbreviations iv
Acknowledgements v
Executive Summary 1
Chapter 1. Introduction 5
Chapter 2. The Sustainable Development Goals and the End TB Strategy 7
Chapter 3. TB disease burden 21
Chapter 4. Diagnosis and treatment: TB, HIV-associated TB and drug-resistant TB 63
Chapter 5. TB prevention services 97
Chapter 6. Financing for TB prevention, diagnosis and treatment 107
Chapter 7. Universal health coverage, social protection and social determinants 123
Chapter 8. TB research and development 137

Annexes
1. The WHO global TB database 149
2. Country profiles for 30 high TB burden countries 155
3. Regional and global profiles 217
4. TB burden estimates, notifications and treatment outcomes 227

GLOBAL TUBERCULOSIS REPORT 2017 iii

Abbreviations

aDSM active TB drug-safety monitoring and NCD noncommunicable disease
management NFC near-field communication
AIDS acquired immunodeficiency syndrome NHI national health insurance
ART antiretroviral therapy NTP national TB programme
BCG bacille Calmette-Guérin OECD Organisation for Economic Co-operation and
BRICS Brazil, Russian Federation, India, China and Development
South Africa OIE World Organisation for Animal Health
CFR case fatality ratio OOP out-of-pocket
CHOICE CHOosing Interventions that are Cost-Effective PEPFAR President’s Emergency Plan For AIDS Relief
(WHO)
PMDT programmatic management of drug-resistant
CI confidence interval TB
CRS creditor reporting system P:N prevalence to notification (ratio)
DST drug susceptibility testing PPM public-public and public-private mix
EBA early bactericidal activity RR-TB rifampicin-resistant TB
EECA Eastern Europe and Central Asia SDG Sustainable Development Goal
FIND Foundation for Innovative New Diagnostics SHA System of Health Accounts
GAF Global Action Framework for TB Research SMS short message service
GDP gross domestic product SPARKS Social Protection Action Research &
Global Fund The Global Fund to Fight AIDS, Tuberculosis Knowledge Sharing
and Malaria SRL supranational reference laboratory
HBC high-burden country TB tuberculosis
HIV human immunodeficiency virus TBTC TB Trial Consortium
IGRA interferon gamma release assay TDR Special Programme for Research and Training
IHME Institute of Health Metrics and Evaluation in Tropical Diseases
ILO International Labour Organization TNF tumour necrosis factor
LED light-emitting diode TPP target product profile
LMIC low- and middle-income country TST tuberculin skin test
LPA line probe assay UHC universal health coverage
LTBI latent TB infection UN United Nations
MAMS-TB multi-arm, multi-stage TB UNAIDS Joint United Nations Programme on HIV/AIDS
MDG Millennium Development Goal UNICEF United Nations Children’s Fund
MDR/RR-TB multidrug-resistant TB or rifampicin-resistant US United States
(but isoniazid-susceptible) TB USAID US Agency for International Development
MDR-TB multidrug-resistant TB, defined as resistance VICTORY Viet Nam Integrated Center for TB and
to rifampicin and isoniazid Respirology Research
M:F male to female (ratio) VR vital registration
MoH ministry of health WHO World Health Organization
MOLISA Ministry of Labour – Invalids and Social Affairs WRD WHO-recommended rapid diagnostic
(Viet Nam)
XDR-TB extensively drug-resistant TB

iv GLOBAL TUBERCULOSIS REPORT 2017

with contributions from Marzia Calvi. Review and validation of TB/ to universal health coverage included in Chapter 7. The team was led by Katherine Floyd. was the focal point for communications with the jointly by the WHO Regional Office for Europe and the graphic designer and designed the report cover. and to HIV data was undertaken in collaboration with UNAIDS staff. The report team is grateful to various internal and external we thank in particular Encarna Gimenez. The country End TB Strategy) were prepared by Katherine Floyd. Katherine Floyd. Annabel Baddeley. European Centre for Disease Prevention and Control (ECDC). Gebreselassie and Christopher Gilpin. HIV-associated TB and drug-resistant TB) was Andrew Siroka gave input to the design and content of the led by Dennis Falzon and Wayne van Gemert. Medea Gegia. Avinash Kanchar. Avinash Kanchar Philippe Glaziou. Dennis Falzon. Daniela Cirillo. Dennis Falzon. The Uplekar  and Rajendra Yadav. Irwin Law coordinated the finalization Wayne van Gemert and Matteo Zignol. Avinash Kanchar. Inés Garcia Baena and Andrew was provided by the Director of the Global TB Programme. Katherine Floyd and Matteo Zignol. UNAIDS managed the process of reviews of Chapter 4 and Chapter 5. Diana Weil and Matteo (Financing for TB prevention. services) was prepared by Yohhei Hamada. with input Inés Garcia Baena. Katherine Floyd.  Mary from staff throughout the WHO Global TB Programme. his substantial contribution to follow-up and validation of data to Jesus Maria Garcia Calleja and Satvinder Singh for their for all European countries. Siroka. Linh Nguyen. Hazim Timimi. preparation of Laughon. with contributions from Annabel Christian Lienhardt. Particular and Andrei Dadu from the WHO Regional Office for Europe for thanks are due to Colin Mathers for his review of Chapter 3. social protection and social determinants) was led by Diana The data collection forms (long and short versions) were Weil. Claudia Denkinger.Acknowledgements This global TB report was produced by a core team of 20 Hannah Monica Dias. The production of Chapter 7 (Universal health coverage. Nebiat Gebreselassie. Chapter 6 Hazim Timimi. Chapter profiles that appear in Annex 2. For Annex 2. Chapter 1 (Introduction) Annex 1. Christopher Gilpin. which provides an overview of the global and Chapter 2 (The Sustainable Development Goals and the TB database. Inés Sismanidis and Mukund Uplekar. Yohhei Hamada. of the report. Nebiat that included Annabel Baddeley. Chapter 8 (TB research and review and follow-up of data was done by a team of reviewers development) was prepared by Christian Lienhardt. The writing of Chapter 4 (Diagnosis and Hazim Timimi. Tomáš Matas. Charalambos Sismanidis. Karin Stenberg. Priya Pantoja. The Executive Summary. of figures and tables for all chapters and subsequent review Data for the European Region were collected and validated of proofs. Irwin Law. Yohhei Hamada. Wayne van Gemert. Irwin Law. Andrew Siroka. and Haileyesus Getahun. diagnosis and treatment) was Zignol. with contributions from Laura Anderson information is available (Annex 4) were also prepared by and Peter Dodd. Thomas Joseph. Anna Dean. Philippe Glaziou. Avinash Kanchar. Mukund Uplekar. Mukund Timimi led and organized all aspects of data management. Hazim Antonette Remonte. Shete and Diana Weil. Baddeley. Vahur Hollo and reviewers for their useful comments and suggestions on Csaba Ködmön from ECDC for providing validated data files advanced drafts of the main chapters of the report. developed by Philippe Glaziou and Hazim Timimi. Katherine appear in Annex 3 and the detailed tables showing data for Floyd. Yohhei Hamada. Andrew Siroka. Thomas Katherine Floyd and Karin Weyer and contributions to specific Joseph. Irwin Law. people: Laura Anderson. Andrew Siroka. to Callum Brindley and data collection from national AIDS programmes and provided Odd Hanssen for their reviews of financing estimates related access to their TB/HIV dataset. Mario Raviglione. Charalambos Sismanidis key indicators for all countries in the latest year for which and Matteo Zignol. Andrew Siroka. Anna Dean. Irwin Law and treatment of TB. Annabel Baddeley. The preparation of of figures and tables was led by Hazim Timimi. the regional profiles that 3 (TB disease burden) was prepared by Anna Dean. Jonathan Daniels. Diana Rozendaal. and writing required for the main chapters Woolley for their reviews of Chapter  8. and the preparation that are associated with TB incidence. Mel Spigelman and Jennifer figures and tables. with support from Inés García Baena. Amy Collins.  Philippe Glaziou. Chapter 5 (TB prevention Garcia Baena. used to estimate the burden of disease caused by TB was GLOBAL TUBERCULOSIS REPORT 2017 v . with support pages on indicators in the Sustainable Development Goals from Katherine Floyd and Matteo Zignol.  Katherine Floyd. Overall guidance prepared by Katherine Floyd. other chapter the online technical appendix that explains the methods contributors included Laura Anderson. Andrea components of chapter content from Dennis Falzon. Barbara Many people contributed to the analyses. Charalambos Hannah Monica Dias. was written by Hazim Timimi.

Katrina Smith. Richard Oleko Rehan. Daniel Olusoti. Silviu Ciobanu. Ogtay Gozalov. Reynold Hewitt. Szabolcs Szigeti. Samuel Ogiri. Hubert Wang. Leonard Mbemba. Andrei Dadu. Production of the report was also supported by monitoring and evaluation unit for impeccable administrative the governments of Japan and the Republic of Korea. led by Philippe Glaziou. Lastone Chitembo. We also thank Sue Hobbs for we thank in particular Edith Alarcon. Louisa Ganda. Jean Iragena. Siriman Camara. Nobu Nishikiori and Wilfred Nkhoma for their of the report) on indicators in the Sustainable Development contribution to data collection and validation. we are particularly appreciative of her work on Annex Noudjo. Traore Tieble. Addisalem Yilma. Javier Aramburu Guarda. WHO Eastern Mediterranean Region Mohamed Abdel Aziz. Araksia Hovhannesyan. Samuel Hermas Andrianarisoa. the report benefited from the input of many staff among HIV-negative people. Samiha Baghdadi. Babou Bazie. Daniel Kibuga. Jean Marie Rwangabwoba. Assefash Zehaie. Gayane Ghukasyan. and clearance of report material by countries in advance of The principal source of financial support for WHO’s work publication. Ayodele Awe. Mohamed Abdul Aziz. and review Goals that are associated with TB incidence. Harura Adamu. without which Charalambos Sismanidis and Matteo Zignol. Nayé Bah. mortality. Davi Kokou Mawule. Gazmend Zhuri. Patrice Lawrence. Agency for International Development (USAID). Jules Mugabo Semahore. Her contribution. Alina Perez. Nicolas Nkiere. Cassandra Butu. Boingotlo Gasennelwe. Jorge Victoria. Christine Musanhu. as always. Franklin Hernandez. Chijioke Osakwe. Daniel Kibuga. Amos Omoniyi. thank for her excellent work. and Juliana Daher and to the review of report material prior to publication. her outstanding work on the design and layout of this report. Marie Catherine Barouan. Dinnuy Kombate-Noudjo. Edith Alarcon. Philip Patrobas. Alfonso Tenorio. Kathryn Bistline for providing working in WHO regional and country offices and hundreds of supplementary financial data for South Africa. Angel Roberto Sempertegui. Dinnuy Kombate- year. Télesphore Houansou. Beatriz Cohenca. André 2. Desta Tiruneh. Ishmael Nyasulu. Ndella Diakhate. Masoud Dara. David Chavarri. Sharmila Lareef-Jah. These and Mary Mahy (UNAIDS) for providing epidemiological data people are listed below. with contributions from Peter Dodd. Khelifi Houria. Pedro Avedillo. Rafael López Olarte. Kathryn Vogel Johnston. Nkateko Mkhondo. Jamshid Gadoev. Fabio Moherdaui. Hillary Kipruto. Partha Pratim Mandal. Eva De Carvalho. Marcos Espinal. without which this report could not have been produced. WHO Region of the Americas Zohra Abaakouk. Enrique Perez. This Khurshid Alam Hyder. and temporary advisors: Ana Ciobanu. Wilmer Marquino. who we Among the WHO staff not already mentioned above. Viatcheslav Grankov. Guillermo Gonzalvez. Samiha Baghdadi. vi GLOBAL TUBERCULOSIS REPORT 2017 . Ahmada NassuriI. Myrat Sariyev. Kassa Hailu. Denise Nkezimana. Claudina Augusto da Cruz. Doris Ma Fat from the WHO Mortality and Burden acknowledge with gratitude their support. Mirtha Del Granado. Susan Zimba-Tembo. Roberto Salvatella. Massimo Ghidinelli. Marcelo Vila. Moses Jeuronlon. Hermann Ongouo. Inácio Alvarenga. Mohammad Aloudal. Percy Halkyer. Felicia Owusu-Antwi. We thank that were used to estimate HIV-associated TB incidence and them all for their invaluable contribution and collaboration. Nino Mamulashvili. Angela Katherine Lao Seoane. Rafael Lopez Olarte. of Disease team for providing data extracted from the WHO In addition to the core report team and those mentioned Mortality Database that were used to estimate TB mortality above. Carolina Cardoso da Silva Gomes. Francisco Leon Bravo. Martin van den Boom. was very highly appreciated. Alba Lidia Sánchez. Romeo Montoya. organized by WHO region. Hans Salas. Masoud Dara. Michael Jose. Ismael Hassen Endris. Sandra Jones. on global TB monitoring and evaluation is the United States WHO staff in Regional and Country Offices WHO African Region Boubacar Abdel Aziz. André Ndongosieme. Alexey Bobrik. Mai Eltigany Mohammed. Abel Nkolo. Javahir Suleymanova. Addisalem Tefera. Philip Onyebujoh. Soledad Pérez. WHO European Region Nikita Afanasyev. Sithembile Dlamini-Nqeketo. Richard Mbumba Ngimbi. Ghislaine Nkone Asseko. notably the new content (compared with previous editions Ndongosieme. Neema Gideon Simkoko. Wilfred Nkhoma. Sindani Ireneaus Sebit. Hapsa Toure people working for national TB programmes or within national for providing national health account data that were not surveillance systems who contributed to the reporting of data available in the Global Health Observatory. Inna Motrich. Esther Aceng-Dokotum. Patrick Hazangwe. it would be impossible to produce the Global Tuberculosis We thank Valérie Robert in the Global TB Programme’s Report. Noel Djemadji. Aristide Désiré Komangoya Nzonzo. Mirtha Del Granado. The entire report was edited by Hilary Cadman. Hania Husseiny. Soudeh Eshani. Harry Geffrard. Abdoulaye Mariama Baïssa. Qutbuddin Kakar. We support.

Wlimer Salazar. Karla María Sánchez Mendoza. Clarisse Tsang. Nicholas Siziba. Botshelo Tebogo Kgwaadira. Adama Jallow. Faith Ngari. Alfred Etwom. Sanele Masuku. Hugo Fernandez. Olga Joglar. Patrick Migambi. Juan Victoria. Sofiane Alihalassa. Rosamunde Amutenya. Ernesto Moreno Naranjo. Lindiwe Mvusi. Eugene Maduro. Vera Nestor. Juan Eyene Acuresila. Norbert Ndjeka. Samuel Williams. Guido Sliva. Michelle Trotman. Patricia Bartholomay. Eulynis Brown. Marcela Rojas. Anupama Hazarika. Badr Alabri. Claudia Llerena. Désiré Aristide Komangoya Nzonzo. Rajendra-Prasad Yadav. Luz Marina Duque. Daniel Vázquez. Al Saidi Fatmah. Partha Pratim Mandal. Vineet Bhatia. Mariela Contrera. Ferosa Roache. Setiawan Jati Laksono. Rafael Rosales. Carlos Vital Cruz Lesage. Georges Hermana. Katia Romero. Arrieta Pessolano Fernando. Aiban Ronoh. Lourdes Suarez Alvarez. Richard Rehan. Arelisabel Ruiz Guido. Gemma Chery. Athelene Linton. Jacques Sebert. Willy Morose. Fulgence Ndayikengurukiye. Franck Hardain Okemba-Okombi. David Rodríguez. Cielo Rios. Lerole David Mametja. Yakhokh Fall. Namatullah Ahmadzadah. Victor Gallant. Nada Almarzouqi. Younoussa Assoumani. Felix Kwami Afutu. Ambrosio Disadidi. Sicelo Dlamini. Marie Edwige Razanamanana. Zeidy Mata Azofeifa. Carmen Arraya Gironda. María Bermúdez. Navaratnasingam Janakan. Maureen Kimenye. Rahwa Tekle. James Upile Mpunga. Lepaitai Hansell. Andrea Maldonado Saavedra. Tania Herrera. Adam Langer. Aw Boubacar. Clara Chola Kasapo. Jennifer Wilson. Robert Pratt. Wiedjaiprekash Balesar. Narantuya Jadambaa. Maria Rodriguez. Francis Morey. Tamara Bobb. Abu George. Antonio Marrero Figueroa. Chila Sylvia Simwanza. Tseliso Isaac Marata. Jorge Jone. Danilo Solano Castro. Frank Rwabinumi Mugabe. Ronald Cedeño. Roscio Gomez. GLOBAL TUBERCULOSIS REPORT 2017 vii . Narda Gonzalez Rincon. Ofelia Cuevas. Thipphasone Vixaysouk. Sybil Marabel Knowles Smith. Monica Meza. Andrés Oyola. Edwin Aizpurua. Thato Raleting. Jackurlyn Sutton. Ikushi Onozaki. Jocelyn Mahoumbou. Martín Castellanos Joya. Malik Parmar. Ugyen Wangchuk. Tomasa Portillo Esquivel. Khawaja Laeeq Ahmad. Dadang Supriyadi. Fatma Al Yaqoubi. Jeetendra Mohanlall. Julia Rosa Maria Rios Vidal. Khanh Pham. Iyanna Wellington. Chris Archibald. Sergio Maulen. Dedeh Kesselly. Belaineh Girma. Mohammad Abouzeid. James Holima Katta. Vikarunnessa Begum. Bakary Konate. Quang Hieu Vu. Nilda de Romero. Agbenyegan Samey. Kebba Sanneh. Nii Hanson-Nortey. WHO Region of the Americas Sarita Aguirre García. Abdulbari Al-Hammadi. Beatriz Gutiérrez. Subhash Lakhe. Joseph Oluwatoyin Kuye. Izzy Gerstenbluth. Oumar Abdelhadi. Dorothea Hazel. Lungten Wangchuk. Deborah Stijnberg. Nobuyuki Nishikiori. de Lourdes Martínez. Adama Diallo. Aboubacar Mzembaba. Greta Franco. Ahmadi Shahnaz. Maria Regina Christian. Maritza Samayoa Peláez. Louine Renee Bernadette Morel. Boukoulmé Hainga. Thaddée Ndikumana. Themba Dlamini. Mary Mercedes. Fukushi Morishita. Diana Khan. Lynda Foray. WHO Western Pacific Region Shalala Ahmadova. Evangelista Chisakaitwa. Emile Rakotondramamanana. Margarita Godoy. Shalauddin Ahmed. Xochil Alemán de Cruz. Eric Commiesie. Martin Rakotonjanahary. Denise Arakaki-Sanchez. Sidina Mohamed Ahmed. Md Kamar Rezwan. Belkys Marcelino. Gertrude Lay. Ranjani Ramachandran. Jean Louis Abena Foe. Melissa Valdez. Adjima Combary. Kalpeshsinh Rahevar. Marie Sarr Diouf. Maria Henry. Ballé Boubakar. Charles Sandy. Frank Adae Bonsu. Wilfried Bekou. Irad Potter. Jorge Noel Barreto. Mukta Sharma. Ivan Manhiça. Arlindo Tomás do Amaral. Leilawati Mohammed. Diana Sotto. Al Hamdan Khlood. Adebola Lawanson. Amanuel Hadgu. Norma Leticia Artiles Milla. Alice Neymour. Subhash Yadav. Juma John Hassen Mogga. Thusoyaone Titi Tsholofelo. Bongiwe Mhlanga. Fatou Tiépé Coulibaly Adjobi. Sandra Ariza. National respondents who contributed to reporting and verification of data WHO African Region Abderramane Abdelrahim Barka. Adama Marie Bangoura. Aisha Andrewin. Evariste Gasana. Samia Hammadi. Manohar Singh Rajamanickam. Myrian Román. Martha López. Nestor Segovia. Katsunori Osuga. Jacquemin Kouakou Kouakou. Tauhid Islam. Angelica Medina. Andres Rincón. Godwin Ohisa. Norma Lucrecia Ramirez Sagastume. WHO Eastern Mediterranean Region Tarig Abdalla Abdallrahim. Md Khurshid Alam Hyder. Agnès Pascaline Audzaghe. Michel Kaswa. Deus Ndikumagenge.WHO South-East Asia Region Mohammad Akhtar. Clara De la Cruz. Antoine De Padoue Etoundi Evouna. Yaren Cruz. Cheryl Peek-Ball. Santiago Fadul. Dorothea Bergen Weichselberger. Nicola Skyers. Llang Bridget Maama. Patrick Konwloh. Shawn Charles. Abdullatif Al-Khal. Mirian Alvarez. Karolyn Chong. Carlos Alberto Marcos Ayala Luna. Timothy McLaughlin- Munroe. Séverin Anagonou. Antoine Ngoulou. Kenyerere Henry Shadreck. Mercedes España Cedeño. Natalia Sosa. Beatrice Mutayoba. Abdoulaye Diallo. Julio Garay Ramos. Hervé Gildas Gando. Ma. Hyang Song. Hilda María Salazar Bolaños. Gilberto Frota. Yaskara Halabi. Shushil Dev Pant. Aoua Hima Oumarou Hainikoye. Emmanuel Nkiligi. Fabio Scano. Sundari Mase. Adulai Gomes Rodrigues. Keita Mariame Tieba Traore. Yanni Sun. Araia Berhane. Lelisa Fekadu. Mohammed Fezul Rujeedawa. Cecilia Figueroa Benites. Norman Gil. Achuthan Nair Sreenivas. Farai Mavhunga. Marvin Manzanero.

Rouseli Haq. Alexander Spina. Liliia Masiuk. Aysoltan Charyeva. Florence Flament. Suksont Jittimanee. Gerard Scheiden. Gloria Mendiola. Jerker Jonsson. Daniel Chemtob. Temilo Seono. Irina Soroka. Jocelyn Flores-Cabarles. Donika Mema. Kifah Alshaqeldi. Esam Al-Saberi. Maja Stosic. Patrick de Smet. Aleksandar Simunovic. Pakr Won Seo. Abdulhameed Kashkary. Kuniaki Miyake. Lanfranco Fattorini. Tonka Varleva. Analita Pace Asciak. Jiri Wallenfels. Erhan Kabasakal. Irina Lucenko. Velimir Bereš. Connie Olikong. Mohemmed Tabena. Du Xin. Rikke Bruun de Neergaard. Risa Bukbuk. Kanthi Ariyarathne. Irina Vasilyeva. Sarah Jackson. Liza Lopez. Zhang Hui. Sabine Pfeiffer. Kang Hae-Young. Seiya Kato. Sawsan Jourieh. Ekkehardt Altpeter. Dace Mihalovska. Ahmed Dmiereih. Frank Underwood. Nadia Sabrah. Hiam Yaacoub. Layth Al-Salihi. Ucha Nanava. Victoria Petrica. Tong Chol Choe. Noel Itogo. Chi-chiu Leung. Hayk Davtyan. Valentina Vilc. Viet Nhung Nguyen. Majlinda Gjocaj. Snježana Brčkalo. Chi-kuen Chan. Yelena Arbuzova. Asik Surya. Valerija Edita Davidaviciene. Syed Mahmoudi. Wang Lixia. Gerard de Vries. Amal Galal. Abdylat Kadyrov. Pronab Kumar Modak. Andrei Corloteanu. Ivan Solovic. Phalin Kamolwat. Wagdy Amin. Ibrahim Bdwan. Mohammed Sghiar. Tieng Sivanna. Jane Dowabobo. Samir Amin. Penitani Sosaia. Raquel Duarte. Peter Helbling. Sulistyo SKM. Istvan Zsarnoczay. Armen Hayrapetyan. Ilievska Poposka Biljana. Mladen Duronjić. John Ryan McLane. Pierre Weicherding. Biljana Grbavčević. Domnica Ioana Chiotan. Dhikrayet Gamara. Abdul Hameed. Victor Spinu. Ludovic Floury. Asmah Razali. Lena Fiebig. Kazimierz Roszkowski-Śliż. Nirupa Pallewatte. Kazuhiro Uchimura. Nico Cioran. Mulham Saleh. Valeriu Crudu. Chou Kuok Hei. Tagizade Sevinj. Jamyang Pema. Ourania Kalkouni. Joan O’Donnell. Zaza Avaliani. Alice Manalo. Mojibur Rahman. Chandima Hemachandra. Violeta MIhailovic Vucinic. WHO Western Pacific Region Zirwatul Adilah Aziz. Khin Mar Kyi Win. Uranchineg Borgil. Sirinapha Jittimanee. Maja Zakoska. Jean-Paul Guthmann. Neti Herman. Mihaela Obrovac. Thierry Comolet. Md. Nese Ituaso Conway. Reiher Bereka. Mohamed Naim bin Abdul Kadir. Irène Demuth. Ratna Bahadur Bhattarai. Mei Jian. Shamim Mannan. Sharat Chandra Verma. Bahnasy Samir. Mao Tan Eang. Phannasinh Sylavanh. Aminath Aroosha. WHO European Region Natavan Alikhanova. Dzmitry Klimuk. Rafaat Hakeem. Trude Margrete Arnesen. Assia Haissama Mohamed. Nino Lomtadze. Yassir Piro. Stevan Lucic. Razia Kaniz Fatima. Anna Marie Celina Garfin. Mohamed Furjani. Gabriele Rinaldi. Myo Su Kyi. Saen Fanai. Mulham Mustafa. Petra Svetina. Donna Mae Gaviola. Constantino Lopes. Alice Cuenca. Bernard Rouchon. Maria Korzeniewska-Koseła. Paul Aia. Edwina Tangaroa. Petra Svetina Sorli. Maryse Wanlin. Firuze Sharipova. Hawa Hassan Guessod. Sergey Sterlikov. Dhammika Vidanagama. Asyliddin Radzhabov. Hasan Žutić. Jerôme Robert. Kovacs Gabor. Natalia Nizova. Shunji Takakura. Phurpa Tenzin. Phonenaly Chittamany. Anita Seglina. Sarah Anderson. Si Thu Aung. Alfred Tonganibeia. Urška Hribar. Enkhmandakh Danjaad. Aysegul Yildirim. Hanna Soini. Maha Nasereldeen. Daniela Schmid. Walter Haas. Yullita Evarini Yuzwar. viii GLOBAL TUBERCULOSIS REPORT 2017 . Nou Chanly. Piret Viiklepp. Mohammad Khalid Seddiq. Erika Slump. Sarah Brown-Ah Kau. Rafidah Baharudin. Cho Kyung Sook. Vladimir Milanov. Ebrahim Al-Romaihi. Mohd Rotpi Abdullah. Maeve Lalor. Nasehi Mahshid. Salma Haudi. Daniel Houillon. Ekaterina Maliukova. Shahnoza Usmanova. Viktor Gasimov. Gennady Gurevich. Yee Tang Wang. Rosa Cano Portero. Clara Palma Jordana. Ahmadul Hasan Khan. Nasir Mahmood Khan. Kyaw Thu. Yana Levin. Binh Hoa Nguyen. Ngoc-Phuong Luu. Nargiza Parpieva. Elena Sacchini. Louise Fonua. Mohamed Belkahla. Janaka Thilakeratne. WHO South-East Asia Region Nazis Arefin Saki. Chewang Rinzin. Justin Wong. Zhumagali Ismailov. Jack Ekiek Mayleen. Lameka Sale. Devesh Gupta. Marcelina Rabauliman.

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LEAVE NO ONE BEHIND UNITE TO END TB .

respectively. countries on the path to ending the TB epidemic.7 million in for more than 10 years. disease. which share a started on treatment for drug-resistant TB. Drug-resistant TB is a continuing threat. The WHO Global Ministerial Conference on ending TB Most deaths from TB could be prevented with early in the SDG era in November 2017 and the first UN General diagnosis and appropriate treatment. 65% were male. and technological the incidence-treatment enrolment gap for drug-resistant TB. TB (46% of the estimated incidence). first (2020) milestones of the End TB Strategy. In 2016. Indonesia. China. Specific targets set in the End TB Strategy include a 90% treatment success remains low.4 million people fell ill with TB in resources needed to achieve universal health coverage.3 inter­national donors (especially in low-income countries). treatment reg- Globally. A total of 129 689 people were (UN) Sustainable Development Goals (SDGs). there were an estimated 1. HIV infection.3 million new cases of TB were reported (up a comprehensive and up-to-date assessment of the TB from 6. two priority risk groups of people living with HIV and children TB is the ninth leading cause of death worldwide and the under 5. reduction in TB deaths and an 80% reduction in TB incidence Making large inroads into these gaps requires progress in (new cases per year) by 2030.1 million in 2015). most people eligible for TB preventive leading cause from a single infectious agent. the top three were India (25%). Achieving a particular subset of high TB burden countries. years. from 125 629 in 2015 but only 22% of the estimated incidence.Executive Summary The purpose of WHO’s Global Tuberculosis Report is to provide In 2016. incidence of 10. There were 476  774 reported cases of HIV-positive and broader development goals. especially in the or to make major headway in closing persistent gaps. by 2020. However. China and the Russian Federation. the latest picture is one of a still high burden of African Region. In 2016. of whom 85% were on these are WHO’s End TB Strategy and the United Nations’ antiretroviral therapy (ART). Total health spending also falls short of the people. Millions of people are Assembly high-level meeting on TB in 2018 provide a historic diagnosed and successfully treated for TB each year. Increased year. a small increase common aim: to end the global TB epidemic. these figures need to to be any chance of achieving the technological breakthroughs improve to 4–5% per year and 10%. GLOBAL TUBERCULOSIS REPORT 2017 1 . Most TB). to reach the needed by 2025.3 million TB Financing for TB care and prevention has been increasing deaths among HIV-negative people (down from 1. and progress that is not fast enough to reach targets TB preventive treatment is expanding. 10% were people Closing these gaps requires more resources from both living with HIV (74% in Africa) and 56% were in five countries: domestic sources (especially in middle-income countries) and India. breakthroughs by 2025 so that incidence can fall faster than India and China accounted for 39% of the global gap.3 The pipelines for new diagnostics. For the period 2016–2035. the Philippines and Pakistan. reported cases.4 Almost half (47%) of these reach SDG targets related to these and other determinants. but there are still step up the battle against TB and put the world and individual large gaps in detection and treatment.3 2000) and an additional 374 000 deaths among HIV-positive billion in 2017). 2016: 90% were adults. but slowly. cases were in India. Ten countries these targets requires provision of TB care and prevention accounted for 76% of the total gap between TB incidence and within the broader context of universal health coverage.5 Ten countries accounted for 75% of determinants and consequences of TB. undernutrition and smoking. Indonesia multisectoral action to address the social and economic (16%) and Nigeria (8%). 6. but funding gaps still exist (US$ 2. at 54% globally. HIV/AIDS. similar to recent recommended global TB strategies and associated targets.2 An estimated 10. of the gaps related to HIV-associated TB were in the WHO Overall. there Broader influences on the TB epidemic include levels of were 600  000 new cases with resistance to rifampicin (RR. poverty. ranking above treatment are not accessing it. equivalent to 61% of the estimated epidemic and of progress in care and prevention at global. compared with 2015. averting opportunity to galvanize the political commitment needed to millions of deaths (53 million 2000–2016).6 Most rates achieved historically. the most effective first-line drug. TB incidence is falling at about 2% per year and 16% of invest­ment in research and development is needed for there TB cases die from the disease.1 This is done in the context of show a global treatment success rate of 83%. of which 490 000 had high TB burden countries have major challenges ahead to multidrug-resistant TB (MDR-TB).4 million. the TB mortality rate is falling at about 3% per imens and vaccines are progressing. drugs. the latest treatment outcome data regional and country levels.

indicating that notification data floors/systems. technology. since 2010). people.3%) of new cases and 19% (95% CI: 9. indicators. the fastest in TB incidence. and proportion of the urban the new TB cases that were notified in 2016. WHO has developed a TB-SDG monitoring prevalence surveys provide an interim approach to directly framework of 14 indicators that are associated with TB measuring the burden of TB disease in an important subset of incidence. prevalence of diabetes. As part of efforts to improve countries. In WHO’s occurred in the WHO African Region and the WHO South-East 2017 round of global TB data collection. the WHO European (up from 81% in 2015). UNAIDS and the World Bank.1% (95% confidence at global and national levels. the The main data sources for the report are annual rounds of Russian Federation. In the WHO African Region (25%) and the WHO Western Pacific Region African Region. HIV-associated TB that are out-of-pocket. Additional highlights from the report European Region (4. 89 countries and territories had Democratic People’s Republic of Korea. health expenditure per capita. compared with levels in 2015. gross domestic product (GDP) per capita. 8. Mozambique. the United Republic of Tanzania. the WHO documented HIV test result. Globally. under seven SDGs.8– monitoring of notifications of TB cases and their treatment 27%) of previously treated cases had MDR/RR-TB. Most of the estimated number of incident cases in 2016 Globally in 2016. 10 and 11. and that no TB declines in the TB mortality rate are in the WHO European patients and their households should face catastrophic costs Region and the WHO Western Pacific Region (6. under SDG 3 (health and well-being): coverage of essential health services. smaller proportions of cases occurred in the WHO highest. The decline since Introduction 2010 has exceeded 4% per year in several high TB burden countries. Regionally. 57% of notified TB patients had a occurred in the WHO South-East Asia Region (45%). June 2017. prevalence of smoking. Lesotho. 7. of TB incidence and mortality in all countries. India accounted for 33% of global TB deaths among The SDGs and the End TB Strategy HIV-negative people. standardized interval [CI]: 2. linked to SDGs 1. National TB In 2017. and estimates of TB incidence and mortality have been to be strengthened towards the goal of direct measurement published annually by WHO for more than a decade. Lesotho.8–5. For example. TB) (2014 cohort) it was 30%. up from 55% in 2015. Zambia global TB data collection implemented by WHO’s Global TB and Zimbabwe. 2. HIV and drug-resistant TB prevalence. children (aged <15 years) accounted for 6. The other seven since 2013 is explained by a 37% increase in India 2013–2016. Regionally. Kenya. these regions accounted for 85% of the territories that account for over 99% of the world’s population combined total of TB deaths in HIV-negative and HIV-positive and TB cases reported data. outcomes at global and national levels has been in place since National notification and vital registrations systems need 1995. an estimated 4. population living in slums. In 2016. the TB mortality rate (per 100  000 population) They are a 35% reduction in TB deaths and a 20% reduction fell by 37% between 2000 and 2016. 201 countries and Asia Region in 2016. prevalence of undernourishment. The treatment success rate for HIV-associated TB (2015 The annual number of incident TB cases relative to cohort) was 78% and for extensively drug-resistant TB (XDR- population size varied widely among countries in 2016. started using bedaquiline and 54 had used delamanid by the Philippines and South Africa. Gini Globally. The first milestones of the End TB Strategy are set for 2020. coverage of testing for rifampicin resistance was TB disease burden 33% for new TB patients and 60% for previously treated TB patients.7. where the burden of HIV-associated TB is (17%).9% of index for income inequality. Programme since 1995 and databases maintained by other About 82% of TB deaths among HIV-negative people WHO departments. Namibia. Results from national TB prevalence surveys of adults proportion of the population covered by social protection show higher M:F ratios. percentage of total health expenditures Diagnosis and treatment: TB. proportion understate the share of the TB burden accounted for by men of the population with primary reliance on clean fuels and in some countries. per year. are: proportion The global male:female (M:F) ratio for notifications was of the population living below the international poverty line. and 39% overall (up from 31% in 2015).6% from 2015 to 2016). There are seven indicators high TB burden countries.0% and 4. and above 500 in a few countries including the outcomes for MDR/XDR-TB. from under 10 per 100 000 population in most high-income At least 35 countries have introduced shorter regimens countries to 150–300 in most of the 30 high TB burden for treatment of MDR/RR-TB. the fastest decline in TB incidence is in the WHO 2 GLOBAL TUBERCULOSIS REPORT 2017 . and for 26% of the combined total of TB deaths in HIV-negative and HIV-positive people. respectively. 1. 82% of TB patients had a documented HIV test result Eastern Mediterranean Region (7%). Region (3%) and the WHO Region of the Americas (3%). including Ethiopia. Monitoring of TB-specific indicators is well established Globally in 2016. Most of the global increase in notifications of new TB cases and prevalence of alcohol use disorder.6% as a result of TB disease.

2016. followed Myanmar. This was an increase from US$ 6. In Kenya. How. the Philippines. social determinants 5 The ten countries. However.3 million. the Projections of total health expenditures in low and middle. South Africa. Nigeria. social protection and most effective first-line drugs. most funding during the period 2006–2016 has countries.4 million incident cases of TB in 2016.9 billion in Few diagnostic technologies emerged in 2017 and the evalua- 2017 in 118 low and middle-income countries that reported tion of GeneXpert Omni®. which collectively account for almost half of the world’s TB cases. Financing for TB prevention. Democratic Republic of the Congo. Myanmar and Uzbekistan.3 billion that was available in 2006. As in previous years. Zimbabwe and Malawi. Overall. The SDG The number of children aged under 5 years who were reported Health Price Tag. Indonesia. this Examples of high TB burden countries doing relatively well means that the global total of people living with HIV who in terms of at least some of the indicators associated with TB were started on TB preventive treatment in 2016 was at least incidence include Brazil. However.3 billion in 2016 and more There are 17 drugs in Phase I. Viet Nam. Indonesia. and nine in Phase II or Phase III. including eight than double the US$ 3. coverage and achievement of other SDG-related health Ukraine. Bangladesh. the Philippines. Nigeria.8 was provided to a total of 390 298 people living with HIV in million to diabetes. were: India. health targets during this period. China and the United Republic of income countries 2016–2030 compared with estimates of 6 Tanzania. and this remains the each profile. India. commitment from the Prime Minister to the goal of ending TB There are 12 vaccine candidates in clinical trials: three in by 2025. GLOBAL TUBERCULOSIS REPORT 2017 3 . an in HIV care who were started on TB preventive treatment in estimated 1. The ten countries. domestic funding dominates (95% overall. including US$ 387 million Phase I. TB preventive treatment 1. were started on TB preventive treatment in 2016. almost double the level of 2016). a second page has been introduced to been provided from domestic sources. For example. the Russian Federation. This year. II or III trials. which is intended as a close-to-care data (and accounted for 97% of reported TB cases globally). coverage ranged from 2. of preventive treatment in 2016. Kenya. In low-income 1 WHO has published a Global Tuberculosis Report annually since 1997. were: India. the two Universal health coverage. South Africa. has been delayed. the funding required for progress towards universal health China.9 billion). Indonesia. data on the number of people newly enrolled Of the 10. they suggest that most middle- to have been started on TB preventive treatment increased by income countries could mobilize the funding needed to 85% between 2015 and 2016 (from 87 242 to 161 740). the underlying cause is funding and in the 25 high TB burden countries outside BRICS classified as HIV in the International classification of diseases system (ICD-10). countries. aggregated figures conceal substantial variation among monitoring framework developed by WHO in 2017. of and recent trends in the indicators included in the TB-SDG ever. This provides an overview of the latest status case in 2017 (84% of the global total of US$ 6. Thailand and 1.8 million to smoking and 0. of the 30 and Viet Nam. accounted for the largest share of the total (41%). based on Surveys of costs faced by TB patients and their house­ data from 60 countries. Various new combination reg- million. for TB was substantially increased in 2017 (to US$ 525 and seven repurposed drugs. Annex 2 contains country profiles for the 30 high TB burden Overall.3 million estimated to be eligible. diagnosis and treatment TB research and development Funding for TB care and prevention reached US$ 6. the Philippines. levels of domestic and international donor funding are similar. 4 MDR-TB is defined as resistance to both isoniazid and rifampicin. Pakistan. Timor Leste by Mozambique. international donor funding exceeds domestic 2 When an HIV-positive person dies from TB disease. new compounds. 2016 were not available. Combined with data reported by other countries. following political imens are in Phase II or Phase III trials. range 74–100%) in Brazil. South Africa holds have been completed in seven countries: Ghana.4% in expenditures on health account for a high proportion (>30%) Indonesia to 73% in Zimbabwe. Republic of Moldova. The budget is fully funded. 3 Countries are listed in descending order of their number of incident cases. in descending order of the size of their gap. In the 12 high TB/HIV burden This is consistent with data showing that out-of-pocket countries that did report data. Final results from Myanmar and Viet Nam high TB/HIV burden countries. of total health expenditures in most high TB burden countries. China and South Africa (BRICS).0 million to HIV infection. in descending order of the size of their gap. the Russian Federation. 0. but achieve universal health coverage and other SDG-related was still only 13% of the 1. but that low-income A total of 940  269 people newly enrolled in HIV care countries are unlikely to have the domestic resources to do so.9 million were attributable to undernourishment. Pakistan. countries. (74%) from domestic sources (triple the amount of US$ 124 Country profiles million in 2016) and the remainder (26%) from international donor sources. two drugs that have received accelerated or India stood out as a country in which the budget envelope conditional regulatory approval based on Phase IIb results. platform for rapid molecular testing.TB prevention services targets have been published in a 2017 WHO report. 18 did not report any provision show a high economic and financial burden due to TB disease.

the treatment regimens recommended  Sputum smear microscopy –Developed more than 100 by WHO typically lasted for 20 months. they require more developed laboratory is about US$ 1000 per person. confirmed. Natural history of tuberculosis: duration and fatality rifampicin (the most effective first-line anti-TB drug). They include Xpert MTB/ a Tiemersma EW. As a result of new evidence sputum samples using a microscope to determine the from several countries. for example. First-line LPAs were 4 GLOBAL TUBERCULOSIS REPORT 2017 . a considerable Calmette-Guérin (BCG) vaccine. RIF. Since 2013.1 TB is an infectious disease caused by the bacillus first recommended by WHO in 2008. and sequencing technologies. either before or after confirmed. Globally. who are sick with pulmonary TB expel bacteria into Without treatment. the probability individuals with sputum smear-positive pulmonary TB of developing TB disease is much higher among people died within 10 years of being diagnosed. there is currently no vaccine that is effective pulmonary cases reported to WHO were bacteriologically in preventing TB disease in adults. Phase II or Phase III trials. However. and also higher among people affected 20% of people with culture-positive (but smear-negative) by risk factors such as under-nutrition. accessed 27 July rifampicin and isoniazid (referred to as first-line LPAs). tuberculosis will develop TB treatments became available) found that about 70% of disease during their lifetime. In the current case definitions May 2016. 2011. Effective drug treatments were first developed in the Diagnostic tests for TB disease include the following: 1940s.gov/pubmed/21483732. LPA). WHO issued updated guidance in presence of bacteria. n Basic facts about TB BOX 1.nlm. The test has much better accuracy (RR-TB) and multidrug-resistant TB (MDR-TB)b is longer. one positive result is required recommended for patients (other than pregnant women) for a diagnosis of smear-positive pulmonary TB. the two most and injectable anti-TB drugs (referred to as a second-line powerful anti-TB drugs. a rapid LPA that tests for resistance to fluoroquinolones b Defined as resistance to isoniazid and rifampicin.nih. which was developed proportion of the TB cases reported to WHO are still almost 100 years ago and has been shown to prevent clinically diagnosed rather than bacteriologically severe forms of TB in children. it has also been recommended drug-susceptible TB are regularly reported to WHO by its for use in children and to diagnose specific forms of 194 Member States. is still widely used. The bacille Despite advances in diagnostics. 2016). and cost about years ago. The Global TB Drug Facility supplies a provide results within 2 hours.7 billion of treatment with anti-TB drugs (conducted before drug people infected with M. as did about infected with HIV. Until early 2016.a and alcohol consumption. 54%. for example by coughing. The latest data reported capacity and can take up to 12 weeks to provide to WHO show a treatment success rate for MDR-TB of results. PLoS One. The currently recommended treatment for cases  Rapid molecular tests – The only rapid test for of drug-susceptible TB is a 6-month regimen of four diagnosis of TB currently recommended by WHO first-line drugs: isoniazid. Culture-based lungs (pulmonary TB) but can also affect other sites methods currently remain the reference standard for (extrapulmonary TB).6(4):e17601 (http://www. ethambutol and is the Xpert® MTB/RIF assay (Cepheid. this technique requires the examination of US$ 2000–5000 per person. rifampicin. Borgdorff MW. unevaluated treatment outcomes and treatment failure. It typically affects the LPA was first recommended in May 2016. and many countries are phasing out the use of smear There are 17 TB drugs in clinical trials and combination microscopy for diagnostic purposes (although microscopy regimens that include new compounds as well as other and culture remain necessary for treatment monitoring). and was initially complete 6-month course for about US$ 40 per person. globally. recommended (in 2010) for diagnosis of pulmonary TB Treatment success rates of at least 85% for cases of in adults. of untreated pulmonary tuberculosis in HIV negative patients: a rapid line probe assays (LPAs) that test for resistance to systematic review. Williams BG. It can pyrazinamide. van der Werf MJ. diabetes. the air. than sputum smear microscopy. Overall. The cost of a shortened drug regimen standard. which simultaneously tests for TB and resistance to Nagelkerke NJ. Shortened regimens of 9–12 months are now recommended by WHO. only 57% of the However. smoking pulmonary TB. and requires more expensive and more toxic drugs. USA). There are also tests for TB that is resistant to first-line and second-line anti-TB drugs.  exposure to TB infection. a relatively Studies of the natural history of TB disease in the absence small proportion (5–15%) of the estimated 1. The disease is spread when people drug susceptibility testing.ncbi. reflecting high rates of loss to follow-up. There are 12 TB vaccines in Phase I. with pulmonary RR-TB or MDR-TB that is not resistant to  Culture-based methods – The current reference second-line drugs. drugs are also being tested in clinical trials. In 2016. the second-line n Mycobacterium tuberculosis. the mortality rate from TB is high. Treatment for rifampicin-resistant TB extrapulmonary TB. use of rapid molecular tests is increasing.

technological breakthroughs required to end TB. discussed by Heads of State. In November 2017. data were The report also has four annexes. and about antiretroviral therapy for HIV- positive TB patients. Introduction Tuberculosis (TB) has existed for millennia and remains a major (OECD). The topics of Chapter 5 and Chapter 6 are TB As usual. at global.1 This is despite the fact that. Further details are provided in Annex 1. This framework goes beyond the TB-specific States during the 2014 World Health Assembly. Annex 4 provides data the HIV department in WHO and the Joint United Nations tables that give details of key indicators for the most recent Programme on HIV/AIDS (UNAIDS). Basic facts about TB are summarized in Box 1. Other data sources used in the report include 3 contains global and regional profiles. about the provision of TB preventive treatment to people living with HIV. this will be followed WHO has published a global TB report every year since by the first UN General Assembly high-level meeting on 1997. with the theme of ending TB in the era can be cured. Targets set in the End TB Strategy and Chapter 4 provides data on diagnosis and treatment of include a 90% reduction in TB deaths and an 80% reduction TB.CHAPTER 1. The main aim of the report is to provide a comprehensive TB. This global TB report. and the global health problem.1. at which a multisectoral approach to ending TB and an and up-to-date assessment of the TB epidemic. ranking above and national efforts to end TB. and are for the period 2016–2030. seven SDGs that will influence the future course of the TB The SDGs and the End TB Strategy share a common aim: to epidemic. other indicators 1996. Chapter 8 discusses TB system was opened for reporting in April. diagnosis and treatment. Annex 2 estimated TB cases.int/tme www. For the period 2016–2035. recommended global TB strategies and associated targets. the End TB and Sustainable Development Goals (SDGs). and is for the indicators of the End TB Strategy and the SDG target that is period 2016–2035. this in the TB-SDG monitoring framework.3 death worldwide. focusing attention on 14 other indicators under States in September 2015. Strategy.who. 2000–2016. with a timely diagnosis host the first global Ministerial Conference on TB in Moscow. and correct treatment. the 2017 global TB report is based primarily prevention services and TB financing. end the global TB epidemic. and subsequent review and follow.int/tb/data GLOBAL TUBERCULOSIS REPORT 2017 5 . respectively. published regional and country levels. up of submitted data between June and August. In the second half of 2018. the creditor reporting system of the Organisation for Economic Co-operation and Development 1 3 Further details are provided in Chapter 3. HIV-associated TB and drug-resistant TB. It causes ill-health for approximately WHO national health accounts database. WHO will HIV/AIDS.who. it has been the leading The years 2017 and 2018 are landmark ones for global cause of death from a single infectious agent. these are the End TB Strategy Chapter 2 provides an overview of the SDGs. for all countries. which is critical to achieving the deadline for reporting. (UN). In 2017. Data reported in 2017 were analysed contains country profiles for the 30 high TB burden countries alongside data collected in previous rounds of global TB (profiles for other countries are available online4) and Annex data collection. Following the May research and development. Chapter 7 on data gathered from countries and territories. as provides the latest data and analysis to inform discussions well as broader development goals set by the United Nations and deliberations at both events. Chapter 3 provides estimates of TB disease burden. compared with 2015. which collect information year for which data or estimates are available. 2 4 https://extranet. and a new TB-SDG monitoring framework developed The End TB Strategy was endorsed by WHO’s 194 Member by WHO in 2017. Annex 1 describes the available for 201 countries and territories that collectively online WHO global TB database and provides further details account for more than 99% of the world’s population and about the 2017 round of global TB data collection. For the past 5 years. The SDGs were adopted by UN Member specific to TB. for the period in TB incidence by 2030. and trends in. for development indicators. most people who develop TB disease Russian Federation. All data are stored 10 million people each year and is one of the top ten causes of in WHO’s global TB database. with an online system2 used since 2009. of the SDGs. the World Bank. and of associated multisectoral accountability framework will be progress in prevention. This is done in the context of shortly in advance of the WHO Ministerial Conference. WHO has assesses progress towards universal health coverage and implemented annual rounds of global TB data collection since analyses the latest status of.

Children in Batad. Philippines IAN TROWER / ALAMY STOCK PHOTO .

the SDG framework of goals. 2015. SDG targets and indicators that will influence SDG  3 also includes a target (Target 3. 4 6 Analysis of these indicators is featured in Chapter 7.pdf?ua=1. 3 5 Uplekar M. the latest data for each indicator are shown for all who. accessed 2 August 2017).1 The Sustainable Development Goals and TB mortality rates by 2015 compared with their levels The 17 SDGs are shown in Box 2. It then 2.un. Global tuberculosis report 2015. organigram/htm/progress-hiv-tb-malaria-ntd/en/.com/science/article/pii/ 2016–2030. TB Partnership.sciencedirect.4. Tracking universal health data and recent trends for each indicator are shown for high TB burden coverage: first global monitoring report.int/about/structure/ S0140673615605700?via%3Dihub.5 including the End TB Strategy (Section (Section 2. 2015 (http://www. adopted this target and set two additional targets.CHAPTER 2. because universal health coverage (UHC) in which TB is explicitly achieving the ambitious targets set in the SDGs and End TB mentioned.385(9979):1799–1801 (http:// malaria.2).8 includes an 1 World Health Organization. tuberculosis.2 Similarly. and a desire for universal its assessment of whether the 2015 global TB targets for relevance rather than a focus on issues mostly of concern to reductions in TB incidence. Target 3. In October 2015.2). WHO has defined three lists of high burden targets set within the context of the Millennium Development countries (HBCs): for TB. Lienhardt C.org/topics/sustainabledevelopmentgoals. This is a composite indicator based eng. targets and 2030. Lancet. The Stop are presented and explained in Section 2. as in the Stop TB Strategy). WHO published with three health-related MDGs. Geneva: WHO. This is important. had the overall goal previous eight). 2 United Nations. and 13 targets have been set for this goal (Box 2. and for this reason they 6c of MDG 6 was to “halt and reverse” TB incidence. end the epidemics of AIDS. accessed 2 August 2017). the Stop TB Strategy. hepatitis and neglected tropical diseases: A new agenda for www. et al. It is defined as In 2016. Geneva: WHO. water- initiated work on a new global TB strategy in 2012.3 is TB incidence per 100 000 population per year.8) related to the course of the TB epidemic. the MDGs were succeeded by a new set of “Ensure healthy lives and promote well-being for all at all goals. Sustainable Development Goals (https:// sustainabledevelopment.3 the Joint United Nations Programme on HIV/AIDS (UNAIDS) This chapter provides an overview of both the SDGs for the post-2015 era. The End TB Strategy was unanimously language of “ending epidemics” is also now a prominent endorsed by all WHO Member States at the 2014 World element of global health strategies developed by WHO and Health Assembly. accessed 2 August 2017). accessed 2 August 2017). countries. The MDGs were established by the United (MDR-TB). Weil D.1) and the End TB Strategy (Section 2. In Annex 2. Such language is much more ambitious than the MDG defines and explains a new TB-SDG monitoring framework language of “halting and reversing” epidemics (or “stopping” that has been developed by WHO in 2017 (Section 2.3. These were to halve TB prevalence 2. which was borne diseases and other communicable diseases”.pdf. and encourage 3. indicator on the coverage of essential prevention. The WHO/World Bank definition of UHC is that Strategy requires that these broader influences on the risks all people receive the health services they need.1 The consolidated goal on health is SDG 3.who.who. while at the of developing TB and the consequences of TB disease are same time ensuring that the use of these services does not addressed. The Sustainable Development Goals and the End TB Strategy From 2000 to 2015. global and national efforts to reduce the For the first 5 years of the SDGs and End TB Strategy burden of tuberculosis (TB) disease were focused on achieving (2016–2020). The global TB strategy developed by WHO for the MDGs include a broader agenda (17 goals compared with the decade 2006–2015.6 Target 3. ages”. In Annex 4. 2015 (http://apps. the latest World Health Organization/World Bank Group.1. explicitly mentions TB: “By of consultations.3). Dias HM. accessed 2 August 2017). Adopted by the UN in September 2015 following 3  years One of these targets. TB/HIV and multidrug-resistant TB Goals (MDGs).int/iris/bitstream/10665/174536/1/9789241564977_eng. and is for the period 2016–2035. World Health Organization. WHO neglected tropical diseases and combat hepatitis. Lonnroth K. Departures from the in 1990. prevalence and mortality were developing countries. known as the Sustainable Development Goals (SDGs). Particular attention is given to the countries in each Nations (UN) in 2000 and targets were set for 2015. Accelerating progress on HIV. This them. Geneva: WHO.2). Jaramillo E. The completed in 2014. GLOBAL TUBERCULOSIS REPORT 2017 7 . established in 2001.int/iris/bitstream/10665/191102/1/9789241565059_ and care interventions.4 expose the user to financial hardship. treatment 2015 (http://apps. tuberculosis. malaria and indicators is for the period 2016–2030. Target of these lists throughout this report. countries. WHO’s new End TB Strategy. The TB indicator for Target framework is designed to focus attention on. analysis of. one consolidated goal on health compared of reaching all three targets. achieved.

Protect. Conserve and sustainably use the oceans. resilient and sustainable Goal 12.1 Goal 1. inclusive and sustainable economic growth. sustainable and modern energy for all Goal 8. promote inclusive and sustainable industrialization and foster innovation Goal 10. Promote sustained. Ensure availability and sustainable management of water and sanitation for all Goal 7. intergovernmental forum for negotiating the global response to climate change. full and productive employment and decent work for all Goal 9. Ensure sustainable consumption and production patterns Goal 13. Reduce inequality within and among countries Goal 11. Take urgent action to combat climate change and its impactsa Goal 14. Make cities and human settlements inclusive. Promote peaceful and inclusive societies for sustainable development. Ensure access to affordable. reliable. Ensure healthy lives and promote well-being for all at all ages Goal 4. Build resilient infrastructure. and halt and reverse land degradation and halt biodiversity loss Goal 16. accountable and inclusive institutions at all levels Goal 17. provide access to justice for all and build effective. Strengthen the means of implementation and revitalize the Global Partnership for Sustainable Development a Acknowledging that the United Nations Framework Convention on Climate Change is the primary international. End poverty in all its forms everywhere n Goal 2. restore and promote sustainable use of terrestrial ecosystems. Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all Goal 5. achieve food security and improved nutrition and promote sustainable agriculture Goal 3. n The Sustainable Development Goals BOX 2. Achieve gender equality and empower all women and girls Goal 6. sustainably manage forests. 8 GLOBAL TUBERCULOSIS REPORT 2017 . End hunger. safe. seas and marine resources for sustainable development Goal 15. combat desertification.

such as vital registration systems for accurate tracking of causes of death (this is Part b of Indicator 17. in accordance with the Doha Declaration on the TRIPS Agreement and Public Health.c Substantially increase health financing and the recruitment. quality and affordable essential medicines and vaccines for all 3. especially in least developed countries and small island developing States 3. as appropriate 3.b Support the research and development of vaccines and medicines for the communicable and non- communicable diseases that primarily affect developing countries. ensure universal access to sexual and reproductive health-care services.4 By 2030. people with disabilities. victims of work which is TB treatment. water-borne diseases and other communicable diseases 3. examples include disaggregation by age.8 Achieve universal health coverage.7 By 2030.d Strengthen the capacity of all countries. provide access to medicines for all 3.g. information and education. 16 interventions have been selected as “tracers” for progress vital registration systems as the basis for direct measurement towards UHC for all interventions. substantially reduce the number of deaths and illnesses from hazardous chemicals and air. Trade-Related Aspects of Intellectual Property Rights on the coverage of 16 so-called “tracer interventions”. Some indicators also given to the importance of death registration within national give particular attention to specific subpopulations. provide access to affordable essential medicines and vaccines. tuberculosis. bottom 40%. n Sustainable Development Goal 3 and its 13 targets BOX 2. risk reduction and management of national and global health risks TRIPS. training and retention of the health workforce in developing countries. reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being 3.5 Strengthen the prevention and treatment of substance abuse. end preventable deaths of newborns and children under 5 years of age.a Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries.3 By 2030. Depending on the subheading of “Data. emphasis on disaggregated analysis and reporting of data SDG 17 includes two targets and associated indicators under (as well as reporting for an entire country). effective.1 By 2030. including for family planning. In this context. including narcotic drug abuse and harmful use of alcohol 3. the SDGs include considerable disaggregation for many SDG indicators under SDGs 1–16. for early warning.9 By 2030. location and economic status (e. injuries and migrants. including financial risk protection. Emphasis is also bottom versus top income quintiles). end the epidemics of AIDS. halve the number of global deaths and injuries from road traffic accidents 3. and. Strengthening national 1 There are many different prevention and treatment interventions.2 By 2030. in particular. In addition to the specification of such In contrast with the MDGs. in particular developing countries.19).1). water and soil pollution and contamination 3. of the number of TB deaths is one of the five strategic GLOBAL TUBERCULOSIS REPORT 2017 9 . with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 live births and under-5 mortality to at least as low as 25 per 1000 live births 3. the indicator. malaria and neglected tropical diseases and combat hepatitis. monitoring and accountability”. access to quality essential health-care services and access to safe.6 By 2020.2 SDG3: Ensure healthy lives and promote well-being for all at all ages n Targets 3. or needed to generate such data (Table 2. reduce the global maternal mortality ratio to less than 70 per 100 000 live births 3.1 one of pregnant women. which affirms the right of developing countries to use to the full the provisions in the Agreement on Trade-Related Aspects of Intellectual Property Rights regarding flexibilities to protect public health. and the integration of reproductive health into national strategies and programmes 3. development. which specifically refer to disaggregated data and mechanisms sex.

in to increase significantly the availability of high-quality. Dodd PJ. as discussed further in Chapter 3. migratory status. efficacious and End TB. 2.2 The End TB Strategy during the 1950s and 1960s.1 SDG 17.5% per year in 2015 to 4–5% per year by and disease. in countries in western Europe 2. More details about this plan are provided in Chapter 6. PLoS Med.7 billion people2 who are already the milestone for 2020 is zero. and targets and indicators related to data.nlm. and support statistical capacity-building in developing countries per cent birth registration and 80 per cent death registration areas of work of the WHO Global Task Force on TB Impact needed to reach the 2020 milestones of the End TB Strategy. TABLE 2. For will depend on a technological breakthrough that can the third indicator (the percentage of TB-affected households substantially reduce the risk of developing TB disease among that experience catastrophic costs as a result of TB disease). given the influence for reductions in TB cases and deaths set for 2020 and 2025 of sex. 17. Second. Analysis of CFRs at global and national levels is  the percentage of TB-affected households that experience included in Chapter 3. If UHC and social protection in 2015. 2020. timely and reliable accordance with the Fundamental Principles of Official Statistics data disaggregated by income. Measurement. compared with levels in 2015. build on existing initiatives to develop measurements of 17. compared high-quality diagnosis and treatment without incurring with levels in 2015. only been documented in the context of UHC combined with The overall goal is to “End the global TB epidemic”. Chapter 3 and Chapter 4 of this report include 2020. and then to 10% per year by 2025. geographic location and other characteristics relevant in national contexts 17. compared with levels as well as social protection. age. then people with TB should be able to access and an 80% reduction in the TB incidence rate. A CFR of 6. Disaggregation is intended to inform analysis of Progress towards UHC and actions to address health-related within-country inequalities and associated assessments risk factors for TB as well as broader social and economic of equity. to be sustained thereafter. age.5% by 2025. the there are three high-level.org/global/plan/. attention is needed. The at which TB incidence falls globally is required if the 2030 trajectories of TB incidence and TB deaths that are required to and 2035 targets are to be reached.18  By 2020.1 which focuses on the actions and funding 2 Houben RM. gender. reaching the milestones consideration for the TB community. The most immediate milestones. sex and location.nih. 2015 2016. enhance capacity-building support to developing countries. are a 35% reduction in TB deaths and a 20% reduction After 2025.19. linked to the SDGs. (http://www. monitoring and accountability SDG 17: Strengthen the means of implementation and revitalize the global partnership for sustainable development TARGETS INDICATORS 17. Declines of 10% per year have The End TB Strategy “at a glance” is shown in Box 2. possible if all those with TB disease can access high-quality  the TB incidence rate per year. with findings used to identify particular areas determinants of TB will be fundamental to achieving the or subpopulations where progress is lagging and greater targets and milestones for reductions in TB cases and deaths.gov/pubmed/27780211. the national level with full disaggregation when relevant to the target.ncbi. and (b) have achieved 100 product. 10 GLOBAL TUBERCULOSIS REPORT 2017 . the approximately 1. 2016–2020. but is only  the number of TB deaths per year. Geneva: Stop TB Partnership. an unprecedented acceleration in the rate in the TB incidence rate. disability. The percentage of TB patients and their households facing The 2035 targets are a 95% reduction in TB deaths and a catastrophic costs is a good tracer for progress towards UHC 90% reduction in the TB incidence rate. The 2030 targets are a 90% reduction in TB deaths are in place. and treatment. 1 The Global Plan to End TB.1.2  Proportion of countries that (a) have conducted at least one progress on sustainable development that complement gross domestic population and housing census in the last 10 years. per year is equivalent to the best-ever performance to date at national level – for example. catastrophic costs as a result of TB disease.18. Such disaggregation is also an important There are two reasons for this. The three indicators are: by 2020 and then to 6. and for 2035) and (the case fatality ratio.5% is similar to the current level in many high-income countries. accessed 2 August 2017). race. and broader social and economic development. overarching indicators and related global proportion of people with TB who die from the disease targets (for 2030.19  By 2030.stoptb.3.1  Proportion of sustainable development indicators produced at including for least developed countries and small island developing States. socio­economic status and differential access to requires the annual decline in the global TB incidence rate to health care on the risks for and consequences of TB infection accelerate from 1. ethnicity. or CFR) needs to be reduced to 10% milestones (for 2020 and 2025). The global burden of latent tuberculosis infection: a re-estimation using mathematical modelling. infected with Mycobacterium tuberculosis. set for catastrophic costs. 2016–2020.13(10):e1002152 (https://www. A decline of 10% analyses of TB data disaggregated by age. Examples include The Stop TB Partnership has developed a Global Plan to an effective post-exposure vaccine or a short. accessed 2 August 2017). Such an acceleration reach these milestones and targets are shown in Fig. First.

Engagement of communities. The table also indicates the particular and vaccines is presented in Chapter 8. INTEGRATED. PATIENT-CENTRED CARE AND PREVENTION A. Lancet.2. safe treatment for latent TB infection (LTBI). Collaborative TB/HIV activities. The three pillars are integrated. and reporting.pdf. disease and suffering due to TB GOAL END THE GLOBAL TB EPIDEMIC MILESTONES TARGETS INDICATORS a 2020 2025 SDG 2030 END TB 2035 Percentage reduction in the absolute number of TB 35% 75% 90% 95% deaths (compared with 2015 baseline) Percentage reduction in the TB incidence rate 20% 50% 80% 90% (compared with 2015 baseline) Percentage of TB-affected households experiencing 0% 0% 0% 0% catastrophic costs due to TB (level in 2015 unknown) PRINCIPLES 1.com/science/article/pii/ systems (including UHC.385(9979):1799–1801 (http://www. protection revision of WHO’s framework for TB case definitions and and promotion of human rights. Universal health coverage policy.who. and systematic screening of contacts and high-risk groups B. Political commitment with adequate resources for TB care and prevention B. 1 Uplekar M. civil society organizations. and intensified research and innovation. Protection and promotion of human rights. n The End TB Strategy at a glance BOX 2. Social protection. ethics and equity 4.2 Collection of data on the costs faced by TB patients adaptation of the strategy and targets at country level. interventions and strategies B. Geneva: WHO. 2 World Health Organization. and promote innovations a Targets linked to the Sustainable Development Goals (SDGs). GLOBAL TUBERCULOSIS REPORT 2017 11 . patient. BOLD POLICIES AND SUPPORTIVE SYSTEMS A. with global collaboration. Lienhardt C. quality and rational use of medicines. The Data for five of the 10 indicators cannot be captured principles are government stewardship and accountability.2).sciencedirect. Adaptation of the strategy and targets at country level. chapter of this report in which available data for each indicator To achieve the targets and milestones. a strong coalition with for paper-based systems that are included in the latest civil society organizations and communities. Research to optimize implementation and impact. The 10 determinants). and vaccination against TB 2.int/iris/ in association with the publication of a journal article about bitstream/10665/79199/1/9789241505345_eng.3. Weil D. et al. accessed 2 August 2017). Jaramillo E.3 A WORLD FREE OF TB n VISION — zero deaths. the End TB can be found. Treatment of all people with TB including drug-resistant TB. development and rapid uptake of new tools. Early diagnosis of TB including universal drug-susceptibility testing. The latest status the End TB Strategy)1 to monitor their implementation are of the development pipelines for new TB diagnostics. 2015. Government stewardship and accountability. drugs shown in Table 2. with global collaboration PILLARS AND COMPONENTS 1. and management of comorbidities D. social protection and action on TB S0140673615605700?via%3Dihub. vital registration. and the 10 priority indicators (defined in March 2015 (WHO/HTM/TB/2013. Strategy has four underlying principles and three pillars. Dias HM. poverty alleviation and actions on other determinants of TB 3. and public and private care providers C. centred TB care and prevention. and regulatory frameworks for case notification. and infection control D. Preventive treatment of persons at high risk. Discovery. with monitoring and evaluation 2. INTENSIFIED RESEARCH AND INNOVATION A. accessed 2 August 2017). Definitions and reporting framework for The 10 components of the three pillars are shown in tuberculosis – 2013 revision (updated December 2014) Box 2. Lonnroth K. ethics and equity. Strong coalition with civil society organizations and communities 3. 2013 (www. bold policies and supportive WHO’s new End TB Strategy. indicators are defined and explained in an appendix. routinely using the standard recording and reporting forms with monitoring and evaluation. and patient support C.

or these systems inform broader actions in the health sector and beyond that can be adapted to do so. Raviglione M.3).5 In operational guidance on the End TB Strategy.sciencedirect. For example. Lönnroth K. In: Blas E & Kurup A (eds. Implementing the End TB Strategy: the Monitoring and evaluation of TB in the context of the Sustainable essentials. Equity. 1 6 World Health Organization. Alternatively.html.2 Lienhardt C. See in particular “TB in the context of the Sustainable Development Goals”.1 Projected incidence and mortality curves that are required to reach End TB Strategy targets and milestones. Microbiol. care. Glaziou P. pdf. alongside continued efforts to strengthen 3 Lönnroth K. Williams B. 6 and 8 in Table 2. Glaziou P et al. Chauhan LS. Raviglione M. request.6 2.3. social determinants and public health programmes. accessed 2 August 2017). Castro KG. accessed 2 August 2017).3 A TB-SDG monitoring framework WHO has developed a TB-SDG monitoring framework that Monitoring of TB-specific indicators is well established comprises 14 indicators under seven SDGs (Table 2. further includes targets and indicators related to these risk factors details are provided in Chapter 7.375(9728):1814–1829 be reliably used for direct measurement of TB incidence and (http://www.). and social development. 2009. 5.2). and estimates of TB incidence and mortality have role of risk factors and social determinants.who. 2016 (http://www.com/science/ article/pii/S0277953609002111?via%3Dihub. the SDG framework surveys of a representative sample of TB patients.5 Incidence rate per 100 000 population per year 20% reduction 100 35% reduction Deaths (millions) 1. and expanded monitoring to S0140673610604837?via%3Dihub. building on this previous work as well as further analysis of the relationship between SDG indicators and TB incidence. Lönnroth K. Available on Part II. achieving the End TB Strategy v10/n6/full/nrmicro2797. Geneva: WHO. Soc related risk factors for TB infection and disease. notification and vital registration systems so that they can Tuberculosis control and elimination 2010–50: cure. In this context. 2010 In the era of the End TB Strategy and SDGs. will continue. Nat Rev have been introduced in the context of the End TB Strategy). to systems for recording and reporting of data. accessed 2 August 2017).nature. 2010. Dye C. Chakaya JM. periodic surveys of the will be necessary to end the TB epidemic.5 80% reduction 25 TARGET FOR 2035 = 90% REDUCTION 90% reduction TARGET FOR 2035 = 95% REDUCTION 0 0 2015 2020 2025 2030 2035 2015 2020 2025 2030 2035 and their households. As explained in Section 2. medical records or patient cards of a random sample of TB Previously published work has identified clear linkages patients can be done.2) requires periodic and disease.1 2017. 5 targets and milestones requires progress in reducing health. Floyd K. For the other four indicators and determinants. been published annually by WHO for more than a decade. Drivers of tuberculosis epidemics: the role of risk factors and social determinants. TB monitoring needs to (Indicators 4. Jaramillo E. 2012.0 75 50% reduction 50 75% reduction 0.int/iris/bitstream/10665/44289/1/9789241563970_eng.1. at global and national levels. data may already be be further expanded to include analysis of selected SDG captured routinely in countries with electronic case-based indicators that will influence the course of the TB epidemic.4. Section 2.com/science/article/pii/ TB deaths (see also Chapter 3). 2.com/nrmicro/journal/ As explained in Section 2. such monitoring (http://apps.sciencedirect. Jaramillo E. FIG.10(6):407-416 (https://www. 2015–2035 125 1.4. Raviglione M.who. Further guidance is provided in WHO between various SDG indicators and TB incidence. accessed 2 August 2017). Dye C. 12 GLOBAL TUBERCULOSIS REPORT 2017 . standardized monitoring of notifications of TB cases and their treatment outcomes at global and national levels has been in place 2 Lönnroth K. Williams BG. Lancet. 4 include new priority indicators (five of those listed in Table 2. accessed 2 August 2017).68(12):2240–2246 (http://www. Uplekar M. WHO.int/tb/publications/2015/ Development Goals: Background Paper for WHO Ministerial Conference on The_Essentials_to_End_TB/en/. and assessment of whether these broader social and economic determinants of TB infection are catastrophic (Indicator 3 in Table 2. as well as Sci Med.2.2. Tuberculosis: the since 1995. Getahun H. Global tuberculosis control: lessons learnt and future prospects.

LTBI. 6 Contact investigation coverage Contact tracing is a key component of As above for LTBI. DST. eligible patients for treatment with new drugs may differ among countries. divided by the number eligible for Mycobacterium tuberculosis. case fatality ratio. ≥90% confirmed TB who were evaluated for TB. divided by the total number of notified cases of Chapter 4 bacteriologically confirmed pulmonary TB in the same year. notifications percentage. tuberculosis. expressed as a coverage of appropriate treatment Chapter 4 percentage. Sustainable Development Goal. High of TB incidence. UHC. expressed as a percentage. every person diagnosed with TB. 10 Case fatality ratio (CFR) This is a key indicator for monitoring Mortality divided by incidence. Chapter 3 CFR. treatment. RECOMMENDED MAIN METHOD OF MEASUREMENT. universal health coverage.2 Top 10 indicators (not ranked) for monitoring implementation of the End TB Strategy at global and national levels. including antiretroviral therapy. latent TB infection. or national Number of patients with bacteriologically confirmed to provide the right treatment for survey of medical records or patient 100% pulmonary TB with a DST result for at least rifampicin. is essential to provide the best care expressed as a percentage. The target level is for 2025 at the latest. expressed as a ≤5% milestones. Number of contacts of people with bacteriologically TB prevention. SDG. 7 Drug-susceptibility testing (DST) coverage for TB Testing for drug susceptibility for Routinely collected data (as part of patients WHO-recommended drugs is essential case-based surveillance). In combination. Rapid molecular case-based surveillance). 5 Latent TB infection (LTBI) treatment coverage Treatment of LTBI is the main Routinely collected data (as part of Number of people living with HIV newly enrolled in treatment intervention available to case-based surveillance). drug-susceptibility testing. a WRD at the time of diagnosis. 8 Treatment coverage. The target is for drug-susceptible ≥90% will be used as tracer indicators for and drug-resistant TB combined. a Catastrophic costs are provisionally defined as total costs that exceed 20% of annual household income. cards of TB patients. In Number of TB deaths divided by estimated number progress towards the 2020 and 2025 countries with a high-performance of incident cases in the same years. although outcomes monitoring progress towards UHC should also be reported separately. Xpert MTB/RIF) as well as conventional phenotypic DST results. 4 Percentage of new and relapse TB patients tested Accurate diagnosis is a fundamental Routinely collected data (as part of using a WHO-recommended rapid diagnostic (WRD) component of TB care. achieve the 2025 global milestone for approximate incidence. incident TB cases in the same year. 9 Documentation of HIV status among TB patients One of the core global indicators Routinely collected data for all TB Number of new and relapse TB patients with used to monitor collaborative TB/HIV patients. WRD. divided by innovations in all countries. divided by the number of activities. DST coverage includes results from molecular (e. is a fundamental requirement for achieving the milestones and targets 2 TB treatment success rate Routinely collected data. expressed as a percentage (separately for Chapter 5 each of the two groups). Documentation of HIV status Chapter 4 100% new and relapse TB patients notified in the same year. new TB drugs An indicator that is relevant As above for DST. Number of TB patients treated with regimens that to monitoring the adoption of include new (endorsed after 2010) TB drugs. expressed as a percentage. expressed as a percentage. A CFR of 6% is required to surveillance system. divided by the number eligible. especially in children. Percentage of notified TB patients who were Chapter 4 it is likely that these two indicators successfully treated. divided by the total Chapter 4 number of new and relapse TB patients. divided by the estimated number of ≥90% TB and to cut transmission. or national at the time of diagnosis diagnostic tests help to ensure early survey of medical records or patient Number of new and relapse TB patients tested using ≥90% detection and prompt treatment. a key marker of patients. people treated for TB. or national HIV care and the number of children aged <5 years prevent development of active TB survey of medical records or patient who are household contacts of cases started on ≥90% disease in those already infected with cards of people living with HIV and LTBI treatment. for HIV-positive TB patients. human immunodeficiency virus. ≥90% the number of notified patients eligible for treatment The definition of which patients are with new TB drugs. AND INDICATOR MAIN RATIONALE FOR INCLUSION IN TOP 10 TARGET LEVEL RELEVANT CHAPTER OF THIS REPORT 1 TB treatment coverage High-quality TB care is essential to Routinely collected notification data Number of new and relapse cases that were notified prevent suffering and death from used in combination with estimate and treated. within the SDGs.g. with recommended target levels that apply to all countries. TB patients. documented HIV status. WHO. Number of people treated for TB (and their financial risk protection (one of the Chapter 7 0% households) who incur catastrophic costs (direct and two key elements of UHC) and social indirect combined). of the End TB Strategy. reductions in TB deaths and cases. cards of TB patients. TB. GLOBAL TUBERCULOSIS REPORT 2017 13 . expressed as a percentage. HIV. divided by the total number of protection for TB-affected households. WHO-recommended rapid diagnostic. 3 Percentage of TB-affected households that One of the End TB Strategy’s three National survey of notified TB experience catastrophic costs due to TBa high-level indicators. World Health Organization.TABLE 2.

3  End the epidemics 3. to inform access the WHO Framework tobacco use among those those aged ≥15 although a link with TB incidence to smoking cessation Convention on Tobacco aged ≥15 years years (%) at the national (as opposed to interventions).3.g. diabetes or at the national (as opposed to comorbidities.1 Age-standardized Prevalence of Smoking is a strong risk factor for WHO Could be considered implementation of prevalence of current smoking among TB disease at the individual level. universal health coverage. Sustainable Development Goal. 3.a.1  Number of new HIV prevalence HIV is a strong risk factor for UNAIDS Yes. although a link comorbidities. acquired immune deficiency syndrome.5 Strengthen 3. TB. AIDS. not applicable. Health expenditure per capita is correlated with TB incidence.2 Alcohol Prevalence of alcohol Alcohol use is a strong risk WHO Could be considered at prevention and treatment consumption per capita use disorder factor for TB disease and poorer country level.8. although a link with TB incidence planning of care for diseases and promote cancer. Joint United Nations Programme on HIV/AIDS. Diabetes prevalence is more relevant than mortality for TB since it directly influences the risk of developing TB. 3.1  Coverage of NA Achieving UHC is required to WHO To assess progress including financial risk essential health services achieve the three high-level in elimination of protection. UHC.a Strengthen 3. HIV. UNAIDS. Control individual) level has been difficult to establish due to confounding.8  Achieve UHC. World Health Organization. SDG. 3. country level. human immunodeficiency virus. coverage and treatment success on health as a share pocket have been monitored for years of total household and the composite indicator of expenditure or income Health expenditure “effective treatment coverage” (the per capita product of treatment coverage and treatment success) is now one of 16 tracer indicators for UHC in the SDG framework.2  Proportion of Percentage of total costs for TB patients and their recommended. to inform of substance abuse.5. 14 GLOBAL TUBERCULOSIS REPORT 2017 . to inform from non-communicable cardiovascular disease.3. chronic respiratory individual) level has been difficult being disease to establish due to confounding. WHO.3A TB-SDG monitoring framework: indicators to monitor within SDG 3 SDG 3: Ensure healthy lives and promote well-being for all at all ages ALTERNATIVE COLLECT DATA FOR TB PATIENTS SDG TARGETS FOR 2030 SDG INDICATORS RATIONALE DATA SOURCE INDICATORS TO MONITOR SPECIFICALLY? 3. tuberculosis.4  Reduce premature 3. medicines and vaccines population with large health expenditures households. TB treatment for all household expenditures that are out-of. the number of TB deaths households. The prevalence of alcohol use disorder is the most relevant indicator in the context of TB. (e. and neglected tropical uninfected population associated with poorer treatment diseases and combat 3.8. TABLE 2. abuse and harmful use of aged ≥15 years (harmful with TB incidence at the national alcohol level defined nationally) (as opposed to individual) level has been hard to establish due to confounding.1 Mortality Prevalence of Diabetes is a strong risk factor WHO Could be considered at mortality by one third rate attributed to diabetes for development of TB disease. 3. periodic to safe. HIV prevalence (rather WHO NA hepatitis. TB. quality tracer indicators) and eliminating catastrophic surveys of TB patients are and affordable essential 3. mental health and well. effective. NA. access to (composite indicator. already routinely of AIDS.4. water-borne 100 000 population than incidence) will be monitored diseases and other because it is directly measured communicable diseases and those newly infected with HIV are at lower risk of developing TB compared with those who have been infected for more than 1 year. including TB treatment reductions in the TB incidence TB patients and their care services and access coverage as one of 16 rate. malaria HIV infections per 1000 development of TB disease and is collected. per year (in litres of pure treatment outcomes at the planning of care for including narcotic drug alcohol) among those individual level. 3.2  TB incidence per outcomes. targets of the End TB Strategy for catastrophic costs for quality essential health.

TABLE 2. protection systems social protection floors/ lower TB burden. TB.1  Proportion of NA seeking. GLOBAL TUBERCULOSIS REPORT 2017 15 . achieve food security and improved nutrition and promote sustainable agriculture 2. ensure access by all undernourishment body’s defence against infections database to plan food support). 1.1  Growth rates of Gini index for TB is a disease of poverty. OECD. United Nations. overcrowding. inclusive and sustainable economic growth. operating through several database. Organisation for Economic Co-operation and Development. tuberculosis. resilient and sustainable 11. Sustainable Development Goal.1.1  Proportion of NA Poverty is a strong risk factor for UN SDG No poverty for all people population living below TB.1  Prevalence of NA Under-nutrition weakens the UN SDG Could be considered (e. reliable.1 Proportion NA Living in a slum is a risk factor for UN SDG No all to adequate. nutritious and is a strong risk factor for TB at and sufficient food year.1.1  Ensure access for 11. NA.1. combined with economic growth OECD the population at a rate overall and for the should have an effect on the TB higher than the national bottom 40% of the epidemic. It is also a risk factor and basic services and informal settlements or for developing TB disease. Progress on both and measures for all.1  End hunger and 2. and World Bank No sustain income growth household expenditure income inequality deceasing income inequalities of the bottom 40% of or income per capita. round SDG 7: Ensure access to affordable.1  Annual growth rate GDP per capita Historic trends in TB incidence are World Bank No growth with at least 7% of real GDP per capita closely correlated with changes growth in GDP per year in the absolute level of GDP per in the least developed capita (but not with the growth countries rate). SDG 2: End hunger. population with primary for TB disease at the individual reliable and modern reliance on clean fuels level. people to safe.g.1  Ensure universal 7. SDG. sustainable.3B TB-SDG monitoring framework: indicators to monitor beyond SDG 3 SDG 1: End poverty in all its forms everywhere ALTERNATIVE COLLECT DATA FOR TB SDG TARGETS FOR 2030 SDG INDICATORS RATIONALE DATA SOURCE INDICATORS TO MONITOR PATIENTS SPECIFICALLY? 1.2  Proportion of NA Indoor air pollution is a risk factor WHO No access to affordable. the national and individual level. full and productive employment and decent work for all 8. gross domestic product. systems indicators will help to achieve the including floors End TB Strategy target to eliminate catastrophic costs for TB patients and their households. and modern energy for all 7. due to upgrade slums inadequate housing links with air pollution and under- nutrition.3 Nationally 1. GDP. Reducing poverty should World Bank line also facilitate prompt health-care Could be considered (e. SDG 10: Reduce inequality within and among countries 10. everywhere the international poverty pathways. safe of urban population TB transmission due to its link with database and affordable housing living in slums. WHO.1.g. World Health Organization. UN. SDG 8: Promote sustained.1  Achieve and 10.1  Eradicate extreme 1.1  Sustain per capita 8.3. Countries with higher to facilitate access to appropriate social population covered by levels of social protection have social protection). safe.1. average population SDG 11: Make cities and human settlements inclusive. There has been limited study energy services and technology of ambient air pollution but it is plausible that it is linked to TB incidence. not applicable.1.

Geneva: WHO. and this risk needs to be avoided. (discussion paper). and a better (but closely related) alternative has Use of high burden country lists for TB by WHO in the post-2015 era been identified and justified (five indicators under SDG 3. and familiar and widely used in the context of TB. data would be collected for all TB patients).4 Lists of high-burden countries being excludes: used by WHO during the period  indicators that are additional sub-indicators under 2016–2020 indicators that have already been included (e. HBC list for TB (22 countries) had remained unchanged since education under SDG 4. as shown in Table 2. Table 2. UN and World Bank databases  health expenditure per capita. In 2015.g. it was an and reporting efforts by national TB programmes. The TB risks.2. 8. considered as an alternative to routine surveillance (in which  gross domestic product (GDP) per capita. It 2. plus the additional 10 countries with the most analysis of the status of. For SDG 3. the seven indicators selected for monitoring are: either WHO.  proportion of the population covered by social protection However. UNAIDS or the World Bank (also shown  coverage of essential health services. periodic surveys should be clean fuels and technology. the 14 indicators severe burden in terms of incidence rates per capita that do related to TB will be based primarily on accessing the data held in the UN’s SDG database. Therefore. incident cases. They will not be available for  HIV prevalence.g. data sources are publications/global_report/high_tb_burdencountrylists2016-2020.  prevalence of alcohol use disorder. with the exception of HIV prevalence  prevalence of smoking. TB/HIV and MDR-TB – were in use.  percentage of total health expenditures that are out-of- The data for the indicators shown in Table 2. and the HBC lists for TB/HIV (41 countries) and MDR-TB resilient infrastructure under SDG 9). During the period 1998 to 2015. OECD.who.4 established a monitoring system for SDG indicators. will be for national populations. and trends in. since it is the population-level prevalence that monitoring are: influences population-level TB risks. indicator is considered important enough to monitor among  proportion of the population with primary reliance on TB patients at country level. accessed 28 July 2017). far too complex. the Organisation for Economic Co-operation and Development (OECD). 7.3 WHO defined beyond those to which countries have already committed three new HBC lists for the period 2016–2020: one for TB. the seven indicators selected for determinants. best metric. gender equality under SDG 5 and 2002. 16 GLOBAL TUBERCULOSIS REPORT 2017 . 2. The latest status and recent trends in each indicator The rationale for the selection of these 14 indicators.1 and Analysis of the indicators in the TB-SDG monitoring  proportion of the urban population living in slums. each list will be reviewed in June 2020. 2. and the last year of the Stop TB Strategy in Table 2.4). in Table 2. With 2015 marking the end of the MDGs and a Collection and reporting of data for the 14 indicators shown new era of SDGs. (27 countries) had not been updated since 2009 and 2008. other countries in profiles that are available online2). there is a clear risk of making routine TB surveillance floors/systems. These are defined countries are expected to report data on an annual basis via as the top 20 in terms of the absolute number of estimated the appropriate UN agencies (including WHO). TB patients specifically.  proportion of the population living below the international Collection of data for a few of the indicators included in poverty line. Nor ideal time to revisit these three HBC lists.3.3).3 does not require any additional data collection before its replacement with the End TB Strategy. framework for high TB burden countries is included in Chapter 7. the UN has one for MDR-TB and one for TB/HIV (Fig.int/tb/ one under SDG 8 and one under SDG 10). and as part of national TB surveillance for more than a decade). under SDG 3). sub. This is not a problem for monitoring of TB risk factors and For SDGs 1. the three lists have a lifetime of 5 1 The index can take values between 0 and 1. If the  prevalence of undernourishment. 10 and 11. available in the WHO. (HIV status among TB patients has been routinely monitored  prevalence of diabetes.4. and that operate mainly through other SDGs (e. In 2 http://www. pdf?ua=1. 2015 (http://www. does it require data collection and reporting efforts that go Following a wide consultation process. and Each list contains 30 countries (Table 2. data are also shown for these countries on the second page of the sources and comments on whether it is relevant to collect country profiles in Annex 2 (this information is shown for data for TB patients specifically are provided in Table 2. 4 As explained in the last row of Table 2.3. three  indicators that are much more remotely associated with HBC lists – for TB.3 could be considered for TB patients specifically. The framework includes only indicators for which a relationship with TB incidence could be established.4).who.3 that will be pocket.int/tb/publications/global_report/en/ (Accessed 2 August those cases where the SDG indicator is not considered the 2017) 3 World Health Organization Strategic and Technical Advisory Group for TB.  Gini index for income inequality. the concept of an HBC became indicators related to UHC. Table 2. and the countries included in each list and the criteria used to define equality and 1 representing perfect inequality. in the context of the SDGs. with 0 representing perfect years. respectively. At the global level.

not already appear in the top 20 and that meet a minimum The 30 high TB burden countries are given particular threshold in terms of their absolute numbers of incident cases attention in the main body of this report. a Indicates countries that are included in the list of 30 high TB burden countries on the basis of the severity of their TB burden (i. TB incidence per 100 000 population). The lists were defined using the latest estimates are for TB/HIV and MDR-TB specifically.FIG. Papua online global TB database. which are included on the basis of their absolute number of incident cases per year. Country profiles for all countries New Guinea. World Health Organization. and 1000 per year for TB/HIV and disease burden and assessment of progress in the response MDR-TB). human immunodeficiency virus. South Africa.e.1 1 www. Each list TB/HIV and MDR-TB lists. as opposed to the top 20. tuberculosis. Where estimates of (10  000 per year for TB. Data for all countries are included in Annex 4 and in WHO’s Indonesia. with most of attention. DR Congo. India. Ethiopia. MDR. United Republic of Tanzania. but 48 countries between the 20 countries included on the basis of absolute appear in at least one list. Myanmar. Kenya. and their areas of overlap TB Cambodiaa Sierra Leonea Bangladesh Brazil DPR Korea Central African Republica Pakistan Congoa Philippines Lesothoa Russian Federation Angola Liberiaa Azerbaijan Viet Nam China Namibiaa Belarus DR Congo UR Tanzania Botswana Kazakhstan Ethiopia Zambiaa Cameroon Kyrgyzstan India Chad Indonesia Ghana Peru Kenya Republic of Moldova Guinea-Bissau Mozambique Malawi Somalia Myanmar Tajikistan Nigeria Swaziland Ukraine Papua New Guineaa Uganda Uzbekistan South Africa Thailand Zimbabwea MDR-TB TB/HIV DPR Korea. the Democratic Republic of the Congo. the 30 high TB burden countries. 2. the countries in the of TB disease burden available in October 2015.2) are Angola. TB/HIV and MDR-TB being used by WHO during the period 2016–2020. The 14 countries that are in all three numbers of incident cases and the 10 additional countries lists (shown in the central diamond in Fig. UR Tanzania. 2. HIV. respectively. TB.2 Countries in the three high-burden country lists for TB. Mozambique. Nigeria. Thailand and Zimbabwe. Democratic People’s Republic of Korea. with a clear demarcation There is overlap among the three lists. are given particular accounts for about 90% of the global burden.int/tb/data GLOBAL TUBERCULOSIS REPORT 2017 17 . included on the basis of the incidence rate per capita. (with the same content as those presented in Annex 2) are also available online. Democratic Republic of the Congo.who. China. multidrug-resistant. WHO. Annex 2 contains a two-page profile for each of this accounted for by the top 20 countries in each list.

4% 84% 5. tuberculosis. human immunodeficiency virus. DPR Korea. >1000 estimated >1000 estimated incident MDR-TB cases incident TB/HIV cases per year). plus the 10 countries with the highest estimated living with HIV. estimated incident TB cases per year). Sustainable Development Goal. countries in June 2020). Democratic People’s Republic of Korea. to help build and sustain help build and sustain national political funding in the countries with the highest national political commitment and funding commitment and funding in the countries burden in terms of absolute numbers or in the countries with the highest burden in with the highest burden in terms of absolute severity. Joint United Nations Programme on HIV/AIDS. Definition The 20 countries with the highest estimated The 20 countries with the highest estimated The 20 countries with the highest estimated numbers of incident TB cases. UNAIDS. plus the top numbers of incident TB cases among people numbers of incident MDR-TB cases. TABLE 2.4 The three high-burden country lists for TB.8% 85% 4. countries in June 2020). MDR. Countries in The top 20 by The additional 10 by The top 20 by The additional 10 by The top 20 by The additional 10 by the list estimated absolute estimated incidence estimated absolute estimated incidence estimated absolute estimated rate per number (in rate per 100 000 number (in rate per 100 000 number (in 100 000 population alphabetical order): population and with alphabetical order): population and with alphabetical order): and with a minimum a minimum number a minimum number number of 1000 Angola of 10 000 cases per Angola of 1000 cases per Bangladesh cases per year (in Bangladesh year (in alphabetical Brazil year (in alphabetical China alphabetical order): Brazil order): Cameroon order): DPR Korea China China DR Congo Angola DPR Korea Cambodia DR Congo Botswana Ethiopia Azerbaijan DR Congo Central African Ethiopia Central African India Belarus Ethiopia Republic India Republic Indonesia Kyrgyzstan India Congo Indonesia Chad Kazakhstan Papua New Guinea Indonesia Lesotho Kenya Congo Kenya Peru Kenya Liberia Lesotho Ghana Mozambique Republic of Moldova Mozambique Namibia Malawi Guinea-Bissau Myanmar Somalia Myanmar Papua New Guinea Mozambique Liberia Nigeria Tajikistan Nigeria Sierra Leone Myanmar Namibia Pakistan Zimbabwe Pakistan Zambia Nigeria Papua New Guinea Philippines Philippines Zimbabwe South Africa Swaziland Russian Federation Russian Federation Thailand South Africa South Africa Uganda Thailand Thailand UR Tanzania Ukraine UR Tanzania Zambia Uzbekistan Viet Nam Zimbabwe Viet Nam Share of global incidence in 84% 2. to help build and TB Strategy. TB/HIV and MDR-TB being used by WHO during the period 2016–2020 LIST THE 30 HIGH TB BURDEN COUNTRIES THE 30 HIGH TB/HIV BURDEN COUNTRIES THE 30 HIGH MDR-TB BURDEN COUNTRIES Purpose and To provide a focus for global action on TB To provide a focus for global action on To provide a focus for global action on target audience in the countries where progress is most HIV-associated TB in the countries where the MDR-TB crisis in the countries where needed to achieve End TB Strategy and SDG progress is most needed to achieve End progress is most needed to achieve End targets and milestones. SDG. UNAIDS and SDG targets TB Strategy targets and milestones. to sustain national political commitment and and milestones. WHO. a well-defined set of countries. multidrug resistant. UR Tanzania. and numbers or severity. 18 GLOBAL TUBERCULOSIS REPORT 2017 . plus the top 10 countries top 10 countries with the highest estimated TB incidence rate that are not in the top 20 with the highest estimated TB/HIV incidence MDR-TB incidence rate that are not in the by absolute number (threshold. World Health Organization. of countries. number (threshold. per year). and to promote global monitoring terms of absolute numbers or severity. TB.7% 2016 (%) Lifetime of list 5 years (review criteria and included 5 years (review criteria and included 5 years (review criteria and included countries in June 2020). United Republic of Tanzania. Democratic Republic of the Congo. >10 000 rate that are not in the top 20 by absolute top 20 by absolute number (threshold. and to promote global of progress in a well-defined set of to promote global monitoring of progress in monitoring of progress in a well-defined set countries. DR Congo. HIV.

.

A cured TB patient has a follow-up chest X-ray in Howrah. India IMAGEBROKER / ALAMY STOCK PHOTO .

The countries with the largest numbers this needs to improve to 4–5% per year by 2020 to of MDR/RR-TB cases (47% of the global total) were reach the first milestones of the End TB Strategy. National TB prevalence surveys provide an Kenya. access to TB diagnosis and treatment that need to be addressed. were incident cases).6% from 2015 to 2016). KEY agent. respectively. Among HIV-positive people. China. that were susceptible to isoniazid but resistant Globally. were million cases of multidrug-resistant TB (MDR-TB) (in descending order) India. MESSAGES an additional 374  000 deaths among HIV-positive There is considerable country variation in the CFR. the WHO European Region (3%) and deaths. the fastest declines in the TB mortality of 25 surveys that used the screening and diagnostic rate are in the WHO European Region and the WHO methods recommended by WHO were implemented.CHAPTER 3. countries. Viet Nam and Zimbabwe. TB incidence is falling at about 2% per year. since 2010). smaller proportions of people. including Ethiopia. the WHO Region of the Americas (3%). the interim approach to directly measuring the burden of United Republic of Tanzania. anti-TB drug. the with rates of decline exceeding 6% per year since underlying cause is classified as HIV in the international 2010 include Ethiopia. TB disease burden n TB is the ninth leading cause of death worldwide Globally. Between 2007 and the end of 2016. ranking above HIV/AIDS. In 2016. High TB burden countries a When an HIV-positive person dies from TB disease. This needs to fall to 10% FACTS an estimated 1. the Russian Federation.e. Most of the estimated number of incident cases in 2016 occurred in the WHO South-East Asia Region Between 2000 and 2016. the Russian Federation.a from under 5% in a few countries to more than 20% An estimated 10. 10% people living with HIV) fell ill with TB in shows considerable inequalities among countries in 2016 (i.6% per year. by 2020 to reach the first milestones of the End TB AND negative people (down from 1. the WHO African Region (25%) and the WHO estimated 44 million deaths among HIV-negative Western Pacific Region (17%). China.3 million TB deaths among HIV. the fastest decline in TB incidence is in National notification and vital registrations systems the WHO European Region (4. Namibia.0% and 4. Regionally. Zambia and Zimbabwe.4 million people (90% adults. TB treatment averted an (45%). with 490 000 five countries. the emerging in 2016 and an additional 110 000 cases Philippines and Pakistan. need to be strengthened towards the goal of direct The decline since 2010 has exceeded 4% per year in measurement of TB incidence and mortality in all several high TB burden countries. Indonesia. the proportion of people who develop TB and the leading cause from a single infectious and die from the disease (the case fatality ratio. the most effective first-line per year. there were or CFR) was 16% in 2016. Western Pacific Region (6. The top Drug-resistant TB is a persistent threat. TB treatment cases occurred in the WHO Eastern Mediterranean supported by ART averted an additional 9 million Region (7%). Lesotho. India and the Russian Federation. the TB mortality rate is falling at about 3% to rifampicin (RR-TB). 65% in most countries in the WHO African Region. classification of diseases system (ICD-10). with 56% of estimated cases.7 million in 2000) and Strategy. the United Republic of Tanzania. n people. GLOBAL TUBERCULOSIS REPORT 2017 21 . a total Regionally. This male. TB disease in an important subset of high TB burden countries.

One of the when a target of halving prevalence by 2015 compared with a baseline of standards is that levels of underreporting of detected TB cases should be 1990 was set.1 Methods to estimate TB incidence set in the End TB Strategy are a 90% reduction in TB deaths TB incidence has never been measured at national level and an 80% reduction in TB incidence. 22 GLOBAL TUBERCULOSIS REPORT 2017 . This is in line with the increasing emphasis on the importance of within-country disaggregation of key  incidence – the number of new and relapse cases of TB indicators in the SDGs and the End TB Strategy (Chapter 2). with TB incidence (per 100  000 population per year) defined as 3.1). Section 3. usually 1 year. and highlight sources TB notifications in all countries. A TB resistance to anti-TB drugs. with little underreporting of diagnosed cases). a total of has been set during the period 2016–2035. includes a target to end the global TB epidemic by 2030. WHO. between the 2015 estimates to reduce that burden. minimal. which would have also been defined (Table 3.1 TB incidence the indicator for measurement of progress. Geneva: 8 August 2016). standardsandbenchmarks/en/. accessed 15 August 2016). Section 3. and estimates of the incidence of surveillance checklist developed by the WHO Global Task multidrug-resistant TB (MDR-TB) and rifampicin-resistant TB Force on TB Impact Measurement (Box 3. The 2030 targets 3. absolute number of TB deaths 35 75 90 95 (compared with 2015 baseline) a survey to quantify the level of underreporting of detected TB cases).who.who. also. WHO End TB Strategy: global strategy and publications/inventory_studies/en/. Geneva: World Health Organization.5 To date. Section 3.1 SDG 3 provided in Box 3. A summary of the main updates to disease have been set as part of the Sustainable Development available data and methods since the 2016 global TB report is Goals (SDGs) and WHO’s End TB Strategy (Chapter 2). standards that need to be met for notification data to provide TB prevalence is not an indicator for which a global target a direct measure of TB incidence. care and control after 2015.2. but interest and This chapter has five major sections. results from an Percentage reduction in the TB incidence rate 20 50 80 90 inventory study can be combined with capture–recapture (compared with 2015 baseline) methods to estimate TB incidence. WHO updates its estimates of the burden of TB disease  prevalence – the number of cases of TB at a given point in annually. results from national TB in this report and the 2015 estimates in the previous report) are not prevalence surveys can inform estimates of TB incidence appropriate. burden set in WHO’s End TB Strategy and in which the quality of and access to health care means MILESTONES TARGETS that few cases are not diagnosed. 2015 (http://www. better quantification of incidence and mortality. Assessing tuberculosis underreporting through inventory studies. The burden of tuberculosis (TB) disease can be measured in covers estimates of TB incidence and mortality disaggregated terms of: by age and sex.2 Nevertheless.5 Health Organization.3 focuses on the burden of underreporting (i. national TB prevalence surveys still provide http://www. However. if certain conditions are met.g.3). In the large number of INDICATORS 2020 2025 2030 2035 countries that have not yet met these criteria. 5 Inventory studies can be used to measure the number of cases that are and mortality.3. the umbrella of the WHO Global Task Force on TB Impact Global targets and milestones for reductions in the burden of TB Measurement (Box 3. This requires a combination of data and actions needed to improve measurement of TB of strengthened surveillance. notifications of TB cases provide a good proxy indication of TB TABLE 3. 2012 (http://www.e. and thus contribute to monitoring of progress diagnosed but not reported.e.1.4 discusses national TB prevalence surveys.int/tb/ 1 World Health Organization. 2014 (http://www. Geneva: WHO.4 Since 2006. Targets for 2035 and milestones for 2020 and 2025 cohorts (hundreds of thousands) of people. the number of cases that are missed by drug-resistant TB. using the latest available data and analytical time. Finally. Standards and benchmarks for tuberculosis WHO. Therefore. accessed 24 August 2016).int/tb/post2015_strategy/en/. In addition. For a guide to inventory studies.who. 6 targets for tuberculosis prevention.1 and Section implementation is growing (Box 3. involve high costs and challenging logistics.int/tb/publications/ 2 This is in contrast to the period covered by the Stop TB Strategy (2006–2015).g.1 incidence in countries that have high-performance surveillance Targets for percentage reductions in TB disease systems (e.who. estimates presented in this chapter for 2000−2015 supersede those of (including by age and sex) and for planning actions needed previous reports. see World towards SDG and End TB Strategy targets. including progress in global surveillance of surveillance systems) and universal health coverage. arising in a given time period. under time period.int/tb/publications/global_report/en/ 4 the best method for estimating the burden of TB disease The updates can affect the entire time-series back to 2000.1) defines the (RR-TB).6 By August 2017. such studies have been undertaken in only a few countries. 3. usually 1 year. Section 3. concerted efforts have been made  mortality – the number of deaths caused by TB in a given to improve the available data and methods used. compared with levels because this would require long-term studies among large in 2015. and methods. better estimates Percentage reduction in the of TB incidence can be obtained from an inventory study (i.1).2 present the latest WHO estimates of TB incidence and The ultimate goal is to directly measure TB incidence from mortality between 2000 and 2016. and direct comparisons (e. accessed surveillance and vital registration systems: checklist and user guide. in 3 The online technical appendix is available at many countries.

this included 18 of the 22 necessary because indirect estimates will be required until global focus countries. 38 countries including d. sex. Work on strengthened surveillance included the following: 2. By the end of 2015. The underlying estimates of TB mortality in 127 countries. standards and benchmarks (with 10 core and three supplementary standards). which has surveillance and surveys as much as possible (as opposed continued. by age. and contributions to wider efforts to promote measurement of TB disease burden (epidemiological and. the number of TB deaths reporting. Priority studies to periodically measure TB disease can be used to systematically assess the extent to burden. The mandate was defined as follows: regional and country levels was as rigorous.1 Establishment and progress made. measure underreporting of detected TB cases. with consensus reached and using TB data at country level (as well as generating on methods to be used for the 2015 targets assessment data. However. TB incidence. surveys to produce estimates of the number of TB Strategic areas of work 1–3 are focused on direct deaths. 2035) systems. Strengthening national notification systems for direct disease burden estimates. drug resistance surveys direct measurement of TB incidence and mortality. 2006–2015 Updated strategic areas of work.e set in the context of the MDGs were achieved at global. promote and support the analysis and use of TB data for policy. A second thorough and comprehensive area of work 5 recognizes the importance of analysing review was undertaken in 2015. and the percentage of TB-affected households that face  Expanded use of data from VR systems and mortality catastrophic costs as a result of TB disease (Chapter 2). including the published in WHO’s 2015 global TB report. tools and capacity building. Between 2007 and the end of 2015. surveys of costs faced by TB patients and their 16 high burden countries had used the checklist. Periodic review of methods used by WHO to estimate electronic databases are the reference standard for the burden of TB disease and latent TB infection. a total of to indirect estimates based on modelling and expert 23 countries completed a survey and a further two had opinion). up from principle for the Task Force’s work since 2006 has been three in 2008. n The WHO Global Task Force on TB Impact Measurement BOX 3. Case-based 4.b and efforts to introduce such 5. including: systems were supported. and support such studies in priority countries. c. economic). and The five strategic areas of work are as follows:  periodically reviewing methods used to produce TB 1. strategic area of work 4 remains done so by the end of 2016.c and b. households. regional and country levels are as rigorous. An updated mandate and five strategic to ensure that WHO’s assessment of whether 2015 targets areas of work for the period 2016–2020 were agreed. including drug-resistant TB and HIV-associated TB specifically. the Task Force met in April 2016 to review and 2006 and is convened by the TB Monitoring and Evaluation reshape its mandate and strategic areas of work for the unit of WHO’s Global TB Programme. 2016–2020 n The WHO Global Task Force on TB Impact Measurement In the context of a new era of SDGs and WHO’s End TB (hereafter referred to as the Task Force) was established in Strategy. to provide a b. location)  Development of a guide on inventory studies to to assess inequalities and equity.      ➜ GLOBAL TUBERCULOSIS REPORT 2017 23 .a This checklist 3. Strategic and October 2009. a. robust and consensus-based as possible. VR systems. robust and  strengthening routine surveillance of TB cases (via consensus-based as possible. national TB prevalence surveys required for notification and VR data.d disaggregated analyses that are now given much greater attention in the SDGs and End TB Strategy. guidance. as in strategic areas of work 1–3). VR data were used to produce in the case of cost surveys. recording and reporting TB surveillance data. Three strategic areas of work  To ensure that assessments of progress towards End were pursued: TB Strategy and SDG targets and milestones at global.  To guide. measurement of TB cases. disaggregated analyses (e. including: which a surveillance system meets the standards a.g. An inventory c. Its original aim was post-2015 era. Strengthening national VR systems for direct  Development of a TB surveillance checklist of measurement of TB deaths. that is. national notification systems) and deaths (via national VR systems) in all countries. A guide was produced in 2012. A Task Force subgroup undertook a all countries have the surveillance systems or the periodic major review and update of methods between June 2008 studies required to provide direct measurements.  undertaking national TB prevalence surveys in 22 global focus countries. that estimates of the level of and trends in disease burden There was substantial success in the implementation of should be based on direct measurements from routine national TB prevalence surveys 2007–2015.  Electronic recording and reporting. Analysis and use of TB data at country level. projections of disease burden. study can be used to quantify the number of cases that The SDG and End TB Strategy targets and milestones are detected but not reported to national surveillance referred to in the mandate are the targets (2030. planning and programmatic action. By 2015. mortality surveys respectively. and can serve as a basis for improving and milestones (2020. 2025) set for the three high-level estimates of TB incidence and addressing gaps in indicators.

Further details are provided in Box 3. accounting for the and 570 000 incident cases. and for the Democratic Republic of Korea it Zimbabwe. The prevalence from national TB prevalence surveys in Bangladesh.who.51 [0.int/tb/areas-of-work/monitoring- int/tb/publications/electronic_recording_reporting/en/.2 HIV in the general population is under 1%. Between Data on the prevalence of HIV among prevalent TB cases 2007 and 2016. 2014 0. 1. 2015 0. This demonstrated the need The post-survey estimate of TB prevalence in the for a stronger intersectoral response to TB. 0. These data were used to cases in 2016 (1 in 15 of the prevalent cases globally) re-estimate TB incidence in Nigeria.58.2.32.47 [0. 2012 (http://www. Measurement. Report of the sixth meeting of the full Task Force.10] estimate. Geneva: WHO. Geneva: WHO. 2015 (http://www. Kenya and the 2000). a large HIV prevalence among prevalent TB cases increases the proportion of the population living below the national estimated average duration of disease. 19–21 surveillance and vital registration systems: checklist and user April 2016.int/tb/advisory_bodies/impact_measurement_ standardsandbenchmarks/en/.g consultation_april_2015_tb_estimates_subgroup/en/.1% and has a limited Kenya. 0. addressing Philippines was significantly higher than anticipated from undernourishment and other social and economic the results of previous national prevalence surveys.6. 2014 (http://www. Geneva: WHO. With incidence ➜ poverty line (25% in 2012).73 [0. accessed 11 September World Health Organization. undernourishment (population attributable fraction) was estimated at 48%.int/tb/publications/factsheet_tb_ impactmeasurement. tuberculosis care and control. The survey in the Democratic Republic of Korea confirmed RE Model 0. and low coverage of health insurance and social protection (4% in the poorest quintile FIG B3. 0.20 [0. Switzerland.07 [0.4 0. there were an estimated 1 million prevalent available from seven countries.40. g Available at: http://www. 2015–2016 0.1).int/ Task Force are strengthening of national notification and tb/publications/inventory_studies/en/.2 and anticipated updates n Updates in this report contributing to the severity of the TB epidemic is high levels of undernourishment.2. 2013 0.35.65] that the country has one of the highest burdens of TB disease among countries where the prevalence of 0 0.int/ available online.int/tb/publications/ (http://www.59] slightly lower. 2014 0. Standards and benchmarks for tuberculosis Measurement. 0. Based on survey identified during national prevalence surveys are now results. accessed 15 August 2017). 2012 0.70 [0. The prevalence of HIV in the TB cases) general population remains below 0. had found a decline between 1997 (the second national survey) and 2007 (the third national survey). Third meeting of the TB estimates subgroup: methods to use for WHO’s definitive assessment of whether 2015 global Further details about the work of the Task Force are TB targets are met. the of undernourishment was 42% in 2015 (38% in Democratic People’s Republic of Korea. accessed 24 August 2017). 0.74] Rwanda.8 1 1. B3.f an up-to-date summary is provided in the tb/advisory_bodies/impact_measurement_taskforce/meetings/ latest brochure about its work. accessed 11 September 2017). which increases the risk 1.91] was similar to the pre-survey estimate. final results (see also Chapter 2 and Chapter 7). f Available at: http://www.45] The best estimate of TB incidence in Kenya based on UR Tanzania. c ➜  In the years up to 2020. 2012 (http://www. VR systems as the basis for direct measurement of TB d World Health Organization Global Task Force on TB Impact incidence and TB mortality.44 [0. b taskforce/meetings/tf6_report. Geneva: WHO. with a prevalence by 32%. Malawi. These adjustment. the top priorities for the World Health Organization.1 in 2013). which determinants of the TB epidemic.70] impact on the size of the TB epidemic. The post-survey estimate of TB incidence for Bangladesh was Zambia.who.01. but with overlapping uncertainty intervals. resulting in financial barriers to accessing health HIV prevalence ratio (survey/notified services and high levels of out-of-pocket expenditures on health care (34% in 2014). Assessing tuberculosis underreporting through inventory studies. This can be explained by the fact that a lower of 14% in 2015 and no improvement since 2008.who.who.2 0. 0.who. 0.38] the prevalence survey was higher than the pre-survey Uganda. Geneva: WHO.who.who. Electronic recording and reporting for 2017). As a result of this burden of TB disease being higher than expected.33.6 0.53 [0. accessed 11 evaluation/impact_measurement_taskforce/en/ September 2017). 2015 guide. Broader social and economic lower prevalence of HIV among survey cases compared influences on the TB epidemic are plausible reasons for the with notified cases (Fig. there was no decline.11. 2012 0. and the percentage of TB cases attributable to Philippines became available. One factor HIV prevalence ratio (prevalent/notified TB) 24 GLOBAL TUBERCULOSIS REPORT 2017 .pdf?ua=1 n Updates to estimates of TB disease burden in this report BOX 3.34. Glion-sur-Montreux. the updated incidence estimate was reduced influences include undernourishment. New data from national TB prevalence surveys of breakdown to TB disease among infected people Between October 2016 and August 2017. e a World Health Organization Global Task Force on TB Impact World Health Organization.pdf?ua=1.

based on results from the distribution of disease duration. National TB epidemiological reviews India is planned for 2018.2): Netherlands and the United Kingdom. Lim SS. This method is used for 134 countries can be grouped into four major categories. for HIV. Newly reported data and estimates from other underdiagnosis unlikely. with 2014. leaving little room for underreporting New VR data were reported to WHO between mid-2016 of detected TB cases. 5–14. the amount available to WHO. there may disease caused by HIV were obtained from UNAIDS in be some over-diagnosis of people screening positive for mid-July 2017. This included data from the Islamic Republic (or both) are routinely used for diagnosis.10). Country-level estimates of TB incidence and the Institute of Health Metrics and Evaluation (IHME). The 24 countries in 2016. (previously. The surveys in Myanmar and Viet Nam are repeat surveys. In-depth epidemiological reviews with an assessment a Downloaded from http://ghdx. This makes 2. Wolock TM. provided in Box 3. association with a TB epidemiological review or regional  Notifications in high-income countries adjusted by workshop focused on analysis of TB data (Fig. and contact tracing undertaken for all TB cases.nih. Bourne D.5. Ortblad KF.c IHME estimates used in this report were adjusted to fit WHO estimates of the total number Updates to estimates of TB disease burden are expected of deaths (referred to as the mortality envelope). prevalence surveys. Global.05). For of the duration of disease. For 18 countries (Fig. Second. Bradshaw D. Laubscher R. which would compensate for intervals of previously published estimates.healthdata. Third. regional and systems. following the completion of national TB (interquartile range.nlm. to notification data to allow for underreporting or Identifying deaths from AIDS in South Africa. 55–64 and ≥65 years). Guinovart C. with the latter derived from a three countries (France.gov/pubmed/15668545. there is an extensive and regular screening this increase in estimated disease duration results in a programme. tuberculosis. Fourth.org/gbd-results-tool. China and the Russian Federation. South Africa median country-year envelope ratio (WHO/IHME) was 1.03 and Viet Nam.a mortality disaggregated by age and sex These are based on combining data from national VR Previous reports have included global. a standard factor to account for underreporting and Methods currently used by WHO to estimate TB incidence under­diagnosis.92–1. This update was justified for four major (http://www.sciencedirect. notification of cases agencies is mandatory and the reporting system has complete national coverage. This method is used studies of underreporting. 61 countries.1). 2005. Nannan N. and malaria during 1990–2013: a systematic During a review in February 2017. These 134 countries accounted for 24 countries. AIDS. TB incidence were revised downwards by 15%. culture or molecular testing and mid-2017.b.1) had completed the checklist. For the 18 countries. including 23 of the 30 high TB burden countries accounted for 68% of the estimated global number of (listed in Table 3. Mozambique. This report includes includes predictors of mortality. regional. Updated estimates of the burden of reporting practices in recent years. often in incident cases in 2016. estimates of TB mortality among HIV-negative people were based on estimates from 4.384(9947):1005–1070 (http://www. that comprise all high-income countries except the 3. accessed 24 August 2016). 3. GLOBAL TUBERCULOSIS REPORT 2017 25 . a standard adjustment had been applied c Groenewald P. estimated using prevalence survey results and estimates including Brazil. plus selected upper-  Results from TB prevalence surveys. Republic of Korea and Turkey) the model that accounts for the impact of HIV coinfection on adjustment was country specific. Estimates in South Africa are adjusted by IHME for miscoding of deaths caused Updates anticipated in the near future by HIV and TB. with all adults screened every 1–2 years. and trends any underdiagnosis or underreporting. diagnostic and to historical data. Namibia. A national TB prevalence survey in 3. best estimates of analysis for the Global Burden of Disease Study 2013. In addition. 15–24. 45–54. all children and adolescents screened every year. quantity of mortality data available to IHME is larger than 25–34. 0. Lancet. accessed 24 August 2016). Incidence is middle-income countries with low levels of underreporting. First. Further details are were generally consistent. data from sample VR systems and data from country-specific estimates of TB incidence and TB mortality verbal autopsy surveys in a Bayesian framework that by age (adults and children) and sex. 3. 3.1) inform 2017 b Murray CJ.ncbi. there of Iran for 2013–2015 and updates by other countries have been no major changes in screening. The in 2018 for Myanmar. The main update from DA et al. of which 23 have national survey data and for 15% of the estimated global number of incident cases one – India – had a survey in one state. as follows (Fig. ➜  estimated as prevalence divided by disease duration. reduction in estimated incidence. In most instances.com/science/ notifications assumed to be a good proxy for TB incidence article/pii/S0140673614608448?via%3Dihub. the estimates for more age categories (0–4.19(2):193–201 underdiagnosis). and national incidence and mortality such a review in this report is for the Russian Federation. 35–44. Roberts estimates of TB disease burden. reasons. July of the performance of TB surveillance (Fig. any resulting changes TB but with no bacteriological confirmation using the most to TB burden estimates were well within the uncertainty sensitive TB diagnostics.

where most. accessed 15 August Progress in 2016–2017 includes the completion of 2017). Final results TB cases provides a good proxy for TB incidence. int/tb/publications/inventory_studies/en/. B3. the Netherlands and cases as well as underdiagnosis mean that there Portugal are also under way as part of a project funded are gaps between the number of notified TB cases by the European Centre for Disease Prevention and and TB incidence. Geneva: WHO. 26 GLOBAL TUBERCULOSIS REPORT 2017 . National TB inventory studies can Control. however.a a Countries in which a national inventory study has been World Health Organization.3.3 TB cases: progress to date n In countries with state-of-the-art national surveillance in children in Pakistan. n Inventory studies to measure the underreporting of detected BOX 3. The Netherlands is carrying out a repeat of the inventory study conducted in 2006. underreporting of detected National studies in Denmark. results can also be used national TB programmes (NTPs) and funding agencies. 2012 (http://www. and a study protocol is being developed for a be used to quantify one of these gaps – the level study in South Africa. new TB cases are for the first-ever such studies (covering adults and diagnosed and registered. from certain assumptions are met. implemented since 2000 are shown in Fig. a study focused on the underreporting of TB cases FIG.1. Assessing tuberculosis underreporting through inventory studies. If there is a need for increased commitment. many countries. the number of notified children) in Indonesia and Viet Nam.1 Countries in which national inventory studies of the underreporting of detected TB cases have been implemented since 2000 (status in August 2017)a National inventory study completed National inventory study ongoing National inventory study planned No data Not applicable a Pakistan has completed a second inventory study focusing on children with TB. of underreporting – and in turn can inform better As countries begin working towards the TB incidence estimates of TB incidence as well as the actions targets set within the SDGs and the End TB Strategy.3.who. Nigeria is planning to undertake a subnational level study (in metropolitan Lagos). needed to minimize levels of underreporting. and completion of fieldwork systems. B3. if not all. In from these three studies are expected by early 2018. methods. to estimate TB incidence using capture–recapture to conduct and fund TB inventory studies.

3.1 Strengthening national TB surveillance (status in August 2017) Countries in which a national TB epidemiological review has been undertaken since July 2012 2012–2015 2016–2017 Not applicable Countries in which a checklist of standards and benchmarks has been completed since January 2013 Number of standards met (out of 13) 1–3 4–6 7–9 10–13 Not applicable Countries covered by a regional or country- specific workshop focused on TB data analysis and use for action since October 2015 Completed Not applicable GLOBAL TUBERCULOSIS REPORT 2017 27 .FIG.

Nigeria and South for the WHO Global Task Force on TB Impact Measurement Africa each accounted for 4% of the global total. how the list of 30 high TB burden countries was defined. is used in the WHO South-East Asia Region (45%).2 and Table 3. the WHO African to estimate levels of underreporting and underdiagnosis.5% of the estimated global to 140 cases per 100 000 population (estimates of absolute number of incident cases in 2016. Of these. 28 GLOBAL TUBERCULOSIS REPORT 2017 . see Chapter 2. from under 10 per 100  000 population much as possible. the United Kingdom and Yemen. The 30 high report. 1 3 The online technical appendix is available at These countries are listed in Table 3.3).3). 3.8  million to 12. as opposed to indirect estimates that rely in most high-income countries to 150–300 in most of the on modelling and expert opinion. This method is used for five countries: Egypt. Trends are estimated through mortality data.1. elicited Most of the estimated number of cases in 2016 occurred through regional workshops or country missions. which together accounted for 56% of is relied upon only if one of the other three methods cannot the global total. standard adjustment Prevalence survey No data Not applicable  Results from inventory studies and capture–recapture 3. Globally in 2016 there were an estimated 10. For an explanation of http://www.2 Estimates of TB incidence in 2016 analysis. 8. As explained in Box 3.2 Main methods used to estimate TB incidence Main method Capture–recapture Case notifications. since its establishment in 2006 has been that estimates of the The annual number of incident TB cases relative to level of and trends in TB disease burden should be based on population size (the incidence rate) varied widely among direct measurements from routine surveillance and surveys as countries in 2016. China.1. the WHO European Region using estimates of case-detection gaps for 3 years. 3. as having the largest number of incident cases in 2016 were (in descending order) India. numbers are shown in Table 3. China. FIG.3. and above 500 in a Further details about these methods are provided in the online technical appendix. 3. about case-detection gaps.int/tb/publications/global_report/en/. cases of TB (range. this method is used for 54 countries that accounted TB burden countries3 accounted for 87% of all estimated for 17% of the estimated global number of incident cases incident cases worldwide. the underlying principle accounted for 45% of global cases in 2016. “range” refers to the 95% uncertainty interval.who. Region (25%) and the WHO Western Pacific Region (17%).4 million incident Iraq. Indonesia.2 equivalent These countries accounted for 0. India and Indonesia alone be used. In this (3%) and the WHO Region of the Americas (3%). Expert opinion.4).2  million). the Netherlands. The five countries that stood out in 2016. the Philippines Of the four methods.2 and estimates of rates per  Case notification data combined with expert opinion capita are shown in Table 3. expert opinion Case notifications.1 2 Here and elsewhere in the report. 30 high TB burden countries (Fig. the last one is the least preferred and it and Pakistan (Fig. surveys of smaller proportions of cases occurred in the WHO Eastern the annual risk of infection or exponential interpolation Mediterranean Region (7%).

0 0.50 0.7–5.9 274 255–294 30 28–33 Eastern Mediterranean 669 000 82 69–95 3.5 4.2 3.7 16 10–23 12 7.3–7.66 54 35–78 1.48–1.9 1.5–6.63–1.2 11 8.56–1.66–1.8 2.3–4.4–5.3 35 28–42 3.4 2.0–5.4 895 766–1 030 11 6. b Deaths among HIV-positive TB cases are classified as HIV deaths according to ICD-10.6 191 141–249 18 13–24 Namibia 2 000 0.02–0.82 0.9 3.5–14 4.46 DR Congo 79 000 53 31–80 8.28 0.1–3.0–15 254 165–363 20 13–29 Ethiopia 102 000 26 16–37 4.2 0.8–16 0.2 3.9 3.85–1.0 2.75 0.1 1.7–6.6 573 321–895 6.5 Philippines 103 000 22 22–22 0.0 1.4 0.9–15 Europe 916 000 26 25–27 5.4 19 12–28 5.2 1.9–15 Congo 5 000 3. c Estimates of TB incidence and mortality for India are interim in nature.5–4.0 19 12–27 6.7 0.14–0.0–6.5 South Africa 56 000 23 17–29 101 67–142 438 304–595 258 176–355 Thailand 69 000 8.8–4.09 130 113–148 0.7 94 61–135 18 12–26 Sierra Leone 7 000 3.60–1.1 0.1 0.4–2.1 1.2 2.98–3.5 22 14–32 3.9–18 62 40–89 36 23–52 Zimbabwe 16 000 1.1 126 103–151 4.9 1.6 2.2 Mozambique 29 000 22 13–33 33 20–48 159 103–227 72 46–104 Myanmar 53 000 25 16–35 4.84 Brazil 208 000 5.61–1.4 290 251–333 34 26–42 South-East Asia 1 950 000 652 542–772 35 25–46 4 670 3 190–6 440 163 120–211 Western Pacific 1 890 000 103 85–123 5.1 34 24–44 23 15–32 High TB burden countries 4 710 000 1 130 998–1 270 317 268–369 9 060 7 450–10 800 866 755–986 Africa 1 020 000 417 351–488 320 272–372 2 590 2 310–2 900 764 660–876 The Americas 996 000 17 16–18 6.45 0.TABLE 3.2 1.9 Central African Republic 5 000 2.6 7.01–2.0 2.6–8.0–4.4 4.3 12 7.2 2.3 0.0–7.2–23 1 020 660–1 460 45 21–78 Kenya 48 000 29 16–45 24 14–36 169 103–250 53 32–79 Lesotho 2 000 1. pending results from the national TB prevalence survey planned for 2018/2019.29–0.6–4.0–5.5 1.8 0.87 0.4 182 128–245 14 9.25–0.7–3.5–30 Bangladesh 163 000 66 43–94 0.1 2.7–4.9 3.9 China 1 404 000 50 34–70 1.4 87 74–100 11 9.1 0.2 0.85 0.2 2.9 5.5 766 573–985 9.4–3.5–11 Russian Federation 144 000 12 11–12 1.9–6.30 <0.2 Estimated epidemiological burden of TB in 2016 for 30 high TB burden countries.6–19 2 790 1 440–4 570 87 56–125 Indonesia 261 000 110 75–152 13 6.6 518 335–741 6.71–1.8–7.8 2.1 2.6–19 Indiac 1 324 000 423 324–534 12 6.1 Zambia 17 000 4.2–20 2. Numbers in thousands.6 2.2 3.4 DPR Korea 25 000 11 6.8 1.7 4.4–12 107 66–156 18 8.8 5.05 0.85–2. WHO regions and globally.2–12 Papua New Guinea 8 000 3.18 0.45–1.3 1 800 1 500–2 130 29 23–36 GLOBAL 7 440 000 1 300 1 160–1 440 374 325–427 10 400 8 770–12 200 1 030 915–1 150 a Numbers shown to two significant figures if under 100 and to three significant figures otherwise.3–17 Liberia 5 000 2.9 119 70–180 10 6.9–5.09–0.1–16 UR Tanzania 56 000 28 13–50 27 12–46 160 75–275 54 35–78 Viet Nam 95 000 13 8.0 3.9 2.7 1.4 3.1–4.6–6.3–5.3–9.4 14 9.1 3.2 5. GLOBAL TUBERCULOSIS REPORT 2017 29 .4–18 0.1–13 Cambodia 16 000 3.2–10 3.96 0.a POPULATION HIV-NEGATIVE TB MORTALITY HIV-POSITIVE TB MORTALITY b INCIDENCE HIV-POSITIVE TB INCIDENCE BEST UNCERTAINTY BEST UNCERTAINTY BEST UNCERTAINTY BEST UNCERTAINTY ESTIMATE INTERVAL ESTIMATE INTERVAL ESTIMATE INTERVAL ESTIMATE INTERVAL Angola 29 000 18 10–29 6.4–50 0.0 Nigeria 186 000 115 67–176 39 23–58 407 266–579 63 40–93 Pakistan 193 000 44 34–55 2.30 360 262–474 0.

24 64 55–74 1.6 172 102–261 8.1–5.5 2.3 Estimated epidemiological burden of TB in 2016 for 30 high TB burden countries.9 268 174–383 1. TABLE 3.6–1.7 7.13 0. pending results from the national TB prevalence survey planned for 2018/2019.2 4.90 0.5–12 Africa 41 34–48 31 27–36 254 227–284 30 24–35 The Americas 1.5 554 311–866 1.35 513 446–584 0.9 2.4–5.9 0.7–7.55 0.90 0.45 0.3 Indiab 32 24–40 0.4 Western Pacific 5.2 42 36–48 13 12–14 Cambodia 20 14–28 2.1 Congo 60 34–93 41 21–66 378 240–547 26 17–37 DPR Korea 43 27–63 0.7 5.60–1.6 1.56–0.6 UR Tanzania 51 23–90 48 22–83 287 136–495 34 30–38 Viet Nam 14 8.4–11 27 19–38 208 152–273 67 65–69 High TB burden countries 24 21–27 6.16–0.35 DR Congo 67 39–101 11 5.0–15 Philippines 21 21–22 0.7 391 253–558 4.1 0. WHO regions and globally.2–2.1–19 323 209–461 8.1 GLOBAL 17 16–19 5. HIV-NEGATIVE TB MORTALITY HIV-POSITIVE TB MORTALITYa TOTAL TB INCIDENCE HIV PREVALENCE IN INCIDENT TB (%) BEST UNCERTAINTY BEST UNCERTAINTY BEST UNCERTAINTY BEST UNCERTAINTY ESTIMATE INTERVAL ESTIMATE INTERVAL ESTIMATE INTERVAL ESTIMATE INTERVAL Angola 64 36–99 24 12–41 370 230–543 16 10–24 Bangladesh 40 26–58 0.4 240 164–331 3.3 0.0 0.4 2.59–1.01–2.7–12 361 266–471 9.4–8.18 221 161–291 0.1 Europe 2.05–0.6–15 South-East Asia 33 28–40 1.6 7.1–3.8–2.43–0.11–0.68 114 86–147 1.1 2.4–8.69 32 27–36 12 8.50–2.26 0.2 0.8 0.7 140 118–164 10 8.92 0.5 211 109–345 3.9–19 0.6 Zambia 29 17–44 74 48–107 376 244–535 58 53–63 Zimbabwe 7.8 7. b Estimates of TB incidence and mortality for India are interim in nature.2 0.8 2.2 7.3–2.6 2.0–20 304 195–435 14 13–15 South Africa 41 31–52 181 120–254 781 543–1 060 59 53–65 Thailand 13 10–15 5.3 177 125–239 7.6–5.5 8.7 Central African Republic 59 33–92 54 29–87 407 263–581 33 22–45 China 3.8–12 Eastern Mediterranean 12 10–14 0.5–6.39 95 79–113 1.14 0.0–8.70 27 26–29 11 9.05–0.6–12 Ethiopia 25 16–36 3.66–1.2 345 223–493 2.27–0.3 3. Rates per 100 000 population except where indicated.51–1.7 1.8–3.5 Indonesia 42 29–58 5.5–6.2 133 109–159 3.71–2.22 Brazil 2.5–16 432 352–521 10 6.1 Papua New Guinea 44 29–62 10 5.9 66 42–94 19 18–21 Sierra Leone 47 28–70 14 9.50–1.8–8.4–5.6 2.8 1.3 0.8 Kenya 60 33–93 50 30–75 348 213–516 31 29–33 Lesotho 49 26–80 238 148–350 724 468–1 030 72 64–80 Liberia 60 35–91 21 13–30 308 199–440 16 14–18 Mozambique 75 44–115 114 70–167 551 356–787 45 40–50 Myanmar 47 30–66 9.5 0.9 1.7–10 Namibia 30 20–44 35 25–48 446 342–565 38 37–40 Nigeria 62 36–95 21 12–31 219 143–311 16 13–18 Pakistan 23 18–29 1.3–2.8 192 158–230 9.6 1.8–4.6 2.0 4.11 0.08–0.20 0.1–12 a Deaths among HIV-positive TB cases are classified as HIV deaths according to ICD–10.2–2.1 0.1 2.4 4.21 0.9–9.0 4.6 Russian Federation 8.74–2. 30 GLOBAL TUBERCULOSIS REPORT 2017 .7 3.66–1.9 0.29 <0.09–0.63 0.3 6.

FIG. 2016 Incidence per 100 000 population per year 0–24 25–99 100–199 200–299 ≥300 No data Not applicable GLOBAL TUBERCULOSIS REPORT 2017 31 .4 Estimated TB incidence rates. 3.3 Estimated TB incidence in 2016. 3. for countries with at least 100 000 incident cases China Philippines Pakistan Number of incident cases Nigeria India 100 000 500 000 Indonesia 1 000 000 South Africa 2 500 000 FIG.

2. 3. For consistency with these international classifications.8%) and the Russian Federation in 2016 were among people living with HIV (Table 3. Lesotho.5%).5 Estimated HIV prevalence in new and relapse TB cases. The fastest 1 World Health Organization. In Trends are shown for the six WHO regions in Fig. 2016 HIV prevalence. provided that these systems have high coverage in the TB incidence rate was 1. 3. 2016. HIV in the general population decreases.4% per year in 2000−2016. FIG. in both absolute terms and per directly using data from national vital registration (VR) capita (Fig. negative people and TB deaths in HIV-positive people.7%). The proportion of TB cases coinfected with HIV was highest in countries in the WHO African Region. Ethiopia (6. Mortality (Chapter 2).3 Estimated trends in TB incidence. Kenya (6. Sample VR systems covering to 4–5% per year by 2020 to achieve the milestones for representative areas of the country (the approach used. International statistical classification of diseases declines are in the WHO European Region (4. of Korea.8 and 2016. most countries with a high burden of TB lacked national for the 30 high TB burden countries in Fig. this Estimates of the incidence of zoonotic TB are shown in Box section makes a clear distinction between TB deaths in HIV- 3.0%). 2016).9%). 3. surveys can also be used to estimate deaths caused by TB. 16–27).3). the United Republic of Tanzania (6. Zambia (4. 8–12%) of the incident TB cases Namibia (6. all ages (%) 0–4.int/classifications/icd10/browse/2016/en).5). The risk of Deaths from TB among HIV-negative people are classified developing TB in the 37 million people living with HIV was 21 as TB deaths in the most recent version of the International times higher than the risk in the rest of the world population classification of diseases (ICD-10). the underlying cause is classified as HIV.2 TB mortality 50% in parts of southern Africa (Fig. Lesotho (7%). 3. exceeding 3. the Philippines and South including Zimbabwe (11%).6% from 2015 to and health related problems (The) ICD-10.(http://apps. and that causes of death are accurately determined and and 1. The estimated decline in the incidence rate since 2010 who. The relative risk increases as the prevalence of person dies from TB. 3. Fig. Mozambique. 3. 3. 3.7). in China) provide an interim solution.9.9 5–9. the number of TB mortality among HIV-negative people can be measured incident cases is falling slowly.1 When an HIV-positive (range.9%).1 Methods to estimate TB mortality Consistent with previous global TB reports. Africa (Table 3.3). This needs to accelerate coded according to ICD-10. Globally.4. An estimated 10% (range. Table (4.9 10–19 20–49 ≥50 No data Not applicable few countries including the Democratic People’s Republic has exceeded 4% per year in several high TB burden countries.1. the average rate of decline systems.9% between 2015 and 2016. Geneva: WHO.6. 2000–2016 3. 32 GLOBAL TUBERCULOSIS REPORT 2017 .2. for reductions in cases and deaths set in the End TB Strategy example.

where it is Tuberculosis and Lung Disease. Bovine TB has an n which belongs to the M. This burden of disease cannot be Organisation for Animal Health (OIE) and the Food reduced without improving standards of food safety and Agricultural Organization of the United Nations and controlling bovine TB in the animal reservoir. animal species.4 Zoonotic TB is predominantly caused by M. improved health of human and animal populations. bovis. including wildlife. INCIDENT CASES DEATHS REGION BEST ESTIMATE UNCERTAINTY INTERVAL BEST ESTIMATE UNCERTAINTY INTERVAL Africa 72 700 19 500–160 000 9 300 2 460–20 600 The Americas 822 223–1 810 41 11–90 Eastern Mediterranean 7 660 1 930–17 300 654 173–1 450 Europe 1 160 309–2 570 84 23–183 South-East Asia 46 700 11 100–107 000 2 080 548–4 620 Western Pacific 18 000 4 740–40 000 350 92–777 GLOBAL 147 000 71 800–249 000 12 500 4 870–23 700 GLOBAL TUBERCULOSIS REPORT 2017 33 .4. humans. it also causes TB in other multidisciplinary “One Health” approach that includes a more comprehensive analysis of risks.1 Estimated incidence and mortality due to M. better coverage of interventions. more efficient use of resources.4. The roadmap calls for a referred to as bovine TB. the World 2016 (Table B3. reduced costs and. In important economic impact and threatens livelihoods. The roadmap is centred on 10 priorities grouped under three core themes: Improve the scientific evidence base  Collect and report more complete and accurate data  Improve diagnosis in people  Address research gaps Reduce transmission at the animal–human interface  Ensure safer food  Improve animal health  Reduce the risk to people Strengthen intersectoral and collaborative approaches  Increase awareness. there were an estimated 147 000 new cases In 2016–2017. Best estimates (absolute numbers) are followed by the lower and upper bounds of the 95% uncertainty interval. tuberculosis complex. a roadmap for zoonotic TB was of zoonotic TB and 12 500 deaths due to the disease in developed by the tripartite of WHO. engagement and collaboration  Develop policies and guidelines  Implement joint interventions  Advocate for investment TABLE B3. ultimately. n Zoonotic TB BOX 3. together with the International Union Against The organism is host-adapted to cattle.1). bovis TB. (FAO).

United States of America (USA) measure even when VR systems are in place. which collectively accounted surveys. which accounted for less than 10% of the 1 2 Downloaded from http://ghdx. TB deaths among HIV-positive people were ICD-10. This was substantially improved to Estimates of the number of deaths caused by TB are shown 89 countries in 2009. FIG. The online technical appendix is available at world’s TB cases. and few had conducted mortality for 129 countries (Fig. For the current report. 2000–2016. and that has the greatest need to introduce or strengthen VR contributory causes (e. or through ecological modelling of VR data and resulting estimates of TB deaths published using mortality data from countries with VR systems. analyses the case fatality ratio (CFR).7 Global trends in estimated TB incidence and mortality rates. Shaded areas represent uncertainty intervals. For 18 countries.10).int/tb/publications/global_report/en/. 3. 3. TB for 57% of the estimated number of TB deaths (among HIV- mortality can be estimated as the product of TB incidence and negative people) globally in 2016. WHO estimates of TB mortality used VR data 3. 2000–2016. by the Institute of Health Metrics and Evaluation (IHME) at TB mortality among HIV-positive people is hard to the University of Washington. estimated as the product of TB incidence and the CFR. July 2017.1 The WHO African Region is the part of the world among HIV-positive people are coded as HIV deaths. for the six WHO regions and for the 30 high TB countries in the WHO European Region and the WHO Region of the Americas.g.5 10 TB deaths among Millions per year Millions per year HIV-negative people All TB cases 1. 34 GLOBAL TUBERCULOSIS REPORT 2017 . 3. VR data were used http://www. although most of the data were from globally. In the absence of VR systems or mortality surveys.org/gbd-results-tool. TB) are often not reliably assessed systems in which causes of death are classified according to and recorded.6 Global trends in the estimated number of incident TB cases and the number of TB deaths (in millions). Until 2008.who. with Details about the methods used to produce estimates of the latter accounting for the protective effect of antiretroviral TB mortality are provided in the online technical appendix.healthdata.0 5 Notifications of new and relapse cases 0.5 TB deaths among HIV-positive people HIV-positive TB cases 0 0 2000 2008 2016 2000 2008 2016 FIG.2. Shaded areas represent uncertainty intervals. TB incidence TB deaths 1. TB incidence TB mortality (HIV-negative) 200 30 Rate per 100 000 population per year Rate per 100 000 population per year 150 All TB cases 20 100 Notifications of new 10 50 and relapse cases HIV-positive TB cases 0 0 2000 2008 2016 2000 2008 2016 or sample VR systems. because deaths were used.2 therapy (ART).2 Estimates of TB mortality in 2016 for only three countries.

int/gho/data/node. 3.0% and 4. Indonesia.6).3 million (range. death per 100 000 population in many high-income countries ranking above HIV/AIDS (Fig. 3.3 million in 2016 (Fig.13).7 million Asia Region in 2016. and for 26% of the combined total TB Rates have also been falling in all six of the WHO regions (Fig. FIG. the proportion of people who die from TB can be under 5% (section 3.8 Regional trends in estimated TB incidence rates by WHO region. the treatment success rate was 83% globally (Chapter 4).2 million to 1. Myanmar and Papua New Guinea). these regions accounted for 85% of the in 2000 to 1. 3. ranging from less than one TB the leading cause of death from a single infectious agent. the fastest average rates of decline in the Estimates of TB mortality rates (per 100 000 population) mortality rate have been in the WHO European Region and 1 the WHO Western Pacific Region (6. reported and treated in 2015. TB is the ninth leading cause of death people were included. 3. in Table 3. The black lines show notifications of new and relapse cases for comparison with estimates of the total incidence rate. available at http://apps. and by 3.4).11. Fig. from 1. India accounted for 33% of global TB deaths among and 2016 (Fig.4% between 2015 and 2016. in Table 3. and for the past five years (2012–2016) has been among countries (Fig. people whose TB was detected. 325 000–427 000) deaths from TB among was 17 in 2016. for the six WHO regions and for the 30 high 1. 2000–2016. Fig. 3. 3. There were an estimated are shown globally. respectively).2. Globally. deaths in HIV-negative and HIV-positive people.2.15).14).GHECOD?lang=en (accessed 23 August 2017). Shaded areas represent uncertainty intervals. For example. 3.3.7). 2000–2016 About 82% of TB deaths among HIV-negative people Globally. WHO Global Health Observatory data repository. Since 2010. HIV-negative people.4.6% per year.3 Estimated trends in TB mortality. Total TB incidence rates are shown in green and incidence rates of HIV-positive TB are shown in red. Africa The Americas Eastern Mediterranean 400 40 150 300 30 100 20 200 Rate per 100 000 population per year 50 10 100 0 Europe South−East Asia Western Pacific 60 400 150 40 300 100 200 20 50 100 0 0 0 2000 2008 2016 2000 2008 2016 2000 2008 2016 burden countries.1 to 40 or more deaths per 100 000 population in much of the Most of these deaths could be prevented with early diagnosis WHO African Region and in five high TB burden countries in and appropriate treatment (Chapter 1). among Asia (Bangladesh. and slowest in the WHO Eastern Mediterranean GLOBAL TUBERCULOSIS REPORT 2017 35 . There was considerable variation worldwide.12.main. the absolute number of TB deaths among HIV- occurred in the WHO African Region and the WHO South-East negative people has been falling since 2000.4 million) deaths from TB burden countries.2. The TB mortality combined total of TB deaths in HIV-negative and HIV-positive rate (per 100  000 population) fell by 37% between 2000 people. the Democratic People’s Republic of Korea. 3. who. Estimates of the number of deaths caused by zoonotic TB and in high-income countries with universal health coverage are shown in Box 3. the number of TB TB among HIV-negative people in 2016 and an additional deaths among HIV-negative people per 100 000 population 374  000 (range. and 22 when TB deaths among HIV-positive HIV-positive people. 3. 1.

FIG.9 Trends in estimated TB incidence in the 30 high TB burden countries. Angola Bangladesh Brazil Cambodia Central African Republic 300 60 800 1500 400 600 200 1000 40 400 200 100 20 500 200 0 0 0 0 0 China Congo DPR Korea DR Congo Ethiopia 600 600 400 100 400 400 300 400 200 50 200 200 200 100 0 0 0 0 0 India a Indonesia Kenya Lesotho Liberia 1000 600 400 400 1500 750 300 Rate per 100 000 population per year 300 400 500 1000 200 200 200 250 500 100 100 0 0 0 0 0 Mozambique Myanmar Namibia Nigeria Pakistan 800 600 1200 400 300 600 900 300 400 200 400 600 200 200 100 200 300 100 0 0 0 0 0 Papua New Guinea Philippines Russian Federationb Sierra Leone South Africa 600 400 750 100 1000 400 300 500 200 50 500 200 250 100 0 0 0 0 0 Thailand UR Tanzania Viet Nam Zambia Zimbabwe 400 800 800 900 300 600 200 600 600 200 400 400 100 100 200 300 200 0 0 0 0 0 2000 2008 2016 2000 2008 2016 2000 2008 2016 2000 2008 2016 2000 2008 2016 a Estimates of TB incidence for India are interim in nature. 36 GLOBAL TUBERCULOSIS REPORT 2017 . 3. Shaded areas represent uncertainty intervals. TB incidence rates are shown in green and incidence rates of HIV-positive TB are shown in red. b For an explanation of why notifications are assumed to be equivalent to TB incidence in the Russian Federation. pending results from the national TB prevalence survey planned for 2018/2019.5. The black lines show notifications of new and relapse cases for comparison with estimates of the total incidence rate. see Box 3. 2000–2016.

Deaths Estimated number of deaths from HIV/AIDS and from TB among HIV-positive people are shown in grey. Deaths from TB among HIV-positive people are shown in grey.b Ischaemic heart disease TB Stroke HIV/AIDS Lower respiratory infections Chronic obstructive 0 0.c Top causes of death worldwide in 2015.org/en/resources/ Diabetes mellitus documents/2017/HIV_estimates_with_uncertainty_bounds_1990-2016.main.int/ gho/data/node. TB in 2016. b Deaths from TB among HIV-positive people are officially classified as deaths Alzheimer disease caused by HIV/AIDS in the International classification of diseases.0 1. the latest estimates of the number of deaths in 2016 that have been published by UNAIDS are available at www. 3.a.11 FIG. See WHO Global Health Observatory data repository. 3. GLOBAL TUBERCULOSIS REPORT 2017 37 . and other dementias Diarrhoeal diseases Tuberculosis Road injury 0 1 2 3 4 5 6 7 8 9 Millions (2015) a This is the latest year for which estimates for all causes are currently available. bronchus. c Deaths from TB among HIV-positive people are officially classified as deaths caused by HIV/AIDS in the International classification of diseases.12 a. FIG. Further details are provided in the online technical appendix. a lung cancers For HIV/AIDS.10 Main methods used to estimate TB mortality in HIV-negative people Main method Indirect estimatea VR (IHME) VR (WHO) No data Not applicable a Mortality is estimated as the product of TB incidence and the TB case fatality ratio. b For HIV/AIDS. available at http://apps.org/en/resources/ documents/2017/HIV_estimates_with_uncertainty_bounds_1990-2016.unaids.5 1. the estimates for 2016 are those published in this report.b. 3.GHECOD (accessed 28 August 2017).FIG.unaids. the latest estimates of the number of deaths in 2016 that have been published by UNAIDS are available at www. For TB. For TB.5 pulmonary disease Millions (2016) Trachea. the estimates for 2016 are those published in this report.who.

9 1–4. ranging from caused by TB and HIV (in millions). the Russian Federation.9 5–19 20–39 ≥40 No data Not applicable 38 GLOBAL TUBERCULOSIS REPORT 2017 . 3. 2016 Mortality per 100 000 population per year 0–0. 2020 and 2025 in the End TB Strategy.13 Region (2. among HIV-positive people accounted for 37% of deaths classified as caused by HIV/AIDS in 2016. Further Millions of deaths per year 1.16).0 HIV deaths year since 2010 included Ethiopia.14 Estimated TB mortality rates excluding TB deaths among HIV-positive people.a. the Russian Federation and Viet Nam) to limited changes (e. Deaths from TB to fall to 10% by 2020 and to 6% by 2025 (Chapter 2). Shaded areas represent uncertainty intervals. the CFR would be low in all countries).0 3. FIG. 3.5 the disease. 2000–2016. Congo and South Africa). Viet Nam and Zimbabwe. the latest estimates of the number of deaths in 2016 that have quality treatment. High TB burden countries with rates of decline exceeding 6% per 2. divided by the total number of incident cases in both FIG. the United Republic of Tanzania. achieve the milestones for reductions in TB deaths set for b the estimates for 2016 are those published in this report.2.2% per year). The CFR allows assessment of variation in equity in terms of access 0 to TB diagnosis and treatment among countries (because if 2000 2008 2016 everyone with TB had access to timely diagnosis and high- a For HIV/AIDS.4 The CFR and across-country equity The CFR is the proportion of people with TB who die from 0.5 details about trends in TB disease burden in the Russian Federation. the global CFR needs Deaths from TB among HIV-positive people are officially classified as deaths caused by HIV/AIDS in the International classification of diseases. Myanmar. in Cambodia. China. 3. in Angola. In 2016.b substantial reductions since 2000 (e. 1.g. To been published by UNAIDS are available at www. based on an epidemiological review conducted in TB deaths in HIV-negative people February 2017. For TB. Trends in mortality rates in the 30 high Global trends in the estimated number of deaths TB burden countries vary markedly (Fig. it can be approximated as the number of TB TB deaths in HIV-positive people deaths divided by TB incidence in the same year.org/en/resources/ documents/2017/HIV_estimates_with_uncertainty_bounds_1990-2016. the global CFR (calculated as the combined number of TB deaths in HIV-negative people and HIV-positive people.5.g.unaids. are provided in Box 3. Ethiopia.

2 3 Further details about methods used to estimate lives saved. 3. resources/en/.0 20 2 2. depending on the country and its HIV burden. available at (http://www.5 Estimated number of deaths averted by TB (Table 3. FIG. accessed 16 August 2017). The number of and remains a major public health concern in many countries. TB treatment alone averted an estimated 44 million deaths among HIV-negative people 3. cases (without further testing for isoniazid resistance) are which could be reduced by effective detection and care programmes. it number of estimated incident cases (Section 3. Intensified efforts are required to reduce the on future levels of infections. including CFRs World Health Organization.5 0 0 0 2000 2008 2016 2000 2008 2016 2000 2008 2016 HIV-negative and HIV-positive people)1 was 16%. CFRs restricted to HIV-negative TB deaths and cases can also be calculated but are being detected and notified (Chapter 4). RR-TB also by the relevant estimated CFR for untreated TB.17). deaths that would have occurred each year in the absence of TB Three major categories are used for global surveillance and treatment (and without ART provided alongside TB treatment treatment. TB treatment treatment. to estimate the Drug-resistant TB threatens global TB care and prevention. 3. The actual numbers of TB deaths (presented above) can be compared with the number of TB deaths that would have 3. are provided in the online technical tuberculosis (2016 update) (WHO/HTM/TB/2016.int/tb/publications/global_report/en/. WHO treatment guidelines for drug-resistant for different categories of TB case. cases and deaths.int/tb/areas-of-work/drug-resistant-tb/treatment/ http://www. and estimated mortality rates of HIV-positive TB are shown in red. from under 5% in a few services or the availability of ART on the level of TB incidence. CFRs can also be restricted to resistant TB (XDR-TB) is defined as MDR-TB plus resistance to HIV-negative TB deaths. the two most powerful anti-TB drugs.2. in particular to illustrate the high CFRs in African countries. Geneva: WHO. 2000−2016.who.15 Regional trends in estimated TB mortality rates by WHO region.04). Among HIV-positive people.3 With increasing 1 The CFR was calculated based on the combined total of deaths in use of Xpert® MTB/RIF for simultaneous detection of TB HIV-negative and HIV-positive people for the purpose of cross-country and resistance to rifampicin. Africa The Americas Eastern Mediterranean 70 20 3 60 15 50 2 10 Rate per 100 000 population per year 40 5 1 30 0 Europe South-East Asia Western Pacific 12.4). 2016 appendix.5 4 5. CFR to 10% globally by 2020.5 8 60 10. Extensively drug- not shown here.3 Drug-resistant TB occurred in the absence of TB treatment. Estimated TB mortality rates in HIV-negative people are shown in blue. Shaded areas represent uncertainty intervals. a growing number of RR-TB comparisons. countries to more than 20% in most countries in the WHO or for the indirect. 2000–2016 supported by ART averted an additional 8. downstream impact of these interventions African Region.who.0 6 40 7. MDR-TB is TB that is resistant to both rifampicin for HIV-positive cases) can be conservatively estimated as the and isoniazid. At the subnational level.2 Estimates are requires treatment with second-line drugs. number of deaths averted by TB interventions. GLOBAL TUBERCULOSIS REPORT 2017 39 .5 million deaths. Between 2000 and 2016.1) multiplied requires treatment with a second-line regimen. It varied conservative because they do not account for the impact of TB widely among countries (Fig.

TB mortality rates in HIV-negative people are shown in blue and mortality rates of HIV-positive TB are shown in red.5 50 25 50 25 0 0 0 0 0 India a Indonesia Kenya Lesotho Liberia 120 60 200 600 60 150 80 Rate per 100 000 population per year 40 400 40 100 20 200 40 20 50 0 0 0 0 0 Mozambique Myanmar Namibia Nigeria Pakistan 100 200 150 40 75 200 150 30 100 100 50 20 100 50 50 25 10 0 0 0 0 0 Papua New Guinea Philippines Russian Federation Sierra Leone South Africa 25 150 40 300 20 30 100 100 15 200 20 10 50 50 100 10 5 0 0 0 0 0 Thailand UR Tanzania Viet Nam Zambia Zimbabwe 50 200 200 40 40 200 150 150 30 100 100 20 20 100 10 50 50 0 0 0 0 0 2000 2008 2016 2000 2008 2016 2000 2008 2016 2000 2008 2016 2000 2008 2016 a Estimates of TB mortality for India are interim in nature. 40 GLOBAL TUBERCULOSIS REPORT 2017 . Shaded areas represent uncertainty intervals.5 75 150 75 100 5. 3. 2000–2016.0 50 100 50 2. Angola Bangladesh Brazil Cambodia Central African Republic 120 6 60 100 600 90 75 40 4 400 60 50 2 20 30 200 25 0 0 0 0 0 China Congo DPR Korea DR Congo Ethiopia 100 200 100 150 7. FIG.16 Trends in estimated TB mortality rates in the 30 high TB burden countries. pending results from the national TB prevalence survey planned for 2018/2019. The black lines show observations from vital registration systems.

n The burden of TB disease is falling in the Russian Federation, but the
BOX 3.5 incidence of MDR-TB is increasing
n A national TB epidemiological review was undertaken FIG B3.5.2
in the Russian Federation in February 2017. It included Notifications of new and relapse cases in
a thorough review of the latest epidemiological data,
including TB case notifications, death registration data
the Russian Federation, 2000–2016. The
from the national VR system and results from DST for dashed line shows the notification rate of new
anti-TB drug resistance. The main conclusions from this cases that were bacteriologically confirmed.
review were that the burden of TB disease (incidence
100

Rate per 100 000 population per year
and mortality) is falling but the incidence of MDR-TB is
increasing.
80
Data from the VR system show that the TB mortality rate
(excluding TB deaths in HIV-positive people) has been 60
falling rapidly since 2009, at an average rate of 11% per
year. This trend is consistent in all of the eight federal 40
regions (okrugs), although the decline has been especially
impressive (at 17% per year) in the North Caucasus region 20
(Fig. B3.5.1).
The case notification rate of new and relapse TB cases 0
has fallen at an average rate of 4.8% per year since 2009 2000 2008 2016
(Fig. B3.5.2). This is considered to be a good proxy for the
trend in TB incidence, for four main reasons: Furthermore, there seems to be an over-reliance on
clinical diagnostic criteria, since a large proportion of
 There is extensive and regular screening for TB. It
the notified cases found through screening do not have
is mandatory for every citizen aged 17 and above
bacteriological confirmation of pulmonary TB, despite
to be screened every 1–2 years (with the frequency
the systematic use of sensitive and modern diagnostic
depending on residence); this screening is typically
tests.
done using fluorography, and otherwise using sputum
microscopy. Children and adolescents are screened  Notification of detected TB cases is mandatory, and
annually using tuberculin skin tests. Contacts of TB the TB notification system has complete coverage.
cases are also screened (in 2015, 470 000 contacts Underreporting of detected cases is unlikely.
were screened). The high coverage of active case
 Culture or molecular tests are routinely used for
finding means that there is a low probability of missed
diagnosis.
diagnoses. Instead, it is more likely that there is some
overreporting of cases due to the lower predictive value  There have been no major changes to TB screening,
of laboratory tests among the general population. diagnostic and reporting practices since 2009.  ➜

FIG. B3.5.1
Annual TB mortality rates per 100 000 population for eight federal regions (okrugs),
2009–2015. Rates were adjusted for ill-defined causes of death.
Central North-West Volga Ural
15 15 20 25

20
15
10 10
15
10
Rate per 100 000 population per year

10
5 5
5
5

0 0 0 0
2009 2011 2013 2015 2009 2011 2013 2015 2009 2011 2013 2015 2009 2011 2013 2015

Siberia Far-East North Caucasus South
30 15 25
30 20
20 10
20 15

10
10 10 5
5

0 0 0 0
2009 2011 2013 2015 2009 2011 2013 2015 2009 2011 2013 2015 2009 2011 2013 2015

GLOBAL TUBERCULOSIS REPORT 2017 41

➜  Trends in all of the eight federal regions (okrugs) are broadly (6000 cases) to 11 per 100 000 population in 2015 (8000 cases).
consistent with the national trend. The far-Eastern region reports The proportion of TB cases with a DST result who had MDR-TB
the highest notification rates (123/100 000 in 2015); the lowest has risen from 17% in 2010 to 27% in 2015 (Fig. B3.5.3). Reasons
rates are found in the central region (43/100 000 in 2015) and the for this increase, which is in contrast to the overall decline in TB
North Caucasus region (41/100 000 in 2015). burden, are not clear. Coverage of DST among laboratory-confirmed
cases has been consistently high over the period (Fig. B3.5.4). It
Despite the steady decline in the overall TB notification rate, a
will be important to closely monitor trends and to continuously
concerning national trend is that the case notification rate for MDR-
assess the performance of the national response to MDR-TB.
TB has been increasing, from 8 per 100 000 population in 2010

FIG. B3.5.3
MDR-TB detection among new cases of pulmonary TB, 2010–2015
30
8000
MDR-TB among tested (%)

Number of MDR-TB cases
20 6000

4000
10
2000

0 0
2010 2011 2012 2013 2014 2015 2010 2011 2012 2013 2014 2015

FIG. B3.5.4
Culture confirmation and DST coverage among new cases of pulmonary TB, 2010–2015
50 100
DST coverage in confirmed (%)

40 80
Laboratory confirmed (%)

30 60

20 40

10 20

0 0
2010 2011 2012 2013 2014 2015 2010 2011 2012 2013 2014 2015

TABLE 3.4
Cumulative number of deaths averted by TB and TB/HIV interventions 2000–2016 (in millions),
globally and by WHO region
HIV-NEGATIVE PEOPLE HIV-POSITIVE PEOPLE TOTAL

BEST UNCERTAINTY BEST UNCERTAINTY BEST UNCERTAINTY
WHO REGION ESTIMATE INTERVAL ESTIMATE INTERVAL ESTIMATE INTERVAL

Africa 5.1 4.2–6.0 5.7 5.0–6.5 11 10–12
The Americas 1.5 1.3–1.6 0.32 0.29–0.34 1.8 1.7–1.9
Eastern Mediterranean 3.5 3.0–4.0 0.05 0.04–0.06 3.6 3.1–4.0
Europe 1.8 1.6–2.0 0.20 0.18–0.21 2.0 1.8–2.2
South-East Asia 20 16–24 1.9 1.5–2.4 22 18–26
Western Pacific 12 11–13 0.32 0.28–0.36 12 11–13
GLOBAL 44 38–50 8.5 7.5–9.5 53 47–58

42 GLOBAL TUBERCULOSIS REPORT 2017

FIG. 3.17
Estimates of the case fatality ratio (CFR), (including HIV-negative and HIV-positive people), 2016

CFR (%)
0–4.9
5–9.9
10–19
20–24
≥25
No data
Not applicable

at least one drug in both of the two most important classes because of overlap between the two groups1), 37 have data
of medicines in an MDR-TB regimen: fluoroquinolones and on levels of drug resistance. The three countries that that
second-line injectable agents (amikacin, capreomycin or have never conducted a drug resistance survey are Angola,
kanamycin). Congo and Liberia. Among the other 37 high TB burden or
Estimates of the disease burden caused by drug-resistant high MDR-TB burden countries, the data for Sierra Leone are
TB presented in this chapter focus on MDR/RR-TB. from before the year 2000, and four countries (Brazil, Central
African Republic, Democratic People’s Republic of Korea and
3.3.1 Global surveillance of anti-TB drug resistance Papua New Guinea) rely on drug resistance surveillance data
Since the launch of the Global Project on Anti-tuberculosis gathered from subnational areas only.
Drug Resistance Surveillance in 1994, data on drug resistance In 2015–2016, the first-ever national drug resistance
have been systematically collected and analysed from 160 surveys were completed in Burkina Faso, Democratic Republic
countries worldwide (82% of the 194 WHO Member States), of the Congo, Ghana, India and Sudan, and repeat surveys were
which collectively have more than 97% of the world’s completed in Côte d’Ivoire, Mongolia and Zimbabwe. In 2016–
population and TB cases. This includes 90 countries that 2017, drug resistance surveys were ongoing in 11 countries,
have continuous surveillance systems based on routine with the first nationwide surveys in four countries (Burundi,
diagnostic drug susceptibility testing (DST) of all TB patients, Eritrea, Indonesia, Lao People’s Democratic Republic, Mali
and 70 countries that rely on epidemiological surveys of and Togo) and repeat surveys in seven countries (Bangladesh,
representative samples of patients (Fig. 3.18). Surveys Cambodia, Ethiopia, Malawi, Sri Lanka, Swaziland, Thailand
conducted about every 5 years represent the most common and the United Republic of Tanzania).
approach to investigating the burden of drug resistance in
resource-limited settings where routine DST is not accessible 3.3.2 Estimates of the disease burden caused
to all TB patients, owing to lack of laboratory capacity or by MDR/RR-TB
resources. Globally in 2016, an estimated 4.1% (95% confidence interval
Progress towards achieving global coverage of drug [CI]: 2.8–5.3%) of new cases and 19% (95% CI: 9.8–27%) of
resistance surveillance data is shown in Fig. 3.19. Among previously treated cases had MDR/RR-TB (Table 3.5). The
the 30 high TB burden countries and the 30 high MDR-TB proportions of new and previously treated TB cases with
burden countries (which comprise a total of 40 countries, 1
For a full list of the high TB burden and high MDR-TB burden countries, see
Chapter 2.

GLOBAL TUBERCULOSIS REPORT 2017 43

FIG. 3.18
Data sources available to estimate levels of TB drug resistancea

Source of data
Surveillance
Survey
No data
Not applicable

a
Data shown refer to new TB cases only.

FIG. 3.19
Global coverage of surveillance data on drug resistance, 1995–2017

Year of most
recent data
1995–2004
2005–2009
2010–2014
2015–2017
Ongoing in 2017
No data
Subnational data
Not applicable

44 GLOBAL TUBERCULOSIS REPORT 2017

TABLE 3.5
Estimated incidence of MDR/RR-TB in 2016 for 30 high MDR-TB burden countries,
WHO regions and globally
ESTIMATED % OF PREVIOUSLY
ESTIMATED % OF NEW CASES
TREATED CASES WITH MDR/ INCIDENCE OF MDR/RR–TB
WITH MDR/RR-TB
RR-TB

% OF MDR
BEST UNCERTAINTY BEST UNCERTAINTY NUMBER UNCERTAINTY UNCERTAINTY
RATEb AMONG
ESTIMATEa INTERVAL ESTIMATE INTERVAL (IN 1000S) INTERVAL INTERVAL
MDR/RR-TB

Angola 2.6 0.10–5.1 18 0.10–36 4.3 1.4–7.3 15 4.8–25 68
Azerbaijan 13 10–16 39 37–42 2.4 2.0–2.9 25 20–30 77
Bangladesh 1.6 0.59–2.6 29 22–36 8.8 4.8–13 5.4 2.9–7.8 91
Belarus 38 36–40 72 68–75 3.4 2.6–4.1 35 28–43 99
China 7.1 5.6–8.7 24 20–28 73 56–89 5.2 4.0–6.4 75
DPR Korea 2.2 0.51–3.9 16 5.8–27 5.7 3.2–8.1 22 13–32 90
DR Congo 2.2 1.0–3.5 17 9.6–24 7.6 3.9–11 9.7 4.9–15 68
Ethiopia 2.7 1.5–4.0 14 3.6–25 5.8 3.1–8.5 5.7 3.0–8.3 62
India 2.8 2.0–3.5 12 10–13 147 95–199 11 7.2–15 86
Indonesia 2.8 2.2–3.5 16 10–20 32 19–45 12 7.3–17 68
Kazakhstan 26 25–28 44 42–46 7.0 5.4–8.6 39 30–48 91
Kenya 1.3 0.68–1.9 9.4 8.7–10 3.0 1.6–4.4 6.2 3.2–9.1 59
Kyrgyzstan 27 25–29 60 57–63 4.8 4.0–5.5 80 68–92 94
Mozambique 3.7 2.4–5.0 20 2.1–37 7.6 4.5–11 26 16–37 85
Myanmar 5.1 3.2–7.0 27 10–44 13 8.8–18 25 17–34 99
Nigeria 4.3 3.2–5.4 25 19–31 20 12–29 11 6.4–15 66
Pakistan 4.2 3.2–5.3 16 15–17 27 17–37 14 8.8–19 90
Papua New Guinea 3.4 1.7–5.0 26 15–36 1.9 1.2–2.6 23 15–32 78
Peru 6.3 5.9–6.7 24 23–26 3.5 2.9–4.2 11 9.1–13 89
Philippines 2.6 1.8–3.3 29 20–38 30 21–40 30 20–39 75
Republic of Moldova 26 24–28 56 51–60 2.3 1.9–2.6 56 47–65 97
Russian Federation 27 27–28 65 65–66 63 52–74 44 36–51 100
Somalia 8.7 5.9–11 47 23–71 3.9 2.2–5.6 27 16–39 64
South Africa 3.4 2.5–4.3 7.1 4.8–9.5 19 12–25 34 22–45 62
Tajikistan 22 21–24 45 40–50 2.6 2.1–3.1 30 24–36 96
Thailand 2.2 1.5–2.9 24 16–32 4.7 3.0–6.3 6.8 4.4–9.2 86
Ukraine 27 26–27 47 46–48 21 16–26 47 37–58 85
Uzbekistan 24 18–30 63 50–75 10 7.6–13 32 24–40 97
Viet Nam 4.1 2.6–5.5 26 25–27 8.2 6.1–10 8.7 6.5–11 94
Zimbabwe 4.6 3.0–6.2 14 8.9–20 1.9 1.3–2.6 12 8.0–16 41
MDR/RR HBCs 4.4 2.8–6.0 19 8.7–30 546 487–609 12 11–13 83
Africa 2.7 2–3.5 14 8.4–20 93 81–106 9.1 7.9–10 68
The Americas 2.9 1.4–4.3 13 6.9–20 12 11–13 1.2 1.1–1.3 88
Eastern Mediterranean 4.2 1.7–6.7 17 14–19 41 31–52 6.2 4.7–7.8 83
Europe 19 12–26 55 43–67 122 110–134 13 12–15 96
South-East Asia 2.8 2.4–3.1 13 10–15 214 163–272 11 8.4–14 86
Western Pacific 5.3 2.9–7.8 25 20–29 119 101–139 6.3 5.3–7.4 77
GLOBAL 4.1 2.8–5.3 19 9.8–27 601 541–664 8.1 7.3–8.9 82


a
Best estimates are for the latest available year.
b
Rates are per 100 000 population.

GLOBAL TUBERCULOSIS REPORT 2017 45

46 GLOBAL TUBERCULOSIS REPORT 2017 . Belize. French Polynesia. which varies among countries. Data reported before 2002 are not shown. Puerto Rico and Sao Tomé and Principe refer to only a small number of notified cases (range: 1–8 notified previously treated TB cases). FIG. The high percentages of previously treated TB cases with MDR-TB in Bahamas. 3. Data reported before 2002 are not shown. which varies among countries.9 3–5.20 Percentage of new TB cases with MDR/RR-TBa Percentage of cases 0–2.21 Percentage of previously treated TB cases with MDR/RR-TBa Percentage of cases 0–5.9 6–11 12–29 30–49 ≥50 No data Not applicable a Figures are based on the most recent year for which data have been reported. 3.9 6–11 12–17 ≥18 No data Not applicable a Figures are based on the most recent year for which data have been reported. FIG.

Thailand. with of MDR-TB accounting for 82% (490 000) of the total (Table the burden of MDR-TB either increasing faster or decreasing 3. the average at least 3 years of data: Belarus. By the end of 2016. The countries with the largest numbers of MDR/RR-TB more slowly than the overall TB burden in each country.5% (95% CI: recommended diagnostic tests. resistance are available for 158 countries over the period Data compiled from surveys and continuous surveillance 2002–2016. 3. 3. 540 000– on these data.5% in 2015. there is a slight trend for cases of MDR-TB to 660 000) incident cases of MDR/RR-TB in 2016. the global an estimated 350 000 (range. 3.23 shows trends in data available in previous years (9.6–9. Combining their data. cases (47% of the global total) were China. These are the MDR/RR-TB cases were notified in the country to generate a global average. Kazakhstan. Myanmar.4–9. with the best estimate lower than those based on and Viet Nam.2% (95% CI: Republic of Moldova. In new and previously treated TB cases.FIG. the proportion of new TB Fig.22 Estimated incidence of MDR/RR-TB in 2016.3 Trends in drug resistance 123 WHO Member States.3% (95% CI: 6.7% in 2014 GLOBAL TUBERCULOSIS REPORT 2017 47 . There were about 240 000 3.22). with cases increase as a proportion of all TB cases in these countries. 3. nine have cases that had XDR-TB. Among these countries. 140 000–340 000) deaths from MDR/RR-TB in 2016. For these settings.3. that could be detected if all notified patients were tested Among all TB cases. 9.20 and the number of new TB cases notified.21. cases with MDR. respectively. 91 countries and five Of the 40 countries with a high TB or MDR-TB burden (or territories reported representative data from continuous both). Peru.4 Resistance to isoniazid and to second-line (range. 17).1–8. only 22 have repeated a survey at least once to evaluate surveillance or surveys regarding the proportion of MDR-TB trends in drug resistance. The proportions of TB patients resistant to of drug resistance among TB patients also allow estimation isoniazid but susceptible to rifampicin in each country were of the number of MDR/RR-TB cases among notified TB weighted according to the number of new TB cases that patients with pulmonary TB. and per capita TB and MDR-TB rates. for countries with at least 1000 incident cases Russian Federation China India Number of incident cases 1 000 10 000 100 000 150 000 MDR/RR-TB at the country level are shown in Fig.5). India and the Russian Federation (Fig. 3. proportion of MDR-TB cases with XDR-TB was 6. Of these. Russian Federation. there were 7. 330 000–370 000) MDR/RR-TB averages were 7. without concurrent rifampicin resistance was 8. XDR-TB had been reported by 3.5%). anti-TB drugs similar to the best estimate for 2015 that was published in the Levels of resistance to isoniazid without concurrent rifampicin 2016 edition of the WHO global TB report. the global average of isoniazid resistance for drug resistance to rifampicin and isoniazid using WHO. Fig. Ukraine 3. Globally in 2016. Based There were an estimated 600 000 (range.3.6) and 14% (95% CI: 12– cases among notified TB patients.7).

01 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 and 9.01 0.23 Trends in levels of drug resistance in selected high MDR-TB burden countries with at least three years of data. Belarus Kazakhstan Myanmar 1000 1000 1000 5% per year -6% per year 100 -8% per year 100 100 10 10 10 -2% per year -6% per year 8% per year 1 1 1 0.2 In an important subset of countries with a large proportion of the world’s TB burden.1 Furthermore.0% in 2013).01 TB and MDR-TB cases per 100 000 population (log scale) 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 Peru Republic of Moldova Russian Federation 1000 1000 1000 -3% per year -5% per year -6% per year 100 100 100 10 10 -1% per year 10 2% per year 1 1% per year 1 1 0.01 0.01 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 Thailand Ukraine Viet Nam 1000 1000 1000 3% per year -11% per year 0% per year 100 100 100 10 10 10 -1% per year 1 1 1 4% per year 5% per year 0. because they are derived from incidence and drugs. This decrease is explained by the use of a 3. to any fluoroquinolone for which testing was done – including indirect estimates of TB prevalence (i.1 0.01 0. The blue line shows the number of new notified MDR-TB cases per 100 000 population. These can be provided upon request to tbdata@who.1 0. 3. target has been set for the period 2016–2035. levofloxacin and moxifloxacin – was 20% (95% CI: from a national TB prevalence survey) are not presented in 14–26%).1 0.01 0.1 0.1 0.1 0. FIG. Among the 40 countries with a high TB or MDR-TB burden. For these two reasons. estimates that are not ofloxacin. and no global drug resistance among MDR/RR-TB cases.int.1 0. when one of the global targets for reductions in TB disease burden was to halve prevalence between 1990 and 2015.4 National TB prevalence surveys larger quantity of routine surveillance data and more precise The prevalence of TB disease is not an indicator in the SDGs country-specific measures of the prevalence of second-line or a high-level indicator of the End TB Strategy. 48 GLOBAL TUBERCULOSIS REPORT 2017 . national TB prevalence 1 This is in contrast to the era of the Millennium Development Goals (MDGs) and Stop TB Strategy.1 0.01 0. 2 WHO will continue to produce indirect estimates of TB prevalence. this chapter. The proportion of MDR-TB/RR-TB cases with resistance assumptions about disease duration. indirect estimates of prevalence suffer from considerable 22 have surveillance data on resistance to second-line anti-TB uncertainty. however.e.1 0.01 0. The red line shows the number of MDR-TB cases among new TB patients per 100 000 population.

a total of b These surveys have started or field operations are scheduled to start in 2017.2). 3. In 2016. health services among men are required. 3.int/tb/advisory_bodies/impact_measurement_taskforce/ accessing available diagnostic and treatment services more meetings/tf6_report. Geneva: WHO. had narrower uncer. The WHO Global Task Force on TB 2001 Impact Measurement has retained national TB prevalence 2002 Cambodia surveys within its strategic areas of work 2016–2020 2003 Malaysia (Box 3. work (Box 3. conducting a survey were defined for two groups of countries: those that with ratios ranging from 1. Malawi. 3. There were 24 countries in the first group and 33 in the second group.5 (in Viet Nam) implemented a survey in 2009–2015 and in which a repeat survey could be for bacteriologically confirmed TB. thus contributing to monitoring of progress towards SDG and 2000 China End TB Strategy targets. estimates were within the to female (M:F) ratio of cases for the same set of surveys shows 1 In the Task Force’s April 2016 meeting. the prerequisites for conducting a survey defined in the WHO to compare detection and reporting gaps (Fig.int/tb/ advisory_bodies/impact_measurement_taskforce/resources_documents/ suggests that strategies to improve access to and use of thelimebook/.2 (in Ethiopia) to 4. However. prevalence per 100  000 were almost always more precise (i. whereas for the other seven in Asian countries (of which two were in the Philippines) and countries the survey found a burden that was either signifi- 12 in African countries. Uganda and Zambia). surveys were completed in cantly above (six countries) or below (one country) the burden Bangladesh. An unprecedented 2017 Mozambiqueb South Africab Myanmarb Namibiab Viet Namb number of surveys were implemented in 2007–2015. Between 2007 and the end of 2016. The ratio of prevalence to notifications (P:N) can be used In particular.17). national notification and VR systems 2007 Philippines Viet Nam of the quality and coverage required to provide reliable and 2008 Bangladesh a routine direct measurements of the number of TB cases and 2009 Myanmar deaths. Mozambique.g. This included 13 surveys pre-survey uncertainty interval. and the Philippines.who. Switzerland.surveys continue to provide the best method for measuring FIG. including in India. the 25 surveys in Fig. 3.6). In Asia and some African countries (e. the Democratic People’s Republic of Korea.1). Post-survey prevalence estimates Sudan. it was emphasized that feasibility criteria must also be considered. surveys of the prevalence of TB disease. For 18 countries. The surveys in Myanmar and Viet Fig. Tuberculosis prevalence surveys: a handbook combined with larger gaps in detection and reporting.1). actual Findings can inform assessment of actions needed to reduce (2000–2017) and expected (2018) this burden as well as estimates of TB incidence (Fig. A further 10 surveys will be implemented The distribution of TB disease by age (in adults) and sex in 2017 or 2018. accessed 11 September 2017).25. the United Republic of Tanzania and A comparison of estimates of TB prevalence before and Zimbabwe). and those that have never conducted a survey. and defined the group of countries where they 2004 Indonesia continue to be relevant as those with a relatively high burden 2005 Eritreaa of TB (about 150 incident cases per 100 000 population) that 2006 Thailand do not yet have health. see World Health Organization Global Task Force on variation in these gaps by sex (Fig. 2015 (http://www.29b).who. The P:N ratios from TB Impact Measurement. GLOBAL TUBERCULOSIS REPORT 2017 49 .27 and South Africa and Viet Nam. 3. 2 World Health Organization. 3. 3.1 An excellent recent example of a prevalence survey 2010 China that has informed understanding of trends in TB disease 2011 Cambodia Ethiopia Lao PDR Pakistan burden. 2011 (www. Nigeria. countries. a 2018 Botswana India Lesotho Nepal Swaziland period in which the WHO Global Task Force on TB Impact Measurement defined national TB prevalence surveys in 22 a The surveys in Bangladesh (2008) and Eritrea (2005) collected sputum samples global focus countries as one of its three strategic areas of from all individuals (aged ≥15 years). epidemiological criteria for a systematically higher burden of TB disease among men. Gambia. surveys implemented in 2007–2016 suggest that women are 19–21 April 2016. Ghana. 25 surveys that used the screening and diagnostic methods recommended in the second edition of the WHO handbook on prevalence surveys2 were completed. prevalence increases with age. The male tainty intervals). the ratio considered. In most countries. Kenya that had been estimated in the absence of survey data. population peaks among those aged 35–54 years. and by age and sex). Glion-sur-Montreux.pdf?ua=1.24 the burden of TB disease (both in absolute terms and to assess Global progress in implementing national trends when repeat surveys are done. 2014 Indonesia Zambia Zimbabwe Countries in which national prevalence surveys were 2015 Bangladesh Kenya Mongolia Uganda implemented in 2000–2016 or are planned for 2017–2018 2016 DPR Korea Philippines are shown in Fig. and did not use chest X-ray and/or a symptom questionnaire to screen individuals for sputum submission.26. The higher disease burden in men. 3. also (WHO/HTM/TB/2010. estimates of TB incidence and identification of actions 2012 Gambia Nigeria Rwanda UR Tanzania Thailand required to reduce the burden of TB disease is the 2016 survey 2013 Malawi Ghana Sudan in the Philippines (Box 3. in after the implementation of a national survey is shown for several African countries (e. For further details.29a) and handbook on national TB prevalence surveys (see next footnote) should be met. effectively than men. 3.24 and Fig.e. Rwanda. For any of these 57 was in the range 2–4. Geneva: WHO. based on prevalence survey data is shown in Fig. Ethiopia. Report of the sixth meeting of the full Task Force.28. Nam are repeat surveys.g. Myanmar. accessed 24 August 2017).

and was particularly high in the 15–24 year age 13 517 (29%) screened positive for TB by both screening group. Department of Health and the Philippine as non-participation and other missing data.b Of these. Of the 466 Methods cases. It (87%) submitted at least one sputum specimen. taking into account clustered sampling. as well Programme.3).1 (Fig. n The 2016 national TB prevalence survey in the Philippines: results and BOX 3. culture (Ogawa solid media) and bacteriologically confirmed TB. Of all participants.2). B3. B3. international recommendations of the WHO Global Task Force on TB Impact Measurement (Box 3.a higher among men than women: 673 (95% CI: 528−819) A total of 89 663 people of all ages were enumerated per 100 000 population compared with 205 (95% CI: during the survey. There were 2615 (5.1). in the lung consistent with TB – were asked to submit TB prevalence per 100 000 population aged 15 years two sputum specimens (one spot and one early morning). 80 Of the 2815 participants. only 534 (19%) consulted a health-care worker. private and sex clinics or hospitals (7.3%) had screening symptoms of at least 2 weeks cough or haemoptysis. A further 5080 participants who were A total of 170 survey participants (0. following surveys in 1981–1983. 16 242 2016.6 lessons learned n The fourth national survey of the prevalence of TB disease asked to submit sputum samples (Fig.6. rate for smear-positive TB cases in 2016 (142 per 100 000 Participation was higher for females (82%) than males population) in the same age group gave a P:N ratio of (70%) (Fig. culture- positive TB or Xpert MTB/RIF.6. Among the in the Philippines was conducted from March to December 18 597 participants eligible for sputum collection.6. with more females (23%) seeking a Male consultation compared with males (16%). B3. or both) among the general A total of 466 bacteriologically confirmed pulmonary TB population aged 15 years or more. Prevalence was highest in the 45−54 defined as having spent at least the past 2 weeks in the year age group (Fig. 60 15–24 25–34 35–44 45–54 55–64 ≥65 Of the 466 bacteriologically confirmed TB cases identified Age group (years) in the survey.6%) survey 100 participants who reported a past history of TB treatment (1595 men and 1020 women).c Council for Health Research and Development. under the National TB Control prevalence. women. Female Participation rate (%) 90 A total of 2815 (6%) survey participants reported the presence of screening symptoms at the time of interview. cases were found in the survey. Of the 173 smear-positive TB cases. Most of these people reported taking or FIG. 159 (34%) were diagnosed by Xpert MTB/RIF and culture. 1997 and 2007. 61 466 (69%) were and 1713 (95% CI: 1482−1943) compared with 627 (95% eligible and invited to participate in the survey based CI: 516−739) per 100 000 population for bacteriologically on age (≥15 years) and residency status. However. B3. methods. 238 (51%) were diagnosed by Xpert MTB/RIF only. and men more than women) and 1130 (40%) self-medicated (predominantly women). Participants with positive on chest X-ray. and provincial hospitals or public medical centres (1. or more was estimated as 434 (95% CI: 350−518) for These were examined by direct light-emitting diode smear-positive TB.e.4%) reported being asymptomatic but did not have a chest X-ray were also on TB treatment at the time of the survey (111 men and 59 women). 150 (32. which covered 106 randomly selected 141−270) per 100 000 population for smear-positive TB. The average number of participants 3. or both. The main survey objective was to estimate the prevalence of Main results pulmonary TB (bacteriologically confirmed. Survey design and overall methods followed the and 69 (15%) were diagnosed by culture only. 1143 (41%) took 70 no action (younger more so than older participants.6.4). the time in the past month. Residents were confirmed TB. ➜ 50 GLOBAL TUBERCULOSIS REPORT 2017 . The P:N ratio was higher in men than per cluster was 440 (range 149−576). 46 689 people (76%) participants aged 15 years or more to the case notification participated in the survey’s cluster operations. clusters across four strata. and 1159 (95% CI: 1016−1301) for (LED-FM) microscopy.1).6%). and 430 (92%) screened and by digital chest X-ray examination. Prevalence was much Xpert MTB/RIF in one of six laboratories.8%). B3. 150 (32%) participants were screened for symptoms by interview reported screening symptoms. of whom 173 had smear- positive TB and 293 had smear-negative TB. There was no statistically cluster or having slept in the household more than 50% of significant variation between the four geographical strata. All survey Of the 466 bacteriologically confirmed cases. i. Comparing the prevalence of smear-positive TB among Of those who were eligible. followed by private pharmacies (12%). any of the following – cough of at least 2 weeks and/or 88 (51%) reported screening symptoms and 159 (92%) haemoptysis (screening symptoms) or radiological lesion(s) screened positive on chest X-ray.6. was implemented by the Foundation for the Advancement Best-practice analytical methods were used to estimate TB of Clinical Epidemiology.1 obtaining treatment in local health centres or in TB clinics Survey participation rate by age group (77%).

9%) Xpert MTB/RIF only 238 (51%) Culture MTB only 69 (15%) Xpert MTB/RIF and culture 159 (34%) a Symptom screening negative but chest X-ray exempted.8%) Symptom negative. chest X-ray positive 298 (64%) Smear-positive TB cases 173 (37%) Othersa 18 (3. chest X-ray negative or N/A 1 457 (7.4%) Total 2 815 Chest X-ray screening Suspicious for TB 12 146 (29%) Not suspicious for TB 29 297 (71%) Total chest X-ray taken 41 443 Eligible for sputum examination 18 597 (40%) Symptom positive. chest X-ray negative or N/A 18 (3.6.2%) 61 466 (69%) Total participants 46 689 (76%) Symptom screening Cough ≥2 weeks only 2 250 (80%) Haemoptysis only 357 (13%) Cough ≥2 weeks & haemoptysis 208 (7. B3.3%) Symptom positive.9%) Any Xpert MTB/RIF positive 397 (83%) Any culture MTB positive 232 (48%) Central panel review for final confirmation and classification of survey cases Total bacteriologically confirmed TB cases Symptom positive.9%) Eligible study population Missing data 65 (0. chest X-ray positive 1 358 (7. GLOBAL TUBERCULOSIS REPORT 2017 51 .8%) Symptom negative. FIG. chest X-ray positive 132 (28%) 466 Symptom positive.9%) Smear-negative TB cases 289 (63%) Smear not done TB cases 4 (0.2 Consort diagram of the 2016 national TB prevalence survey in the Philippines Individuals enumerated in census 89 663 Ineligible individual 28 197 (31%) Children <15 years 27 885 (99%) Ineligible of residential criteria 247 (0.7%) Laboratory results Total available 16 241 (99. chest X-ray positive 10 702 (56%) Othersa 5 080 (27%) Submitted specimens At least one specimen 16 242 (87%) Both specimens 15 547 (84%) Only one specimen 695 (3.

≥15 years. but rather to obtain a combination of case-detection gaps. 4. Adjustments were made to ensure that the two data sets and with 25% of people living below the national poverty line in 2012. and broader social and 2016 survey was therefore not powered to detect small differences economic influences on the TB epidemic. The in diagnosis. 95% CI: electronic case-based management systems. 52 GLOBAL TUBERCULOSIS REPORT 2017 . with a prevalence of 14% an assessment of the trend in TB disease burden since 2007. Replace smear microscopy with a rapid point-of-care diagnostic upwards (see also Box 3. There were 56 (37%) people who self-medicated all forms of TB. the elderly. with adjustment of the 2007 survey results to account for the more coverage of only 4% in the poorest quintile in 2013. possibly significant delays an estimate of prevalence in 2016 with a specified precision. in all DOTS facilities and enhance the survey was 554 (311–866) per 100 000 population. it is estimated that there are about 1 million people and 51 (34%) who did not take any action at the time they in the Philippines with TB disease.6. Task Force on TB Impact Measurement agreed on a standard including 4Ps members (these are beneficiaries of a conditional recommendation for diagnostic and screening practices in surveys. resulting in an upward and low coverage of health insurance and social protection. methods were as comparable as possible. the level of poverty. partners have defined eight strategic actions at the local level under the general approach of “REACH.1% 2007 and 512 per 100 000 population (95% CI: 420−603) in 2016. The probability that prevalence did not decline over the period In response to the high estimate of TB prevalence. this limitation did not prevent include the level of undernourishment.7–19).e 100 000 population in 2016. Implement chest X-ray screening among high-risk groups. compared sputum delivery mechanism at all levels. Although it is not surprising that and smokers). Undertake intensive supervision and monitoring based on of culture-confirmed TB alone was high (587 per 100 000.2). with the pre-survey WHO estimate (which had assumed a decline 2. the prevalence of culture. inmates. Notwithstanding the limitation of a 76% participation rate. Based on these adjustments. B3. The service delivery network and human resources and by enforcing estimated mortality rate based on the survey was 21 (21–22) per the policy of mandatory TB case notification.d with both revised 1. The estimate of TB incidence after test. The sample size in 2016 was not designed to detect a specified The lack of decline in TB prevalence since 2007 can be explained by effect size in comparison with the 2007 survey. indigenous populations. The Philippines is thus facing one of the highest burdens with 33 (75%) consulting a public provider and 10 (23%) going to a of TB in the world. an improved Phil Health TB package and social protection. the prevalence 6. and has a limited impact on the size of the TB epidemic. people with diabetes bacteriologically-confirmed TB. leading to sensitive screening and diagnostic methods used in the 2016 financial barriers to accessing health services and high levels of survey. 488−687). ≥15 years. Nonetheless. Improve the availability of patient-centred health facilities providing quality services through a revised certification Programmatic implications programme. out-of-pocket expenditures on health care (34% in 2014). survey results are of high quality and have provided a robust and up-to. the NTP and 2007–2016 was estimated at 75%. Increase engagement of private providers by expanding the TB in incidence since 2007) of 322 per 100 000 (95% CI 277–370). These broader influences with the 2007 survey. The positive TB was 463 per 100 000 population (95% CI: 333−592) in prevalence of HIV in the general population remains below 0.” These Updated estimates of TB disease burden are: Results from the 2016 prevalence survey were used to update estimates of TB incidence and mortality. 3. when the WHO Global 5.6. health system weaknesses. community health-care seeking behaviour. all prevalent cases globally. FIG. in 2015 and no improvement since 2008. Of the 23 surveys implemented since 2009. B3. such as Xpert MTB/RIF.3 FIG.4 Prevalence of smear and bacteriologically Ratio of prevalence to notificationa confirmed pulmonary TB 5 2500 Prevalence per 100 000 population Bacteriologically confirmed 4 Smear-positive 2000 P:N ratio (years) 3 1500 2 1000 1 500 0 0 15–24 25–34 35–44 45–54 ≥65 Female Male Total 15–24 25–34 35–44 45–45 55–64 ≥65 a Prevalence is for bacteriologically confirmed smear-positive TB cases. compared to a pre-survey estimate of 13 (8.  use of Xpert MTB/RIF increased the diagnostic yield. the survey in the Philippines found the highest prevalence of contacts. ➜  only 44 (29%) of these people consulted a health-care worker. CURE and PROTECT. which is equivalent to 1 in 15 of experienced the symptoms. Use integrated communication strategies to influence date measurement of the burden of TB disease in the Philippines. Notifications are for all pulmonary smear-positive TB in Age group (years) 2016. cash transfer programme for maternal child health. When prevalence is extrapolated to all ages and private provider.

c Countries were implementing field operations in August 2017 or were undertaking data cleaning and analysis. GLOBAL TUBERCULOSIS REPORT 2017 53 . Lagahid J. appendix. still needs to be effectively implemented. Recent surveys completed in Bangladesh. b A country has submitted at least a draft survey protocol and a budget plan to the WHO Global Task Force on TB Impact Measurement. Region 3 and 4A.gov/ pubmed/24074436.10(1):10 (https://www. linked to stakeholders to address social determinants. and reducing the percentage of TB patients and their Floyd S. accessed 11 September 2017). only greater investment to find and cure TB cases but also FIG. Region 2 TB Reference Laboratory.nih. from December 2016 to July 2017. Davao TB Reference Laboratory. and mortality is indirectly estimated from prevalence using of the health sector with deployment of sufficient human resources CFRs estimated from VR data. 10767). 3.nlm. It is anticipated that the eight strategic actions can be implemented d Incidence is indirectly estimated from prevalence using plausible distributions with the full support of the Department of Health. Sismanidis C. establishment http://www. Daniel R. e A repeat national survey is one in which participants were screened with chest X-ray. and Northern Mindanao TB Reference The main priorities are protecting those who are financially Laboratory. Philippine Strategy.25 Countries in which national population-based surveys of the prevalence of TB disease have been implemented using currently recommended screening and diagnostic methodsa since 2000 or are planned in the future (status in August 2017) No survey planned Survey planned Repeat survey plannedb Survey ongoingc One survey completedd ≥1 repeat survey completede Not applicable a Screening methods include field chest X-ray. for more than 90% of the poor through increased coverage of Phil f The NTP implemented a survey of costs faced by TB patients and their households Health and expanded social protection programmes. Analysis of tuberculosis prevalence surveys: new guidance on best-practice methods. Stratum 3: Visayas. Stratum 2: the rest of insurance coverage. the SDGs and multisectoral partnerships at the national and local levels. e Mandatory notification of TB cases (Republic Act No. Ensure the governance and sustainable funding of local governance units to support implementation of the End TB a National TB Reference Laboratory. c have it. Kenya and the Philippines used both culture and Xpert MTB/RIF to confirm diagnosis. d A survey was conducted in accordance with WHO recommendations as outlined in Tuberculosis prevalence surveys: a handbook (2011) and at least a preliminary report has been published. ending TB will require not to TB. rising to 67% for those with drug-resistant TB. 2013. increased domestic funding. Medical Research Laboratory. and Stratum 4: Mindanao. Preliminary results indicate that 35% of TB- affected households spent at least 20% of their household income on costs related At the most fundamental level. vulnerable to TB through expanded social insurance and health b Stratum 1: the National Capital Region.ncbi. preventing TB among those who do not yet Luzon. 8. which is available at a presidential executive order for drug regulation.7. Network with other government agencies and other key comprehensive and sustained poverty alleviation efforts. enacted in April of a high-level steering group.int/tb/publications/global_report/en/.f Emerg Themes Epidemiol.who. at least culture was used to confirm diagnosis. full mobilization of disease duration. General Hospital. Yamada N. and (at least) culture was used to diagnose TB cases. and ensuring financial protection 2016. Cebu TB Reference Laboratory. Other details are provided in the online technical at national and subnational levels. households facing catastrophic costs as a result of TB to zero. Mecatti F et al.

FIG. Data are not shown for UR Tanzania because laboratory challenges during the survey meant that it was only possible to directly estimate the prevalence of smear-positive (as opposed to bacteriologically confirmed) TB. Africa Asia UR Tanzania Philippinesa Malawi Lao PDR Ghana Indonesia Mongolia Kenya Cambodia Nigeria Philippinesb Zambia Thailand Uganda China Rwanda Pakistan Sudan Myanmar Zimbabwe DPR Korea Ethiopia Viet Nam Gambia Bangladeshc 25 50 100 200 500 1000 25 50 100 200 500 1000 Prevalence per 100 000 population (log scale) a These data relate to the repeat prevalence survey conducted in 2016. c These data relate to the prevalence survey conducted in 2015−2016. FIG. Data in the presented age groups were not available for Gambia and Rwanda. b These data relate to the prevalence survey conducted in 2007. 54 GLOBAL TUBERCULOSIS REPORT 2017 . before (in blue) and after (in red) results from national TB prevalence surveys became available since 2007. Panels are ordered according to the before-after difference. c These data relate to the repeat prevalence survey conducted in 2016.27 Age-specific prevalence rate ratio of bacteriologically confirmed TB in surveys implemented 2007–2016a Africa Asia 25 25 Cambodia Lao PDR Myanmar Malawi Viet Nam 10 10 Bangladesh China Sudan Pakistan Prevalence ratio 5 Ghana 5 Indonesia Zimbabwe Philippinesb Zambia Uganda DPR Korea Nigeria Thailand Philippinesc Kenya Mongolia 1 1 Ethiopia 15–24 25–34 35–44 45–54 55–64 ≥65 15–24 25–34 35–44 45–54 55–64 ≥65 Age group (years) Age group (years) a Age-specific prevalence ratios were calculated using the prevalence of the 15–24 year age group as the baseline. 3. all forms of TB) for 25 countries. b These data relate to the prevalence survey conducted in 2007. 3.26 Estimates of TB prevalence (all ages.

Seddon JA.com/science/ article/pii/S2214109X17302899?via%3Dihub.sciencedirect. and variation in HIV prevalence by age and sex.5. Gardiner E. Estimates of TB incidence Myanmar in adults were derived by first subtracting incidence in children Kenya from incidence in all ages. The estimate for adults was then DPR Korea disaggregated into six age groups (15–24. Jenkins HE. Yuen CM. a CFR was applied to the adult These data relate to the prevalence survey conducted in 2015−2016. GLOBAL TUBERCULOSIS REPORT 2017 55 . The global burden of tuberculosis mortality in children: a mathematical modelling study.4). accessed 11 September 2017).5(9):e898-e906 (http://www.com/science/article/ pii/S2214109X14702451?via%3Dihub. Lancet Glob Health. age. 55–64 and ≥65 years) using data from national TB Indonesia prevalence surveys implemented in 2007–2016 (Section 3. Switzerland. Pérez-Vélez CM et al.2 Thailand followed by disaggregation by sex using results from a meta- Philippinesd analysis of the M:F notification ratio. 35–44. Yuen CM.int/tb/publications/global_report/en/. The Lancet. If available. Pakistan this disaggregation was based on regional M:F ratios from a Ghana systematic review and meta-analysis.28 3. Tolman AW. Geneva: WHO. 2017.5 1 Jenkins HE. Viet Nam 3. Seddon JA. 55–64 and ≥65 A value is not shown for UR Tanzania because laboratory challenges during the survey meant that it was only possible to directly estimate the prevalence of years) using VR data.FIG. Sex ratio (male:female) data on TB deaths among adults were disaggregated for six a age groups (15–24. whereas for other countries the Sudan age distribution was predicted using prevalence survey data. Sismanidis C.4 and then by sex.sciencedirect.2 Results for the 0–14 age group (0–4 and Mongolia 5–14 years) in each country were then further disaggregated Philippinesc using outputs from an established deterministic model. Keshavjee S. Lao PDR 45–54.5 Estimates of TB incidence and mortality The male to female ratio of bacteriologically disaggregated by age and sex confirmed adult TB cases detected in prevalence This section presents estimates of TB incidence and TB mor- surveys implemented 2007−2016a tality disaggregated by age and sex.who. For other countries. 35–44.com/science/article/pii/ S0140673614601951?via%3Dihub. 2014. accessed 24 August 2017). Nigeria Country-specific distributions were used for countries that Cambodia had implemented a survey. 5 The online technical appendix is available at http://www. Parr JB. were not based on VR data. 4 Dodd PJ. c These data relate to the repeat prevalence survey conducted in 2016. on the assumption that 1 2 3 4 5 the pattern was the same as that for incidence. Report of the sixth meeting of the full task force. Glion-sur-Montreux. 25–34.int/ tb/advisory_bodies/impact_measurement_taskforce/meetings/tf6_report. Coghlan R. Details of the methods used are provided in the online technical appendix. pdf?ua=1.3 Zimbabwe TB mortality in children was estimated for the two age Ethiopia groups using a previously published approach derived from dynamic modelling. 25–34. 19–21 April 2016. Zambia Disaggregation by sex was based on actual M:F ratios for Malawi countries that had implemented surveys. 3 World Health Organization Global Task Force on TB Impact Measurement. 45–54. accessed 11 September 2017).1 Methods to disaggregate estimates by age Uganda and sex Rwanda Estimates of TB incidence in children (aged under 15 years) Bangladeshb were based on case notifications adjusted for underdiagnosis Gambia and underreporting1 combined with estimates derived from China dynamic modelling. Lancet Glob Health. 2015 (http://www. For countries whose mortality estimates b smear−positive (as opposed to bacteriologically confirmed) TB. This CFR accounted for d These data relate to the prevalence survey conducted in 2007.sciencedirect. 2 Dodd PJ. Burden of childhood tuberculosis in 22 high-burden countries: a mathematical modelling study.383(9928):1572–1579 (http://www.2(8):e453-459 (http://www.and sex-disaggregated incidence. Incidence of multidrug-resistant tuberculosis disease in children: systematic review and global estimates. accessed 24 August 2017). 3. 2014. differences between HIV-positive and HIV-negative TB cases.who.

d These data relate to the prevalence survey conducted in 2007.29A FIG. 3. b These data relate to the repeat prevalence survey conducted in 2016.24). 3. c These data relate to the prevalence survey conducted in 2015−2016.29B The prevalence to notification (P:N) ratio The prevalence to notification (P:N) ratio of adult TB cases in prevalence surveys by sex for adult TB cases in prevalence surveys implemented 2007−2016a implemented 2007−2016a Nigeria Nigeria Sudan Sudan Lao PDR Lao PDR Kenya Kenya Philippines b Philippinesb UR Tanzania UR Tanzania Pakistan Pakistan Uganda Uganda Bangladesh c Bangladeshc Zimbabwe Zimbabwe Mongolia Mongolia Malawi Malawi Ghana Ghana Viet Nam Viet Nam Indonesia Indonesia Myanmar Myanmar Zambia Zambia DPR Korea DPR Korea Philippinesd Philippinesd Thailand Thailand China China Cambodia Cambodia Rwanda Rwanda female Ethiopia Ethiopia male Gambia Gambia 1 2 3 4 5 6 2 4 6 P:N ratio (years) P:N ratio (years) a The P:N ratio is for smear−positive TB. Prevalence estimates are from a cross-sectional survey. Notification data are from the main year of the survey (shown in Fig. 3. 56 GLOBAL TUBERCULOSIS REPORT 2017 . FIG. except for Uganda and Zimbabwe where it is based on bacteriologically confirmed TB. and therefore only represent one point in time.

2 million to 5. male in green).31 Regional estimates of TB incidence (black line) and case notifications disaggregated by age and sex (female in red.30 (global). 3. male in green). 3. These numbers correspond to 65% of cases 15–24 being males and 35% females. 3.0  million to ≥65 9. Most of the estimated cases among males in 2016 were in Asia (64%) and the WHO African Region (24%). 340 000–760 000) were children.1 The M:F ratio of incident TB cases for all ages ranged 0–4 from 1.7 million to 8.1 in the WHO Western Pacific Region.2 million) incident cases of 35–44 TB in females. Globally in 2016.5. 300 000–680 000) 25–34 were children. 2016 Africa The Americas Eastern Mediterranean ≥65 55–64 Age group (years) 45–54 35–44 25–34 15–24 5–14 0–4 200 000 0 200 000 10 000 0 10 000 20 000 40 000 0 40 000 Europe South-East Asia Western Pacific ≥65 55–64 45–54 Age group (years) 35–44 25–34 15–24 5–14 0–4 20 000 0 20 000 40 000 200 000 0 200 000 400 000 100 000 0 100 000 200 000 Number of TB cases Number of TB cases Number of TB cases 1 Further breakdowns by HIV status are not possible.2 TB incidence disaggregated by age and sex FIG.30 Estimates of TB incidence disaggregated by age and sex are Global estimates of TB incidence (black line) and shown in Fig.4 million) incident cases of TB among males. 3. whereas for children the M:F ratio was Number of TB cases close to 1. 3. 3.2 million (range. and 90% of cases being adults 5–14 and 10% children. (female in red.7 million (range. whereas for females the percentages were 59% FIG.2 million (range.5 million) were adults and 490 000 (range.7 million (range. 2. of which 6. Similar M:F ratios were 400 000 0 400 000 800 000 1 200 000 estimated for adults. of which 3.31 (WHO regions) and case notifications disaggregated by age and sex Fig.32 (30 high TB burden countries). 3. GLOBAL TUBERCULOSIS REPORT 2017 57 . 1.9 million to 4.1 in all WHO regions. because data on the HIV status of TB cases by age and sex are not available. 2016 there were an estimated 6. There were 45–54 Age group (years) 3. Fig.3 in the WHO Eastern Mediterranean Region to 2. 4.6 million) were adults and 55–64 550 000 (range.

32 Estimates of TB incidence (black line) and case notifications disaggregated by age and sex (female in red. FIG. in the 30 high TB burden countries Angola Bangladesh Brazil Cambodia Central African Republic ≥65 55–64 45–54 35–44 25–34 15–24 5–14 0–4 10 000 0 10 000 20 000 0 20 000 40 000 5 000 0 5 000 10 000 5 000 2 500 0 2 500 5 000 1 000 0 1 000 2 000 China Congo DPR Korea DR Congo Ethiopia ≥65 55–64 45–54 35–44 25–34 15–24 5–14 0–4 50 000 0 50 000 100 000 1 000 0 1 000 2 000 10 000 0 10 000 20 000 0 20 000 20 000 10 000 0 10 000 20 000 India Indonesia Kenya Lesotho Liberia ≥65 55–64 45–54 35–44 25–34 15–24 5–14 Age group (years) 0–4 200 000 100 000 0 100 000 200 000 300 000 50 000 0 50 000 100 000 10 000 0 10 000 20 000 30 000 1 000 0 1 000 2 000 1 000 0 1 000 2 000 3 000 Mozambiquea Myanmar Namibia Nigeria Pakistan ≥65 55–64 45–54 35–44 25–34 15–24 5–14 0–4 10 000 0 10 000 20 000 10 000 0 10 000 20 000 1 000 0 1 000 20 000 0 20 000 40 000 60 000 30 000 0 30 000 60 000 Papua New Guinea Philippines Russian Federationb Sierra Leone South Africa ≥65 55–64 45–54 35–44 25–34 15–24 5–14 0–4 2 000 0 2 000 4 000 25 000 0 25 000 50 000 75 000 0 10 000 20 000 2 000 0 2 000 40 000 20 000 0 20 000 40 000 Thailand UR Tanzania Viet Nam Zambia Zimbabwe ≥65 55–64 45–54 35–44 25–34 15–24 5–14 0–4 0 10 000 10 000 0 10 000 20 000 30 000 0 10 000 20 000 5 000 0 5 000 10 000 4 000 2 000 0 2 000 4 000 Number of TB cases a No age and sex disaggregated case notifications were available for Mozambique. male in green).5. 2016. b For an explanation of why notifications are assumed to be equivalent to TB incidence in the Russian Federation. 3. 58 GLOBAL TUBERCULOSIS REPORT 2017 . see Box 3.

2016a Africa The Americas Eastern Mediterranean 0–4 5–14 15–24 Age group (years) 25–34 35–44 45–54 55–64 ≥65 Europe South-East Asia Western Pacific 0–4 5–14 15–24 25–34 Age group (years) 35–44 45–54 55–64 ≥65 a The total area represents TB mortality and all rectangles are proportional to their share of total TB mortality by region. These numbers correspond to 55% of FIG. 60 000– a The total area represents global TB mortality and all rectangles are proportional to their share of total TB mortality.3 TB mortality disaggregated by age and sex 5–14 Estimates of TB mortality disaggregated by age and sex 15–24 are shown in Fig.6. 3. 3.5. Global 0–4 3. 2016a African Region with 30% and the WHO Western Pacific Region with 20%. For children. and in Table 3. followed by the WHO (female in red. 3.34 Regional distribution of TB mortality in HIV-negative people by age group and sex (female in red. male in green). FIG. 308 000–454 000) deaths from TB among HIV-negative women and 91 000 (range.33 (global).33 for Asia and 27% for the WHO African Region. GLOBAL TUBERCULOSIS REPORT 2017 59 . 75 000–151 000) among boys. given that the cause of TB deaths among HIV-positive people is classified as HIV in ICD-10 (see also 35–44 Section 3. male in green). TB mortality among HIV-negative people 45–54 Globally in 2016.35 (30 high TB burden countries). There were ≥65 an additional 378 000 (range. 3. Global distribution of TB mortality in the top three regions were the WHO South-East Asia Region HIV-negative people by age group and sex with 35% of incident TB cases in 2015. Fig.2). there were an estimated 718  000 (range.34 (WHO regions) and Fig. 129 000) among girls. 55–64 619 000–824 000) deaths from TB among HIV-negative men and 110 000 (range. 3. Estimates are shown for HIV-positive and HIV-negative 25–34 Age group (years) people separately.

FIG. 60 GLOBAL TUBERCULOSIS REPORT 2017 . 3. 2016a Angola Bangladesh Brazil Cambodia Central African Republic 0–4 0–4 0–4 0–4 0–4 5–14 5–14 5–14 15–24 15–24 5–14 5–14 15–24 15–24 25–34 15–24 25–34 25–34 25–34 25–34 35–44 35–44 35–44 35–44 45–54 35–44 45–54 45–54 45–54 55–64 45–54 55–64 55–64 55–64 55–64 ≥65 ≥65 ≥65 ≥65 ≥65 China Congo DPR Korea DR Congo Ethiopia 0–4 0–4 0–4 0–4 5–14 5–14 0–4 5–14 15–24 5–14 15–24 15–24 15–24 5–14 25–34 25–34 25–34 25–34 15–24 35–44 25–34 35–44 45–54 35–44 35–44 35–44 45–54 45–54 55–64 45–54 55–64 55–64 45–54 55–64 ≥65 55–64 ≥65 ≥65 ≥65 ≥65 India Indonesia Kenya Lesotho Liberia 0–4 0–4 0–4 0–4 5–14 5–14 0–4 5–14 5–14 15–24 15–24 5–14 15–24 15–24 25–34 25–34 15–24 25–34 25–34 35–44 35–44 35–44 25–34 35–44 45–54 35–44 45–54 45–54 45–54 55–64 45–54 Age group (years) 55–64 55–64 55–64 55–64 ≥65 ≥65 ≥65 ≥65 ≥65 Mozambique Myanmar Namibia Nigeria Pakistan 0–4 0–4 0–4 5–14 0–4 0–4 5–14 5–14 15–24 5–14 5–14 15–24 15–24 15–24 15–24 25–34 25–34 25–34 25–34 25–34 35–44 35–44 35–44 35–44 45–54 35–44 45–54 45–54 55–64 45–54 45–54 55–64 55–64 55–64 55–64 ≥65 ≥65 ≥65 ≥65 ≥65 Papua New Guinea Philippines Russian Federation Sierra Leone South Africa 0–4 0–4 0–4 5–14 0–4 0–4 5–14 15–24 5–14 15–24 5–14 25–34 15–24 5–14 35–44 25–34 25–34 15–24 15–24 45–54 25–34 35–44 25–34 35–44 35–44 55–64 45–54 45–54 35–44 45–54 55–64 45–54 ≥65 55–64 55–64 55–64 ≥65 ≥65 ≥65 ≥65 Thailand UR Tanzania Viet Nam Zambia Zimbabwe 0–4 0–4 0–4 5–14 0–4 5–14 0–4 5–14 15–24 15–24 5–14 15–24 5–14 25–34 15–24 15–24 25–34 25–34 25–34 35–44 25–34 35–44 35–44 45–54 35–44 35–44 45–54 45–54 55–64 55–64 45–54 45–54 55–64 55–64 55–64 ≥65 ≥65 ≥65 ≥65 ≥65 a The total area represents TB mortality and all rectangles are proportional to their share of total TB mortality by country. male in green).35 Distribution of TB mortality in HIV-negative people in the 30 high TB burden countries by age group and sex (female in red.

2 1.5 39 31–49 30 22–38 Europe 26 26–27 2. deaths occurring in men.3 in the WHO Eastern Mediterranean Region to 2.2 1.7 1.76–0.7 Europe 5. The WHO African Region accounted for 86% of these reporting are higher among men (Fig.4 0. 2016a HIV-NEGATIVE TOTAL MALE 0–14 YEARS FEMALE 0–14 YEARS MALE ≥15 YEARS FEMALE ≥15 YEARS BEST UNCERTAINTY BEST UNCERTAINTY BEST UNCERTAINTY BEST UNCERTAINTY BEST UNCERTAINTY WHO REGION ESTIMATE INTERVAL ESTIMATE INTERVAL ESTIMATE INTERVAL ESTIMATE INTERVAL ESTIMATE INTERVAL Africa 417 351–488 32 16–55 27 13–48 231 183–285 126 92–165 The Americas 17 16–18 2. 115 000 (range.0–2.3–24 49 38–62 22 15–31 GLOBAL 1 300 1 160–1 440 110 75–151 91 60–129 718 619–824 378 308–454 HIV-POSITIVE TOTAL MALE 0–14 YEARS FEMALE 0–14 YEARS MALE ≥15 YEARS FEMALE ≥15 YEARS BEST UNCERTAINTY BEST UNCERTAINTY BEST UNCERTAINTY BEST UNCERTAINTY BEST UNCERTAINTY WHO REGION ESTIMATE INTERVAL ESTIMATE INTERVAL ESTIMATE INTERVAL ESTIMATE INTERVAL ESTIMATE INTERVAL Africa 320 272–372 23 20–27 20 17–23 177 151–206 100 85–116 The Americas 6.1 3.1 0.21 0. with the M:F ratio being 1.0 0.3 1.4 16 15–16 5.3–1. They are also consistent with evidence from prevalence 131  000) among HIV-positive women and 52  000 (range.6–6.1–2. and 16% in children.59 0. 3.6 South-East Asia 35 25–46 2.39 0. 179 000–236 000) the estimate that 65% of incident cases were among men in TB deaths among HIV-positive men.6 Eastern Mediterranean 82 69–95 7.2 1.78 0.7 20 15–27 9.3 0.20 1.91–1.8 South-East Asia 652 542–772 48 22–84 39 16–72 375 293–467 191 133–258 Western Pacific 103 85–123 17 9.9–9.0–7.0 2.6–3. 99 000– 2016.4–3.86 0.4 1.1–13.3–3.87–2.5 0.0 0.26 0.36–0.39 0.7–8.7–4.95 2.8–2.5 GLOBAL 374 325–427 28 24–32 24 20–27 207 179–236 115 99–131 a Numbers shown to two significant figures if under 100 and to three significant figures otherwise.62–1.1 3.8.TABLE 3.47 0.2 Western Pacific 5.30–0.5 1.2 5. and that gaps in case detection and 3. which show that TB disease affects men more than 46 000–57 000) among HIV-positive children in 2016 (Table women (Fig.70–1.28).0 1.4–28 14 7.4–2. deaths.8 2. TB mortality among HIV-positive people Higher numbers of TB deaths among men are consistent with There were an estimated 207 000 (range.5 5.1 3.9 4.5 2. 3.9 2.4–2.12–0. The M:F ratio in other regions varied from 1.9 7.57–1.3 7. surveys.7 2.2 0.6).1 1.6 Estimated number of TB deaths (in thousands) by HIV status in children and adults.29b). 29% in women.8–4.4 in the WHO European Region.2 0.93 0. globally and for WHO regions.31 1.9–6.0 3.49 3.48–1. GLOBAL TUBERCULOSIS REPORT 2017 61 .9 1.2–5.4 0.8–11 5.2 2.2 2.4 0.1 0.7–3.15–0.95–1.4 8.6 Eastern Mediterranean 3.9 2.6 2.

Peru CRIS BOURONCLE / GETTY IMAGES .A TB patient passes a health promotion poster about TB in Lima.

6.CHAPTER 4. GLOBAL TUBERCULOSIS REPORT 2017 63 . 153 119 The global male:female (M:F) ratio for notifications cases of multidrug-resistant TB and rifampicin. Globally. In positioning Xpert MTB/RIF as the initial diagnostic 2016. The number of for treatment of MDR/RR-TB. As part of efforts to improve estimated incidence of TB among people living with outcomes for MDR/XDR-TB. 54% for MDR/RR-TB there are major geographical or financial barriers (2014 cohort) and 30% for extensively drug-resistant to accessing care).3 million subset of countries. Of the 48 Despite increases in notifications of TB. 82% of TB patients had a documented The WHO-recommended rapid diagnostic test for HIV test result. 57% of notified TB patients had a Globally. Results from national TB prevalence surveys resistant TB (MDR/RR-TB) were notified in 2016. Diagnosis and treatment: TB.9% of the new and relapse cases that were notified and a 19-fold increase since 2004.7. 78% for and underdiagnosis (especially in countries where HIV-associated TB (2015 cohort). Of these. The number of MDR/RR-TB cases TB (XDR-TB) (2014 cohort). was 1.9 million in 2016. up from 55% in 2015 6. Ten countries n have both been increasing since 2013. African Region. where the burden of HIV-associated TB is highest. in MDR-TB treatment in 2016 and the estimated number of incident MDR/RR-TB cases in 2016. with India. reflecting a mixture of underreporting of detected TB cases The latest treatment outcome data show treatment (especially in countries with large private sectors) success rates of 83% for TB (2015 cohort). Coverage was 33% for new TB patients and 60% for previously treated TB patients. progress in closing detection countries. African Region. HIV-associated TB and drug-resistant TB n Globally in 2016. Indonesia and Nigeria MESSAGES and the notification rate per 100 000 population accounting for almost half of the total. Globally in 2016. mostly accounted for 75% of the gap between enrolments explained by a 37% increase in notifications in India. notification data understate the share of the TB burden accounted for by men in some countries. estimate of the number of incident cases. 39% of the 3. 28 had adopted national algorithms and treatment gaps is slow and big gaps remain. 85% available is the Xpert MTB/RIF® assay. there was a gap of 4.1 million (39%) between test for all people suspected of having pulmonary TB notifications of new and relapse cases and the best by the end of 2016. children (aged <15 years) accounted for documented HIV test result. indicating that 129 689 were enrolled in treatment. A total of 476 774 TB cases among detection of TB and rifampicin resistance currently HIV-positive people were reported and of these. China In 2016. of cartridges procured by countries eligible for concessional prices was 6. Most confirmed and previously treated TB cases notified of the gaps in detection of HIV-positive TB cases and globally were reported to have been tested for provision of ART in 2016 were accounted for by the resistance to rifampicin. and of adults show higher M:F ratios. with high treatment notified HIV-positive TB cases was only 46% of the success rates (87–90%). up from 31% in 2015. 89 countries and HIV. In the WHO in 2016. At least 35 countries in started on treatment in 2016 was only 22% of the Africa and Asia have introduced shorter regimens estimated incidence of MDR/RR-TB.6 million people with tuberculosis From a global perspective. The of the total estimated gap between TB incidence AND global number of new and relapse TB cases notified and notifications. The number were on antiretroviral therapy (ART). closing detection and (TB) were notified to national TB programmes (NTPs) treatment gaps requires progress in a particular KEY and reported to WHO. MDR/RR-TB countries in at least one of the lists of high burden and HIV-associated TB.6 million new bacteriologically and India accounted for 39% of the total gap. Ten countries account for 76% FACTS had an incident episode (new or relapse) of TB. territories had started using bedaquiline and 54 had used delamanid by June 2017. just over 6.

They are burden countries (HBCs).2 Further country-specific details for among the major themes that will be discussed at the WHO all of the indicators covered in this chapter are provided in Global Ministerial Conference on ending TB in the era of the Annex 2 and Annex 4.6 million people with TB were notified to national notifications of TB cases and associated coverage of diagnostic TB programmes (NTPs) and reported to WHO (Table 4. and an additional 300  000 had been previously diagnosed Section 4.  collaborative TB/HIV activities. and  social protection.1 Pillar 1 of the End TB Strategy is “Integrated. poverty alleviation and actions on other determinants of TB. and management of comorbidities.or district-level data have now been stored The latter is only feasible if all people with TB are promptly for a time period of at least 5 years. and patient support. The rifampicin-resistant TB (MDR/RR-TB).2. including drug-resistant TB. and illustrates how such diagnosed and effectively treated. 64 GLOBAL TUBERCULOSIS REPORT 2017 .int/conferences/tb-global-ministerial-conference/en/. prevention – backed by bold policies and supportive systems Throughout the chapter.4 TB deaths set in the End TB Strategy (Chapter 2) require the describes a global initiative to help countries make better use case fatality ratio (the proportion of people with TB who die of subnational data. and providers of public and private care. Sustainable Development Goals (SDGs). prevents deaths outcomes. civil society organizations.2 focuses on treatment coverage (and detection with TB but their treatment was changed to a retreatment and treatment gaps) for patients with TB. which regional. World Health Organization 2 (www. 6.3 provides the most recent data on treatment treatment in line with international standards. TB patients and limits ill-health among people who develop the disease. as well as trends since 2000.1 that was issued by WHO in 2017 is featured in Box 4. and infection control.  treatment of all people with TB.1 TB case notifications and bacteriological compilation. testing.1). summarizes the number of countries for from the disease) to fall to 10% by 2020 and to 6. For an overview of all aspects of the End TB Strategy. close to 6. Pillar 2 of the End TB Strategy is “Bold policies and supportive systems”. The fourth component of Pillar 1 is the topic of Chapter 5. living with HIV and patients with multidrug-resistant TB and It also prevents further transmission of infection to others.1).3 million had a new or relapse (incident) contribution of community engagement and public–public and episode of TB (shown as the total of new and relapse cases).1 Case notifications and testing coverage TB and drug-resistant TB. The components of Pillar 2 are primarily discussed in Chapter 7. safeguarding and use of subnational data. in Chapter 2. and treated with underlying estimates of disease burden. followed by provision of Section 4. confirmation Section 4. which is to be held in New guidance related to the topics covered in this chapter November 2017. Section 4. and vaccination against TB.who. and  preventive treatment of persons at high risk. 1 WHO Global Ministerial Conference. HIV-associated 4. public–private mix (PPM) initiatives to case-finding efforts. Prompt and accurate diagnosis of tuberculosis (TB).  engagement of communities. see Chapter 2. HIV-associated regimen.  UHC policy and regulatory frameworks for case notification. vital registration.5% by 2025. quality and rational use of medicines. This pillar also has four components:  political commitment with adequate resources for TB care and prevention. giving particular attention to high – are Pillars 1 and 2 of the End TB Strategy (Box 4. Patient-centred care and data can be used through a country case study. data are presented at global. for new and relapse TB patients.1 presents and discusses data for 2016 on In 2016. comparing numbers detected n Pillars 1 and 2 of the End TB Strategy BOX 4. and highlights progress in the 4. associated TB and drug-resistant TB. patient-centred care and prevention”. accessed The three lists of HBCs (for TB. as well as global trends 2020 and 2025 milestones for reductions in TB incidence and for these three groups between 2012 and 2015. It has four components: n  early diagnosis of TB including universal drug-susceptibility testing (DST). HIV-associated TB and MDR-TB) are explained 21 August 2017).1. This chapter provides the latest national data reported to WHO on the diagnosis and treatment of TB. Ending tuberculosis in the SDG era: a multisectoral response – November 2017. such as universal health coverage (UHC) and social protection regional and country levels. and systematic screening of contacts and high-risk groups. It includes data on the Of these. HIV. TB and drug-resistant TB.

that is. 4.2.9% of the new and relapse cases that were notified globally.pdf. differential access to or use that facilitates reporting of detected cases by care providers of health-care services. it is recommended that it be ethics and equity is one of the four key principles of phased out. Geneva: treatment of with a 6-month regimen of 2HRZE/4HR WHO.1). or differential reporting practices. notification rates subsequently increased (Fig.4 overall. based on symptoms. Children (aged <15 years) accounted for 6. 2017 (http://apps.pdf. Variation among 2012 and the rollout (also since 2012) of a nationwide web. the TB epidemic is a markedly ageing one. (i.b scheduled for publication in late 2017. culture or WHO-recommended rapid regions. TB remains closely therapy is preferred to thrice weekly dosing. There was an improvement in the WHO men in some countries (see Chapter 3 for further details). This indicates that notification WHO South-East Asia (67% to 61%) and Western Pacific data understate the share of the TB burden accounted for by regions (43% to 38%). The increase since 2013 is were highest among younger adults. then fell slowly until 2013. n New guidelines on ethics in TB and treatment of drug-susceptible BOX 4. on World TB Day 2017. The recommendations also state that daily the End TB Strategy. South-East Asia and Western Pacific is positive by smear microscopy.5 in Viet Nam. civil society and the fields of public OF THE END TB STRATEGY susceptible but isoniazid-resistant TB. In contrast. mainly reflecting trends in the reached 4. accessed 11 July 2017). health law and human rights. 57% were bacteriologically shown globally and for WHO regions in Fig. countries in the child:adult and M:F ratios of cases may reflect based and case-based reporting system (called “Nikshay”) real differences in epidemiology. and slightly since 2013 (Fig. and between 2000 and 2009. In all countries. a 6 months of isoniazid and ethambutol) for The number of new and relapse TB cases notified and progressive increase in the notification rate with age. The percentage of cases prevalence surveys of adults in African and Asian countries with bacteriological confirmation worldwide has declined implemented in 2007–2016 approximated 2.2 TB issued by WHO in 2017 n Guidelines on ethics in TB: Protecting human rights.a The guidance was WHO is updating the 2016 treatment guidelines produced by affected individuals and a for drug-resistant TB to include evidence-based broad constituency of other experts from ETHICS GUIDANCE recommendations for the treatment of rifampicin- FOR THE IMPLEMENTATION NTPs. 4. as well as three high TB burden in India (+37% between 2013 and 2016). abnormalities on chest the M:F ratio of cases identified in 25 national TB disease radiography or suggestive histology.who. Elsewhere. 2017 (http://apps. susceptible TB: An updated edition of A compendium that summarizes all WHO policies on guidelines on the treatment of drug- TB diagnosis and treatment in one document is susceptible TB was published in April 2017. In the WHO 1 A bacteriologically confirmed case is one from whom a biological specimen Eastern Mediterranean. GLOBAL TUBERCULOSIS REPORT 2017 65 .7. TREATMENT OF TUBERCULOSIS The revised guidelines include a strong recommendation to treat new pulmonary a World Health Organization. in April 2017. This update health. Treatment of tuberculosis: by 4 months of isoniazid and rifampicin). such as Xpert MTB/RIF. following the countries in Asia – China. and has most noticeably in the WHO African Region. such patients is still in use. and there are barriers to the equitable drug formulations. clinically. African (57% to 67%) and European regions (59% to 66%).who. rifampicin. ethics. and the notification rate per 100 000 population increased a peak among those aged 65 years or over.4). Geneva: WHO. pyrazinamide and ethambutol.3). 2 months of isoniazid. 2 months of isoniazid. 4. Of the nearly 5.e.1 The remaining patients were diagnosed male:female (M:F) ratio for notifications was 1.e. The global confirmed. New guidance so that people with drug-resistant TB are treated on ethics for TB care and prevention that with regimens appropriate for their pattern of drug addresses these challenges was released resistance.05).int/iris/bitstre drug-susceptible (i. with a diagnostic. am/10665/254820/1/9789241512114-eng. followed b patient care World Health Organization. in the public and private sectors.int/iris/bitstre pyrazinamide and ethambutol. Thailand and Viet Nam – less than introduction of a national policy of mandatory notification in 2% of notified cases were children (Fig. 4. follows a Guideline Development Group meeting held Guidelines on the treatment of drug. guidelines for treatment of drug-susceptible tuberculosis 2017 UPDATE If the 8-month regimen of 2HRZE/6HE and patient care (2017 update) (WHO/HTM/TB/2017. followed by am/10665/255052/1/9789241550000-eng.4  million new and relapse pulmonary TB The distribution of notified cases in 2016 by age and sex is patients notified globally in 2016. Wider use of DST is supported and ethical delivery of care. Ethics guidance for the Guidelines for TB patients with drug-susceptible TB implementation of the End TB Strategy. accessed 11 July tuberculosis and 2017). and that associated with the most vulnerable and marginalized fixed-dose combination tablets are preferred to single populations. rifampicin. In several central and mostly explained by a continuous increase in notifications eastern European countries.

FIG. 2016 PULMONARY NEW AND RELAPSE OF WHICH EXTRAPULMONARY HIV-POSITIVE TOTAL NEW AND BACTERIOLOGICALLY NEW AND RELAPSE NEW AND NOTIFIED RELAPSEa NUMBER CONFIRMED (%) (%) RELAPSE MDR/RR-TB XDR-TB Africa 1 303 483 1 273 560 1 065 327 66% 16% 358 237 27 828 1 092 The Americas 233 793 221 008 186 940 77% 15% 20 528 3 715 112 Eastern Mediterranean 527 693 514 449 390 367 53% 24% 1 367 4 713 152 Europe 260 434 219 867 187 898 64% 15% 24 871 49 442 3 114 South-East Asia 2 898 482 2 707 879 2 291 793 61% 15% 60 245 46 269 2 926 Western Pacific 1 400 638 1 372 371 1 268 798 38% 8% 11 526 21 152 618 GLOBAL 6 624 523 6 309 134 5 391 123 57% 15% 476 774 153 119 8 014 a New and relapse includes cases for which the treatment history is unknown. It excludes cases that have been re-registered as treatment after failure. HIV-positive TB and MDR/RR-TB cases. Africa The Americas Eastern Mediterranean Europe 400 40 60 150 300 30 100 40 200 20 Rate per 100 000 population per year 50 20 100 10 0 0 0 0 2000 2004 2008 2012 2016 South-East Asia Western Pacific Global 400 150 200 300 150 100 200 100 50 100 50 0 0 0 2000 2004 2008 2012 2016 2000 2004 2008 2012 2016 2000 2004 2008 2012 2016 66 GLOBAL TUBERCULOSIS REPORT 2017 . Shaded areas represent uncertainty bands. 4. TABLE 4. globally and for WHO regions. 2000–2016. globally and for WHO regions. all forms) (black) compared with estimated TB incidence rates (green). as treatment after lost to follow up or as other previously treated (whose outcome after the most recent course of treatment is unknown or undocumented).1 Case notification rates (new and relapse cases.1 Notifications of TB.

4.9 ≥10 No data Not applicable a 2015 data were used for 15 countries.2 New and relapse TB case notification rates by age and sexa in 2016.9 2–4. FIG. 4. Cases included account for 89% of reported cases. FIG. globally and for WHO regions Africa The Americas Eastern Mediterranean Europe ≥65 55–64 45–54 35–44 25–34 15–24 0–14 Age group (years) 200 100 0 100 200 300 400 South-East Asia Western Pacific Global ≥65 Female 55–64 45–54 Male 35–44 25–34 15–24 0–14 200 100 0 100 200 300 400 200 100 0 100 200 300 400 200 100 0 100 200 300 400 TB case notification rate per 100 000 population per year a Countries not reporting cases in these categories are excluded. GLOBAL TUBERCULOSIS REPORT 2017 67 .3 Percentage of new and relapse TB cases that were children (aged <15). 2016a Percentage 0–1.9 5–9.

except for the European Region where data on confirmation by culture were also available for the period 2002−2012. FIG. 2000−2016 Africa The Americas Eastern Mediterranean Europe 100 100 80 80 60 60 40 40 Percentage bacteriologically confirmed 20 20 0 0 2000 2004 2008 2012 2016 South-East Asia Western Pacific Global 100 80 60 40 20 0 2000 2004 2008 2012 2016 2000 2004 2008 2012 2016 2000 2004 2008 2012 2016 a The calculation is for new pulmonary cases in years prior to 2013 based on smear results. 68 GLOBAL TUBERCULOSIS REPORT 2017 .5 Percentage of new and relapse pulmonary TB cases with bacteriological confirmation.4 Percentage of new and relapsea pulmonary TB cases with bacteriological confirmation. FIG. 2016a Percentage 0–49 50–64 65–79 ≥80 No data Not applicable a 2015 data were used for 17 countries. 4. 4. globally and for WHO regions.

detection of HIV- pulmonary TB patients that are bacteriologically confirmed is associated TB and screening for TB among evident even among countries with a similar epidemiological people living with HIV profile (Fig. Considerable variation in the percentage of new and relapse 4. In 2016. was in place. Elsewhere. trends have having a high burden of HIV-associated TB the figure was 87%. in the counties defined as Bangladesh. private sectors should be integral components of national Globally.6 Percentage of extrapulmonary cases among new and relapse TB cases. The microbiological detection of TB This represented a 19-fold increase in testing coverage allows patients to be correctly diagnosed and started on the since 2004. at least 75% of is critical for infection control. the contribution of PPM to total notifications increased by more than 10% between 2012 and 2016 in 1 Although the national figure for China was 43%.1. 2016a Percentage 0–9 10–19 20–29 ≥30 No data Not applicable a 2015 data were used for 17 countries.5).9).6 and Table 4.3 million incident cases that were testing coverage increased from 66% in 2015 to 87% in 2016. 4. India and the Philippines. associated TB in 2016 (Chapter 3).7). notified in 2016. equivalent to 13% of TB to HBCs in Asia and Africa. See also Table 3. which accounted for 74% of the global burden of HIV- (Fig. 167 countries reported 3. which may HIV burden countries.1). 4.3. 2 remained static or declined. In the WHO African Region to 24% in the WHO Eastern Mediterranean Region Region. as should equivalent to 57% of notified TB cases (up from 55% in 2015). Extrapulmonary TB the WHO African Region. In 116 countries and territories.2 HIV testing for TB patients.2 similar to the gap in 2015. 476 774 cases of TB among people living with TB strategies.2 in Chapter 3 for the global estimate of TB incidence among people living with HIV. and (Fig. when WHO first asked countries to report data most effective treatment regimen as early as possible. GLOBAL TUBERCULOSIS REPORT 2017 69 .FIG. Documentation of and abnormalities on chest radiography or histology results HIV status averaged 66% of TB patients in the 30 high TB/ generally associated with TB have low specificity. In areas where monitoring living with HIV (Fig. 4. 4. 4. 4. The number notified was only notifications in countries that have reported PPM data for 46% of the estimated number of incident cases among people several years are shown in Box 4. reductions over time.6  million notified new Reasons for a low proportion of cases being bacteriologically and relapse TB patients with a documented HIV test result. The contribution of PPM to total patients with an HIV test result. from 14% in lead to false diagnoses of TB. ranging from 8% in the WHO Western Pacific following inclusion of data from prisons. 82% of TB patients had Engagement of all care providers in the public and their HIV status documented. reported represented 15% of the 6. confirmed should be assessed at country level.1 In the Russian Federation. and hence to people being Indonesia to above 80% in 18 high TB/HIV burden countries in enrolled in TB treatment unnecessarily.1). and PPM initiatives have particular relevance HIV were notified in 2016 (Table 4.8). Most clinical features of TB TB cases knew their HIV status (Fig. but varied considerably.

public sector support to private providers (with or without financial incentives.3 million people who were newly enrolled in HIV 1 WRDs use molecular techniques to detect TB among people with signs or care in 2016 were diagnosed with TB during the same year. including public hospitals. these include private individual and institutional providers.who. and use of international standards of care for diagnosis and treatment. military facilities. railways and public health insurance organizations.2 which was launched in 2016. United States) and the LoopampTM MTBC Detection Kit (Eiken Chemical Company data for the 14 high TB/HIV burden countries that reported Ltd. In all countries. In 2016. Overall. antiretroviral therapy (ART) labindicators/en/. where the proportion of TB patients a WHO-recommended rapid diagnostic (WRD1) is one of the testing HIV-positive has increased from 3% in 2008 to 15% in three main objectives of TB laboratory strengthening efforts 2016. 88  200 (7%) of the 1.1 Contribution of public–public mix to TB case notifications in eight countries. As a first step towards reaching Systematic symptom screening for TB among people living this objective and as the first indicator of the Framework of with HIV is recommended by WHO as an essential component indicators and targets for laboratory strengthening under of the HIV care package. countries the number of TB cases notified among those newly enrolled should adopt policies that include diagnostic algorithms in in HIV care (up from 76 countries in 2015). They include the XpertMTB/RIF® assay (Cepheid. African Region (34%).18). Geneva: WHO. prisons or detention centres. n Trends in the contribution of PPM to TB case notifications BOX 4.3. 2012–2016 Afghanistan Bangladesh China India 25 20 60 20 Contribution of public–public mix to total notifications (%) 20 15 15 40 15 10 10 10 20 5 5 5 0 0 0 0 2012 2014 2016 2012 2014 2016 2012 2014 2016 2012 2014 2016 Indonesia Philippines Thailand Viet Nam 25 30 6 8 20 6 20 4 15 4 10 10 2 5 2 0 0 0 0 2012 2014 2016 2012 2014 2016 2012 2014 2016 2012 2014 2016 As in previous years. especially those with many public providers of TB care operating outside the remit of the ministry of health or a large private health sector. PPM is needed to ensure prompt referral by non-treating providers. nongovernmental organizations and faith-based organizations. and regulatory approaches such as enforcing mandatory TB case notification and the rational use of TB medicines. Public–private mix is defined as engagement by the NTP of private sector providers of TB care. the region with the highest proportion and TB preventive treatment – on the burden of TB among of HIV-positive cases among those tested for HIV was the WHO people living with HIV. 70 GLOBAL TUBERCULOSIS REPORT 2017 . Improvements in the coverage 2 World Health Organization. the percentage of TB patients testing HIV-positive has been falling globally since 2008. Japan).2.3 Rapid testing for TB decline is evident in all WHO regions with the exception of the Increasing patient access to early and accurate diagnosis using WHO European Region. 90 countries reported data on the End TB Strategy.1. This 4. FIG.int/tb/publications/ impact of HIV care – in particular. data are shown in Table 4. reporting of all detected cases. including linking TB insurance payments to notification). the corporate or business sector. Examples of approaches used to engage public and private care providers include strengthening coordination within hospitals. accessed 21 August 2017). In total. mission hospitals. public medical colleges. under the End TB Strategy. Framework of indicators and targets for laboratory strengthening under the End TB Strategy (WHO/HTM/ and quality of data for this indicator are necessary to track the TB/2016. B4. establishing linkages between hospitals and peripheral health centres. 2016 (http://www. symptoms of TB.3 Public–public mix is defined as engagement by the NTP of public sector providers of TB care that are not under the n direct purview of the NTP.

Inventory studies that quantify the underreporting of detected TB cases in both public and private sectors can help to identify where further PPM efforts are needed. 35% (2. In Pakistan. the number of procured cartridges in 2016 initial diagnostic test. transport of specimens and variation in clinical of Moldova.4 million) 2016 (Table 4. TB/HIV and MDR-TB burden countries.3). GLOBAL TUBERCULOSIS REPORT 2017 71 .05).3. Geneva: WHO (http://www.1 Between 2010 and 2016. The contribution of PPM to case notifications quantifies the engagement of different providers in the delivery of TB care.2. United States) is currently the WRD used most frequently by countries world­ 1 World Health Organization (2017). Despite the major scale-up in procurement of and territories. Indonesia and Viet Nam. to achieve zero underreporting. and thus inform the setting of targets for the share of notifications that should come from PPM. B4.2. B4.e. They can also indicate the share of notifications that would be accounted for by PPM in the absence of underreporting. a modular testing device that can detect multiple August 2017). and are underway in China. a cumulative total of 6659 signs or symptoms of TB. following further efforts based on the results of the inventory study. Kazakhstan. Outside South Africa (where machine throughput is than half of their notified TB cases had received a WRD as the relatively high). where t is the target level.3. compared with the total number of instrument modules as of The Xpert MTB/RIF® assay (Cepheid. were for the 48 countries included in one or more of the lists of procured by the public sector in 130 of 145 countries eligible high TB. while PPM accounted for 18% of notifications. inventory studies have been implemented in India and Pakistan.3. In 2016. installed instruments are still underused system captures the data required to monitor this indicator. B4.a By 2016.who.2 Contribution of public–private mix to TB case notifications in eight countries. c is the overall PPM contribution to total notifications and U is the level of underreporting measured in an inventory study. B4. and the alignment of their TB management practices with national and international standards. Of the countries shown in Fig.9  million test cartridges reported that such an algorithm was in place by the end of were procured by eligible countries. the contribution of PPM had risen to 28%. as other parts of the world have adopted the WRD as the initial diagnostic test. 2012–2016 Bangladesh Ethiopia India Indonesia 30 15 20 12 Contribution of public–private mix to total notifications (%) 15 20 10 8 10 10 5 4 5 0 0 0 0 2012 2014 2016 2012 2014 2016 2012 2014 2016 2012 2014 2016 Kenya Myanmar Pakistan Philippines 25 25 30 30 20 20 20 20 15 15 10 10 10 10 5 5 0 0 0 0 2012 2014 2016 2012 2014 2016 2012 2014 2016 2012 2014 2016 which a WRD is the initial diagnostic test for all people with diseases. a i. the Republic infrastructure. Considerations for adoption and use of wide. the targeted level for the contribution of PPM would thus be 43%. accessed 21 platform. This is an especially high priority GeneXpert instruments.3. 108 indicated that their routine surveillance cartridges globally.1 and Fig. further details are provided in Chapter 3. in many countries due to challenges such as network Among the 48 HBCs. it simultaneously detects both TB and resistance to multidisease testing devices in integrated laboratory networks (WHO/HTM/ TB/2017. South Africa and Swaziland reported that more demand. Of 190 reporting countries technology.1 and Fig. comprising 29  865 modules. Trends in the contribution of PPM to notifications in selected countries where PPM has been recognized as a priority and from which data have been reported to WHO for each year 2012–2016 are shown in Fig. t = c(1-U) + U. only Belarus.3. The second indicator of the framework is went to South Africa. The assay is performed using the GeneXpert® considerations_multidisease_testing_devices_2017/en/. 6. Of these. B4. and 28 HBCs for concessional pricing.                                     FIG.int/tb/publications/2017/ rifampicin. this percentage has fallen from a high the percentage of new and relapse TB cases tested with a of 63% in 2013. the level of underreporting of adult cases was 24% in 2014.

FIG. FIG. 4. globally and for WHO regions Africa The Americas Eastern Mediterranean Europe 100 80 60 40 Percentage with documented status 20 0 2004 2007 2010 2013 2016 South-East Asia Western Pacific Global 100 80 60 40 20 0 2004 2007 2010 2013 2016 2004 2007 2010 2013 2016 2004 2007 2010 2013 2016 a The calculation is for all cases in years prior to 2015. 2004−2016. 4.7 Percentage of new and relapsea TB cases with documented HIV status.8 Percentage of new and relapse TB cases with documented HIV status. 2016a Percentage 0–24 25–49 50–74 ≥75 No data Not applicable a 2015 data were used for 9 countries. 72 GLOBAL TUBERCULOSIS REPORT 2017 .

accessed 15 August 2017). Extensively drug-resistant TB (XDR-TB) is defined as MDR-TB when 25% of new and 53% of previously treated TB cases plus resistance to at least one fluoroquinolone and a second.9 2015 reflects an average rate of only 1.pdf. WHO treatment guidelines for drug-resistant Assembly resolution the following month: WHA62. rifampicin resistance (up from 31% in 2015).1.9 1 India 174 125 21 032 12 Indonesia 36 294 9 792 27 Liberia 4 528 1 219 27 0. 2016 update (October 2016 revision). There was a reduction susceptibility testing (DST). MDR-TB and XDR-TB.5 Angola 16 658 2 884 17 China 110 295 2 931 2.7 Myanmar 34 765 3 960 11 Nigeria 216 293 14 794 6. capreomycin or kanamycin). of multidrug-resistant tuberculosis and extensively drug-resistant Geneva: WHO. and it remains a major public health concern in many countries. 2009.9 TABLE 4. 1. Geneva. DST for at least rifampicin in coverage in the WHO African Region. accessed 11 July MDR-TB.3 In 2016. GLOBAL TUBERCULOSIS REPORT 2017 73 . 4. These figures represent an improvement since 2015. with coverage of a growing number of RR-TB cases (without further testing 33% for new TB patients and 60% for previously treated TB for isoniazid resistance) are being detected and notified.10 shows progress in DST coverage since 2009. respectively. 2009 (http://apps. Three categories are used for global surveillance DST for first-line drugs and detection of MDR/RR-TB and treatment: RR-TB. in April 2009 preceding a World Health 1 World Health Organization. Resolutions and decisions. the two WHO intensified efforts to track progress in the programmatic most powerful anti-TB drugs. Shaded areas represent NUMBER NUMBER NOTIFIED TB CASES uncertainty bands. WHO regions between 2015 and 2016.4 TOTAL 1 278 088 88 155 6. but this reflected a for all TB cases.04).6  million new bacteriologically confirmed and second-line drugs.0 test per module per second-line injectable agents among all TB cases with working day globally.8 0 Papua New Guinea 4 595 425 9. Further details are provided in Chapter 3. that is. China.2 2004 2006 2008 2010 2012 2014 2016 Swaziland 138 016 2 342 1. had a test result for rifampicin resistance.1 With increasing use of Xpert MTB/RIF for previously treated TB cases notified globally were tested for simultaneous detection of TB and resistance to rifampicin. RR-TB also requires treatment with of the 3. FIG. Sixty-second World Health Assembly.7 a The calculation is for all cases in years prior to 2015. DST coverage increased in five of the six regimen. number in 2016 who were also notified as a TB case started on antiretroviral therapy (blue) and in 2016. rifampicin resistance. 2004−2016. plus DST for at least fluoroquinolones and 3 This happened following a ministerial conference for high MDR-TB burden countries.7 Ethiopia 36 761 2 165 5.int/gb/ 2 Surveillance and survey data show that about 83% of RR-TB cases have ebwha/pdf_files/WHA62-REC1/WHA62_REC1-en. major progress since 2009.2 patients.who. cases (red). 2017). MDR-TB is TB Fig. 4. when that is resistant to both rifampicin and isoniazid.4 DST and detection of drug-resistant TB The most widespread technology currently available to test Drug-resistant TB threatens global TB care and prevention. in the WHO European Region in 2016. DST methods include both phenotypic (conventional) and genotypic (molecular) testing methods. they also represent line injectable agent (amikacin. OF PEOPLE NEWLY NOTIFIED AS A AS A PERCENTAGE ENROLLED IN TB CASE OF THOSE HIV CARE NEWLY ENROLLED IN HIV CARE New and relapse cases per year (millions) 1. (WHO/HTM/TB/2016.int/tb/areas-of-work/drug-resistant. with a high of 84% The End TB Strategy calls for universal access to drug. it requires treatment with a response to drug-resistant TB. held in Beijing.a 14 high TB/HIV burden countries that estimated number of incident HIV-positive TB reported data.5 Zimbabwe 168 968 9 176 5. tuberculosis.who. Thailand 10 359 1 447 14 Uganda 181 314 13 586 7.5 Malawi 145 117 2 402 1.2 Global numbers of notified new and relapse Number of people newly enrolled in HIV care casesa known to be HIV-positive (black).4  million (39%) second-line regimen.9% and the two most important classes of medicines in an MDR-TB 5.15: Prevention and control tuberculosis. 4. when the figures were 2. for drug resistance is Xpert MTB/RIF. 18–22 May tb/treatment/resources/en/. annexes. 2016 (http://www.9%.

TABLE 4.3
National policies and their implementation to increase access to rapid TB testing and universal DST,a
2016
NATIONAL POLICY AND PERCENTAGE OF NATIONAL PERCENTAGE PERCENTAGE OF NOTIFIED
ALGORITHM INDICATE NOTIFIED NEW AND POLICY AND OF NOTIFIED RIFAMPICIN-RESISTANT TB
A WRD AS THE INITIAL RELAPSE TB CASES ALGORITHM BACTERIOLOGICALLY CASES WITH DST RESULTS
Yes  No 
HIGH HIGH DIAGNOSTIC TEST FOR TESTED WITH A INDICATE CONFIRMED TB CASES FOR FLUOROQUINOLONES
HIGH TB TB/HIV MDR-TB ALL PEOPLE PRESUMED WRD AS THE INITIAL UNIVERSAL WITH DST RESULTS AND SECOND-LINE
BURDEN BURDEN BURDEN TO HAVE TB DIAGNOSTIC TEST ACCESS TO DST FOR RIFAMPICIN INJECTABLE AGENTS

Angola     0.8  1.4 0
Azerbaijan     39  65 64
Bangladesh     –  30 14
Belarus     80  98 79
Botswana     –  4.7 0
Brazil     21  40 17
Cambodia     –  12 0
Cameroon     –  6.8 100
Central African Republic     –  3.8 0
Chad     3.1  6.8 0
China     –  47 –
Congo     3.2  8.9 –
DPR Korea     –  2.6 0
DR Congo     –  3.0 31
Ethiopia     –  >100b 4.0
Ghana     –  64 0
Guinea-Bissau     –  – –
India     17  47 60
Indonesia     <0.1  14 39
Kazakhstan     85  >100b –
Kenya     26  44 63
Kyrgyzstan     36  72 34
Lesotho     –  – –
Liberia     –  60 0
Malawi     –  – 0
Mozambique     –  >100 b 95
Myanmar     –  48 –
Namibia     –  5.6 15
Nigeria     –  57 –
Pakistan     –  15 71
Papua New Guinea     –  – 61
Peru     –  >100b 76
Philippines     13  34 8.3
Republic of Moldova     51  86 84
Russian Federation     70  74 –
Sierra Leone     0 – 0.5 100
Somalia     –  12 11
South Africa     69  – 62
Swaziland     82  >100b 100
Tajikistan     73  89 93
Thailand     1.4  17 52
Uganda     24  27 21
Ukraine     –  87 100
UR Tanzania     8.2  34 49
Uzbekistan    – – – – –
Viet Nam     6.0  47 18
Zambia     –  2.5 0
Zimbabwe     –  – 53

– Data were not available.
a
The 48 countries shown in the table are the countries that are in one of more of the three lists of high TB, TB/HIV and MDR-TB burden countries (see also Chapter 2, Figure
2.2 and Table 2.4).
b
Testing in cases with unknown previous treatment history is not included. The percentage exceeded 100% for several reasons, e.g. samples rather than cases are counted in
the numerator; laboratory specimen results are not linked to the denominator data source when enumerated; or there is incomplete reporting of bacteriologically confirmed
cases in the denominator. Bacteriologically confirmed extrapulmonary cases are not included in the denominator because they cannot be differentiated from clinically
diagnosed ones in the way data are reported to WHO.

74 GLOBAL TUBERCULOSIS REPORT 2017

FIG. 4.10
Percentage of bacteriologically confirmed TB cases tested for RR-TB, globally and for WHO regions,
2009−2016a
Africab The Americas Eastern Mediterranean Europe
100

80

60

40

20
Percentage of cases

0
2010 2012 2014 2016
South-East Asia Western Pacific Global
100

80

60

40

20

0
2010 2012 2014 2016 2010 2012 2014 2016 2010 2012 2014 2016

a
Among new laboratory confirmed and retreatment cases; test results in cases with unknown previous history are not included.
b
The increase in the African Region from 2014 to 2015 was to due a big increase in reporting of laboratory results for cases in South Africa in 2015.

change in reporting in South Africa.1 DST coverage varied Drug-susceptibility testing for second-line drugs and
substantially between countries, even within the same region, detection of XDR-TB
and among the 30 high MDR-TB burden countries (Fig. 4.11). Among MDR/RR-TB patients notified in 2016, 39% were
Globally, 153 119 cases of MDR/RR-TB were detected and tested for resistance to both fluoroquinolones and second-
notified in 2016 (Table 4.1). This was a small increase from line injectable agents, a slight increase from 36% in 2015.
2015 (Fig. 4.12), although aggregate global trends conceal Coverage varied widely among countries (Fig. 4.14). A total
considerable progress in some countries (Fig. 4.13). Between of 8014 cases of XDR-TB were reported by 72 countries, with
2015 and 2016, the number of reported MDR/RR-TB cases 75% of cases from the WHO European and South-East Asia
increased by more than 30% in nine of the 30 high MDR-TB regions (Table 4.1). The five countries that reported the
burden countries (Democratic People’s Republic of Korea, largest numbers of cases were China (525), Belarus (572),
Democratic Republic of Congo, Mozambique, Nigeria, Papua South Africa (967), Ukraine (1195) and India (2464).
New Guinea, the Philippines, the Russian Federation, Somalia
and Thailand). 4.2 Treatment coverage
The global number of MDR/RR-TB cases notified in 2016 The SDGs include a target to “Achieve universal health
was 26% of the estimated 600 000 incident cases in 2016 coverage, including financial risk protection, access to quality
(Fig. 4.12; incidence estimates are discussed in more detail essential health-care services and access to safe, effective,
in Chapter 3) and 44% of the estimated 350  000 cases of quality and affordable essential medicines and vaccines for
MDR/RR-TB among notified TB cases. Closing these large all” (Chapter 2). One of the indicators for Target 3.8 of SDG 3
detection gaps will require improvements in both overall TB is the coverage of essential health services; this is a composite
detection (Section 4.2) and coverage of diagnostic DST. The indicator based on 16 tracer indicators, one of which is
latter requires further strengthening of laboratory capacity TB treatment coverage. Achieving UHC is a fundamental
and wider uptake of new rapid diagnostics. requirement for achieving the milestones and targets of the
End TB Strategy; hence, both TB treatment coverage and
1
DST results were reported separately for new and previously treated cases in
the percentage of TB patients and their households that
2015, but this was not done in 2016. face catastrophic costs as a result of TB disease are priority

GLOBAL TUBERCULOSIS REPORT 2017 75

FIG. 4.11
Percentage of bacteriologically confirmed TB cases tested for RR-TB, 2016a

Percentage
0–9.9
10–39
40–69
≥70
No data
Not applicable

a
Among new laboratory confirmed and previously treated cases; cases with unknown previous treatment history are not included. 2015 data were used for 19 countries.

FIG. 4.12 indicators for monitoring progress in implementing the End
Global number of MDR/RR-TB cases detected TB Strategy (Chapter 2).
(purple) and number enrolled on MDR-TB TB treatment coverage is defined as the number of new and
treatment (green), 2009−2016, compared with relapse cases detected and treated in a given year, divided by
estimate for 2016 of the number of incident cases the estimated number of incident TB cases in the same year,
of MDR/RR-TB (uncertainty interval shown in expressed as a percentage. In this section, numbers of notified
blue) and the number of MDR/RR-TB cases among new and relapse cases in 2016 are used as the numerator for
notified pulmonary cases (uncertainty interval the indicator, because these are the data that are available.
shown in black) However, as discussed further below, there are people with
TB who are treated but not notified to national authorities
(and in turn are not notified to WHO), and people who are
600
notified but who may not have started treatment.
Number of cases (thousands)

ART is recommended for all HIV-positive TB patients, and a
second-line MDR-TB treatment regimen is recommended for
400
people with MDR/RR-TB. This section includes estimates of
treatment coverage for these two interventions as well.

200 4.2.1 TB treatment coverage
Trends in notifications of new and relapse cases and estimated
incidence are shown for the 30 high TB burden countries
0 in Fig. 4.15. Estimates of TB treatment coverage in 2016
2009 2010 2011 2012 2013 2014 2015 2016
(calculated as notifications of new and relapse cases divided
by estimated TB incidence) are shown globally, for WHO
regions and the 30 high TB burden countries, in Fig. 4.16.
Globally, TB treatment coverage was 61% (range, 52–72%)
in 2016, up from 53% (range, 46–64%) in 2010 and 35%
(range, 30–43%) in 2000. Three WHO regions achieved levels
above 75%: the WHO Region of the Americas, the WHO

76 GLOBAL TUBERCULOSIS REPORT 2017

FIG. 4.13
Number of MDR/RR-TB cases detected (purple) and enrolled on MDR-TB treatment (green), 2009−2016,
30 high MDR-TB burden countriesa
Angola Azerbaijan Bangladesh Belarus China
400 1200 12000
2500
1000
300 900 2000 9000
750
1500
200 600 6000
500 1000
100 300 250 3000
500

0 0 0 0 0

DPR Korea DR Congo Ethiopia India Indonesia
1000 800 800 40 000 3000

800 600 600 30 000
2000
600
400 400 20 000
400
1000
200 200 200 10 000

0 0 0 0 0

Kazakhstan Kenya Kyrgyzstan Mozambique Myanmar
1000 4000
8000 600
1500 750 3000
6000
400 1000 500 2000
4000

200 500
2000 250 1000
Number of cases

0 0 0 0 0

Nigeria Pakistan Papua New Guinea Peru Philippines

3000 3000 5000
1500 300
4000
1000 2000 200 2000
3000

2000
500 1000 100 1000
1000
0 0 0 0 0

Republic of Moldova Russian Federation Somalia South Africa Tajikistan
1200 30 000 30000 1000
250
25 000
900 200 800
20 000 20000
150 600
600 15 000
100 400
10 000 10000
300
5000 50 200

0 0 0 0 0

Thailand Ukraine Uzbekistan Viet Nam Zimbabwe
1000 12 000 6000 600
3000
5000
800 9000
4000 400
600 2000
6000 3000
400
2000 1000 200
200 3000
1000
0 0 0 0 0
2010 2012 2014 2016 2010 2012 2014 2016 2010 2012 2014 2016 2010 2012 2014 2016 2010 2012 2014 2016

a
Enrolment may exceed detection of MDR/RR-TB cases for a number of reasons, including the empirical treatment of TB patients considered at risk of having MDR-TB but for
whom a laboratory-confirmed diagnosis is missing, incomplete reporting of cases with a laboratory diagnosis of MDR/RR-TB, or enrolment of ‘backlogs’ of MDR-TB patients
who were detected before 2016.

GLOBAL TUBERCULOSIS REPORT 2017 77

FIG. 4.14
Percentage of MDR/RR-TB cases tested for susceptibility to second-line drugs, 2016a

Percentage
0–24
25–49
50–74
≥75
No data
Not applicable

a
2015 data were used for 20 countries.

European Region and the WHO Western Pacific Region. High  Underdiagnosis of people with TB. Underdiagnosis can
TB burden countries with high levels of treatment coverage in occur for reasons such as poor geographical and financial
2016 (>80%) included Brazil, China, the Russian Federation, access to health care; lack of or limited symptoms that
Viet  Nam and Zimbabwe. The lowest levels, with best delay seeking of health care; failure to test for TB when
estimates of 50% or less, were in Indonesia, Kenya, Lesotho, people do present to health facilities; and diagnostic tests
Liberia, Mozambique, Nigeria and the United Republic of that are not sensitive or specific enough to ensure accurate
Tanzania. identification of all cases.
Globally in 2016, there was a gap of about 4.1  million
 Uncertainty about the level of TB incidence. In this
(39%) between the 6.3  million new and relapse cases that
report, estimates of TB incidence for 54 countries with 17%
were notified, and the estimated 10.4  million incident TB
of the world’s estimated cases are based on expert opinion
cases in the same year (Chapter 3). The global gap has been
about levels of underreporting and underdiagnosis, as
narrowing, especially in the WHO Eastern Mediterranean and
opposed to direct measurements from surveillance or
Western Pacific regions, and to a lesser extent in the WHO
survey data (Chapter 3). Uncertainty intervals around the
South-East Asia Region.1 Ten countries account for 76% of
best estimates of TB incidence can be wide, and gaps may
the total estimated gap between incidence and notifications
be lower or higher than the best estimates quoted in this
(Fig. 4.17), with India, Indonesia and Nigeria accounting for
section.
almost half of the total.
There are three main reasons for a gap between notifica- In some of the countries with the largest estimated gaps
tions and estimated incidence: between notifications and TB incidence, there is already good
evidence about the reasons for such gaps, and actions to
 Underreporting of detected TB cases. In many
address them are being taken or are planned. In India, multiple
countries, levels of underreporting may be high; this is
sources of evidence from surveys and surveillance show large
especially the case for those countries that lack policies
underreporting of detected TB cases, especially in the private
on mandatory notification and other measures to ensure
sector.2 Three examples of actions that have been taken to
reporting of detected cases by all care providers and large
close reporting gaps are mandatory notification, a simplified
private health sectors.
2
For further details, see Box 3.3 in World Health Organization. Global
tuberculosis report 2016 (WHO/HTM/TB/2016.13). Geneva: WHO; 2016
1
Time trends in countries and regions are shown in Annex 2 and Annex 3, (http://apps.who.int/iris/bitstream/10665/250441/1/9789241565394-eng.
respectively. pdf, accessed 21 August 2017).

78 GLOBAL TUBERCULOSIS REPORT 2017

all forms) (black) compared with estimated TB incidence rates (green). Angola Bangladesh Brazil Cambodia Central African Republic 600 300 60 800 1500 400 200 600 40 1000 400 200 100 20 500 200 0 0 0 0 0 China Congo DPR Korea DR Congo Ethiopia 600 600 600 150 400 400 400 400 100 200 200 200 200 50 0 0 0 0 Indiaa Indonesia Kenya Lesotho Liberia 1000 2000 600 400 400 750 1500 300 400 Rate per 100 000 population per year 500 1000 200 200 200 250 500 100 0 0 0 0 0 Mozambique Myanmar Namibia Nigeria Pakistan 600 1200 800 300 400 600 400 800 300 200 400 200 200 400 100 200 100 0 0 0 0 0 Papua New Guinea Philippines Russian Federationb Sierra Leone South Africa 1000 150 600 400 1200 750 100 400 300 500 800 200 200 50 250 400 100 0 0 0 0 0 Thailand UR Tanzania Viet Nam Zambia Zimbabwe 300 800 400 800 1000 300 600 600 200 750 200 400 400 500 100 100 200 250 200 0 0 0 0 0 2000 2004 2008 2012 2016 2000 2004 2008 2012 2016 2000 2004 2008 2012 2016 2000 2004 2008 2012 2016 2000 2004 2008 2012 2016 a Estimates of TB incidence for India are interim in nature. 2000−2016.5 in Chapter 3. GLOBAL TUBERCULOSIS REPORT 2017 79 . pending results from the national TB prevalence survey planned for 2018/2019. b For an explanation of why notifications are assumed to be equivalent to TB incidence in the Russian Federation. FIG. see Box 3. Shaded areas represent uncertainty bands. 30 high TB burden countries. 4.15 Case notification rates (new and relapse cases.

2 3 For further details.1 Similar in six high TB burden countries: China. diagnostic and treatment services.who.int/tb/publications/inventory_studies/en/.int/iris/bitstream/10665/137094/1/9789241564809_eng. (http://www. and further efforts to engage all care providers inventory studies in which electronic lists of notified cases through PPM schemes. 4. the mapping of providers that is required at the but had not been previously diagnosed. 30 high TB burden countries. Geneva: WHO. Geneva: WHO.int/iris/bitstream/10665/191102/1/9789241565059_eng. see Box 2. WHO regions and globally Russian Federation DPR Korea Brazil China Zimbabwe Viet Nam Namibia Papua New Guinea Myanmar Ethiopia Pakistan Indiaa Sierra Leone Bangladesh Cambodia Zambia Philippines Thailand Angola South Africa Congo Central African Republic DR Congo Liberia Lesotho Kenya Mozambique UR Tanzania Indonesia Nigeria The Americas Western Pacific Europe Eastern Mediterranean South-East Asia Africa Global 0 50 100 150 Treatment coverage (%) a Estimates of TB incidence for India are interim in nature. When these studies are done prospectively (as opposed prevalence survey found that 75% of the smear-positive cases to retrospectively. In Indonesia. accessed 27 July 2017). In Nigeria.2 in World Health Organization.3). including in reporting (Box 4. see World Health Organization. can of detected TB cases.08). 2012 (http://apps. national electronic reporting system that facilitates reporting In countries where underreporting is thought to exist. pdf. Global For a guide to inventory studies. Global tuberculosis report 2015 (WHO/HTM/TB/2015.22).who. Assessing tuberculosis report 2014 (WHO/HTM/TB/2014. have already been used to inform estimates of TB incidence in and intensified engagement with public and private hospitals several countries (Chapter 3). and are planned or underway where many people with TB were being treated. suggesting high beginning can subsequently help with efforts to engage all levels of underdiagnosis and a need to strengthen access to care providers. South Africa and Viet survey in the Philippines (Chapter 3). FIG.4 in World Health Organization. ideally employing unique identifiers. see Box 2. 2014 tuberculosis under-reporting through inventory studies.3 Such studies mandatory policy on notification (enacted in January 2017). August 2017). pending results from the national TB prevalence survey planned for 2018/2019. Nigeria findings are emerging from the 2016 national TB prevalence (metropolitan Lagos). the 2013–2014 national are compared with electronic lists of TB cases detected by TB prevalence survey showed high levels of underreporting all care providers. Indonesia. the Philippines. 80 GLOBAL TUBERCULOSIS REPORT 2017 . using electronic databases that are already detected had symptoms that met national screening criteria available).who. of cases. 2015 schemes to notification of cases (as in the Republic of Korea) (http://apps. accessed 15 pdf.2 Examples of mechanisms to ensure reporting of all detected 1 cases include linking reimbursement from health insurance For further details. leading to recommendations such as a be used to quantify levels of underreporting. the 2012 Nam. Geneva: WHO. accessed 15 August 2017).16 Estimated TB treatment coverage (new and relapse patients as a percentage of estimated TB incidence) in 2016.

FIG. 4.17
The ten countries with the largest gaps between notifications of new and relapse (incident) TB cases
and the best estimates of TB incidence, 2016a

China

Bangladesh
Philippines
Pakistan

Nigeria India
UR Tanzania
100 000 Indonesia
DR Congo
500 000

South Africa
1 000 000

a
The ten countries ranked in order of the size of the gap between notified cases and the best estimates of TB incidence in 2016, are India, Indonesia, Nigeria, the Philippines,
South Africa, Pakistan, Bangladesh, DR Congo, China and UR Tanzania. Estimates of TB incidence for India are interim in nature, pending results from the national TB
prevalence survey planned for 2018/2019.

and linking the supply of first-line drugs to notification of more prominent part of national programme monitoring and
cases (as in Brazil). evaluation efforts in future. Engaging communities can also
Recent national TB prevalence surveys1 have also shown add value to efforts to improve case detection and patient
that, in both Africa and Asia, detection and reporting gaps are support (Box 4.4).
systematically higher for men than for women (Chapter 3).
This suggests that specific efforts are needed to improve 4.2.2 Treatment coverage of ART for HIV-positive
access to TB diagnosis and treatment for men. TB cases
Systematic screening for active TB among specific WHO recommends ART for all HIV-positive TB patients within
populations can also help to ensure early diagnosis and the first 8 weeks of starting TB treatment. The number of
reduce levels of underdiagnosis. WHO recommends such notified HIV-positive TB patients on ART has grown in recent
screening for contacts of bacteriologically confirmed cases, years (Fig. 4.18); it reached 399 146 in 2016, equivalent to
people living with HIV and people exposed to silica dust.2,3 85% of the notified TB patients known to be HIV-positive
Other individuals at risk should be considered for systematic (Table 4.1).4 In the 30 high TB/HIV burden countries, overall,
screening based on an assessment of TB epidemiology in 86% of the TB patients known to be HIV-positive were on ART;
each setting. To date, there have been few assessments of six of these countries (India, Kenya, Malawi, Mozambique,
the implementation and outcomes of systematic screening Namibia and Swaziland) maintained coverage of at least 90%
in countries that are currently introducing or scaling it up. in both 2015 and 2016.5 In contrast, there were six high TB/
However, systematic screening is expected to become a HIV burden countries (Brazil, Congo, Ghana, Guinea-Bissau,
Indonesia and Liberia) in which less than 50% of HIV-positive
1
See http://www.who.int/tb/advisory_bodies/impact_measurement_ TB patients were started on ART in 2016. Angola and Chad
taskforce/meetings/tf6_p06_prevalence_surveys_2009_2015.pdf
2
World Health Organization. Systematic screening for active tuberculosis:
did not report data on ART for TB patients.
principles and recommendations (WHO/HTM/TB.2013.04). Geneva: WHO; ART treatment coverage for people with TB can also
2013 (http://www.who.int/tb/tbscreening/en/, accessed 15 August 2017).
4
The data requested in the global monitoring done by WHO focus on There may be discrepancies in data on provision of ART to HIV-positive TB
screening among people living with HIV and close contacts. patients that are reported by NTPs and national HIV programmes. These
3
For this reason, the data requested in WHO’s annual round of global TB data discrepancies have reduced in recent years and are mostly resolved through
collection focus on screening among people living with HIV and close follow-up and validation efforts.
5
contacts. These data are presented in Chapter 5. Further details are provided in Annex 4.

GLOBAL TUBERCULOSIS REPORT 2017 81

n Community contributions to TB notifications and treatment support
BOX 4.4 Engagement of communities, NGOs and other civil percentage of notified TB patients attributed to community
n society organizations (CSOs) is one of the four underlying referrals averaged 16%.
principles as well as one of the core components of the
Globally, over 1.5 million TB patients received some form
End TB Strategy. Community-based TB activities include a
of treatment adherence support from CHWs and volunteers
wide range of activities that contribute to the detection,
in 2016. The proportion of TB patients receiving such
referral and treatment of people with drug-susceptible,
community-based treatment support ranged considerably
drug-resistant and HIV-associated TB that are carried out
among countries. Almost two thirds of the countries
by community health workers (CHWs) and community
(34/53) reported information about the treatment success
volunteers.a Such activities can be part of public health
rate among TB patients who received treatment support in
services or activities implemented by NGOs or CSOs. In
the community. Treatment success rates ranged from 57%
some countries, CHWs are an integral part of the health
in Colombia to 100% in Afghanistan, Honduras, Jordan and
system, and enjoy the rights and privileges of formal
Mozambique.
employment. An example is Ethiopia, where the use of
CHWs has helped to transform primary health care. In 31 other countries, community-based TB activities
were carried out and supported TB services, but data
In WHO’s 2017 round of global TB data collection,
collection systems do not allow the contribution of all
53 countries reported data about the contribution
such activities to be reported at national level. Thirteen of
of communities through CHWs to TB notifications
these 31 countries (42%) reported countrywide coverage
or treatment support. This represents a more than
of community-based activities in all basic management
threefold increase in reporting since 2013, when data
units. Further effort is needed to update the data
were first collected on the two core indicators (referrals
recording systems in these countries to reflect community
and treatment support) used to monitor community
contributions.
engagement. In these 53 countries, 57% (30/53) reported
nationwide coverage by all basic management units a
Community health workers and community volunteers are defined
of community engagement in referrals of cases (thus here: World Health Organization. ENGAGE-TB Approach: Operational
contributing to case notifications) or community-based guidance: integrating community-based tuberculosis activities into
treatment support in 2016 (Fig B4.4.1). In areas where the work of nongovernmental and other civil society organizations
(WHO/HTM/TB/2012.8). Geneva: WHO; 2012 (http://www.who.int/tb/
community-based referral activities were in place, the
publications/2012/engage_tb_policy/en/, accessed 15 August 2017).

FIG. B4.4.1
Percentage of basic management units in which there is community contribution to
new case finding and/or to treatment adherence support, 2016

Percentage
0–24
25–49
50–74
≥75
No data
Not applicable

Data only requested from 114 countries.

82 GLOBAL TUBERCULOSIS REPORT 2017

FIG. 4.18
Number of new and relapse casesa known to be HIV-positive (black) and number started on ART (blue)
compared with estimated number of incident HIV-positive TB cases (red), 2004−2016, 30 high TB/HIV
burden countries
Angola Botswana Brazil Cameroon Central African Republic
15
20 30 24
30

10 15
20 16
20
10
5 10
10 8
5

0 0 0 0 0

Chad China Congo DR Congo Ethiopia
6 60 60
20 9

4 15 40 40
6
10
2 20 20
3
5

0 0 0 0 0

Ghana Guinea-Bissau India Indonesia Kenya
20 4 200
400
80
15 3 150
New and relapse cases per year (thousands)

300
60

10 2 200 100
40

5 1 100 50
20

0 0 0 0 0

Lesotho Liberia Malawi Mozambique Myanmar
30 40
60
3
100 30
20
40
2
20
50
10 20
1
10

0 0 0 0 0

Namibia Nigeria Papua New Guinea South Africa Swaziland
15 150 20

6 400
15
10 100 300
4
10
200
5 50
2 5
100

0 0 0 0 0

Thailand Uganda UR Tanzania Zambia Zimbabwe
40 80
60 150 80
30 60
60
40 100
20 40
40

20 50
10 20 20

0 0 0 0 0
2004 2008 2012 2016 2004 2008 2012 2016 2004 2008 2012 2016 2004 2008 2012 2016 2004 2008 2012 2016

a
The calculation is for all cases in years prior to 2015.

GLOBAL TUBERCULOSIS REPORT 2017 83

FIG. 4.19
Estimated ART treatment coverage for HIV-positive TB cases (HIV-positive TB patients on ART as a
percentage of the estimated incidence of HIV-positive TB) in 2016, 30 high TB/HIV burden countries,
WHO regions and globally
Namibia
Zimbabwe
Swaziland
Malawi
Ethiopia
Zambia
Botswana
Cameroon
Uganda
South Africa
India
Kenya
China
Mozambique
Lesotho
UR Tanzania
Myanmar
Brazil
Thailand
DR Congo
Central African Republic
Nigeria
Liberia
Papua New Guinea
Ghana
Guinea-Bissau
Congo
Indonesia
Chada
Angolaa
Europe
The Americas
Africa
Western Pacific
South-East Asia
Eastern Mediterranean
Global

0 30 60 90 120
Treatment coverage (%)

a
No data.

be assessed by comparing the number of HIV-positive TB 4.2.3 Treatment coverage for MDR/RR-TB
patients on ART with the estimated number of HIV-positive Trends in the number of patients enrolled in MDR-TB
incident TB cases (Fig. 4.19). This comparison reveals larger treatment globally and in the 30 high MDR-TB countries
gaps. Globally in 2016, the number of HIV-positive TB patients since 2009 are shown in Fig. 4.12 and Fig. 4.13, respectively.
on ART was 39% of the estimated global number of incident The number of people enrolled in treatment globally was
HIV-positive TB cases. There was considerable variation 129 689 in 2016, representing a more than fourfold increase
among the high TB/HIV burden countries and, according to since 2009 (when WHO first requested countries to report
best estimates, only five countries achieved ART coverage of data), but limited progress since 2015 (when 125 629 people
more than 50% (Ethiopia, Malawi, Namibia, Swaziland and were enrolled in treatment). There was a notable increase in
Zimbabwe). enrolments in India between 2015 and 2016 (from 26 996 to
Improvements are still needed in the detection of active 32 914), and modest increases in several other high MDR-TB
TB disease among HIV-positive people, the coverage of HIV burden countries. However, the number of enrolments fell in
testing among TB patients, and the enrolment of HIV-positive 10 high MDR-TB burden countries, and fell by more than 1000
TB patients on ART. An overview of progress and gaps in patients in the Russian Federation, South Africa and Ukraine.
TB preventive treatment among people living with HIV is Globally, the 129 689 patients starting second-line MDR-TB
provided in Chapter 5. treatment in 2016 represented 22% of the 600 000 estimated
MDR/RR-TB incident cases in 2016 (Fig. 4.20). Ten countries
accounted for around 75% of the gap between enrolments

84 GLOBAL TUBERCULOSIS REPORT 2017

FIG. 4.20
Estimated treatment coverage for MDR/RR-TB (patients started on treatment for MDR-TB
as a percentage of the estimated incidence of MDR/RR-TB) in 2016, 30 high MDR-TB burden countries,
WHO regions and globally
Kazakhstan
South Africa
Peru
Republic of Moldova
Ukraine
Russian Federation
Belarus
Azerbaijan
Viet Nam
Tajikistan
Kyrgyzstan
India
Zimbabwe
Thailand
Myanmar
Philippines
DPR Korea
Papue New Guinea
Ethiopia
Mozambique
Kenya
Pakistan
Bangladesh
DR Congo
Angola
China
Nigeria
Somalia
Indonesia
Uzbekistana
Europe
The Americas
South-East Asia
Africa
Western Pacific
Eastern Mediterranean
Global

0 30 60 90 120
Treatment coverage (%)

a
No data.

in MDR-TB treatment in 2016 and the estimated number of In many countries, one of the barriers to adequate access
incident MDR/RR-TB cases in 2016; China and India accounted to treatment of drug-resistant TB is that the network for the
for 39% of the total gap (Fig. 4.21). programmatic management of drug-resistant TB (PMDT) is
The number of cases starting MDR-TB treatment in 2016 too centralized and reliant on hospital-based models of care.
was equivalent to 85% of the 153  119 MDR/RR-TB patients Greater decentralization and more use of outpatient models
notified in 2016 (Fig. 4.12). The figure exceeded 90% in 14 of care are needed.
high MDR-TB burden countries (Fig. 4.13) and the WHO Globally, 8511 patients with XDR-TB were enrolled in
European Region and the Region of the Americas; however, treatment in 68 countries and territories, a 17% increase
it was much lower in the WHO African and Western Pacific compared with 2015. In 29 of these countries, the number of
regions.1 Enrolments represented less than 60% of the XDR-TB cases enrolled in treatment was less than the number
number of notified MDR/RR-TB cases in two high MDR- notified. Treatment coverage will not improve globally unless
TB burden countries in 2016: China (50%) and South Africa there is an intensification of efforts in the countries with the
(59%). These low percentages show that progress in detection largest burden, particularly China, India and Indonesia.
is outstripping capacity to provide treatment; they may also
reflect weaknesses in data collection systems. In these
settings the risk of transmission of DR-TB is high and efforts
are needed to rapidly close enrolment/notification gaps.
1
For data for WHO regions, see Annex 3.

GLOBAL TUBERCULOSIS REPORT 2017 85

although the validity of treatment outcome data was not always ascertained. The line regimen in 2015 (including people with HIV-associated absolute number of TB patients reported to have been TB). MDR-TB or XDR-TB successfully treated has risen substantially over the past 15 who started a second-line MDR-TB regimen in 2014. influenced by the high frequency of MDR/RR-TB). Universal access to DST is required to ensure that and death. Myanmar and Bangladesh.3.24).22. Congo. Liberia and Papua New Guinea). Pakistan. were treated in the 2015 cohort was 83%. Ukraine.23. especially countries of the former to high levels of loss to follow-up and missing data) and the Soviet Union. Among the six WHO regions. in several high TB burden countries. 86 GLOBAL TUBERCULOSIS REPORT 2017 .who. the highest treatment success as a basis for improving treatment outcomes. see World Health Organization. 30 high TB burden countries in Fig. and in four countries (Brazil. 4. and the WHO Eastern Mediterranean Region (91%). Globally. accessed 1 July 2017). Definitions and reporting framework for tuberculosis – 2013 revision (updated December 2014) (WHO/HTM/TB/2013. 4. the treatment This section summarizes the latest results of treatment for success rate for the 5.3 Treatment outcomes 2012–2015 is shown in Fig.5.int/iris/bitstream/10665/79199/1/9789241505345_eng. but rates (at 76%) were in the WHO Region of the Americas (due in some parts of the world.21 The ten countries with the largest gaps between the number of patients started on treatment for MDR-TB and the best estimates of MDR/RR-TB incidence. more than 20% of new and relapse cases do WHO European Region (due to high rates of treatment failure (Chapter 3). 21% of cases were either 1 For definitions of treatment outcomes. more than 10% of cases were not evaluated. is discussed in rates in 2015 were in the WHO Western Pacific Region (92%) Box 4. all people with TB receive appropriate treatment. both globally and in all WHO regions (Fig. in 2015 are shown for the world. In four countries (Central Data on treatment outcomes for new and relapse cases of TB African Republic.1 The years. Nigeria. The global trend Congo.1. exceeded a 90% treatment success rate. the completeness TB patients of outcome reporting was low. 4. as discussed Only seven of the 30 high TB burden countries reached or in Section 4. FIG. 2016a Russian Federation Ukraine China Bangladesh Myanmar Philippines Pakistan India Nigeria 10 000 Indonesia 50 000 100 000 a The ten countries ranked in order of the size of the gap between the gap of patients started on MDR-TB treatment and the best estimate of MDR/RR-TB incidence in 2016 are India. the Philippines. lost to follow-up or their treatment outcome was missing. Indonesia. increasing role of digital technologies in treatment support. and people detected with RR-TB. How­ 4. The lowest Most new and relapse cases do not have MDR/RR-TB. China. as in 2014. 4. Geneva: WHO. 4. the six WHO regions and the loss to follow-up exceeded 10%. Ethiopia and India).2).pdf. Russian Federation.1 Treatment outcomes for new and relapse ever. 2013 (www. In Brazil (71% success).9  million new and relapse cases who new and relapse cases of TB who started treatment on a first.

a Among high TB burden countries. FIG. to implement digital health interventions at a large scale. 2016 Public only Private only Public and private Not used No data Not applicable GLOBAL TUBERCULOSIS REPORT 2017 87 . for the first time. Republic of the Congo. n Digital technologies in support of TB medication adherence BOX 4.05). while also making it more challenging to limited. Digital technologies are being used in a variety of ways in the WHO Global Task Force on digital health for TB is TB care (Fig. These include much more widely to help with adherence and other short message service (SMS.5. Papua update) (WHO/HTM/TB/2017.5 and delivery n The updated TB treatment guidelines for drug-susceptible As access to the Internet and to high-performance TB published by WHO in April 2017a (Box 4.int/iris/bitstream/10665/255052/1/9789241550000-eng.1).1 Use of short message service. in the private sector has been reported by the Democratic accessed 11 July 2017).g. Geneva: WHO. aspects of programmatic work (e.5. several studies that are expected to improve the generate an evidence base about their effectiveness.who. B4. B4. Continuous development monitors. New Guinea. 2017 (http://apps. video-supported treatment or electronic medication monitors to improve TB treatment adherence and delivery. surveillance. Treatment of tuberculosis: guidelines for treatment of drug-susceptible tuberculosis and patient care (2017 sector has been reported by Cambodia.http://www.2) include. China. India. Although data on the impact of these and diversification of technologies will create new interventions on improving treatment outcomes of TB opportunities to make interventions more effective patients and reducing costs to health services remain or efficient.int/tb/areas-of-work/ digital-health/en/ whereas several countries – especially high-income ones – are not currently able to report information about the use of digital technologies.int/tb/areas-of-work/digital-health/en/ countries in the WHO African Region report no use (accessed 10 August 2017).b whereas others are implemented at a much larger scale.who. Some interventions are pilot projects developing a practical handbook to address this need. quality of the evidence and provide more information on With increasing demand for technical assistance on how their performance in different settings are now underway. adoption in the public World Health Organization. mobile devices (especially smartphones) grows globally. the Russian Federation and Viet Nam. Many b See http://www. logistics video-supported TB treatment and electronic medication management and e-learning).pdf. Kenya and Lesotho. evidence-based recommendations digital tools are likely to be used (or considered for use) related to the use of digital technologies. use who. mobile phone texting).

30 high TB burden countries. 4.22 FIG. 4. new and relapse HIV-positive TB cases. MDR/RR-TB annual treatment cohorts are reported one year later than other TB cohorts. 88 GLOBAL TUBERCULOSIS REPORT 2017 . 2012−2015 globallya New and relapse TB cases Cambodia 94 2015 83 China 94 Year started on treatment Pakistan 93 Bangladesh 93 2014 83 Viet Nam 92 Philippines 91 DPR Korea 90 2013 86 UR Tanzania 90 DR Congoa 89 Sierra Leonea 88 2012 86 Mozambique 88 Myanmar 87 0 20 40 60 80 100 Kenya 87 Indonesia 85 Zambia 85 Ethiopiaa 84 HIV-positive new and relapse TB cases Nigeria 84 Namibia 83 2015 78 Thailand Year started on treatment 81 South Africa 81 Zimbabwe 81 2014 75 Central African Republic 78 Liberia 77 Lesotho 74 2013 69 Papua New Guineaa 74 India 72 2012 68 Russian Federation 71 Brazil 71 Congo 71 0 20 40 60 80 100 Angola Western Pacific 92 Eastern Mediterranean 91 MDR/RR-TB cases Africa 83 South-East Asia 78 2015 Year started on treatment Europe 76 The Americas 76 2014 54 Global 83 0 20 40 60 80 100 2013 52 Percentage of cohort (%) 2012 50 Treatment success Failure Died Lost to follow-up Not evaluated No data reported 0 20 40 60 80 100 Percentage of cohort (%) Treatment success Failure Died Lost to follow-up Treatment success Not evaluated Failure No data reported Died Lost to follow-up a a Not evaluated Treatment outcomes are for new cases only. WHO regions and globally and MDR/RR-TB cases. cases. FIG.23 Treatment outcomes for new and relapse Treatment outcomes for new and relapse TB TB cases in 2015.

globally A total of 110 countries reported treatment outcomes for the and for WHO regions 2015 patient cohort disaggregated by HIV status. only Kazakhstan. reaching 99  165 cases globally in the 2 2 2014 cohort. a treatment failure was highest in the WHO European Region Cohorts before 2012 included new cases only. 1 1 4. 4. 4. and provision of TB preventive treatment. Liberia and Papua New Guinea (Fig. 15% were lost to follow-up and 7% had no outcome information (Fig. improved 2000 2003 2006 2009 2012 2015 2000 2003 2006 2009 2012 2015 infection control. similar to 0 2000 2003 2006 2009 2012 2015 previous years and about three times the level among all new and relapse cases (4%). although still worse than the 2 level of 83% for all new and relapse TB patients. 4. the treatment success rate was Treatment success Failure/Died/Lost to follow-up highest in the WHO Eastern Mediterranean Region (65%) and Not evaluated lowest in the WHO Region of the Americas (46%). 14 had MDR/ RR-TB cohorts in 2014 with more than 1000 cases. 1 1 cured or treatment completed) was 54%: in 8% the treatment failed. In the 2014 cohort. Overall. WHO recommends routine HIV testing among presumptive and diagnosed TB cases.2 Treatment outcomes for new and relapse TB Treatment outcomes for new and relapse TB patients coinfected with HIV casesa (absolute numbers). 4. Loss to follow-up was highest in the WHO Region of the Americas (21%). In contrast. and delays in starting ART or TB treatment. up from 68% in 2012 (Fig. the treatment success rate was 78%.23). 4. These 110 countries included 24 of the 30 high TB/HIV burden countries. Overall.e. the proportion of HIV-positive TB patients reported having died during treatment was 11%. South-East Asia Western Pacific The number of cases reported in annual cohorts has steadily Number of cases (millions) increased over time. Among the 30 high MDR-TB burden countries. Globally. which also had the highest percentage of cases without outcome data (20%). TB 0 0 screening among people living with HIV. no data Number of cases (millions) were reported by Angola. and the death rate was highest in the WHO African and South-East Asia regions (20%).3. Chad.26). FIG. Ethiopia. Number of cases (millions) 2 2 Reasons for comparatively poor outcomes for HIV-positive TB patients include late detection of HIV-associated TB. 2000−2015.3 Treatment outcomes for TB patients with MDR/RR-TB and XDR-TB 0 0 2000 2003 2006 2009 2012 2015 2000 2003 2006 2009 2012 2015 A total of 138 countries and territories reported treatment outcomes for people started on MDR-TB treatment in 2014. treatment success has increased slightly in recent years.24 4. Eastern Mediterranean Europe Strategic placement of WHO-recommended rapid molecular TB diagnostics such as Xpert MTB/RIF within HIV care settings Number of cases (millions) 2 and uptake of the lateral flow urine lipoarabinamannan assay 2 (LF-LAM) for seriously ill people living with HIV could help to ensure earlier diagnosis. 0 0 2000 2003 2006 2009 2012 2015 2000 2003 2006 2009 2012 2015 Globally. To reduce excessive TB 1 1 mortality in HIV-positive people. as has the completeness of outcome reporting (Fig. The relative difference was smallest Africa The Americas in the WHO African Region (9% versus 7%) and highest in the WHO Western Pacific Region (13% versus 2%). Global these countries accounted for 93% of the HIV-positive TB 6 patients reported by NTPs in 2015.25). collectively.23). 16% died. Myanmar and Viet Nam reported GLOBAL TUBERCULOSIS REPORT 2017 89 . the proportion of MDR/RR-TB patients in the 2014 cohort who successfully completed treatment (i. among these.3. (13%). early ART. the Democratic Republic 4 of the Congo.

India. Geneva: WHO. 30% completed treatment successfully. The wider use of shorter MDR-TB treatment regimens of Among 6904 patients started on treatment for XDR-TB 9–12 months and of new TB drugs for patients with MDR/ in 2014. India.26 Treatment outcomes for new and relapse HIV. the Philippines and 2014 XDR-TB cohort. 90 GLOBAL TUBERCULOSIS REPORT 2017 . WHO regions and globally TB burden countries. 28% 1 World Health Organization. WHO treatment guidelines for drug-resistant died. 2016 up or their treatment outcome was not evaluated. low.int/tb/areas-of-work/drug-resistant-tb/treatment/ resources/en/. 30 high TB/HIV burden cases started on treatment in 2014. 4.who. the (http://www. FIG. treat­ (no treatment outcome data were reported by Uzbekistan for ment success rates for drug-resistant TB remain unacceptably the 2014 cohort). Among seven countries with XDR-TB Ukraine. in 52 countries and territories for which outcomes XDR-TB could help to improve this situation. high rates of treatment failure in Ukraine (18%) and (42%) in India and South Africa. Treatment outcomes for rifampicin-resistant TB positive TB cases in 2015. Peru. WHO regions and globally China 87 DPR Korea 91 Zambia 87 Myanmar 80 Mozambique 86 Somalia 76 UR Tanzania 83 Kazakhstan 76 Kenya 82 Viet Nam 75 Cameroon 81 DR Congo 75 Malawi 81 Nigeria 74 South Africa 80 Bangladesh 74 Namibia 79 Kenya 72 Zimbabwe 79 Ethiopia 70 Swaziland 78 Pakistan 65 Botswana 78 Belarus 59 India 78 Azerbaijan 59 Lesotho 77 Thailand 58 Nigeria 76 Kyrgyzstan 56 Ghana 75 South Africa 54 Central African Republic 75 Papua New Guinea 52 Uganda 75 Zimbabwe 51 Myanmar 72 Russian Federation 51 Thailand 71 Indonesia 51 Guinea-Bissau 68 Republic of Moldova 50 Indonesia 60 Mozambique 50 Brazil 49 Tajikistan 50 Congo 20 Ukraine 46 Angola India 46 Chad Philippines 46 DR Congo Angola 43 Ethiopia China 41 Liberia Peru 34 Papua New Guinea Uzbekistan Africa 80 Eastern Mediterranean 65 Western Pacific 78 Africa 59 South-East Asia 75 Europe 54 Europe 62 Western Pacific 52 Eastern Mediterranean 59 South-East Asia 50 The Americas 55 The Americas 46 Global 78 Global 54 0 20 40 60 80 100 0 20 40 60 80 100 Percentage of cohort (%) Percentage of cohort (%) Treatment success Failure Died Treatment success Lost to follow-up Died Failure Treatment Lost success to follow-up Failure Not evaluated Died Lost to follow-up No data reported Not evaluated No data reported Not evaluated No data reported treatment success of more than 75%. tuberculosis (2016 update) (WHO/HTM/TB/2016. loss to follow-up or missing data in all five countries (19–60%) Although improving globally and in some countries. treatment failed for 21%. due to high death rates in India (21%) and Ukraine cohorts of more than 100 individuals. and 20% were lost to follow. 30 high MDR- countries.04).25 FIG. accessed 15 August 2017). mortality was highest (17%). 4. Treatment success Russian Federation and Ukraine accounted for 68% of the was less than 50% in China.1 were reported.

multiple Microsoft® Excel spreadsheets). reported 4. there is In countries that still rely on paper-based recording and a need for active TB drug-safety monitoring and management reporting systems. Zambia and Zimbabwe. these data are usually ardized shorter MDR-TB regimen is recommended by WHO available at country level and are a key source of information. analysis and use of TB data: two in Africa and one in Asia. 4 The second workshop included Cameroon. Mauritania. of global TB data collection. Cape Verde.28_eng. With the introduction of new drugs and regimens. national and local response efforts. they are in an electronic format. 5 bitstream/10665/204465/1/WHO_HTM_TB_2015. However. 4. Sierra Leone and Togo. Guinea-Bissau. subject to eligibility criteria. Niger. Notification and treatment outcome data for subnational imens have been reported to achieve high treatment success areas are not routinely requested by WHO in annual rounds rates (87–90%) in selected MDR/RR-TB patients and a stand. Namibia.2 The analysis and use countries had used delamanid (Fig. 15 August 2017). Gambia.27 Countries that had used shorter MDR-TB treatment regimens by the end of 2016 Country response Shorter MDR-TB treatment regimens used Not used No data Not applicable By 2016. Mali. Swaziland. Nigeria. the United Republic of TB/2015.who. 89 countries were including for TB epidemiological reviews and assessment of known to have imported or started using bedaquiline and 54 the performance of TB surveillance. 4. Myanmar. Burkina Faso.3.g. Kenya. India.pdf. Geneva: WHO. Malawi. GLOBAL TUBERCULOSIS REPORT 2017 91 . 4. Central African Republic. Nepal. 1 World Health Organization.4.28). if drugs. Ethiopia. Sudan. 35 countries. 2015 (http://apps. Thailand and Viet Nam. Pakistan.int/iris/ Tanzania.5 2 These are discussed in more detail in Chapter 3. By June 2017. Lesotho. mostly in Africa and Asia. the format is not conducive manage and report suspected or confirmed drug toxicities. 3 The first workshop included countries in the West African Regional Network for TB (WARN-TB) that has been established by TDR: Benin.FIG.28 and Fig. Ghana. defined as the active and systematic clinical and major challenge in using and analysing subnational TB data laboratory assessment of patients on treatment with new TB is that the data are not available in electronic format or. Côte d’Ivoire. Indonesia. novel MDR-TB regimens or XDR-TB regimens to detect. Liberia.27). a (aDSM). Uganda. WHO started an initiative to address this problem. 4. or have done so until very recently. and track progress. These reg. accessed The third workshop included Bangladesh. Senegal. 13 of the 30 high MDR-TB burden countries reported 2016. the Philippines. Active tuberculosis drug-safety monitoring and the Democratic Republic of the Congo. Most of routinely collected data at both national and subnational (75%) of the patients treated with bedaquiline were reported levels are essential to understand the TB epidemic. data on adverse events collected from their TB information linked to preparations for three regional workshops on the systems. management (aDSM): framework for implementation (WHO/HTM/ Mozambique. inform by two countries: the Russian Federation and South Africa.29). Chad. In In 2016.1 to analysis (e. Guinea (Conakry).4 Subnational TB data: availability and use having used shorter MDR-TB regimens (Fig. Cambodia.

compassionate use or under normal programmatic conditions by the end of June 2017a Delamanid used Delamanid not used No data Not applicable a Data shown reflects country reporting supplemented with additional information from pharmaceutical manuacturers.28 Countries that had used bedaquiline for the treatment of M/XDR-TB as part of expanded access. 4. FIG. 4. FIG.29 Countries that had used delamanid for the treatment of M/XDR-TB as part of expanded access. compassionate use or under normal programmatic conditions by the end of June 2017a Bedaquiline used Bedaquiline not used No data Not applicable a Data shown reflects country reporting supplemented with additional information from pharmaceutical manuacturers. 92 GLOBAL TUBERCULOSIS REPORT 2017 .

central of integrating the TB module into existing DHIS2 systems. hosted by WHO discussions between staff responsible for national health and the Global Fund to Fight AIDS. The workshops also provided an opportunity for and Training in Tropical Diseases (TDR). 21 now have their district. 2014 (http:// www. 4. Standard dashboards for visualizing the results conducted in the workshops is provided in Box 4. was organized trends. for and southern Africa with the Global Fund. and geographical information system the past 5 years. 4. The first workshop. Tuberculosis and Malaria information systems and staff from NTPs about the possibility (Global Fund). Understanding and using tuberculosis data. Subnational population facility-level data available in the DHIS2 platform for at least estimates. for countries in west Africa.or versions) in a dedicated module.2 countries to feature subnational data in future editions of the During the workshops. Geneva: WHO Global Task Force on TB Impact Measurement. a platform using open-source strengthening TB surveillance.int/tb/publications/understanding_and_using_tb_data/en/. Of the 40 countries. participants focused on examining global TB report.org/ 2 World Health Organization. Participants used the results to develop monitoring Partnership. GLOBAL TUBERCULOSIS REPORT 2017 93 .30 Subnational data stored in the DHIS2 platform developed by WHO. the second was for countries in east. 18 have regional-level data for at least were also entered.dhis2. Other future work includes the development data quality and epidemiological indicators displayed as of a module in DHIS2 for entry of patient-level data.FIG. the past 5 years. and evaluation investment plans. A country example of the subnational analyses each indicator. to identify key activities for Before the workshops. and one had uploaded limited data to the shape-files were included to allow the generation of maps for platform. disaggregated by age and sex wherever possible. DHIS2 software1 was developed to allow the electronic The status of the availability of subnational data for the compilation and storage of historical TB surveillance data countries that participated in the workshops is shown in from quarterly reporting forms (both the 2006 and 2013 Fig. standard graphs and tables. August 2017a District/facility-level (at least 5 years) Regional-level (at least 5 years) Limited data Not applicable a Information shown only for countries where national TB programme staff participated in DHIS2 workshops in 2016–2017. in the context of recent interventions and TB deter­ in collaboration with the Special Programme for Research minants. accessed 24 August 2017). and the third was prospective (as opposed to historic) collection of aggregate- for countries in Asia with the Global Fund and the Stop TB level data. Efforts are from the analyses recommended in the WHO handbook for now underway to obtain the clearances necessary from other understanding and using TB data were also developed.who.30.6. using the data visualization dash­board to help in the discussion and inter­pretation of 1 See https://www.

and less than 15% in Preah Vihear at provincial level will allow the impact of corrective province. and migration or variation in TB cases knew their HIV status. whereas childhood TB appeared to be either actions to be assessed. “hot spots” cases were children aged under 15 years. and possibly overdiagnosed use of TB data in April 2017.6 in Cambodia n Cambodia was one of the 10 Asian countries that underdiagnosed or underreported (<5% of new and participated in a regional workshop on the analysis and relapse cases) in six provinces. This workshop included in 12 provinces (>15% of new and relapse cases). However. these national diagnostic practices for extrapulmonary or childhood figures concealed wide geographical variation. the national TB case notification rate in Cambodia performance for recording and reporting. for these indicators are shown in Fig. and the coverage of HIV testing. In four of analysis of subnational data for case notification rates. and to immediately identify were in the northeast along the border with Lao People’s key provinces where local action to improve HIV testing Democratic Republic and Viet Nam. This subnational variation may indicate differences in the In 2016. FIG. Future monitoring of indicators cases in five provinces. possible issues was 222 per 100 000 population. 34% of all new and with access to health care.1. less than 80% of TB patients knew their proportion of new and relapse cases by site of disease and HIV status. some provinces having large relapse TB cases were extrapulmonary. B4. and the lowest (75 per 100 000 population) evaluation mechanisms. Analysis of the data at this level allowed the NTP to highest TB case notification rates (>300 per 100 000 generate hypotheses for further investigation. 94 GLOBAL TUBERCULOSIS REPORT 2017 . n Using subnational-level TB surveillance data to guide local action BOX 4. Provincial data province (51%). the the 25 provinces. The TB.6. Thailand (April 2017). 16% of notified referral centres for diagnosis or treatment.1 Subnational heterogeneity in TB indicators in Cambodia: a difficult interpretation TB case notification rate per 100 000 population Proportion of extrapulmonary TB among new and relapse TB cases (%) 0–24 25–49 50–74 0–14 75–99 15–24 100–199 25–34 200–299 35–44 ≥300 ≥45 All new and relapse cases under 15 years old (%) TB patients with known HIV status (%) 0–4 40–59 5–14 60–79 ≥15 ≥80 Source: Data provided by the NTP Cambodia for a TB data analysis workshop in Bangkok. with the lowest coverage being in Mondulkiri age group. either population) were in the northwest and southeast of the through operational research or routine monitoring and country. and 86% of all for ongoing transmission. B4. Extrapulmonary TB coverage or investigate the possible over or underdiagnosis accounted for more than 45% of new and relapse TB of childhood TB is required.6.

.

Bangladesh GARY HAMPTON / WHO 96 GLOBAL TUBERCULOSIS REPORT 2017 . A patient attending a health facility is given information about TB in Dhaka.

2015 and 2016 (from 87 242 to 161 740). completion and reporting of TB KEY disease is critical to reduce the burden of disease preventive treatment for other at-risk populations. preventive treatment according to current policy recommendations. Additionally. care and in HIV care ranged from 2. Lithuania. a standard part of these programmes. coverage among people newly enrolled strategy and targets for tuberculosis prevention. In Kenya. China accounted for 39% of these cases. tb/post2015_strategy/en/. infection control. In 2016.3 million. TB prevention services n Prevention of new infections of Mycobacterium In countries with a low burden of TB. silicosis. Based on data from 60 countries. 1. Geneva: WHO. accessed 8 August 2016). adult population is a good indicator of the impact prevention of transmission of M. WHO has developed Mozambique. this means that the global total fewer adverse events. there were an estimated Colombia. Dominican Republic. which require a living with HIV in 2016. GLOBAL TUBERCULOSIS REPORT 2017 97 . of which 111 reported coverage above 90%. tests with improved performance and predictive Of the 30 high TB/HIV burden countries. and to achieve the End TB including clinical risk groups such as patients with AND Strategya targets set for 2030 and 2035. but was still 154 countries reported providing BCG vaccination as only 13% of those estimated to be eligible. As is challenging given the lack of standard systems for in previous years. there is a need tuberculosis and their progression to tuberculosis (TB) to improve initiation. Combined with data reported smaller number of doses and are associated with by other countries. tuberculosis through of TB infection control in health facilities. followed by of multiple service providers. However. the number of TB cases per household contacts of bacteriologically confirmed 100 000 health-care workers was more than double pulmonary TB cases and who were eligible for TB the notification rate in the general adult population. with TB from 60 countries. 2015 (http://www. and the involvement the largest share of the total (41%). and to people living with HIV. will facilitate large-scale of people living with HIV who were started on TB implementation.CHAPTER 5.4% in Indonesia to 73% in control after 2015. Georgia. a total of 940 269 people who were newly enrolled in HIV care were Monitoring and evaluation of TB prevention services started on TB preventive treatment in 2016. 18 did not value are needed to target individuals who will report any provision of preventive treatment in 2016. innovative diagnostic preventive treatment in 2016 was at least 1. in 2016. and vaccination of children with the a total of 8144 health-care workers were reported bacille Calmette-Guérin (BCG) vaccine. patients starting anti-tumour necrosis factor MESSAGES (TNF) therapy and patients preparing for organ Current health interventions for TB prevention are n treatment of latent TB infection (LTBI). benefit most from TB preventive treatment. In 2016. a mobile phone application (app) to facilitate data on the number of people newly enrolled in HIV monitoring and evaluation of the programmatic care who were started on TB preventive treatment management of LTBI. TB preventive Development and expanded use of shorter regimens treatment was provided to a total of 390 298 people for TB preventive treatment. Globally. WHO End TB Strategy: global report data. with particular transplantation. The number of children in this BCG vaccination should be provided as part of age group reported to have been started on TB national childhood immunization programmes preventive treatment increased by 85% between according to a country’s TB epidemiology. South Africa accounted for recording and reporting data. Zimbabwe and Malawi. attention to children aged under 5 years who are The ratio of the TB notification rate among health- household contacts of bacteriologically confirmed care workers to the TB notification rate in the general pulmonary TB cases.3 million children aged under 5 years who were Mexico and Venezuela). In the 12 high TB/HIV burden countries that did a World Health Organization.who. In seven countries (Burkina Faso.int/ Zimbabwe. FACTS and death caused by TB. in 2016 were not available.

and has of reactivation of latent tuberculosis infection in the United States. tuberculosis through 30 high TB burden countries (compared with nine countries infection control. 110  vaccination of children with the bacille Calmette-Guérin reported at least one child started on preventive treatment (BCG) vaccine.3 In some force in 2016. The largest HIV burden countries (Chapter 2).1 Treatment of latent TB infection the global total). with a target of over The targets of an 80% reduction in TB incidence from the 2015 90% coverage by 2025 at the latest (Chapter 2. The rest of this section presents and discusses data new cases of disease. Docker H. Dodd PJ. an 85% increase from 87  242 in 2015. level by 2030. and a 90% reduction by 2035.ncbi. much greater reduction include more effective treatments for The data were gathered from countries and territories in LTBI and development of a vaccine to prevent reactivation of WHO’s 2017 round of global TB data collection. accessed 8 to be eligible for treatment. 2000. 1. care and control after 2015. Geneva: 2016 represented 13% of the 1. Higher levels of coverage were August 2016). Fine PE.152(3):247–263. will require a Data on provision of TB preventive treatment for people historically unprecedented acceleration in the rate at which living with HIV have been collected by WHO for more than TB incidence falls after 2025 (Chapter 2). PLoS Med. 5. 52–58%).who. (compared with 89 countries in 2015).1.nlm. http://www. 68%.2). 5. Geneva: WHO.2 People living with HIV 4 Heldal E.int/tb/challenges/task_force/en/ 8 tuberculosis infection. Mozambique reported the LTBI is defined as a state of persistent immune response to M.7 billion people already infected worldwide2 is drastically Such guidance was developed by a WHO global LTBI task reduced below the current lifetime risk of 5–15%.int/tb/publications/global_report/en/ 98 GLOBAL TUBERCULOSIS REPORT 2017 .1.who.4(4):300–307. reactivation accounts for about 80% of Table 5. Am J Epidemiol. The role of reactivation. accessed 30 August 2016). Navin TR. Particular attention is to have been initiated on TB preventive treatment (Table 5.int/tb/ The online technical appendix is available at publications/ltbi_document_page/en/. achieved in the WHO Region of the Americas (best estimate 2 Houben RM. estimate 55%.5 Interventions that could result in a about TB preventive treatment for these three risk groups. 5 Shea KM. 2014.1 Child contacts aged under 5 years who are are available for TB prevention: household contacts of TB cases There were 191 countries that reported at least one notified  treatment of LTBI through any of the following: isoniazid bacteriologically confirmed pulmonary TB case in 2016. 1 the 161 740 children started on TB preventive treatment in World Health Organization. accessed 2 August 2017). followed by the European Region (best 2016.3 million children estimated WHO. Among the 118 countries. 3 Vynnycky E. range. three major categories of health interventions 5.4. 118 (63%) reported data about the number 3–4 months. 64–72%). and reached 940 269 people in 2016 (Fig.who. or isoniazid of household contacts aged under 5 years who were started plus rifapentine weekly for 3 months.179(2):216–225. overall and by population subgroup.who. Tverdal A. Lifetime risks. Kammerer JS. re-infection and primary infection assessed by previous mass screening data and restriction fragment in HIV care has grown substantially since 2009. isoniazid plus rifampicin daily for these countries.2) given to the 30 high TB burden countries and the 30 high TB/ in 2016. Guidelines on the management of latent http://www.6 eligible for such treatment – are shown in Table 5.int/tb/post2015_strategy/en/. Pulmonary tuberculosis in Provision of TB preventive treatment to those newly enrolled Norwegian patients. 2000. until 2016 there was no standardized rate is possible only if the probability of progression from global guidance on how to monitor the coverage of preventive latent TB infection (LTBI) to active TB disease among the treatment among child contacts or other high-risk groups. However. 5. LTBI in adults. and people living with HIV. low levels.2). numbers were reported by the WHO African Region (46% of the global total) and the South-East Asia Region (19% of 5. and to the 10 indicators listed as highest priority for monitoring achieve the End TB Strategy targets set for 2030 and 2035. The global burden of latent tuberculosis infection: a re-estimation using mathematical modelling. Table 2. At country level. WHO End TB Strategy: global strategy and targets for tuberculosis prevention. tuberculosis without clinically manifested evidence of active Comparisons of the number of children started on TB TB disease. 2015 (http://www. Prevention of new infections of Mycobacterium tuberculosis Coverage of contact investigation and treatment of LTBI and their progression to tuberculosis (TB) disease is critical to among child contacts and people living with HIV are among reduce the burden of disease and death caused by TB. Of daily for 6 or 9 months. largest number (19 634). on TB preventive treatment (Fig.gov/pubmed/27780211.13(10):e1002152 (https://www.1. This accelerated 10 years. 6 7 World Health Organization. The three main sections of this chapter present and discuss A total of 161 740 child household contacts were reported progress in provision of these services. rifampicin daily for 3–4 months. range. of bacteriologically confirmed pulmonary TB cases – and thus confirmed pulmonary TB cases. Caugant DA.1). Currently. Int J Tuberc Lung Dis. Am J Epidemiol.8 Globally. albeit from length polymorphism analysis. Horsburgh CR. and that reported data for 2015). including 16 of the  prevention of transmission of M. and serial interval of tuberculosis. WHO recommends specific efforts to diagnose and preventive treatment in 2016 with national estimates of the treat LTBI in two particular at-risk groups: children aged under number of children aged under 5 years who were contacts 5 years who are household contacts of bacteriologically. followed by Afghanistan (15 417).7 and the recommended indicators are shown in low-burden countries.2. Winston CA. 2015 (http://www. Estimated rate Most of the increase occurred from 2009 to 2014.nih.1 implementation of the End TB Strategy. incubation period.

1 Availability of data on the number of children aged <5 years who were household contacts of bacteriologically confirmed pulmonary TB cases and were started on TB preventive treatment. 5. 9) TB incidence have started treatment.1 Summary of monitoring and evaluation indicators recommended by WHO for the programmatic management of LTBI CORE GLOBAL AND NATIONAL INDICATORS CORE NATIONAL INDICATORS OPTIONAL INDICATORS 1) Proportion of children less than 5 4) Proportion of eligible individuals from at risk populations (according to national years old who are household TB guidelines) tested for latent TB infection. preventive therapy. (according to national guidelines) who have completed a course of TB preventive started on TB preventive therapy. 2016 Country response Number available from routine surveillance Number estimated from a survey Number not available No data Not applicable GLOBAL TUBERCULOSIS REPORT 2017 99 . guidelines). 3) Proportion of eligible people living 8) Proportion of children less than 5 years old who are household TB contacts with HIV newly enrolled in HIV care. FIG.TABLE 5. therapy. 2) Proportion of children under 5 years rate among risk 6) Proportion of individuals from at risk populations (according to national guidelines) populations (as old who are household TB contacts with a positive latent TB test who have started on TB preventive therapy that have defined by national (according to national guidelines) completed the course. who are eligible for starting on TB preventive therapy that have started 7) Proportion of eligible people living with HIV who completed a course of TB treatment. contacts (according to national 5) Proportion of individuals from at risk populations (according to national guidelines) guidelines) who have completed TB with a positive latent TB test who are eligible for starting TB preventive therapy that investigations.

Botswana.4 65 000 (60 000–71 000) 948 1. a There were 15 other countries in the list of high TB or TB/HIV burden countries that did not report data for either risk group.9 (1.5) Russian Federation 21 153 19 611 93 1 700 (1 100–2 300) 9 850d – Sierra Leone 17 843 3 609 20 9 100 (8 300–9 900) – South Africa 751 620 385 932 51 46 000 (42 000–50 000) – Swaziland 138 016 21 320 15 1 300 (1 200–1 400) – Uganda – 21 000 (19 000–23 000) 1 094 5.a WHO regions and globally NUMBER OF PEOPLE NEWLY ENROLLED IN HIV CHILDREN UNDER 5 YEARS OF AGE CARE WHO WERE STARTED ON TB ESTIMATED NUMBER OF CHILD WHO WERE STARTED ON TB PREVENTIVE PEOPLE LIVING PREVENTIVE TREATMENT IN 2016 HOUSEHOLD CONTACTS UNDER 5 YEARS TREATMENT IN 2016 WITH HIV NEWLY OF AGE ELIGIBLE FOR TB PREVENTIVE ENROLLED IN CARE COVERAGE.5 (1.8 (5.7 360 000 (330 000–390 000) 6 637 1. Brazil. Pakistan. Kenya. % COVERAGE.5–11) GLOBAL 2 263 682 940 269 42 1 260 000 (1 220 000–1 300 000) 161 740 13 (12–13) Blank cells indicate data not reported.2 (4. Therefore. These were Angola.3 (5.5 20 000 (19 000–22 000) 6 309 31 (28–34) Viet Nam 13 593 3 474 26 16 000 (14 000–17 000) 3 038 19 (18–21) Zimbabwe 168 968 123 846 73 8 200 (7 500–8 900) 5 177 63 (58–69) Africa 1 862 671 859 727 46 460 000 (450 000–470 000) 74 348 16 (16–17) The Americas 65 485 20 067 31 24 000 (22 000–25 000) 16 219 68 (64–72) Eastern Mediterranean 6 419 1 015 16 150 000 (140 000–160 000) 24 127 16 (15–17) Europe 51 501 36 086 70 14 000 (13 000–14 000) 7 404 55 (52–58) South-East Asia 245 425 10 055 4.7–2) Indonesia 36 294 877 2. Central African Republic.5– 6.1–4.5 (4.2) Western Pacific 32 181 13 319 41 95 000 (89 000–100 000) 9 571 10 (9.8– 2. Papua New Guinea.6 2 100 (1 900–2 300) 92 4. Therefore. d This number includes contacts other than household contacts.1 510 000 (480 000–550 000) 30 071 5.3–1. and eligible for TB preventive treatment. 100 GLOBAL TUBERCULOSIS REPORT 2017 . the estimated coverage was not calculated. Chad.6) Liberia 4 528 390 8.9) Ethiopia 36 761 19 244 52 28 000 (26 000–31 000) – Guinea-Bissau – 2100 (1 900–2 300) 94 4. China.1) Namibia – 3 100 (2 900–3 400) 810 26 (24–28) Nigeria 216 293 62 781 29 47 000 (43 000–51 000) 8 562 18 (17–20) Philippines 5 966 2 938 49 55 000 (51 000–60 000) 2 777 5 (4. The number was also not included in the regional and global figures.9 (1.8–6. estimated coverage was not calculated. Guinea-Bissau. 23 high TB or TB/HIV burden countries that reported data. c This number includes contacts aged 5–7 years. IN 2016 (C)b NUMBER (D) IN 2016 (A) (B*100÷A) (D*100÷C) Bangladesh – 49 000 (45 000–53 000) 8 537 17 (16–19) Cambodia 3 193 631 20 5 200 (4 800–5 700) 1 877 36 (33–39) DPR Korea – 11 000 (9 900–12 000) 11 707c – DR Congo – 75 000 (68 000–82 000) 4 725 6. b This is the estimated number of children under 5 years of age who were household contacts of a notified bacteriologically confirmed pulmonary TB case. Estimates are shown to two significant figures for numbers below 1 million. and to three significant figures for numbers above 1 million.6–5.0– 4. TABLE 5.8) Malawi 145 117 72 446 50 4 700 (4 200–5 100) 2 351 50 (46–55) Mozambique 315 712 162 646 52 20 000 (18 000–21 000) 19 634 100 (91–100) Myanmar 34 765 1 018 2.9) India 174 125 8 135 4. Congo.4 (4. Thailand. Ghana. Lesotho.7) UR Tanzania 49 351 4 202 8. % NUMBER (B) TREATMENT. 2016.8–5. and Zambia.2 TB preventive treatment in 2016 for people living with HIV and children under 5 years of age who were household contacts of a bacteriologically confirmed pulmonary TB case.9 17 000 (15 000–18 000) 317 1.

and in turn expedite the scale-up of key followed by Mozambique. b The gap represents people living with HIV who should have undergone complete evaluation for TB disease or TB preventive treatment. However. a total of 60 countries to HIV-associated TB is one of the eight thematic tracks at the (representing 70% of the estimated global burden of HIV. the number of TB cases detected among people newly enrolled on HIV care. 2005–2016 India and Liberia. including TB preventive Large absolute increases compared with 2015 numbers were treatment. Mozambique (+32 226) and Provision of TB preventive treatment to people Nigeria (+21 926). such that all those without active TB disease are eligible for TB preventive treatment. and the number of people newly enrolled on HIV care who were started on TB preventive treatment. data on the number of people newly enrolled in HIV care who 1000 were started on TB preventive treatment in 2016 were not Number of people living with HIV (thousands) Global available. commitment. reported data for the first time. from 0 2. In 2016. WHO Ministerial Conference on Ending TB in the SDG Era. GLOBAL TUBERCULOSIS REPORT 2017 101 . FIG. Accelerating progress in the global and national response subsequently levelled off.2). 5.2). South Africa accounted for the is hoped that the conference will galvanize greater political largest proportion (41%) of the global total in 2016 (Fig.3 million. 18 Africa did not report any provision of TB preventive treatment in 2016. For example. This theme will include a specific to people newly enrolled in HIV care. Zimbabwe and Malawi (Table 5. to associated TB) reported providing preventive TB treatment be held in November 2017. Combined with data reported by other countries. FIG. compared with 57 focus on ending TB deaths among people living with HIV. of the 30 high TB/HIV burden countries. coverage among world people newly enrolled in HIV care varied considerably. 5.4% in Indonesia to 73% in Zimbabwe (Table 5. 200 Rest of and in the 12 countries that provided data.2). including through wider use of TB preventive treatment. 5. TB preventive treatment was provided to 800 a total of 390 298 people living with HIV in 2016.3 Gaps in TB preventive treatment for people who were newly enrolled in HIV care in 2016. living with HIV. In high TB burden countries. 400 Despite progress in some countries. countries in 2015. this means that the 600 Rest of global total of people living with HIV who were started on TB Africa preventive treatment in 2016 was at least 1. interventions for HIV-associated TB. Two of the 30 high TB/HIV burden countries. Fig. selected countriesa 100 80 60 Percentage 40 20 0 Indonesia Myanmar India Liberia Swaziland Sierra Leone Nigeria Philippines Malawi Ethiopia Zimbabwe Started on preventive treatment Detected and notified with active TB disease Gap in TB detection and TB preventionb a The selected countries are high TB or TB/HIV burden countries that reported on all three of the following: the number of people newly enrolled in HIV care. testing for LTBI is not a requirement for initiation of TB preventive treatment.2 reported in Zimbabwe (+85 357). In Kenya. It As in previous years. 5.3 2006 2008 2010 2012 2014 2016 shows gaps in the provision of TB preventive treatment to people living with HIV for selected high TB burden countries or high TB/HIV burden countries . much remains to be South done.

2015 (http://www.e.3 Provision of TB preventive treatment to other at-risk populations in 2016. WHO policy on TB infection control in 5. Kreiswirth BN et facilitate faster and more complete data collection. The risk of TB trans­ control in health-care facilities. Portugal and Slovakia. Thus. particularly data for clinical risk measure the impact of TB infection control activities in health- groups. An outbreak report case-based data on TB preventive treatment (Box 5. In health- contacts. a comprehensive set that reported denominators (i. Gori A. accessed 13 July 2017).int/tb/publications/monitoring-evaluation-collaborative- TB (MDR-TB) and extensively drug-resistant TB (XDR-TB) tb-hiv/en/. Italy.pdf. End TB Strategy (Chapter 2). To 1 Gandhi NR. TB infection control should be part of national infection the Netherlands. tb_infection_control_in_health_facilities.int/iris/ bitstream/10665/44148/1/9789241598323_eng. Nosocomial transmission of extensively drug-resistant tuberculosis in a rural hospital in South Africa. Coverage was more than 50% in the four countries care facilities and congregate settings.3 Other at-risk populations among people living with HIV have been documented in the Data on provision of TB preventive treatment to other at-risk literature. Geneva: WHO. Republic of Korea and Slovakia prevention and control policy. Geneva: WHO. and nosocomial outbreaks of multidrug-resistant collaborative TB/HIV activities: 2015 revision. Data for clinical risk groups – such as patients environmental and personal protection measures – should starting anti-tumour necrosis factor (TNF) therapy and those be implemented.who. it is also one of the collaborative 4 World Health Organization. TABLE 5. 2009 (http://apps. unregulated private health sector in some countries.5 the risk of TB TB preventive treatment among health-care workers relative to the risk in the general Routine collection of data about TB preventive treatment adult population is one of the global indicators recommended to remains challenging. 1998. Elson I. If effective TB infection control measures are in not mandatory in most countries. Reasons include the fact that notification of LTBI is care facilities. a The denominator is an estimate based on extrapolation from data reported in 2015. measures are in place. developed a mobile phone application (app) to record and 2 Moro ML. Weissman D. of multidrug-resistant tuberculosis involving HIV-infected patients of two hospitals in Milan. AIDS. Franzetti F. Errante I.4 In the latest revision of WHO guidance on monitoring and 5. Portugal.2 populations were reported by six countries: France. Moodley P. c This number includes 64 people in community housing. 2013. J Infec Dis. b Data are limited to individuals identified through contact tracing. Checklist for periodic evaluation of TB infection TB/HIV activities that falls under Pillar 1.who.12(9):1095–1102. for selected low TB burden countries for which data could be reported NUMBER OF INDIVIDUALS AMONG AT RISK POPULATIONS ELIGIBLE AND STARTED ON TB PREVENTIVE TREATMENT AT-RISK POPULATIONS FOR WHICH THERE IS A STRONG RECOMMENDATION AT-RISK POPULATIONS FOR WHICH THERE IS A CONDITIONAL TO PROVIDE PREVENTIVE THERAPY RECOMMENDATION TO PROVIDE PREVENTIVE THERAPY CHILDREN AGED PATIENTS PATIENTS PREPARING IMMIGRANTS 5 YEARS OR PATIENTS PATIENTS ILLICIT INITIATING FOR ORGAN OR FROM HIGH HEALTH HOMELESS OLDER AND RECEIVING WITH PRISONERS DRUG ANTI-TNF HAEMATOLOGICAL TB BURDEN WORKERS PEOPLE ADULT CONTACTS DIALYSIS SILICOSIS USERS TREATMENT TRANSPLANTATION COUNTRIES OF TB CASES France 2750/5500a 186/397b 18/108b 177/300b Japan 4 802 455 1859 20 Netherlands 686/867 60/66 17/19 4/4 0/0 88/107 31/42 Portugal 1250 9 3 229 389 33 68c 87 Republic of Korea 2133/3192 1508/3128 111/230 Slovakia 350/550 158/352 28/64 1/2 2/2 15/120 15/15 6/36 0/2 Blank cells indicate data not reported.pdf. Ramathal M. Sodano L et al. the existence of multiple place.2 TB infection control health-care facilities.1. Geneva: WHO.1. accessed 31 August 2016.3). WHO has al. 3 World Health Organization. This puts health-care workers at greater risk of TB infection 5 World Health Organization.207(1):9–17. TB and HIV programmes (Table 5. Japan. fragmentation of monitoring and with the general adult population should be close to 1.4 Facilitating collection and analysis of data on evaluation of collaborative TB/HIV activities. and a large. data on the number of of infection control measures – comprising administrative. 5. accessed 31 August TB infection control is one of the components of Pillar 2 of the 2016). A guide to monitoring and evaluation for and disease. evaluation systems among multiple service providers.who. 102 GLOBAL TUBERCULOSIS REPORT 2017 . the relative risk of TB in health-care workers compared paper-based registers.3 Periodic assessment of TB infection control preparing for organ transplantation – were reported by the in health-care facilities is essential to ensure that appropriate Netherlands. Infuso A. 2015 (http://www.1. people eligible). These countries reported providing preventive at national and subnational level should provide managerial treatment to children aged 5 years or more and to adult direction to implement TB infection control measures.1).int/ tb/areas-of-work/preventive-care/checklist_for_periodic_evaluation_of_ mission is high in health-care and other congregate settings.

who. Fig. demographic. the existence of a DHIS2 system. provision of the BCG vaccine may care workers to the rate in the general adult population are be limited to neonates and infants in recognized high-risk shown in Fig. with The application is freely downloadable from the WHO support from the European Respiratory Society. such as the availability of national unique into existing national electronic surveillance systems. However. Currently.1 In five high TB/HIV burden countries for which the ratio could Among 178 countries for which data were collected. and the is designed to help health-care workers to collect client presence of different risk groups. A global consultation on LTBI convened by WHO in 2016 recognized the potential role of digital health in facilitating implementation of the programmatic management of LTBI. 5. Lithuania. Indicators are disaggregated by risk groups at management of LTBI remains weak in many countries. This facilitates the are involved.bcgatlas.4. The application generates unique a http://www. n A mobile application for case-based recording and reporting for LTBI BOX 5. tuberculosis and the risk of progression from tscoveragebcg.html. websitea and can be adapted to meet country-specific The application uses DHIS2 software and can be integrated contexts.3 TB vaccination There is a clear need for a vaccine that is more effective 1 The BCG world atlas 2nd Edition. Georgia. the highest rate observed in Mozambique. preventive treatment. to international standards was developed by WHO.int/immunization_monitoring/globalsummary/timeseries/ infection with M.who. care workers could be calculated for 54 of the 60 countries. Mexico and the Bolivarian Republic of Venezuela). individuals in high-risk groups. a mobile phone application to facilitate monitoring and provision of preventive treatment and follow-up visits. Colombia. Using an online dashboard. It identifiers. WHO is planning to start variables (e. http://www. in particular to reduce the risk of 2 http://apps. or to older children who are skin-test negative for TB (Burkina Faso. infection. The ratio was above two in seven countries groups. which are associated with high mortality in infants and young The notification rate among the general adult population children. The latest data on BCG coverage2 (for 2016) are shown in 5.g. the remaining (Botswana and Mozambique) and below 1 in three countries countries had policies of selective vaccination for at-risk (Angola. a single dose of the BCG vaccine should notified TB cases in adults and the estimated size of the adult be provided to all infants as soon as possible after birth as populations from the United Nations population division (2017 part of childhood immunization programmes. and the associated monitoring and evaluation. it BCG vaccination has been shown to prevent disseminated ranged from zero to 701 cases per 100 000 population. If required. the ratio was between 1 and 2 in two countries recommended universal BCG vaccination. in countries with in each country was calculated based on the number of a high TB burden. 8144 TB cases among health-care workers were infection to active TB disease in adults. expected in the near future (Chapter 8). implementation of the End TB Strategy. accessed 25 July 2017. China and Namibia). with low TB incidence rates. with disease. national.int/tb/areas-of-work/preventive-care/ltbi/ltbi_app/ identifiers (based on the demographic data) that allow en/ (accessed 9 October 2017) In 2016. clinical and treatment field-testing of the application to investigate access and outcome variables) required to monitor indicators for TB acceptability in several settings later in 2017. 5. accessed 25 July 2017. The ratios of the TB notification rate among health. Dominican Republic.org/index. Although there are 12 reported from 60 countries.1 Coverage of contact investigation and treatment of LTBI case-based recording and reporting. GLOBAL TUBERCULOSIS REPORT 2017 103 . After the consultation. China accounted for 39% of these candidates in the TB vaccine pipeline. this category includes TB meningitis and miliary TB. 153 be calculated. data n among child contacts and people living with HIV are both can be entered offline and synchronized to the central in the 10 indicators listed as highest priority for monitoring database later. users can track indicators in systematic monitoring and evaluation of the programmatic real time. The dashboard The establishment of monitoring systems is particularly also provides geospatial data and allows users to visualize challenging when multiple health-care service providers the location of clients on a map. a new TB vaccine is not cases and Brazil for 13%. evaluation of programmatic management of LTBI according particularly for household contacts.php. than the BCG vaccine. WHO recommends that.5 summarizes national policies on BCG vaccination. In countries revision). The notification rate among health. subnational and facility levels.

The country recommends BCG vaccination only for specific groups. accessed 25 July 2017. http://www. Source: The BCG World Atlas 2nd Edition. FIG. 2016 Notification rate ratio 0–0. 5. 104 GLOBAL TUBERCULOSIS REPORT 2017 .9 ≥3 No data Not applicable FIG. B.org/index. but currently does not. 5. The country currently has a universal BCG vaccination programme.4 Notification rate ratio of TB among healthcare workers compared with the general adult population.9 1–1. The country used to recommend BCG vaccination for everyone. C.5 BCG vaccination policy by country BCG recommendation type A B C No data Not applicable A.9 2–2.bcgatlas.php.

and 12 reported coverage of at least 90%.6 Coverage of BCG vaccination. Source: http://apps. Among the 30 high TB burden countries. Fig.6. 5. In addition to Angola and Nigeria.int/immunization_monitoring/globalsummary/timeseries/tscoveragebcg.FIG.who. In the 154 countries that reported data. Mozambique. coverage was below 80% in two other high TB burden countries: Lesotho and Papua New Guinea.html. the United Republic of Tanzania and Zambia. China. 5. accessed 25 July 2017. but is typically for the number of live births in the year of reporting. 2016a Percentage 0–49 50–89 90–100 No data Not applicable a The target population of BCG coverage varies depending on national policy. 111 reported coverage of more than 90%. coverage ranged from 58% in Angola and Nigeria to 99% in Cambodia. GLOBAL TUBERCULOSIS REPORT 2017 105 .

Malawi SIMON RAWLES / ALAMY STOCK PHOTO .Patients queue at a hospital pharmacy in Zomba.

46% of the available funding for TB in 2017 (and The median cost per patient treated in 2016 was 48% of the world’s notified TB cases).1 billion in 2017. GLOBAL TUBERCULOSIS REPORT 2017 107 . a marked increase occurred in the TB- KEY low. This followed high-level (Prime AND that are currently available. US$ 5. diagnosis and treatment n The Stop TB Partnership’s Global Plan to End TB.2 billion for HIV. and an single largest source (80% of the total) is the Global additional US$ 9.8 billion for TB. Geneva: Stop TB Partnership. but the amount for 2016 budget of US$ 280 million). diagnosis and treatment of multidrug-resistant TB including US$ 387 million (74%) from domestic (MDR-TB) increases from US$ 2. US$ 52 billion specific budget and the domestic funding for this FACTS is required over 5 years to implement interventions budget in 2017. To provide some context middle-income countries in 2017. funding in low-income countries. this figure the Global Plan. 2016–2020. a further US$ 6. show disbursement totals of close the funding gaps.3 programmes amounts to US$ 1. US$ 6. the US$ 2. the latest estimates (for 2015) of (84%) is from domestic sources. Increased domestic and and Development (OECD) creditor reporting system. which increases to US$ 12. The amount required for Ministerial) political commitment to an ambitious MESSAGES 2017 is US$ 9. international donor funding remains crucial. US$ 1. 56 million for malaria and India. The and treatment of drug-susceptible tuberculosis (TB) budget in 2017 is US$ 525 million (almost double the (e.CHAPTER 6. notified TB cases. and is fully funded. which also provides about one-third of middle-income countries with 97% of the world’s the contributions received by the Global Fund.8 billion for malaria Of the total US$ 6. in disease. international donor commitments are needed to which are for 2015.0 billion in 2017 to sources (triple the 2016 amount of US$ 124 million).6 billion by 2020.and middle-income countries. the Russian Federation. with 95% US$ 1253 for drug-susceptible TB and US$ 9529 for (range 89%–100%) of their funding coming from MDR-TB. the remainder is for TB/HIV International donor funding reported by national TB interventions. The largest bilateral donor is the United States Based on data reported to WHO by 118 low.3 billion compared contributions for HIV and malaria. Tuberculosis and Malaria.org/global/plan/.6 billion annual requirement included in Although an increase from previous years.and and US$ 0. US$ 6.g. diagnosis and treatment in 2017. Financing for TB prevention.8 billion for these amounts. and development. The billion is needed for high-income countries.9 billion available in 118 low. 2015 (http://www. The latest data with the estimated requirement for this group of from the Organisation for Economic Co-operation countries in the Global Plan.0 billion in 2017). Health financing data from national health accounts accounting for 48% of the funding available in the 25 provide important insights into the current status high TB burden countries outside BRICS (which have of progress towards universal health coverage.stoptb. domestic sources. a The Global Plan to End TB. US$ 7. Most of this funding is for diagnosis a new national strategic plan for TB 2017–2025.and government.9 billion is available for International donor funding for TB falls far short of TB prevention. the country with the largest burden of TB 2016–2020a (the Global Plan) estimates that. 67 million for HIV/AIDS. BRICS accounted for 40 million for TB. China and South Africa). this the burden of disease in terms of disability-adjusted aggregate figure is strongly influenced by the BRICS life years (DALYs) lost due to illness and death are group of countries (Brazil. US$ 3. accessed 14 July 2017).0 billion is needed for TB research Fund to Fight AIDS.2 billion. and remains much less than donor still represents a shortfall of US$ 2.3 goal of ending TB by 2025 and the development of n billion in 2020. as 38% of the world’s notified TB cases) and for 56% of discussed in Chapter 7. In other countries with a high TB burden. In India. From 2016 to 2020. However.

Lancet Glob Health.1). 108 GLOBAL TUBERCULOSIS REPORT 2017 .1 Measurement of costs faced by TB patients and their Estimates of funding required for TB prevention. 2016–2020 (the Global Plan).0 billion is needed for global TB End TB Strategy (Section 6.pdf. growing from groupings (Section 6. Estimates treatment requires adequate funding sustained over many of the funding required to achieve these milestones have years. 5 and requirements to meet 2015 targets. FIG.0 billion for drug-resistant TB7 and the remainder for by category of expenditure and country group (Section 6. Domestic and donor financing for tuberculosis care and control in low-income and middle-income countries: an analysis of trends.2. the percentage of TB patients and their households who 2016–2020 face catastrophic costs as a result of TB disease. an estimated total of US$ 9. These two topics – analysis of 10 health financing data. Geneva: WHO. 2002–11. this figure is instead included in estimates of funding required As highlighted in the previous two editions of the Global for HIV.6 trends in funding for TB prevention. to increase between 2016 and 2020. Treatment Action Group.and middle-income countries. US$ 2. 7 2015 (http://apps.who.1 Estimates of funding required to 0 achieve the 2020 milestones of the 2016 2017 2018 2019 2020 End TB Strategy The 2020 milestones of the End TB Strategy are a 35% Drug-susceptible TB MDR-TB reduction in TB deaths compared with deaths in 2015. with breakdowns TB.nih. The third section analyses funding gaps reported billion (75%) for diagnosis and treatment of drug-susceptible by national TB programmes (NTPs) to WHO. accessed 14 July 2017). a 20% TB/HIV collaborative activitiesa reduction in the TB incidence rate compared with 2015. WHO began annual monitoring of funding for TB in been set out in the Stop TB Partnership’s Global Plan to End TB. The 2020 milestone of zero set for this indicator requires progress 14 in terms of both UHC and social protection (included under 12 Pillar 2 of the End TB Strategy). 6. the total amount reviewed publications. It then presents and discusses research and development in the same period. Global tuberculosis report 2015.int/iris/bitstream/10665/250441/1/9789241565394. with findings published in global TB reports and peer.5 Worldwide.org/global/plan/.1 required for implementation of TB prevention. estimates of the funding that could be provide important insights into progress towards universal mobilized from domestic and international donor sources health coverage (UHC).3 billion in 2016 to US$ 12 billion in 2020 (Fig.gov/pubmed/25104145.int/tb/publications/global_report/archive/en/. Fitzpatrick C.and middle- of the three high-level indicators of the End TB Strategy. which is necessary to achieve the End TB Strategy milestones set for 2020 and 2025 (Chapter 2). 2015 115 (http://www. In data for 2017 are also presented for the 30 high TB burden 2017. Global tuberculosis report 2016.who. 1 The most recent publication is: Floyd K. 8 2016 (http://apps.int/tb/data accessed 20 July 2017). diagnostic and This chapter has four main sections. diagnosis and treatment Of the US$  58 billion required over 5 years (excluding by category of expenditure and source of funding for the research and development). Geneva: WHO. 2002.2 billion is required: US$ 7. World Health Organization.1). Such costs are included in global estimates of the funding required for HIV.pdf. rising from US$ 9. The amount for TB/HIV interventions is The final section provides the latest estimates (for 2016) of the comparatively small because it does not include the funding unit costs of treatment for drug-susceptible TB and multidrug. 4 www. TB/HIV interventions.3 analysis of health financing data can In the Global Plan. 6. resistant TB (MDR-TB) (Section 6. Increased funding is required to close 3 World Health Organization.0 countries. accessed 14 July 2017). 2016–2020.8 tuberculosis report. accessed 14 July 2017).stoptb. households is also required to assess progress towards one diagnosis and treatment in low. Raviglione Source: Data from Stop TB Partnership Global Plan to End TB 2016–2020. M.who.ncbi.2 An additional US$ 9. published by UNAIDS. accessed 14 July (http://www. diagnosis and costs as a consequence of TB disease (Chapter 2). eng. Pantoja A. an estimated US$  52 billion is period 2006–2017.nlm.int/iris/bitstream/10665/191102/1/9789241565059_ The burden of drug-resistant TB (in terms of cases per year) is not projected eng. Geneva: Stop TB Partnership. and a Funding estimates for TB/HIV exclude the cost of antiretroviral therapy (ART) for that no TB patients and their households face catastrophic TB patients living with HIV. More detailed country-specific US$ 8. and measurement of costs faced by TB US$ billions 8 patients and their households – are discussed in Chapter 7. Geneva: WHO. is discussed further in Chapter 8.4).who.5 billion in 2016 to US$ 14 billion in resources required to achieve the 2020 milestones of the 2020. It starts with a treatment interventions is US$ 58 billion for the period 2016– summary of the most up-to-date estimates of the financial 2020. which is monitored by the 2 World Health Organization.1(2):e105– The Global Plan to End TB.4 4 2 6. Further country-specific data on TB financing can be found 6 in finance profiles that are available online. that income countries in the Global Plan to End TB is. Progress in tuberculosis (TB) prevention.2). detection and treatment gaps (see also Chapter 4). Funding for TB research and development. 6 2017). needed for antiretroviral therapy for HIV-positive TB patients.3). 2013. published by UNAIDS. 2016 (http://www. Global tuberculosis report 2016. both globally and for major country required in low.

China.2). Tuberculosis and Malaria (the Global 97% of the global number of TB cases notified in 2016. 118 countries with 97% Recent estimates of the funding required in low. GLOBAL TUBERCULOSIS REPORT 2017 109 . 6. funding sources. overall and by category of expenditure and source of funding. diagnosis and The costings in the Global Plan can thus be seen as the financial treatment in total and by category of resources required for Pillars 1 and 3 of the End TB Strategy. The Fund). These countries accounted for Fund to Fight AIDS. it was estimated summarized in Box 6.1 For eligible countries. The shortfall to accessing care. 6.6 billion for TB prevention. investments required to increase the overall coverage and all figures are in constant 2017 dollars).3. up from US$ 6. expenditure. Drug-susceptible TB 2006–2017 4 Data reported by NTPs to WHO since 2006 were used to MDR-TB analyse funding trends for 2006–2017 in 118 low. as explained in FIG.2 The 118 low. of reported cases income countries to achieve UHC by 2030 are presented and 8 US$ billions (constant values for 2017) discussed in Chapter 7. 6. 2006–2017a a Countries were included in trend analyses if at least three years of high-quality finance data were available in the period 2006–2017. Despite this growth in quality of health-care services or to remove financial barriers funding. amounts fall short of what is needed. the 0 Russian Federation and about half of the other 52 countries classified as 2007 2009 2011 2013 2015 2017 upper middle income.3 Chapter 2 and as reflected in Pillar 2 of the End TB Strategy. Progress on these fronts is critical.2 TB funding.and middle.and middle. 2006–2017. treatment and care interventions. billion in 2017.3 billion that was available in 2006 (Fig. not only for TB.and middle-income countries included in analyses of TB financing. 2 Other TB/HIV 1 Countries not eligible to apply to the Global Fund include Brazil.3 billion in 2016 and more than The Global Plan did not attempt to assess the broader double the US$ 3. diagnosis and treatment reached US$ 6.9 per year) would need to be provided by international donors. review and analyse financial data are amounted to US$  29  billion.and middle-income countries. Funding for TB prevention.FIG 6. the funding required over 5 years methods used to collect. were restricted to countries eligible to apply to the Global income countries (Fig. and that the remainder (an average of US$ 2. that about US$ 16 billion could be mobilized from domestic In these 118 low.1. Such investments are needed for many essential preventive. Of this total. Total 6 6.

also by category of expenditure and source of funding. For MDR-TB. WHO analyses of income level) were asked to report on the use of of TB financing have always included estimates of the 110 GLOBAL TUBERCULOSIS REPORT 2017 . including surveys. and TB preventive treatment for data reported to WHO included discussions with NTP people newly enrolled in HIV care).  routine checks for plausibility and consistency. For low. advocacy and communication. All data are stored in the with drug-susceptible TB and MDR-TB on a per-patient WHO global TB database. the comparisons with other data sources are available and from WHO upon request. were asked to report funding requirements and Usually.1 reported to WHO n WHO began monitoring government and international inpatient and outpatient care for treatment of people donor financing for TB in 2002. They are combined with other data  the funding they estimate will be needed for TB to estimate the financial resources used for TB treatment prevention.e purchase of office equipment and vehicles. reported for first-line and second-line drugs. The standard methods used basis (i. recording comprehensive budgets for national strategic plans and reporting of notifications and treatment for TB are an essential requirement for funding outcomes. applications submitted to the Global Fund.  triangulation with other data sources – such  first-line drugs. by HIV programmes. also considered domestic funding. the Global Fund. the categories of expenditure for drug. in 2017 all high-income countries development of national strategic plans. a separate category of drugs per patient treated has been asked. and to There is also a separate category for collaborative TB/ identify whether reported budgets include funding for HIV activities (this excludes any budget items financed buffer stocks. in total reported funding by source and data has been maintained as far as possible to enable by category of expenditure). policy development. NTP managers and provincial or district TB coordinators). or implausibly high or monitoring of trends. to allow for patient support was included. and  NTP staff at central and subnational levels (e. queries. validate and analyse financial data BOX 6. or on the expected use of services based on the typical approach used to Each year. validate and analyse these data have and the average number of outpatient visits to a health been described in detail elsewhere. and individual and Fund. by category of expenditure and source of expenditures (further details are provided below). customized follow-up with in-country staff involved in the As in previous years. such as antiretroviral therapy for TB In 2017. to compile. TB funding reported by NTPs does not include expenditures in total. particular attention has always been given to the high TB burden countries. meetings. They include: year. funding. only a few outpatient care required during TB treatment. linked to the emphasis reviewers to better assess the validity of budgets on financial and social protection in the End TB Strategy. show that these costs can account for a large share of As in previous years. the average number of days spent in hospital. discussions with NTP staff and grant financing from sources other than the Global during workshops on TB modelling. of TB patients (that differ substantially from prices susceptible TB used in the 2017 round of global TB data quoted by the Global TB Drug Facility). the fiscal online reporting system – examples of validation years were 2016 and 2017. an extra question about the average cost related to MDR-TB.g. and The core methods used to review and validate data have  expenditures for the most recently completed fiscal remained consistent since 2002. diagnosis and treatment in their current that are not reflected in NTP-reported budgets and fiscal year. services (preferable where available). Since many countries reported financing data and therefore data for detailed costing studies in a wide range of countries high-income countries are not featured in Chapter 6.and middle-income low values of funding for drugs relative to the number countries. collection were:  discussions with country respondents to resolve  laboratory infrastructure.  operational research. sources include estimates of unit costs from  programme costs (e. A breakdown of the staff at the June 2017 meeting of WHO’s Strategic and total amount of available funding is requested in four Technical Advisory Group for TB and an associated categories: domestic funding excluding loans.d and funding activities.g.g. including validation checks that are built into the In the 2017 round of global TB data collection. external summit in which NTP managers from the 30 high TB loans. public– applications to the Global Fund. Further details about private mix activities and community engagement). However. n Methods used to compile. These data can be based on actual use of summary.a.and middle-income deliver treatment (which may be defined in national countries to report: policy documents). two expenditure categories were used: second-line drugs and programme costs specifically Since 2014.e. burden countries participated. specific efforts to improve the quality of financial patients living with HIV. equipment and supplies.b this box provides a facility). Starting in 2015. management and supervision independent economic evaluationsc. In review and validation of data. WHO asks all NTPs in low. in 2017 all countries (irrespective the cost of treating someone with TB. review. Consistency in categories of checks are checks for implausibly large year-to-year expenditure used to report TB budget and expenditure changes (e. training. without any breakdown by category the financial costs associated with the inpatient and of expenditure or source of funding.

most countries with a high burden of MDR-TB (for details. Costs to health services and the patient expenditure data for drug-susceptible and MDR-TB that are being of treating tuberculosis: a systematic literature review. GLOBAL TUBERCULOSIS REPORT 2017 111 .0 billion in 2017 estimated in the Global outpatient care for TB patients is accounted for by middle-income countries. Dye C.3).7 billion in 2017. accessed May 2017 and country financial gap analysis materials approved Congo. South Africa. accessed 13 July 2017 (http://ghcosting.9 billion available compared in detection and treatment of MDR-TB. and this remains the from 2014 to 2016. For four countries (India. h Health accounts.ncbi.gov/pubmed/17639216.who. and then slightly increased from 2016 to case in 2017 (Fig. However. Griffiths UK. via general for diagnosis and treatment of MDR-TB needs to increase budget support to the health sector). in 2017.5 and Fig. Pharmacoeconomics. 2013.2 billion).theglobalfund. 2011 Department has initiated a process to assess the validity of the (http://www.nlm. This aggregate trend reflects the pattern of the total funding of US$ 6. both globally and in with an estimated requirement of US$ 9. US$ 5. However. 6.nlm. Floyd K. compared with the Global Plan estimate (Section 6.gov/pubmed/25104145. as explained above).h After review. see Of the total US$ 6. c Global Health Cost Consortium unit cost study data repository. 6. 2007. Democratic Republic of the odata/. or from recent studies and discussions with experts accessed 28 July 2016). China and South Africa) (Fig. Fitzpatrick C. outpatient visits and days of inpatient care per patient (reported reporting of funding from these levels (including TB-specific by NTPs each year) by the cost per bed day and per clinic visit budgets) is a particular challenge in large countries with available from the WHO CHOosing Interventions that are Cost- decentralized systems for TB treatment (e.funding required for both inpatient and outpatient care. where a downturn 1 Domestic funding includes both funding for TB-specific budgets and funding after 2014 is explained by decreasing funding in the Russian for inpatient and outpatient care (usually funded through more general Federation (2014–2017) and South Africa (2013–2016). it is assumed that funding for inpatient and outpatient care is funded Funding in other countries has been increasing (Fig.and India. comprehensive reporting of domestic funding for TB. accessed 29 July 2016).int/choice/ to estimates based on reported use and unit costs estimates cost-effectiveness/inputs/health_service/en/. 2008 (http://www.3 billion). Funding for MDR-TB reached US$ 1.1 Thus. data shared by WHO Health Governance and Financing Department on 11 July 2017. billion available in 2017. where international donor funding for such components of care is unlikely Plan is comparatively small (US$ 0. from WHO-CHOICE. This is evident from large and persistent gaps US$  2. Namibia.gov/pubmed/25939501. WHO-CHOICE estimates were replaced analysis of trends. accessed 13 July 2017).who. This is US$ 2.8 billion (84%) 2017 (Fig. 6. accessed tracked through the System of Health Accounts (SHA). These estimates are done separately for drug-susceptible TB and MDR. the SHA data were used in preference Cost effectiveness and strategic planning (WHO-CHOICE): health service delivery costs. July 2016). 2015. The WHO Health Governance and Financing g OECD/Eurostat/WHO. Nigeria and Effective (WHO-CHOICE) database. account data.ncbi. Raviglione M. 6. data were available for 27 countries for one or two years. Pantoja A.7 in the Global Plan. It is also evident from the Global Plan.1 billion less than the requirement estimated billion in 2020. budget lines). Bull World Health Organ. including e Global Fund Data and the Open Data Protocol http://web-api. Financing tuberculosis control: the role of a global TB. f of Tanzania).org/ six high burden countries (Cambodia.3 billion in 2017 (US$  6. declined been provided from domestic sources.4). number of TB patients notified or projected to be notified. sources.9 billion available in 2017.g In 2017. costs per bed day and per clinic visit were estimated financial monitoring system. a Floyd K. In 2017. Pantoja A.1. supporting the costing of national strategic plans. Although much of this contribution is probably for delivery WHO estimates the funding used to provide inpatient and of inpatient and outpatient care (which is included in current outpatient care for TB patients by multiplying the number of WHO estimates of domestic funding for TB. 2002–11. and existing disease-specific tracking systems may facilitate more do not include the costs faced by TB patients and their households. SHA 29 July 2016). the Overall. Geneva: World Health Organization. Lancet Glob with estimates of unit costs obtained directly from national health Health.nih.5). b from the World Bank. accessed 29 latest results from the new SHA.nih. especially Increasing attention is now being given to costs faced by TB reporting of the contributions from subnational administrative patients and their households.org/pages/data/ucsr/app/index) Where possible. in which (73%) is for the diagnosis and treatment of drug-susceptible the annual funding required for MDR-TB reaches US$ 3. the Philippines.g.nih.4). including disease-specific results. as discussed in Chapter 7. Indonesia. 6. Sierra Leone and United Republic for funding in the first rounds of New Funding Model.6. Russian Federation. more than double the amount of US$ 1. most funding during the period 2006–2016 has annual amount increased steadily from 2006 to 2014.pdf. Domestic and donor financing for tuberculosis care and control in low-income and middle-income countries: an Thailand and Viet Nam). funding (such support is more likely to occur in low-income countries. aggregated figures for the 118 low. A system of health accounts. Vassall A. These Expanded implementation of SHA and validation against costs have been estimated from a provider perspective only. 6.ncbi. and requirements to meet 2015 targets.1) is substantially. US$ 4.int/health-accounts/methodology/sha2011. This is justified on the basis The shortfall between the funding available in 2017 and the that most (93%) of the funding estimated to be used for inpatient and requirement of US$ 2. Geneva: World Health Organization. In Fig.1(2):e105–115 (http://www.f and then by the reported South Africa). as also explained in Box 6.8 billion Chapter 4). OECD Publishing.85(5):334–340 using the CHOICE regression model and the latest data available (http://www. domestically and not by international donors.33(9):939–955 (http://www.9 billion for TB is from domestic in the BRICS group of countries (Brazil. levels that are not always known or compiled at the national level. estimates are compared with hospital and clinic d Laurence YV.6 TB.nlm.

funded from domestic sources in 2017 ranges from 0. In the group of nine low-income high TB US$ 3 billion for inpatient and outpatient care in 2017 is accounted for by middle. In 23 of the 30 high 2 International donor funding TB burden countries. While domestic funding 30% in Namibia to 100% in the Russian Federation. 6. and the remainder (11%) were in other countries. international 2017. Table 6.8% in Bangladesh to 88% in Congo. 6.7. most (80%) was treatment by funding source. the proportion ranges from inter­ national sources (Fig.7 and recent developments in India illustrate a the potential to increase domestic funding in some high TB Domestic funding includes TB-specific budgets and the estimated resources used for inpatient and outpatient care (see Box 6.1).2. including BRICS where (Chapter 3). by country groupa BRICS (n=5) 25 TB HBCs outside BRICS Other countries (n=88) US$ millions (constant values for 2017) 2000 1000 1500 1500 750 1000 1000 500 500 500 250 0 0 0 2007 2009 2011 2013 2015 2017 2007 2009 2011 2013 2015 2017 2007 2009 2011 2013 2015 2017 Drug-susceptible TB MDR-TB a BRICS accounted for 48% of the world’s notified TB cases (2016). 112 GLOBAL TUBERCULOSIS REPORT 2017 . 3 2016–2020 is explained in Chapter 2. the country with the largest burden of TB disease country groups shown in Fig. These are discussed in more detail in Chapter 7. such countries do not typically receive international donor funding for inpatient and outpatient care services. burden countries. the proportion of the reported TB budget income countries. 6. FIG. Of this. diagnosis and amounts to US$ 1. 2007 2009 2011 2013 2015 2017 Both Fig. reported by NTPs. and the development of a new national strategic plan levels of domestic funding in the 25 high TB burden countries for TB 2017–2025 that aims to accelerate progress towards outside BRICS (48% of the total in 2017).6. 6. 6.2 a complementary analysis based US$ billions (constant values for 2017) on donor reports to the Organisation for Economic Co- Total operation and Development (OECD) is provided in Box 6.6).2).1. 2006–2017. there was a marked increase in both the TB- domestic funding accounts for 95% of total funding in 2017 specific budget and the domestic funding for this budget in (range 89%-100% among the five countries). more than 80% of funding for the TB- specific budgets included in national strategic plans for TB is 0 from international donors in 2017.3 6 The importance of international donor funding in high TB burden countries is particularly evident when considering only 4 Domestic fundinga the TB-specific budgets included in national strategic plans for TB (Fig. Table 6. Table 6. FIG.2. 2006–2017. because funding 118 countries with 97% of reported TB cases reported by NTPs to WHO does not capture all international 8 donor funding for TB. 93% of the funding of burden countries.4 Funding for drug-susceptible TB and MDR-TB. 6.1 2 Donor funding is also provided to entities other than NTPs. However.3% in Zimbabwe to 24% in Liberia. provided by the Global Fund. The 25 high TB burden countries outside BRICS accounted for 38% of the world’s notified TB cases (2016). In the group of 15 lower-middle- income high TB burden countries the proportion ranges from middle-income countries conceal substantial variation 6. dominates in eight of the nine (not mutually exclusive) In India. political commitment to an ambitious goal of ending TB by income countries (56% of the total in 2017) and is similar to 2025. This increase followed high-level (Prime Ministerial) donor funding exceeds funding from domestic sources in low. 6.1 and Table 6.1 billion in 2017.5 International donor funding reported by NTPs to WHO Funding for TB prevention. In the group of six among countries in the share of funding from domestic and upper-middle-income countries.7. The countries are those listed in Out-of-pocket expenditures are also not included in the financing data Fig. including international and national governmental and nongovernmental 1 The list of 30 high TB burden countries being used by WHO during the period organizations.

5 1 0 0 0 2007 2009 2011 2013 2015 2017 2007 2009 2011 2013 2015 2017 2007 2009 2011 2013 2015 2017 g. Upper-middle-income countries US$ billions (constant values for 2017) 0. Rest of worlda US$ billions (constant values for 2017) 3 0.5 3 0.1 0. 9 country groups a. 6.4 1 1 0. BRICS b.6 1.6 2 2 1. Asiab i. Africa h.2 1. Lower-middle-income countries f. 2006–2017. and the Region of the Americas.2 0. GLOBAL TUBERCULOSIS REPORT 2017 113 . 25 HBCs outside BRICS c.3 4 2 3 0.6 Funding for TB prevention. FIG. c Other regions consist of three WHO regions: the Eastern Mediterranean Region.5 2 1 0.5 1 0 0 0 2007 2009 2011 2013 2015 2017 2007 2009 2011 2013 2015 2017 2007 2009 2011 2013 2015 2017 Domestic funding International donor funding a Rest of the world includes 88 countries that are not in the list of 30 high TB burden countries.4 1 2 0. diagnosis and treatment from domestic sources and international donors.5 0. b Asia includes the WHO regions of South-East Asia and the Western Pacific. Low-income countries e.5 0 0 0 2007 2009 2011 2013 2015 2017 2007 2009 2011 2013 2015 2017 2007 2009 2011 2013 2015 2017 d.2 0. the European Region. Other regionsc US$ billions (constant values for 2017) 0.8 4 2 0.

Japan and the United Kingdom also provided funding streams directly to countries in addition to their disbursements to the Global Fund. increased from US$ 220 million in 2006. the World Bank (1%). US$ 199 million). Almost half of all funding from the US was given bilaterally. France. diagnosis and treatment to non-OECD countries.1 shows trends in international donor FIG.2. In 2015. In 2015. This pattern may reflect the transition to a new funding model that started in 2013. Disbursements from the US government steadily increased from 2004 to 2014. diagnosis and treatment. B6. such as grants from the United States (US) National Institutes for Health flowing to the United Kingdom. such as in-kind transfers or technical assistance. and some associated delays in approving and disbursing funds. the second largest contributor 600 Global Fund was the US governmentc (26%. and a further two non-committee members (Kuwait and the United Arab Emirates). is not captured in the CRS. 2015 USA Asia United Kingdom Africa France Germany Europe Other countries Americas Multilaterals Global Fund Japan Oceania 114 GLOBAL TUBERCULOSIS REPORT 2017 . sources.2 shows the flow of TB funding in 2015. 2006–2015 US$ 754 million. the Global Fund was consistently the largest provider of international donor funding.1 funding between 2006 and 2015. Asia received the largest share of TB FIG. The United Kingdom remaining funding came from the United Kingdom 200 World Bank Other (3%). 64% of international TB donor 800 US$ millions (constant values for 2015) funding was provided by the Global Fund (US$ 484 million).2. B6. The creditor reporting system (CRS) of the OECD is the most comprehensive source of information about international donor funding. The total from all sources in 2015 was diagnosis and treatment by source. the 26 countries that are members of the OECD’s Development Assistance Committee.b Fig.2 based on donor reports to the OECD n Not all international donor funding that is provided for TB prevention. Funding for TB that flows from one OECD member to an institution or government within the OECD. Data on gross disbursementsa for TB (code 12263: Tuberculosis control) received by non- OECD countries during 2006–2015 were analysed.2 International donor funding flows for TB prevention. primarily to non-OECD countries in Asia and Africa.c Fig. n International donor funding for TB prevention. peaking at US$ 249 million in 2014 and then declining in 2015 to US$ 199 million. Disbursement data include both direct transfers to countries and the provision of goods and services. about 400 47% of international donor funding for TB globally United States originated from the US government in 2015. government contributions to multilateral organizations are not attributed to the government of origin. diagnosis and treatment is channelled through NTPs. 2007 2009 2011 2013 2015 From 2006 to 2015. but a marked drop occurred from a peak of US$ 712 million in 2013 to US$ 399 million in 2014. B6. within which the largest contributing country was 0 Belgium. Germany.2.2. Also. followed by a recovery to US$ 484 million in 2015. from five major International donor funding for TB prevention. Funding data (both commitments and disbursements) are provided by 31 multilateral donor organizations. Given that about one third of the contributions to the Global Fund are from the US government. only to the multilateral organization. and other sources (6%). BOX 6. B6.

This trend is mostly explained by large reductions in the funding gaps reported by China. and have in 2016). Relative to total funding The median cost per patient treated for drug-susceptible TB in needs.9 billion available in and MDR-TB was estimated for 111 and 80 countries. 6.2.75 billion (81%) is for drug-susceptible TB and 6. which reported funding gaps in TB programmes.1) and the US$ 6. 6. Funding (US$ 215 million). HIV b An important example is funding from the Global Fund to non-OECD countries. Fig. and analytical methods are summarized in Box 6. estimates were restricted to reported funding gap (US$ 626 million) in 2017 (Fig. US$  0. the funding gap is larger for drug-susceptible TB than 2016 was US$ 1253 (Fig.11. Fig. TB d Source: http://ghdx.3 shows that International donor funding for TB. fallen in recent years.9). national strategic plans for TB are and high MDR-TB burden countries were included in the less ambitious than the targets set in the Global Plan (Section analyses. accessed on 13 July 17. Of the US$  0.2). and the actual amount of funds mobilized) have persisted. GLOBAL TUBERCULOSIS REPORT 2017 115 .org/gbd-results-tool.3 funding (50%). 6.1 Drug-susceptible TB US$ 0. Funding gaps were relatively small in upper- from domestic sources (triple the amount of US$ 124 million middle-income countries in 2017 (US$ 97 million).2 billion estimated to be needed in TB. FIG. 6. Fig. including US$ 387 million (74%) (Table 6. Most of the remaining gap was reported gaps (i. many NTPs continue to be unable to mobilize 2017 is accounted for by countries in the WHO African Region all the funding required for full implementation of their (US$ 502 million). 2016 low. half of the total reported funding gap in donor sources. which may not materialize. 6. Kazakhstan 6.9). This is less than half of the gap of US$ 2.9 6.3 Funding gaps reported by national and the Russian Federation.8 shows that the budget in 2017 is US$ 525 Democratic Republic of the Congo (US$  28 million) and the million (almost double the budget of US$ 280 million in 2016).3. followed by Africa (36%). the difference between assessments by NTPs of in the South-East Asia Region. In 2015.4 Unit costs of treatment for drug- billion. 0 2007 2009 2011 2013 2015 this goal. the few countries.9. 2006–2017 2006–2011 but negligible or zero gaps thereafter. and in 2017 they amounted to a reported total of US$  0.4. Table 6. respec­ 2017 (Section 6. In countries that reported at least 10 patients on second-line treatment for 2017.7. about 60% of this for MDR-TB (not shown). For further details about both lists. 6. Ethiopia (US$  36 million). in many countries. 1 Analysis for drug-susceptible TB was limited to countries that notified at Lower-middle-income countries account for the largest least 100 TB cases in 2016. 6. B6. B6.1). primarily by Indonesia (US$ 98 funding needs for TB prevention.3 In general.1 All countries in the lists of high TB burden countries fact that.d 6 a As opposed to commitments. The disability-adjusted life malaria. see Chapter 2. Fig. Despite growth in funding from domestic and international Geographically. For MDR-TB.3 billion that susceptible TB and multidrug-resistant exists between the US$ 9.and middle-income countries in 2017 according to the The cost per patient treated in 2016 for drug-susceptible TB Global Plan (Section 6. the largest funding gaps among low-income countries 2 MDR-TB. which is attributed to the Global Fund and not to the governments or other entities 4 that contribute to the Global Fund.1).2.e. the official allocation for TB was US$ 242 million 2 Malaria and there was additional funding of US$ 132 million for TB/HIV via the President’s Emergency Plan for AIDS Relief (PEPFAR).2 Unit cost estimates are shown in Fig.10).1). diagnosis and treatment. 56 million for malaria and 40 million for US$ billions (constant values for 2015) 8 TB. 6. with Nigeria reporting the largest gap national strategic plans (Fig. HIV and international funding for TB is less than half that for malaria and approximately one eighth that for HIV. were for high TB burden countries: the United Republic of 3 Median values are cited rather than means because of extreme values for a Tanzania (US$ 40 million).10 and 6. Democratic People’s Republic of Korea (US$  13 million) The budget is fully funded. million) and Bangladesh (US$ 36 million) (Fig. 2006–2015 years (DALYs) lost due to illness and death for these three diseases are 67 million for HIV/AIDS.18 billion (19%) is for MDR-TB.healthdata. c Disbursements from the US government captured in the OECD database are lower than official allocations. The difference can be explained by the tively.9 billion funding gap reported by NTPs in 2017.

7 Sources of funding and funding gaps for the TB-specific budgets included in national strategic plans for TB in 2017. 6. 30 high TB burden countries Low-income Liberia DPR Korea Central African Republic Ethiopia Mozambique Sierra Leone UR Tanzania DR Congo Zimbabwe 0 10 20 30 40 50 60 70 80 90 100 Lower-middle-income Congo India Angola Papua New Guinea Indonesia Philippines Kenya Lesotho Myanmar Cambodia Nigeria Zambia Viet Nam Pakistan Bangladesh 0 10 20 30 40 50 60 70 80 90 100 Upper-middle-income Russian Federation China South Africa Brazil Thailand Namibia 0 10 20 30 40 50 60 70 80 90 100 Percentage Domestic funding Global Fund International donor funding (excluding Global Fund contributions) Budget gap 116 GLOBAL TUBERCULOSIS REPORT 2017 . FIG.

funding gap and share of budget in national strategic plan for TB provided by domestic and international donor funding.8 43 12% 88% 36 Brazil 67 55 <0. 30 high TB burden countries.5 27 5% 95% 28 Ethiopia 84 10 38 20% 80% 37 India 525 387 138 74% 26% 0 Indonesia 185 53 34 61% 39% 98 Kenyaa 62 11 26 30% 70% 26 Lesotho 4.8 3% 97% 0 South Africa 244 220 24 90% 10% 0 Thailandb 20 15 3.3 24% 76% 0 Mozambique 32 1.0 21% 79% 0.3 1.2 6.1 UR Tanzania 70 1.4 Zimbabwe 18 <0.2 7.0 0.7 0.1 18 0% 100% 0 30 high TB burden countries 3 881 2 420 784 76% 24% 677 Blank cells indicate data not reported.8 3.4 1.3 40% 60% 13 DR Congo 57 1.1 Reported budget.9 0.3 China 384 369 11 97% 3% 4. the budget reported by Bangladesh is for the calendar year (as opposed to the fiscal year).7 0.2 2. available funding for this budget from domestic and international donor sources.5 14 20% 80% 19 Central African Republic 1.1 Namibia 56 17 10 62% 38% 29 Nigeria 336 31 90 26% 74% 215 Pakistan 108 7.9 20 23% 77% 44 Zambia 14 1. a In 2017.0 14% 86% 5.6 0.3 88% 12% 0 DPR Korea 27 5.1 100% 0% 12 Cambodia 37 3.TABLE 6.9 27 6% 94% 41 Viet Nam 70 5.9 27% 73% 0 Philippines 104 20 55 27% 73% 29 Russian Federation 1 175 1 175 0 100% 0% 0 Sierra Leone 6.9 7. Totals are computed prior to rounding.8 Liberia 1. 2017 (current US$ millions) BUDGET IN NATIONAL DOMESTIC INTERNATIONAL SHARE OF AVAILABLE FUNDING SHARE OF AVAILABLE FUNDING STRATEGIC PLAN FUNDING DONOR FUNDING (A+B) PROVIDED FROM FUNDING (A+B) PROVIDED BY GAPc FOR TB (A) (B) DOMESTIC SOURCES (%) INTERNATIONAL DONORS (%) Angola 14 3. GLOBAL TUBERCULOSIS REPORT 2017 117 . the budget reported by Thailand was for the central level only.4 30 4% 96% 0 Myanmar 78 13 65 16% 84% 0. c The funding gap reflects the anticipated gap for the year at the time a country reported data to WHO in the 2017 round of global TB data collection.2 20% 80% 0.6 60% 40% 7.0 Congo 2.6 8. b In 2017.5 71 10% 90% 30 Papua New Guinea 11 2.2 a Bangladesh 85 5.9 2. – indicates values that cannot be calculated.4 81% 19% 1.

7 44 9.7 0.2 10 71 Nigeria 336 223 100 13 13 4.7 1.3 1.3 b China 384 356 28 0 – – 384 Congo 2.2 7.3 73 Viet Nam 70 55 13 1.6 6.7 DPR Korea 27 24 3. d In 2017. Totals are computed prior to rounding.4 2.0 48 2.0 5.1 4.2 0. by intervention area and estimated cost of inpatient and outpatient care for drug-susceptible (DS-TB) and MDR-TB.4 15 Philippines 104 92 11 0.6 95 Zambia 14 10 1.c 1 175 590 550 35 – – 1 175 Sierra Leone 6.8 17 Zimbabwe 18 14 3.9 0.2 22 30 high TB burden countries 3 881 2 800 958 122 1 039 205 5 125 – indicates values that cannot be calculated.7 0.3 0.5 64 Central African Republic 1.2 2. 30 high TB burden countries.0 6.4 0.3 0.8 87 7.3 113 Papua New Guinea 11 7.7 2.1 4.3 0.1 1.8 1.2 <0.8 0.1 3.6 82 Namibia 56 48 1.6 1.3 39 Myanmar 78 59 15 4.4 Mozambique 32 20 6.2 0.3 2.1 <0.2 <0.9 28 South Africa 244 203 30 11 16 36 297 Thailandd 20 19 0.2 15 1.3 0.3 0.5 <0.8 1.7 2.0 88 Brazil 67 54 11 2.6 0.4 20 0. b No amounts for the additional resources required for inpatient and outpatient care are shown for China and the Russian Federation because the NTP budgets reported by those countries include all budgets for inpatient and outpatient care.6 79 Bangladesha 85 77 8.3 1.8 75 DR Congo 57 42 11 4.6 75 Lesotho 4.3 0.7 22 2.1 0.0 Liberia 1. TABLE 6. c The total budgets reported for staff and infrastructure costs were allocated to DS-TB (52%) and MDR-TB (48%) by WHO.3 0.5 74 Ethiopia 84 59 18 7. based on the reported proportion of beddays used by patients with DS-TB and MDR-TB.3 63 2.2 5. 2017 (current US$ millions) ADDITIONAL RESOURCES REQUIRED FOR TOTAL RESOURCES BUDGET IN NATIONAL STRATEGIC PLAN FOR TB INPATIENT AND OUTPATIENT CARE REQUIRED FOR TB TOTAL DS-TB MDR-TB TB/HIV DS-TB MDR-TB CARE Angola 14 11 2.9 239 Kenya 62 53 4.7 1.1 0.3 3.2 0. 118 GLOBAL TUBERCULOSIS REPORT 2017 .7 12 0.3 97 India 525 421 97 6.7 <0.6 2.1 2.1 42 5.3 0.2 0.2 24 UR Tanzania 70 57 7.8 0.2 <0.9 6.3 117 Cambodia 37 34 2.0 3.3 0.7 4.2 Reported budget in National Strategic Plan for TB. respectively.9 27 0.8 354 Pakistan 108 99 8. the budget reported by Bangladesh is for the calendar year (as opposed to the fiscal year).6 12 0.6 4. the budget reported by Thailand was for the central level only.9 0.6 2.2 0. a In 2017.4 199 Russian Federationb.2 0.6 579 114 1 217 Indonesia 185 158 20 7.

the median cost per patient treated was 400 US$ 9529  in 2016 (Fig. Reported funding gaps for TB by income group five of the 12 EECA countries reduced the number of bed days and by WHO region. There was India.1 The Low-income countries uptake of such regimens should contribute to a decrease in Lower-middle-income countries Upper-middle-income countries the unit cost of treatment for MDR-TB in future.9 care for patients with drug-susceptible TB. These regimens have been recommended since 2016 by WHO for patients (other than 0 pregnant women) with rifampicin-resistant or MDR pulmo- 2007 2009 2011 2013 2015 2017 nary TB who do not have resistance to second-line drugs. Bosnia and Herzegovina).g. US$ millions (constant values for 2017) 600 6. the exception was Sierra Leone. with National budget for TB and sources of funding in the remainder being inpatient and outpatient care. Kyrgyzstan (33%) and the 700 Russian Federation (66%). FIG. GLOBAL TUBERCULOSIS REPORT 2017 119 . see Chapter 1. 6. and a negative 600 US$ millions (constant values for 2017) relationship with the size of the patient case-load (indicating 500 economies of scale. New shortened regimens of 9–12 months 100 cost about US$ 1000 per person.g. 300 the cost per patient treated was positively correlated with 200 GDP per capita. 2006–2017 a positive relationship between the cost per patient treated and gross domestic product (GDP) per capita. Total gap in 2017 = US$ 929 million 600 US$ millions (constant values for 2017) 500 400 300 200 100 0 2007 2009 2011 2013 2015 2017 Africa The Americas Eastern Mediterranean European South-East Asia Western Pacific 1 For further details about this recommendation. the cost per patient treated for drug-susceptible TB was less than GDP per 300 capita. From 2014 to 2016. Eastern Europe and 100 Central Asia (EECA) countries have relatively high costs owing 0 to extensive use of hospitalization for patients in the intensive 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 phase of treatment. As with drug-susceptible TB. Total gap in 2017 = US$ 929 million Azerbaijan (47%).2 Multidrug-resistant TB 500 For MDR-TB. some EECA countries have markedly reduced their reliance on hospitalization and have changed the model of FIG. with hospital admissions averaging 62 Domestic funding International donor funding Funding gap days per person. 6.11). 6. 2006–2017 per patient treated for drug-susceptible TB: Armenia (10%). e. High programme costs relative to a smaller pool of patients also help to explain comparatively high per- patient costs in some countries (e.8 cost was accounted for by reported NTP expenditures.4. in China and India). In 29 of the 30 400 high TB burden countries included in the analysis. However. 200 The cost per patient treated was typically higher in countries in the WHO European Region. Georgia (38%).

log scale) Russian 10 000 ● ● Federation 250 000 ● ● ●● 5 000 50 000 ●● ● ●● ● Namibia ● Sierra Leone ●● ● ● ●●● ●● ● ● ● ● ● ● ● ●● ●●● ● ● ●● ● ● ● ● ● Nigeria ● Zambia ● DPR Korea ●● Zimbabwe ● Angola 1 000 ● South ● ● ● DR Congo Africa 500 ● Thailand Brazil Kenya ● Philippines China ● ●● ● ● Indonesia ● ● ● ● ● ● Liberia Ethiopia Lesotho Congo Papua New Guinea ● 100 Republic ● Central African Mozambique UR Tanzania Myanmar Viet Nam India WHO region Africa Europe Bangladesh Pakistan The Americas South-East Asia Eastern Mediterranean Western Pacific 100 500 1 000 5 000 10 000 20 000 30 000 GDP per capita (2017 US$. log scale) 10 000 Ukraine ● Moldova ●● ● Federation Russian 20 000 Papua New Guinea ● 100 Ethiopia ● Bangladesh Kyrgyzstan ●● ● ● Nigeria ● ● ● ● Kenya DPR Korea ● ●● ● 10 000 ● DR Congo ● ● ● ● ● Peru ● ● MDA Somalia Mozambique ● ● ● ●● ● South Angola 5 000 ● ● ● Indonesia Africa ● ● Tajikistan Thailand Pakistan Uzbekistan China ● ● Viet Nam ● ● ● India WHO region Zimbabwe Africa Europe Myanmar Philippines 1 000 ● The Americas South-East Asia Eastern Mediterranean Western Pacific 100 500 1 000 5 000 10 000 20 000 30 000 GDP per capita (2017 US$. 2016a 30 000 TB caseload (notified TB cases) 1 000 000 20 000 ● ● ● Cost per patient treated (2017 US$. 120 GLOBAL TUBERCULOSIS REPORT 2017 . 6. 2016a MDR-TB caseload (notified cases) 30 000 Belarus Kazakhstan 50 000 ●● Cost per patient treated (2017 US$.10 Estimated cost per patient treated for drug-susceptible TB in 111 countries.11 Estimated cost per patient treated for MDR-TB in 80 countries. log scale) a Limited to countries with at least 20 patients on second-line treatment in 2016. FIG. log scale) a Limited to countries with at least 100 patients on first-line treatment in 2016. 6. FIG.

An exception was made for the Russian Federation: b Health accounts. available from the WHO-CHOICE information about the typical number of days of inpatient modela and associated database (managed by the WHO care and outpatient visits required on a per-patient basis Health Governance and Financing Department). this calculation was carried out separately validated. multiplied by the number of patients drug expenditure per patient treated was used as a proxy treated in a given year (based on notification data. the numerator was the total expenditures available from national health accountsb were estimated cost of treatment. All other categories (except collaborative TB/ who. Unit costs were then calculated as the sum of 2016 NTP As explained in Box 6. Again. The based on the proportion of bed days used for these two first was the validated expenditure data reported by NTPs categories of patients. TB inpatient and outpatient and MDR-TB.1. In the few during treatment (reported separately for drug-susceptible instances in which no expenditure data were reported. 2008 (http://www. the NTP expenditures of countries expenditures and total costs for use of inpatient and are reported annually to WHO using the online WHO global outpatient care. which has two main parts: the used instead of the estimated cost from this ingredients- national expenditures reported by the NTP. for MDR-TB were second-line drugs and all other inputs or a activities implemented for the programmatic management Cost effectiveness and strategic planning (WHO-CHOICE): health service delivery costs. Geneva: World Health Organization. and the costs based approach. Chapter 4). accessed HIV activities) were assumed to be for drug-susceptible 13 July 2017). and are then reviewed and treated. divided by the reported number of patients TB data collection system. associated with the use of health services for TB patients. Geneva: World Health Organization.3 for drug-susceptible TB and MDR-TB n Two main data sources were used to estimate the cost per by WHO to drug-susceptible TB (52%) and MDR-TB (48%). that are stored in the WHO global TB database. TB. For 27 countries (including six high burden Costs were calculated separately for drug-susceptible TB countries. The second For most countries. In each case. data shared by expenditures for staff and infrastructure were allocated WHO Health Governance and Financing Department on 11 July 2017. of MDR-TB. TB and MDR-TB by NTPs) combined with WHO-CHOICE information about the total funding available or reported unit cost estimates.int/choice/cost-effectiveness/inputs/health_service/en/. the total costs associated with use was country-specific estimates of the unit costs of bed days of inpatient and outpatient care were calculated using and outpatient visits. Categories of expenditure considered as costs for drug-susceptible TB and MDR-TB. patient treated for drug-susceptible TB and MDR-TB. n Methods used to estimate the cost per patient treated BOX 6. see Box 6.1). see for expenditures. GLOBAL TUBERCULOSIS REPORT 2017 121 .

Urbanization in Rio de Janeiro. Brazil MIHAI ANDRITOIU / ALAMY STOCK PHOTO .

Increasing the share of major challenges ahead to reach SDG targets. Universal health coverage. In 2017. Most high TB n determinants and consequences of TB. while others require MESSAGES action to address the social and economic use of new tools and social support.4 million incident cases of TB globally in population is critical to reduce the financial hardships 2016. Analysis of these indicators for the expenditures account for a high proportion (>30%) 30 high TB burden countries shows that most have of total health expenditures. so. these estimates WHO has developed a TB-SDG monitoring and projections suggest that most middle-income framework of 14 indicators that are associated with countries can mobilize the resources required to TB incidence. Examples include make progress towards UHC and reach other SDG. housing quality.8 million to diabetes. financing that is derived from compulsory prepaid sources and pooled to spread risk across the Of the 10.and and vulnerable populations.8 access to care. an estimated 1.9 million were attributable to arising from out-of-pocket expenditures and enable undernourishment. In addition. burden countries have national policies that provide the foundation for expanding social protection. finding ways to link TB middle-income countries during the period patients into these schemes is important. levels of poverty.0 million to HIV infection. funds must then be million to smoking and 0. social protection and social determinants n Achieving the tuberculosis (TB) targets and Results from surveys of costs faced by TB patients milestones of the Sustainable Development Goals and their households reveal a high economic and KEY (SDGs) and End TB Strategy requires provision of TB financial burden due to TB disease. 2016–2030 and compared these with projections of total health expenditures. Improved revenue generation and management HIV prevalence. 0. GLOBAL TUBERCULOSIS REPORT 2017 123 . smoking and diabetes. but that low-income undernourishment. income inequality. related health targets by 2030. under seven SDGs. out-of-pocket the TB epidemic. directed to priority services and populations through the mechanisms used to pay providers. Some of the main FACTS care and prevention within the broader context of cost drivers could be reduced or eliminated through AND universal health coverage (UHC) and multisectoral improved models of care.CHAPTER 7. Overall. coverage of essential health services. 1. coverage of social protection countries are unlikely to have the resources to do programmes. WHO published estimates of the funding including cash transfer programmes for some poor required for progress towards UHC in low. influences on the TB epidemic at national level and inform the multisectoral actions required to end In most high TB burden countries. Monitoring of public expenditures as well as increased public of these indicators can be used to identify key health budgets are needed.

8. effective. Health. total average health spending would need proportion of the population with large household expenditures on health as a share of total household expenditure or income. 2016–2030 expenditures as well as increased public health budgets SDG Target 3.1016/S2214-109X(17)30263-2 124 GLOBAL TUBERCULOSIS REPORT 2017 . time period. are shown in Fig. (published online July 17) Lancet Glob part of SDG Target 3. WHO will publish data related to these Stenberg K. especially in the first few years. measures that could help to alleviate these burdens. Hanssen O. smoking and diabetes).5% by 2030 across all 67 countries 1 (Fig 7. of suffi. TB care delivery. including TB. cover investment needs in low-income countries. Fig. which the resources needed to achieve UHC and other SDG- In 2017. icines and vaccines” (Chapter 2). http://dx. Implications for or programmes is accounted for by noncommunicable improving financing. respectively. Two scenarios were considered 20%. Referred to in shorthand as the WHO SDG Health Specific targets set in the End TB Strategy include a 90% Price Tag. this is a composite indicator that includes TB countries (from an average of 6% in 2014 to around 12% by treatment coverage as one of 16 tracer indicators.6% in 2014 to 7.2 and compared needs as a percentage of gross domestic product (GDP) would rise from 5. As highlighted elsewhere in this report. more focus on the additional (or incremental) resources needed immediate milestones for 2020 are reductions of 35% and compared with levels in 2014. in both low and middle-income countries.3 the estimates are for 67 low. projected health expenditure is not sufficient to TB-SDG monitoring framework defined in Chapter 2. health expenditure is projected to be sufficient to examples of efforts to better plan for the financing and policy cover “ambitious” scenario investment needs in middle- changes needed at country level to reach UHC. protection. and  Overall. which is included as middle-income countries. determinants of the TB epidemic (undernutrition. By 2030. WHO published estimates of the resources needed related health targets can be mobilized in low and middle- during the period 2016–2030 to make progress towards UHC income countries. compared with 2015.  Improved revenue generation and management of public 7. and a technological breakthrough achievement of 2030 SDG targets). there is uneven capacity to The third section includes estimates of the share of the mobilize additional resources and some countries are global TB burden in 2016 that can be attributed to five major expected to face gaps. context of universal health coverage (UHC).8 is to “Achieve UHC. for resource needs (termed “progress” and “ambitious”) and in particular in Chapter 2. are discussed. and an assessment of 39 middle-income countries included in the analysis are the latest status of these and other indicators associated with predicted to face funding gaps. TB incidence in the 30 high TB burden countries based on the  Overall. Tan-Torres Edejer T et al. achieving these targets requires two scenarios (referred to as “moderate” and “optimistic”) provision of TB care and prevention within the broader were also considered for total health expenditures. Further analyses based on the WHO SDG Health Price Tag. The End TB Strategy and the Sustainable Development Goals these with projected total health expenditures in the same (SDGs) include a common aim: to end the global TB epidemic. 7. access to quality essential healthcare services and access to safe. quality and affordable essential med.int/gho/cabinet/uhc. with a much greater increase needed in low-income Two indicators have been defined for Target 3.org/10.1 UHC means that all people focusing on comparisons of total (as opposed to incremental) and communities can use the promotive. indicators related to UHC. the additional invest­ by 2025 so that incidence can fall faster than rates achieved ment (compared with 2014) required per year grows from historically.1. multisectoral Key findings include: action to address the social and economic determinants  In the “ambitious” scenario for resource needs (based on and consequences of TB.doi. The second is the 2024). However. The first is the coverage of essential health services.1 UHC financing prospects. preventive. The first provides an extra US$ 58 per person) in 2030. Financing transformative UHC indicators on UHC day 2017 (in December).jsp Goals: a model for projected resource needs in 67 low-income and 2 One of these is the target of ending the TB epidemic. 7. HIV infection.3. In the period 2026–2030. ditures. overview of estimates of the resources required for progress  Most of the increased investment required (75% of the total) towards UHC and achievement of other SDG-related health is for expanding and strengthening the health workforce targets during the period 2016–2030.2). US$ 134 billion in 2016 to US$ 371 billion (equivalent to an This chapter has three major sections. investment needs with projections of total health expen­ rehabilitative and palliative health services they need.who. The (OOP) expenditures on health and costs borne by TB patients largest share of investments needed for specific diseases and their households as a result of TB disease. published by WHO and health services infrastructure (including buildings and in 2017. these data will be available health systems towards achievement of the health Sustainable Development at http://apps. In addition. income countries. including financial risk are needed. curative.and middle-income reduction in TB deaths and an 80% reduction in TB incidence countries that account for 75% of the world’s population and (new cases per year) by 2030.2017. Methods to calculate the 3 first indicator are under development.3. they indicate that total funding and reach other SDG-related health targets. an average of five out of the alcohol misuse.2 and Fig. The second section summarises recent data for medical equipment) to reach recommended benchmarks. including levels of out-of-pocket The remainder is for specific priorities. 7. and social protection diseases (NCDs). while also ensuring that the use of illustrate the same key messages in terms of the extent to these services does not expose the user to financial hardship. These cient quality to be effective.

5: e875–87. 7. Lancet Global Health 2017. Tan-Torres Edejer T et al. Hanssen O. middle-income countries. 5: e875–87. Financing transformative health systems towards achievement of the health Sustainable Development Goals: a model for projected resource needs in 67 low-income and middle-income countries. Tan-Torres Edejer T et al.3 20 Funding needs (per capita) to progressively expand services towards UHC and reach other 0 2016 2018 2020 2022 2024 2026 2028 2030 SDG health targets by 2030. 72 60 63 40 US$ bilions (constant values for 2014) FIG. by country income groupa Lower-middle-income countries (n=22) US$ (constant values for 2014) per capita 1000 600 887 800 500 748 600 400 400 419 300 200 200 100 0 2016 2018 2020 2022 2024 2026 2028 2030 0 Low-income Lower-middle Upper-middle Upper-middle-income countries (n=17) countries income countries income countries 3500 (n=22) (n=17) (n=28) 3000 3032 2500 Additional health sector resource needs by 2030 2640 Current health expenditure per capita (2014) 2000 1500 a Income groups are defined as of July 2016.1 FIG. 2016–2030 2016–2030 14 Low-and middle-income countries (n=67) Low-income countries 12 4500 Funding needs as % of GDP 4000 3991 10 3500 3451 All (n=67) 3000 8 2500 Lower-middle-income countries 6 2000 1724 1500 4 Upper-middle-income countries 1000 500 2 0 0 2016 2018 2020 2022 2024 2026 2028 2030 2014 2016 2018 2020 2022 2024 2026 2028 2030 Low-income countries (n=28) 100 Source: Data from Stenberg K. 2016 2018 2020 2022 2024 2026 2028 2030 Total health expenditure (moderate scenario) Total health expenditure (optimistic scenario) Health sector resource needs (ambitious scenario) Source: Data from Stenberg K. 1000 Source: Data from Stenberg K. Per person health costs are reported as 1219 population-weighted mean values per income group per year. Financing transformative health systems towards achievement of the health Sustainable 87 Development Goals: a model for projected resource needs in 67 low-income and 80 middle-income countries. FIG. Hanssen O. GLOBAL TUBERCULOSIS REPORT 2017 125 . 7. Lancet Global Health 2017. Financing 500 transformative health systems towards achievement of the health Sustainable Development Goals: a model for projected resource needs in 67 low-income and 0 middle-income countries. 5: e875–87. Tan-Torres Edejer T et al. Hanssen O. Lancet Global Health 2017.2 Funding needs to progressively expand services Funding needs (as a percentage of projected GDP) towards UHC and reach other SDG health targets to progressively expand services towards UHC in 67 low-and middle-income countries compared and reach other SDG health targets in 67 low-and with projected total health expenditures. 7.

Source: Data extracted from WHO’s Global Health Expenditure Database (http://apps.4 Out-of-pocket expenditure as a percentage of total health expenditure. the Russian Federation and Sierra Leone.2 National surveys of costs faced by TB patients US$ 146 per capita in lower-middle-income countries and and their households US$ 536 per capita in upper-middle income countries (Fig. As introduced in the Global TB report 2016. Philippines. 7.2. Findings are needed to inform the improved data in December 2017. design or implementation of care and to assess whether the 126 GLOBAL TUBERCULOSIS REPORT 2017 . 7. WHO recommends conducting a baseline survey by 2020 1 The latest year for which data are available. The percentage of total health impact of TB. 2014a Percentage ≤15 16–29 30–44 ≥45 No data Not applicable a Data for 2015 will be available in December 2017.3). South Africa and Thailand (Fig. the strophic expenditures on health is explained in Box 7. to increase to US$  112 per capita in low-income countries. WHO will report on updated at the latest. and expenditure accounted for by OOP expenditure provides a proxy measure of the extent to which financial protection is  to determine the baseline and periodically measure the in place. Pakistan. there level indicators of the End TB Strategy for which targets were 46 countries in which OOP expenditures accounted for at and milestones have been set (Chapter 2). 7. including high TB burden countries such as needed to monitor progress towards one of the three high- Namibia. WHO aims to 7. This included 11 high The distinction between the indicator of catastrophic total TB burden countries: Bangladesh.int/nha/database/Home/Index/en). These surveys have two 7.2 Reducing financial hardship and primary objectives: increasing social protection  to document the magnitude and main drivers of different 7. Indonesia. Myanmar.who. FIG. Cambodia. in order to guide policies to reduce financial barriers UHC requires that people can access needed services without to accessing care and minimize the adverse socioeconomic suffering financial hardship.1 Out-of-pocket expenditures and financial types of costs incurred by TB patients (and their house- hardship holds). This information is were available. Central African costs due to TB disease and the broader indicator of cata- Republic. Nigeria. However. India. least 45% of total health expenditures.4). annually report on results from national surveys of costs faced by TB patients and their households.2.1. percentage of TB patients (and their households) treated In 2014.1 OOP expenditures were less than 15% of total in the national TB programme (NTP) network who incur health spending in 44 of the 190 countries for which data catastrophic total costs due to TB.

GLOBAL TUBERCULOSIS REPORT 2017 127 . 2020 milestone of the End TB Strategy (that no TB patients health-facility-based surveys in 2016. b Subnational surveys are ongoing in Bolivia (Cochabamba) and Brazil (Sao Paolo).FIG. n The difference between “catastrophic total costs” for TB patients and BOX 7. This handbook builds on mechanism that can help to mitigate costs.int/tb/advisory_bodies/impact_ because access to TB prevention and care requires that general barriers to measurement_taskforce/meetings/tf6_background_5a_patient_cost_ accessing health care are addressed.pdf. surveys_protocol.who. The latter is a population-based indicator that measures the share of the population incurring “catastrophic expenditures” on health. and to TB) is achieved. 2015 (http://www. The TB-specific indicator is also restricted to a particular population: diagnosed TB patients treated by providers that are part of NTP networks. Protocol for survey to determine direct and indirect costs due to TB and to estimate proportion of TB-affected households experiencing catastrophic costs due to TB: field testing version. and catastrophic expenditures on health n It is important to distinguish the indicator of catastrophic total costs due to TB from the indicator of catastrophic expenditures on health being used within the SDG monitoring framework and in regional frameworks for UHC. with a threshold defined based on household ability to pay. a WHO and their households should face catastrophic total costs due handbook for conducting these surveys will be available. lessons learned from surveys implemented 2015–2017 and WHO developed a draft protocol and survey instrument for the conduct of these nationally-representative and 2 World Health Organization. The TB-specific indicator incorporates not only direct medical payments for diagnosis and treatment but also direct non-medical payments (such as for transportation and lodging) and indirect costs (such as lost income).2 By early 2018. accessed 2 August 2017). Expenditures are defined as direct expenditures on medical care. 7. Geneva: WHO.1 their households. 1 This target is in line with policy efforts to move health systems closer to UHC.1 Social protection programmes are one will include an updated protocol.5 National surveys of costs faced by TB patients and their households: progress and plans as of August 2017 Completeda Ongoingb Planned 2017/2018 Not applicable a At least field work has been completed.

with costs to review survey results and refine the elements of the representing on average 347% of annual household income roadmap and the monitoring and evaluation framework was 2 Costs experienced by households affected by TB or MDR-TB. A commitment to periodically monitor TB patient costs has 98% of households affected by MDR-TB experienced catastrophic costs also been made. and to use existing and new research platforms to test new approaches to reduce patient costs. sssssssss sssssssss an estimated 63% of TB-affected households and 98% of sssssssss sssssssss the households of patients with MDR-TB experienced total ssssssss ssssssss costs that were catastrophic. Significant predictors for experiencing catastrophic costs were being in the poorest or less poor household wealth 1 Proportion of households that experienced catastrophic costs quintiles. Viet Nam is a lower-middle-income country and is one of the 30 high TB burden countries. accommodation. 22% of households experienced 32% of households experienced food insecurity food insecurity  enable access to other social protection schemes and 27% of households “perceived” 47% of households “perceived” adapt them to the needs of TB patients. nutritional supplements (post-diagnosis) The roadmap aims to enable policy guidance and Reported household income loss interventions to reduce and compensate for costs faced by TB Medical expenditures (post-diagnosis) patients and their households. and Source: Measuring catastrophic costs due to tuberculosis in Vietnam Hoa B. Nguyen et al.  scale up and adapt for TB patients the existing mechanism borrowing or sale of assets borrowing or sale of assets to purchase health insurance cards for the poor. the Ministry of Health (MoH) amounting on average to: departments of planning and finance. Travel. It includes the development Travel. and local and international nutritional supplements and special foods research institutions. to conduct the first national survey of costs faced by TB patients and their households. a stakeholders’ meeting The poorest households were the most affected. The instrument included questions on costs. 2017 (in press) social service staff in TB issues.  train health service staff in social protection practices. and advocating for donor support for TB- US$ specific patient social support. On average. coping OF COSTS FACED BY TB measures and asset ownership. providing by TB MDR-TB travel vouchers. Using the results of this baseline survey. of which US$ 2142 (50%) was for travel. the NTP in Viet Nam worked with the Viet Nam Integrated Center for TB and Respirology n Research (VICTORY). Participants included representatives from the social protection department of the Ministry of Labour-Invalids Patients faced direct and indirect costs and Social Affairs (MOLISA). food. SURVEY COVERAGE Survey results (see infographic) suggested that. medical services US$1068 FOR AN EPISODE OF TB of which US$ 519 (49%) was reported household income loss administration. use of savings. VICTORY. This was the second national survey in which the WHO-recommended protocol was applied. the financial burden as the financial burden as “serious” or “very serious” “serious” or “very serious”  assess additional financial and human resource needs. taking a loan. The cross-sectional public-facility-based survey involved 735 VIET NAM patients with either drug-susceptible or MDR-TB who were FIRST NATIONAL SURVEY receiving treatment in health facilities across 20 clusters. 128 GLOBAL TUBERCULOSIS REPORT 2017 . and if they HOUSEHOLDS exceeded 20% of household income the household was 2016 classified as “experiencing catastrophic total costs”. accommodation. accommodation. Other elements are the launch of a charity fund for TB patients that can be used for 3 Coping strategies and perceived impact Households affected Households affected by purchasing of health insurance cards for the poor. former TB patients. the Farmer’s Union. The most important cost drivers were reported income losses and non-medical costs after KEY RESULTS diagnosis. time losses. A MOLISA pilot on social protection for MDR-TB patients will be assessed. Total costs were expressed PATIENTS AND THEIR as a percentage of annual household income. a Vietnamese research network. MOLISA will also be engaged to assess and strengthen current regulations for workers’ protection. food. following a survey in Myanmar in 2016. the cost was sssssssssssssss x10 ssssss x10 US$ 1068 for an episode of drug-susceptible TB and US$ 4289 20 CLUSTERS 677 TB PATIENTS 58 DRUG-RESISTANT TB (MDR-TB) PATIENTS per episode of MDR-TB.2 From July to October 2016. nutritional supplements (pre-diagnosis) MDR-TB and costing of a package of ambulatory TB services to be TB Medical expenditures (pre-diagnosis) explored for inclusion in the new National health insurance 0 500 1000 1500 2000 (NHI) scheme. Subsequently. international cooperation and health US$4289 FOR AN EPISODE OF MDR-TB strategy. Viet Nam’s NTP has 63% ofexperienced households affected by TB or MDR-TB costs that were above 20% of their defined a roadmap (2017–2020) involving non-health actors annual household income ÇÇÇÇÇÇÇ ÇÇÇ to address access barriers and an operational research plan. use of savings. food packages or cash. and  monitor and evaluate initiatives. and developing a 38% of households employed one 52% of households employed roadmap for how the MoH can collaborate with MOLISA to: of these strategies: taking one of these strategies: a loan. n Measuring costs faced by TB patients and their households in Viet Nam BOX 7. WHO. on average held. in Viet Nam. the Women’s Union.

The findings also suggest that people vulnerable populations or disabled persons. they protection schemes have some operational experience and financing. and possibly more sustainable approaches through establish­ The Global TB report 2016 provided examples of compul­ ment of linkages with existing social assistance efforts.2. which was conducted in Children’s Fund (UNICEF). social assistance or August 2017 is shown in Fig. and with particular completed. Seven surveys had been social insurance. Global TB Programme Country Social Protection Briefs (www.4 Table 7. countries remains low and fragmented. in Increasing the share of financing that is derived from Brazil. and labour programmes.31). through improved (more patient-centred) models of care and and most have some form of cash transfer system. strategy or relevant legislation for social protection. The findings are similar to those in social protection for TB patients and households specifically: Myanmar. resistant TB highlights evidence that economic and social support is associated with improved treatment results. India and the Philippines) of general social protection compulsory prepaid sources and pooled to spread risk across systems. related to indirect of health and social protection agencies. 2012 (no. 2017 (http://www.int/ forthcoming WHO handbook on surveys of costs faced by TB patients and tb/areasofwork/socialprotection/en). in Ghana.pdf?ua=1). In addition. Geneva: WHO. sory prepayment and pooling to spread risk within the In part stimulated by the adoption of the International 3 International Labour Organization.10). 202). See World Health Organization. Report from the first consultation of the 2 World Health Organization. Stakeholder work­ costs such as income loss.3 and collaboration with other institutions Global TB report 2016 included results from the first national including the World Bank. Kenya.int/tb/ publications/2015/end_tb_essential. Implementing the End TB Strategy: the essentials Health and Social Protection Action Research & Knowledge Sharing (SPARKS) (WHO/HTM/TB/2015. many low and middle-income Myanmar (2015–2016). demonstrating that a high proportion of TB the existence of overall policy.2. 101st ILC session (14 June 2012).g. the funds must then be directed to priority other economic or psycho-social support.4 Improving patient access through tailored The Global TB report 2016 and the WHO guide to provider payment mechanisms implementing the End TB Strategy2 included examples (e.int/tb/ Network (WHO/HTM/TB/ 2017. In these countries and many others. 5 their households.2. publications/sparksreport/en/). as well as to guidance on the treatment of drug-susceptible and drug. Data on adoption of new tools.5. 7. 2015 (http://www. 26 have a policy docu­ serious burden. and that some of these costs could be reduced ment. but coverage in many assistance and other forms of social protection. countries have started to expand their social protection The status of survey planning and implementation as of systems. GLOBAL TUBERCULOSIS REPORT 2017 129 . define research that may be required to inform these efforts. They also indicate collaboration between ministries catastrophic total costs due to TB disease. vouchers. transport or shops to discuss the results from surveys of costs faced by TB food costs. It is anticipated that several additional countries will schemes that exist in the 30 high TB burden countries. with multidrug-resistant TB (MDR-TB) face a particularly Of the 30 high TB burden countries. with results Based on available documentation compiled by the WHO in the process of being analysed.who. R202 – Social Protection Floors Labour Organization (ILO) recommendation on social protec­ Recommendation. and they are TB patient cost surveys and related studies show that TB likely more systematic than most TB-specific social support patients and their households can face debilitating and often projects. while others indicate a need for social coverage levels are not easy to obtain. and of TB (using a threshold of costs representing more than 20% some level of coverage of cash transfers for specific poor or of household income1). The second pillar of the End TB Strategy (bold patients and their households offer an opportunity to engage policies and systems) includes the pursuit of social protection across ministries and with nongovernmental partners on for TB patients and their households.5 Nevertheless. Timor Leste and Viet Nam. or not sufficient. increasing such pooled funding alone is patients.who. WHO and the United Nations survey using the WHO protocol.advice provided by a WHO TB Patient Cost Task Force. Adoption: Geneva. The start planning surveys in 2018. Myanmar.3 Establishing or strengthening national social are managed by administrative authorities or agencies. 1 4 Further explanation and justification of this threshold is provided in the WHO. strategy or legislative frame­ patients are experiencing catastrophic total costs as a result works. these initiatives are increasingly backed by domestic policies. direct medical costs.who. reviewed by national Global TB Programme for policy briefs on social protection stake­holders and prepared for publication. the Philippines. they 7. attention to the needs of low-income populations. for example by providing food. Both publications services and populations through the mechanisms used to also signaled the need to explore more efficient. However. cash. including cash transfer programmes for poor and the population is critical to reduce the financial hardships vulnerable populations. 7. systematic pay providers. with a focus on basic services. Six surveys were systems in high TB burden countries. a register of target populations or beneficiaries.1 shows the ongoing and ten are scheduled to start later in 2017 or in basic components of social protection policy and cash transfer 2018. The tion floors in 2012. focus is on three major elements of social protection schemes A profile of the survey conducted in Viet Nam in 2016 that may be of substantial relevance to efforts to improve is provided in Box 7. Republic of Moldova. arising from out-of-pocket expenditures and enable access TB-specific social support projects are in place to assist to care. WHO ways to provide social protection for TB patients.

the design and management of the fastest historic rates of decline in TB incidence at national provider payment arrangements.3 Addressing broader determinants provider payment systems that include private providers may of the TB epidemic enable greater access without financial burdens for the users. including TB patients. measures still need important contributions to health service delivery. benefits. TB then paid can affect the coverage and quality of care. given that the Philippines is a high MDR-TB drug-susceptible pulmonary and extra-pulmonary TB burden country. Typically. Bredenkamp C. To be eligible for TB files/Synthesis%20Report%20on%20Country%20%20Assessments%20 benefits. increase the to within PhilHealth as the DOTS package) includes number of accredited TB care centres accessible to patients reimbursement for elements of TB care delivery (such and the number of patients using the PhilHEalth TB as follow-up testing once TB patients are diagnosed. the insurance agency. Therefore. One Health. b must be managed by an accredited TB care facility. general health services. The benefit package for TB care (referred accreditation process and. It also commented on related private providers.org/ of the continuation phase (4 months). between TB and poverty. has made Despite substantial achievements.b. and governance for more inclusive as accreditation. the Philippines’ NHI programme. health. indoor contexts. with qualifying contributions. ensuring that services for TB patients are paid and air pollution and income per capita have been analysed. 2015. The Picazo OF. Iglesias R. HIV. and TB programmes within the Ministry of opportunities and challenges for TB care and prevention.3. smoking. when the availability of effective treatments coin- systems that include these mechanisms involve a distinct cided with rapid social and economic development. 7. there are also difficulties in enabling consultation services and health education and counselling reimbursement of providers.3 NHI programmea. tuberculosis directly-observed treatment short-course (DOTS) benefit package. 2016. 2013 (http://tbcare2. 2015–54. Furthermore. and a second payment at the end Development (USAID). because payments made during treatment) delivered by accredited providers and to local government units are not always then passed TB drugs are provided by the NTP. 130 GLOBAL TUBERCULOSIS REPORT 2017 . as well incidence and mortality started to decline in western Europe as how much users. Discussion paper series. social protection. public and the Philippines and Thailand. Revised guidelines for the PhilHealth outpatient anti- that the person is registered. An up-to-date dominates health-care provision even in many low-income summary of TB care provider payment arrangements in place communities. two payments – an initial payment after the accredited a facility has finished provision of the intensive phase of TB USAID TB CARE II Project Synthesis report: inclusion of TB in national insurance programs. benefit from low. which is a significant a flat-rate payment for new and retreatment cases of limitation.org/sites/tbcare2. can affect care and costs. as well as benefit packages level occurred in the same part of the world during the 1950s for TB patients. on the diagnostic criteria defined by the NTP and the care accessed 2 August 2017). development. In such undernutrition. Philippine Institute for Development patient must be an active PhilHealth member. et al. Work is underway to resolve each of these in children and adults. A critical analysis of PhilHealth. that are largely free in the public sector. the prevalence of such as a National Health Insurance (NHI) Fund. concern in these countries is how public and especially private The PhilHealth NHI Fund in the Philippines was one of providers receive payments for services. including those in Indonesia. PhilHealth reimburses along to the facilities or providers that had provided health facilities and providers for providing TB services the services. the Philippines BOX 7. Managing the benefit package through PhilHealth c Kaiser K. Reimbursement is provided in challenges. patient information and private sector engagement. financing and 1960s. well before effective drug treatments became available. alcohol use. comprising included in the benefits package. The private sector the examples profiled in last year’s report. diabetes. The influence of various social and economic determinants on However. and cost or free care. a PhilHealth member must have TB disease based