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Information Resource Centre HTM/STB
World Health Organization
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ISBN 978 92 4 156406 9

Global Tuberculosis Control WHO REPORT 2010

The World Health Organization monitors
the global tuberculosis epidemic in support
of national TB control programmes.

Global
Tuberculosis
Control
2010

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at least. 2011–2015 gross national income high-burden country of which there are 22 that account for approximately 80% of all new TB cases arising each year human immunodeficiency virus Human resource development International Classification of Diseases (tenth revision) isoniazid preventive therapy incidence rate ratio International Standards for Tuberculosis Care Light-emitting diode Line-probe assay Millennium Development Goal multidrug-resistant tuberculosis (resistance to. Tuberculosis and Malaria Global Plan to Stop TB. JW  %FFVIZMEXMSRW ACSM AFR AIDS AMR ARI ART CDR CPT CBC DOT DOTS DRS DST ECDC EMR EU EUR FIND GDF GLC GLI Global Fund Global Plan GNI HBC HIV HRD ICD-10 IPT IRR ISTC LED LPA MDG MDR-TB NGO NTP PAL PPM SEAR TB UNAIDS UNITAID USAID VR WHA WHO WPR XDR-TB ZN advocacy. communication and social mobilization WHO African Region acquired immunodeficiency syndrome WHO Region of the Americas annual risk of infection antiretroviral therapy case detection rate co-trimoxazole preventive therapy community-based TB care directly observed treatment the basic package that underpins the Stop TB Strategy drug resistance surveillance or survey drug susceptibility testing European Centre for Disease Prevention and Control WHO Eastern Mediterranean Region European Union WHO European Region Foundation for Innovative New Diagnostics Global TB Drug Facility Green Light Committee Global Laboratory Initiative The Global Fund to fight AIDS. isoniazid and rifampicin) nongovernmental organization national tuberculosis control programme or equivalent Practical Approach to Lung Health Public–Private Mix WHO South-East Asia Region tuberculosis Joint United Nations Programme on HIV/AIDS international facility for the purchase of diagnostics and drugs for diagnosis and treatment of HIV/ AIDS. malaria and TB United States Agency for International Development Vital registration World Health Assembly World Health Organization WHO Western Pacific Region Extensively drug-resistant TB Ziehl-Neelsen .

Hazim Timimi. Tracy Mawer. validation and review. Daniel Chemtob. particularly for data collection. Dorothée Ntakirutimana. Wayne Van Gemert. The main part of the report was written by Katherine Floyd. . Christopher Gilpin. Karen Ciceri edited the report. Daniel Kibuga. Ernesto Jaramillo. Christopher Gilpin. The team was led by Katherine Floyd and Léopold Blanc. which explains methods used to produce estimates of disease burden. John Puvimanasinghe and Lal Sadasivan Sreemathy – conducted the review and follow-up of data related to epidemiology and the implementation of the Stop TB Strategy. Shalala Ahmadova. Mukund Uplekar contributed a summary of recent progress in engaging all care providers through public-private and public-public mix (PPM) approaches. Overall guidance was provided by the Director of the Stop TB Department. Rafael López Olarte. Charalambos Sismanidis. which contains a wealth of global. regional and country-specific data from the global TB database. Sai Pothapregada. Dennis Falzon. Christopher Fitzpatrick and Inés Garcia conducted all review and follow-up of financial data. Hilary Kipruto. Victoria Birungi. Vainess Mfungwe. Neema Simkoko and Henriette Wembanyama. Nicolas Nkiere. Christopher Fitzpatrick and Inés Garcia analysed financial data. Joseph Imoko. with assistance from Tom Hiatt. Charalambos Sismanidis and Hazim Timimi. Paul Nunn. Sweden. is greatly appreciated. Wilfred Nkhoma. 8)0"GSJDBO3FHJPO Diriba Agegnehu. Salah Ottmani. Kalpesh Rahevar. Hazim Timimi and Mukund Uplekar. Tom Hiatt. Dennis Falzon analysed data and prepared the figures and tables related to MDR-TB. Annemieke Brands. Angélica Salomão. 8)0IFBERVBSUFST(FOFWBBOE6/"*%4 Pamela Baillie. Delphine Sculier and Tom Hiatt analysed TB/ HIV data and prepared the associated figures and tables. Eleanor Gouws. Angélica Salomão. Joel Kangangi. validation and review. Mwendaweli Maboshe. Eva Nathanson. and was the focal point for communications with the graphic designer. Delphine Sculier. The principal source of financial support for WHO’s work on monitoring and evaluation of TB control is the United States Agency for International Development (USAID). Data for the European Region were collected and validated jointly by the WHO Regional Office for Europe and the European Centre for Disease Prevention and Control (ECDC). Christopher Fitzpatrick. Inés Garcia. Alasdair Reid and Diana Weil. Dennis Falzon. Ayodele Awe. Annex 1. ensuring that they were ready for layout and design according to schedule. Roberta Pastore. Wieslaw Jakubowiak. In addition to the core report team and those mentioned above. Hazim Timimi led and organized all aspects of data management. was prepared by Tom Hiatt and Hazim Timimi. without which it would be impossible to produce this report. Delphine Sculier. the report benefited from the input of many staff at the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS). was written by Philippe Glaziou. Annex 2. André Ndongosieme. as in previous years. Katherine Floyd. validation and analysis were also supported by funding from the government of Japan and the Global Fund. Daniel Kibuga. We acknowledge with gratitude their support. with support from Tom Hiatt. and prepared the associated figures and tables. Philippe Glaziou and Charalambos Sismanidis analysed surveillance and epidemiological data and prepared the figures and tables on these topics. her contribution. W %GORS[PIHKIQIRXW 8 his report on global tuberculosis control was produced by a core team of 12 people: Léopold Blanc. with input from staff throughout the Stop TB Department. Haileyesus Getahun. Andrei Dadu. Kefas Samson. Mario Raviglione. Matteo Zignol and four colleagues from the Global Fund – Nino Mdivani. Philippe Glaziou. Bah Keita. Gani Alabi. Malgosia Grzemska. Katherine Floyd. Tom Hiatt. Nobuyuki Nishikiori and Daniel Sagebiel for their major contribution to data collection. Among those listed below. Christian Gunneberg. Christopher Gilpin and Karin Weyer provided an update on the Global Laboratory Initiative and Karin Bergstrom analysed data related to human resource development. an agency of the European Union based in Stockholm. we thank in particular Amal Bassili. Tom Hiatt checked and finalized all figures and tables in an appropriate format. The data collection forms (long and short versions) were developed by Philippe Glaziou. Khurshid Alam Hyder. Fraser Wares. Data collection. Ishmael Nyasulu. We thank Sue Hobbs for her excellent work on the design and layout of this report.

Stefano Barbosa Codenotti Draurio Barreira. Woo-Jin Lew. Younoussa Assoumani. Celestino Teixeira. Bakoliarisoa Ranivomahefa. Gombogaram Tsogt and Richard Zaleskis. Sayohat Hasanova. Those who used the online data collection system to report data to WHO in 2010 are listed below. Peter Knudsen. Nani Nair. R. Ireneaus Sindani. Data are supplied primarily by national TB control programme managers and their staff. Christian García Calavaro. Llang Maama. Alexis Guilarte. Joconiah Chirenda. Andrei Dadu. Thadée Ndikumana. Jennifer George. Tandaogo Saouadogo. Mercedes F. based on data collected in the 2010 round of global TB data collection and previous years. España Cedeño. Mirtha del Granado. Salem Barghout. Kim Son Il. Fodé Cisse. Fabio Scano. Frank Bonsu. Joseph Sitienei. Nkou Bikoe Adolphe. Héctor Oswaldo Jave Castillo. Augé Wilson Ondon. Partha P. WJ 8)03&1035 (-0#"-56#&3$6-04*4$0/530- 8)03FHJPOPGUIF"NFSJDBT Jarbas Barbosa. Thato Raleting. Raúl Álvarez. Farai Mavhunga. Peter Metzger. Egidio Langa. Martin Gninafon. Sombat Thanprasertuk and Supriya Warusavithana. Adolphe Nkou. 8)0&VSPQFBO3FHJPO Pierpaolo de Colombani. Cecilia Lyons De Arango. Foday Dafae. Manohar Singh. Daniel Sagebiel. Michel Gasana. Maria da Conceição Palma Caldas. Nicholas Siziba. Bahtygul Karriyeva. 8)0"GSJDBO3FHJPO Oumar Abdelhadi. 8)03FHJPOPGUIF"NFSJDBT Christian Acosta. Dawit Tsegaye. Ghislaine Nkone Asseko. Jean Paul Okiata Kenkana Mayala. André Kouabosso. Aristide Komangoya-Nzonzo. Adama Bangoura. 8)0&BTUFSO.FEJUFSSBOFBO3FHJPO Samiha Baghdadi. Justin Freminot. Lindiwe Mvusi. Wasiq Khan. Hans Kluge. Ye Myint. Omoniyi Amos. Erwin Cooreman. Xochil Alemán de Cruz. Leilawati Mohammed. Martín Castellanos Joya. Carla Jeffries. María Josefa Llanes Cordero. Ridha Jebeniani. Wiedjaiprekash Balesar. Fantché Awokou. Kenneth Castro. Rajendra Yadav and Liu Yuhong. Aicha Diakité. Jorge Barreto. Omphemetse Mokgatlhe. Saidi Egwaga. Evelyn Morales. Rodolfo Rodríguez. María del Carmen Bermúdez. Inacio de Carvalho Alvarenga. Raúl Marcelo Manjón Tellería. Desta Tiruneh. Jacques Sebert. Roman Spataru. Nathan Kapata. Alister Antoine. Javan Kayobotsi. Zeidy Azofeifa Mata. Celia Martínez de Cuellar. Marafa Boubacar. Rahim Taghizadeh and Martin van den Boom. Mohamed Vadel. Rafael López Olarte. Marvin Maldonado. Jacobo Finkelman. Francisco Maldonado. Ballé Boubakar. Syed Karam Shah. Jamshid Gadoev. Bashir Suleiman. Mineab Sebhatu. Angelo Makpenon. Nobuyuki Nishikiori. Francis Adatu. Aleixo Rodrigues de Sousa Pires. Ed Ellis. Eva Lewis Fuller. Charles Sandy. Alina Jaime. Jaime Bravo. Awa Diop. Margarita Godoy. Khaled Sultan. Martin Rakotonjanahary. Alfonso Tenorio and Adriana Bacelar Gomes. Shalala Ahmadova. Rosalinda Hernández Munoz. Marithel Tesoro. Nkem Chukwueme. Puneet Dewan. Ronala Jamanca Shuan. Ngyuen Nhat Linh. Gérard Ntahizaniye. Mame Bocar Lo. Yndira Morales. Catherine Cooper. Roger Duncan. Belkys Marcelino. Valentin Rusovich. Ada Martínez Cruz. Claudina Cruz. Gemma Chery. Fulgence Ndayikengurukiye. Isaiah Dambe. Yamuna Mundade. Giampaolo Mezzabotta. Mandal. Sofiane Alihalassa. F Rujeedawa. Julio Garay Ramos. Katsunori Osuga. and we thank them all for their invaluable contribution and collaboration. Sevil Huseynova. Evariste Gasana. Marta Isabel Calona de Abrego. Abbas Zezai and Assefash Zehaie. Jacquemin Kouakou. Akihiro Seita. Kitty van Weezenbeek. Mathurin Sary Dembélé. Gabriel Marie Ranjalahy. Themba Dlamini. 8)04PVUI&BTU"TJB3FHJPO Mohammed Akhtar. Mohammed Berthe. Amal Bassili. Catherine Lijinsky. Géneviève Angue. . Azmera Molla. Abdou-Salam Abderemane. Edelmiro Castaño Bizantino. Pearl Mc Millan. Aayid Munim. Ismael Edris. Mohamed Ould Sidatt. Jucael Hermann Ongouo. Mansur Kabir. Chadrakant Revankar. Yamil Silva. Javahir Suleymanova. Ernest Cholopray. Philip Ejikon. Miguel Camará. Jorge Iñiguez. Adama Jallow. The main purpose of this report is to provide the latest data on the TB epidemic and progress in TB care and control. David Mercer. Juan Acuresila. Marie-Léopoldine Mawagali. Evgeny Belilovskiy. Andre Gotingar. Victor Gallant. Momar Talla Mbodji. Jeetendra Mohanlall. Médard Mvé. Francis Gausi. Ernesto Moreno Naranjo. Khurshid Alam Hyder. Diallo Naco. Mery Mercedes. Mirian Álvarez. 8)08FTUFSO1BDJ¾D3FHJPO Cornelia Hennig. Andrea Yvette Maldonado Saavedra. Thabo Hlophe. Clifford Munyandi. Shalauddin Ahmed.A.

Karin Ronning. Elena Skachkova. Oritta Zachariah. Aigul Tursynbaeva. Dhikrayet Gamara. Ulgen Gullu. 8)0&BTUFSO. Serafi Moa Mulumulu. Hashim Suleiman El Wagie. Kinaz Chiekh. Rosalind Vianzon. Rashid Al-Owaish. Fandy Osman. Fathmath Reeza. Emdadul Haque. 8)0&VSPQFBO3FHJPO Elmira Abdrakhmanova. Andrew Kamarepa. Noel Itogo. Bernard Rouchon. Delphine Antoine. Persaud Nordia. Essam Elmoghazy. Lokman Hakim Bin Sulaiman. Elena Pavlenko. Dyah Mustika. Khadiga Adam. Kennar Briand. Bashir Suleiman and Mohemmed Tbena. Yuttichai Kasetjaren. Xaysangkhom Insisiengmay. Joan O’Donnell. Tam Cheuk Ming. 8)03&1035 (-0#"-56#&3$6-04*4$0/530- WJJ Francis Morey. Phannasinh Sylavanh. Khin Mar Kyi Win. Vladimir Milanov. Abdukarim Jalolovich. Saeed Alsaffar. Mohmmad Khalid Seddiq. Grant Storey. Amal Galal. Jennifer Fernández Garcia. Samia Alagab. Efrat Haddad. Kim Tong Hyok. Suksont Jittimanee. António Antunes. Phonenaly Chittamany. Bozidarka Rakocevic. Piret Viiklepp. Svetlana Cherenko. Clarita Torres. Abdelbari Al-Hammadi. Rukije Mehmeti. Elmira Ibraim. Melissa Valdez. Khandaasuren Dovdon. Waimanu Pulu. Bereka Reiher. Kifah Saleh Alshaqeldi. Iobi Batio. Gurbanmammet Elyasov. Bob Pratt. Jane Dowabobo. Jorge Rodríguez-De Marco. Soteroulla Soteriou. Ana Ciobanu. Elena Rodríguez-Valín. Peter Helbling. Anna Esther Reyes Godoy. Jean-Paul Pescheux. Daniel Vázquez. Wanlin Maryse. Maria Grazia Pompa. Damijan Erzen. Risa Bukbuk. Walid Daoud. Firuza Sharipova. Noor Ahmad Baloch. Thandar Lwin. Shahnaz Ahmadi. Kenneth Tabutoa. Nilda Romero. Stephen Macharia. Mercianna Moxey. Kefah. Lakbir Singh Chauhan. Susan Barker. Nadia Abu Sabrah. Michael Williams. Rachid Fourati. 8)04PVUI&BTU"TJB3FHJPO Sunil de Alwis. Cheng Shiming. Olivera Bojovic. Khaled Abu Rumman. Jang Yong Hui.FEJUFSSBOFBO3FHJPO Mohammad Salama Abouzeid. Anna-Marie Garfin. Mohamad Gaafar. Ameera Fabella. Kai Kliiman. Edita Davidavičiené. Hamza Bozkurt. Kinaz. Adalberto Rodríguez. Faafetai Teo-Yandall. Mayleen Jack Ekiek. Abdul Latif Al-Khal. Mohamed Elfurjani. Dhafer Hashim. Richard Brostrom. Ratna Bhattarai. Kenza Bennani. Miriam Nogales Rodríguez. Partha Pratim Mandal. Gianfranco Spiteri. Zohar Mor. Donika Mema. Leonarda Reyes. Suzana Binte Mohd Hashim. Gennady Gurevich. Louise Fonua. Areli Paredes García. Salah Ben Mansour. . 8)08FTUFSO1BDJ¾D3FHJPO Farzana Adam. Maria Korzeniewska-Kosela. Wang Yee Tang and Byunghee Yoo. Aftandil Alisherov. Liza Lopez. Henri-Pierre Mallet. Thorsteinn Blondal. Nguyen Binh Hoa. Petri Ruutu. Ali Mohammed Hussain Al-Lawati. Oksana Segur. Peter Anderson. Ileana Stoicescu. Nazrul Islam. Razia Fatima. Susan Schorr. Radmila Curcic. Laasri Lahsen. Connie Erkens. Margarida Coll Armangué. Assia Haissama Mohammed. Andrei Astrovko. Markleen Tagaro. Kashi Kanta Jha. Paul Ricketts. Tieng Sivanna. Jiri Wallenfels. Ucha Nanava. David Rodríguez Pérez. Dmitri Sain. Hasan Hafizi. Maja Zakoska and Hasan Zutic. Narine Mezhliumyan. Mtanios Saade. Kim Jong Guk. Badri Nath Jnawali. Dottin Ramoutar. Stefan Talevski. Jerker Jonsson. Ibrahim Abubakar. Usha Jayasuriya. Christopher Ulisses Trujillo García. Cecilia Arciaga. Connie Olikong. Hala Alkjhayer. María Rodríguez. David Hunsberger. E. Kalthoom Hassan. Faimanifo Peseta. Johana Ngiruchelbad. Pablo Pacheco. Hlaing Myo Tun. Tomomi Mizuno. Pengiran Khalifah bin Pg Ismail. Natavan Alikhanova. Iagor Kalandadze. Noa Cedar. Tserenbaljid Tseveen. Marites Fabul. William Turner. Dinh Ngoc Sy. Rangiau Fariu. Vija Riekstina. Sayed Daoud Mahmoodi. Issa Ali Al-Rahbi. Stefanos Bonvas. Laurent Morisse. Joseph Lasu. Antonella Sorcinelli. Chou Kuok Hei. Said Abdallah Guelleh. Nese Ituaso Conway. Orlando Sequeira. Mahshid Nasehi. Awatef El Shamry. Temilo Seono. Constantino Lopes. Gulnoz Uzakova. Zulema Torres Gaete. Norbert Charle. Wang Lixia. Olga Krivoanos. Nukutau Pokura. Chewang Rinzin and Asik Surya. Aleksander Simunovic. Ejaz Qadeer. Jean-Paul Klein. Tleukhan Abildaev. Reina Valerio. Gábor Kovács. Tomasa Portillo. Du Xin. Ekkehardt Altpeter. Nou Chanly. Nydia Zelaya and Elsa Zerbini. Bonita Brodhun. Ivan Solovic. Paul Aia. Naila Abuljadayel. Amin Noman Alabsi.

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In 2009. There is considerable variation in what countries spend on a per patient basis (<US$ 100 to >US$ 1000). The target of halving the 1990 prevalence rate by 2015 appears out of reach at global level. Given the scale-up of interventions set out in the plan. 8. The main purpose of the report is to provide a comprehensive and up-to-date assessment of the TB epidemic and progress made in TB care and control at global. which are to halve rates of prevalence and mortality by 2015 compared with their levels in 1990. but could be achieved in three of six regions: the Region of the Americas.8 million notified cases of TB in 2009. for the years 2011–2015. Most cases were in the South-East Asia. To prevent TB. There were 5. Among TB patients notified in 2009. according to the updated targets included in this plan. the Stop TB Partnership launched an updated version of the Global Plan to Stop TB in October 2010. In areas where PPM was implemented. . This is an increase from previous years. African and Western Pacific regions (35%. finance and implement the Stop TB Strategy. 26% of TB patients knew their HIV status (up from 22% in 2008). this could increase to US$ 3 billion by 2015 without intensified efforts to mobilize more resources. Prevalence is falling globally and in all six WHO regions. An estimated 11–13% of incident cases were HIV-positive. the mortality target could be achieved in five of WHO’s six regions. up from 61% in 2008. Looking forwards. Of these. The -2863(9'8-32 and 1)8. the exception is the African Region (although rates of mortality are falling). including 53% of patients in the African Region. a total of 41 million TB patients were successfully treated in DOTS programmes. Reductions in the burden of disease achieved to date follow 15 years of intensive efforts to improve TB care and control. At the regional level. Incidence rates are falling globally and in five of WHO’s six regions (the exception is the South-East Asia Region. and the target of a 50% reduction by 2015 could be achieved if the current rate of decline is sustained. The estimates of the global burden of disease caused by TB in 2009 are as follows: 9. tested HIV-positive). 60–67%). the funding gap is approximately US$ 1 billion in 2011. This could save at least one million lives per year. The Stop TB Partnership has set two additional targets.2 million–1. nonNTP providers accounted for around one-fifth to onethird of total notifications in 2009.3(7 sections of this report explain why this was necessary.9 million–9. A total of 300 000 HIV-positive TB patients were enrolled on co-trimoxazole preventive therapy. almost 80 000 people living with HIV were provided with isoniazid preventive therapy. Compared with the funding requirements estimated in the Global Plan. regional and country levels. 14 million prevalent cases (range.32 million–0. 1.  7YQQEV] 8 he World Health Organization (WHO) has published an annual report on global control of tuberculosis (TB) every year since 1997. respectively).5 million) and 0. the African Region accounted for approximately 80% of these cases. This fifteenth annual report1 contains more up-todate information than any previous report in the series. 30% and 20%. an estimated 250 000 (range. 0. or PPM) can be a particularly effective way to increase the CDR.38 million deaths among HIV-positive people (range. intensified efforts are needed to plan. Collectively. but still represents less than 1% of the estimated number of people living with HIV worldwide.9 million). Mortality rates at global level fell by around 35% between 1990 and 2009. 230 000–270 000) had multidrugresistant TB (MDR-TB). The target included in the Millennium Development Goals (MDGs) is that TB incidence should be falling by 2015.3 million deaths among HIV-negative people (range. equivalent to a case detection rate (CDR. where the incidence rate is stable).6 million patients with sputum smear-positive pulmonary TB in the 2008 cohort. 12 million–16 million).4 million incident cases (range. 86% were successfully treated. Diagnosis and treatment of MDR-TB need to be rapidly expanded. the WHO’s Stop TB Strategy and the Stop TB Partnership’s Global Plan to Stop TB have set out how the 2015 targets can be achieved. and almost 140 000 were enrolled on antiretroviral therapy (75% and 37% respectively of those who 1 Two reports were published in 2009.45 million). If these trends are sustained. 1. Progress towards global targets set for 2015 is given particular attention. Funding for TB control continues to increase and will reach almost US$ 5 billion in 2011. defined as the proportion of incident cases that were notified) of 63% (range. the Eastern Mediterranean Region and the Western Pacific Region. Between 1995 and 2009. following earlier data collection and the completion of the production cycle within a calendar year. slightly more than 30 000 (12%) were diagnosed with MDR-TB and notified. Of the 2. and up to 6 million lives were saved including 2 million among women and children. the MDG target will be achieved. In the five years that remain until the target year of 2015. and the extent to which countries rely on domestic or external sources of funds. New and compelling data from 15 countries show that efforts by national TB programmes (NTPs) to engage all care providers in TB control (termed public-private mix.

The main purpose of the report is to provide a comprehensive and up-to-date assessment of the TB epidemic and progress made in TB care and control at global. It then describes the main components of the Stop TB Strategy and the Stop TB Partnership’s Global Plan to Stop TB. Recent trends in funding for TB control. This section analyses trends in rates of TB incidence. regional and country levels. which in combination have set out how the global targets can be achieved. as follows: N Methods. following earlier data collection and the completion of the production cycle within a calendar year. regional and country levels in 2009.   -RXVSHYGXMSR 8 he World Health Organization (WHO) has published an annual report on global control of tuberculosis (TB) every year since 1997. It also features the topic of human resource development and provides an update about the work of the Global Laboratory Initiative. treatment outcomes. case detection rates (for all forms of TB). N Financing for TB control. prevalence and mortality (absolute numbers and rates) at global. N Progress in implementing the Stop TB Strategy and the Global Plan to Stop TB. as part of the Millennium Development Goals (MDGs) and by the Stop TB Partnership. #09 8IBUµTOFXJOUIJTSFQPSU 8LMWVITSVXMRGPYHIWXLIWEQI[IEPXLSJMRJSVQEXMSREW TVIZMSYWVITSVXWMRXLIWIVMIWFYXJSYVRI[JIEXYVIW EVI[SVXLLMKLPMKLXMRK*MVWXXLIHEXEEVIQSVIYTXS HEXIXLERXLSWIMRGPYHIHMRTVIZMSYWVITSVXW(EXEYT XSERHMRGPYHMRKEVITVIWIRXIHJSVEPQSWXEPPOI] MRHMGEXSVW´RERGMEPHEXEI\XIRHXS7IGSRHIWXM QEXIWSJXLIGEWIHIXIGXMSRVEXIEVITVIWIRXIHJSVEPP JSVQWSJ8&SRP]. N The global burden of disease caused by TB in 2009. whose goal is to strengthen laboratories worldwide. including comparisons with the funding requirements estimated in the Global Plan. This section defines the global targets for TB control that have been set for 2015. the WHO Stop TB Strategy and the Global Plan to Stop TB. Recent successes in strengthening planning and budgeting for TB control using the WHO TB planning and budgeting tool are showcased. the contribution of public–private mix (PPM) initiatives to case notifications. regional and country levels. reviewed and analysed. N Global targets. This section explains how the data used to produce the report are collected. and assesses whether the 2015 targets can be achieved at global. This fifteenth annual report1 contains more up-to-date information than any previous report in the series. implementation of collaborative TB/HIV activities and the management of drugresistant TB. N Progress towards the 2015 targets. This section presents estimates of incidence. The main part of the report is structured in eight major sections. This section includes analysis of case notifications. are presented and discussed. prevalence and mortality from 1990 to 2009.

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'39286= 463*-0)7 for all countries are available online at www. N Conclusions. The first report (March) included key indicators up to and including 2007 (for example. 1 Two reports were published in 2009. . The second report (published on the web in December) included key indicators up to and including 2008. %22)< contains summary tables that provide global. in the context of the policies and recommendations of the WHO Global Task Force on TB Impact Measurement. This final section draws together the main findings and recommendations in the report. who. estimates of disease burden and case notifications).int/tb/data. Two reports were produced in one year in anticipation of a different production cycle in which reports would always contain data up to and including the previous calendar year.3«WKPSFEP8&HEXEFEWI N Improving measurement of the burden of disease caused by TB. their content is advertised in %22)<.&'W SRP] ERHGERFIHS[RPSEHIHSRPMRIEX[[[[LSMRX XFHEXEEP[E]WHVE[MRKSRXLIPEXIWXHEXEEZEMPEFPIMR . %22)< explains the methods that were used to produce estimates of disease burden.VEXLIVXLERXLI. This section summarizes progress at country level in strengthening surveillance (of cases and deaths) and implementing surveys of the prevalence of TB disease. regional and country-specific data for the main indicators of interest..

ensuring that data published for all countries were as up-to-date as possible at the time that the report went to press. Most of the countries that had not reported data by 16 June were high-income countries in western Europe. managed by the WHO Regional Office for the European Region. The short form was adapted for use in high-income countries (that is. As in 2009. utilization of general health services (hospitalization and outpatient visits) during treatment. the Practical Approach to Lung Health (PAL). communication and social mobilization (ACSM). A web-based online system (www. as defined by the World Bank) and/ or low-incidence countries (defined as countries with an incidence rate of <20 cases per 100 000 population or <10 cases in total). human resource development (HRD). Data from the ECDC system are uploaded to the WHO system. This allows fair comparison of funding amounts across years. surveillance and surveys of drug-resistant TB. Brunei Darussalam and Japan. the budgets of national TB control programmes (NTPs) in 2010 and 2011. all reports were carefully reviewed using a system of built-in validation checks (also available to country-based staff reporting data). N Assessments of progress made in implementing PPM initiatives and of global efforts to strengthen laboratory services and impact measurement draw on information obtained from key informants as well as data received via the online WHO TB data collection form. Following the deadlines for reporting of data. together with historical data reported in previous years. Followup queries were returned to respondents online. Four additional points should be highlighted: N NTPs sometimes provide WHO with updated information for previous years. Both forms requested data on the following topics: case notifications and treatment outcomes. 147 countries (excluding the European Region) had reported data (for further details. WHO recommendations for recording and reporting within countries are described at: http://www. In consultation with WHO regional offices. Taken together. 21 out of 53 countries reported data by 16 June. monitoring and evaluation. drug management. This updated dataset was used to create the detailed tables that are included in %22)< . see &3<). including breakdowns by age. N The annual data collection form and database system used by WHO are designed for collecting aggregated national data. and NTP expenditures in 2009. which is managed jointly by the European Centre for Disease Control and Prevention (ECDC) and the WHO Regional Office for Europe. data collection was launched in mid-March. By 16 June (the deadline for responding to queries). One system for countries of the European Union. about four months earlier than in any previous year. Data from the two online systems used in the European Region3 were also uploaded to the master dataset. the other for all European countries. after adjustment for inflation.html . were integrated into the global TB data collection form. TB infection control. the 168 countries that reported data by the dead- line of 16 June account for 99% of the world’s TB cases.stoptb. sex and HIV status. Data were reported for all except Haiti by 31 August 2010 and as a result data for these countries are included in %22)<. countries with a gross national income per capita of ≥US$ 12 196 in 2009. The four countries for which data were not reported by 16 June were Canada.1 In 2010. They are not recommended for collection of data within countries.   1IXLSHW * or the 2010 round of data collection. Haiti. Country respondents continue to have the option of updating or adding data to the online system. to produce the tables and figures that appear in the main part of the report. The master dataset was updated for a second time on 31 August 2010. two versions of the form were developed (a long form and a short form). for incorporation in the global TB database.2 In the European Region.4 1 2 3 4 The European Region has its own system for online reporting of data.org/tme) was used to report and validate data in all regions except the European Region (&3< ). advocacy. N Financial data are presented in real terms.int/tb/dots/r_and_r_forms/ en/index. All data in the global and European online systems as of the morning of 17 June 2010 were then used. a few countries that met the criteria for receiving the short form were instead requested to complete the long form. an overview of services for the diagnosis and treatment of TB. which had previously been asked through a separate data collection effort. WHO updated the forms that were used in 2009. managed by the ECDC. with a deadline of 16 May for all regions except the Region of the Americas (31 May) and the European Region (30 September). management of drug-resistant TB. TB control in vulnerable populations and high-risk groups. All data collected online in 2010 were added to a master dataset that holds the TB-related data that have been compiled by WHO since 1995. The main change was that questions on surveillance of MDR-TB. laboratory diagnostic services. using all data in the global and European online systems at this time. the data presented in this report may differ from those published in previous reports. This included countries that had in previous years provided the more detailed financial data requested on the long form. collaborative TB/ HIV activities. Two data collection tools are used. As a result.who. without distortions caused by changes in prices. PPM.

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prevalence and mortality). empirical data. the results provided in the main text of the report and in %22)< are presented as best. low and high estimates. the lower and higher numbers correspond to the 2.SJ GSYRXVMIW MRXLI.YRI 8LIHEXEXEFPIWTYFPMWLIHMR%22)<EVIFEWIHSRXLIHEXEEZEMPEFPISR%YKYWX9THEXIWVIGIMZIHEJXIV %YKYWXEVIEZEMPEFPIJSVHS[RPSEHMRKEX[[[[LSMRXXFHEXEERH[MPPFIYWIHEWTEVXSJXLIHEXEWIXJSV..5th centiles of the outcome distributions produced by simulations. In line with the methods explained in this annex.3«W KPSFEPVITSVX   'SPPIGXMSRSJHEXEMRXLI)YVSTIER6IKMSRMWQEREKIHWITEVEXIP]F]XLI. which are estimated directly from observed.5th and 97.36IKMSREP3J´GIJSV)YVSTIERHXLI)YVSTIER'IRXVI JSV(MWIEWI'SRXVSPERH4VIZIRXMSR %22)<  provides details about the methods used to produce estimates of the disease burden caused by TB (measured as incidence.IWXIVR4EGM´G6IKMSR-RXLI)YVSTIER6IKMSRSYXSJGSYRXVMIWLEHVITSVXIHHEXEF]. .YRIEGGSYRXJSV SJXLI[SVPH«W8&GEWIW 8LIXEFPIWERH´KYVIWTYFPMWLIHMRXLIQEMRTEVXSJXLIVITSVXEVIFEWIHSRXLIHEXEEZEMPEFPISR. When the term “range” is used after a best estimate in the main text of the report.YRI[IVILMKLMRGSQIGSYRXVMIWMR[IWXIVR)YVSTI8EOIRXSKIXLIV XLIGSYRXVMIWXLEXVITSVXIHHEXEF]XLIHIEHPMRISJ.YRI1SWXSJ XLIGSYRXVMIWXLEXLEHRSXVITSVXIHHEXEF]. These are distinct from 95% confidence intervals..

as slow reductions in incidence rates per capita (see 7)'8-32) continue to be outweighed by increases in population.   8LIKPSFEPFYVHIRSJ8&  *ODJEFODF tinues to increase slightly from year to year. The absolute number of cases con- 5"#-& &TUJNBUFEFQJEFNJPMPHJDBMCVSEFOPG5# 2YQFIVWMRXLSYWERHWI\GITX[LIVIMRHMGEXIHE 1368%0-8= F 43490%8-32 &)78G %JKLERMWXER   &ERKPEHIWLH   &VE^MP  'EQFSHME 'LMRE (6'SRKS )XLMSTME -RHME -RHSRIWME        03.    46):%0)2') .9 million–9.-+. Estimates of the number of cases broken down by age and sex have been prepared by an expert group2 as part of - n 2009. there were an estimated 9. *-+96)). &)78 03. . 8.9 million)1 of TB globally (equivalent to 137 cases per 100 000 population) (8%&0).4 million incident cases (range.-:46):%0)2')-2 -2'-()288&'%7)7.

This expert group is convened by the WHO Global Task Force on TB Impact Measurement. -2'-()2') . See also 7)'8-32 and %22)<. &)78 03. .5th centiles of the outcome distributions produced by simulations. .&'WERHKPSFEPP]GSQTYXIHTVMSVXSVSYRHMRKYWMRK 1SRXI'EVPSWMQYPEXMSRW F  1SVXEPMX]I\GPYHIWHIEXLWEQSRK.-+.-+.-:TSWMXMZI8&GEWIW(IEXLWEQSRK.5th and 97. . See also 7)'8-32 of this report.-:HIEXLWEGGSVHMRKXS-'( G  &IWXPS[ERHLMKLMRHMGEXIFIWXIWXMQEXIWJSPPS[IHF]PS[IVERHYTTIVFSYRHW8LIPS[IVERHYTTIVFSYRHWEVIHI´RIHEWXLIXLERHXL GIRXMPIWSJSYXGSQIHMWXVMFYXMSRWTVSHYGIHMRWMQYPEXMSRW7II%22)<JSVJYVXLIVHIXEMPW H  &ERKPEHIWLGSQTPIXIHEWYVZI]SJXLITVIZEPIRGISJ8&HMWIEWIMR%VIEWWIWWQIRXSJXLIITMHIQMSPSKMGEPFYVHIRSJ8&YWMRKHEXEJVSQXLI WYVZI]GSQFMRIH[MXLERMRHITXLEREP]WMWSJWYVZIMPPERGIERHTVSKVEQQEXMGHEXE[MPPFIYRHIVXEOIRMR I  1]ERQEVGSQTPIXIHEWYVZI]SJXLITVIZEPIRGISJ8&HMWIEWIMR%VIEWWIWWQIRXSJXLIITMHIQMSPSKMGEPFYVHIRSJ8&[MPPFIYRHIVXEOIR JSPPS[MRK´REPM^EXMSRERHHMWWIQMREXMSRSJWYVZI]VIWYPXW 1 2 The range is the uncertainty interval that corresponds to the 2.-+. ¦ ¦ ¦                                             &)78                                          /IR]E              1S^EQFMUYI                              1]ERQEVI 2MKIVME           4EOMWXER                           4LMPMTTMRIW 6YWWMER*IHIVEXMSR              7SYXL%JVMGE              8LEMPERH              9KERHE                 968ER^ERME  :MIX2EQ   >MQFEF[I     %*6 %16 )16 )96 7)%6 .-:TSWMXMZI8&GEWIWEVIGPEWWM´IHEW.46             (MPCBM   )JHICVSEFODPVOUSJFT                                                                                                                        ¦ -RHMGEXIWRSHEXEVITSVXIH E 2YQFIVWJSVQSVXEPMX]TVIZEPIRGIERHMRGMHIRGIWLS[RXSX[SWMKRM´GERX´KYVIW8SXEPWJSV.               03.

  8)03&1035 (-0#"-56#&3$6-04*4$0/530- '*(63& &TUJNBUFE5#JODJEFODFSBUFT CZDPVOUSZ  Estimated new TB cases (all forms) per 100 000 population 0–24 25–49 50–99 100–299 ≥300 No estimate '*(63& &TUJNBUFE)*7QSFWBMFODFJOOFX5#DBTFT  HIV prevalence in new TB cases. all ages (%) 0–4 5–19 20–49 ≥50 No estimate .

By July 2010. When survey data are not available. equivalent to 35% of all cases. range. there were an estimated 0. MDR-TB) plus resistance to a fluoroquinolone and. an estimated 1. and China and India combined account for 35%. range 10 000–16 000). The number of TB deaths per 100 000 population among HIV-negative people plus the estimated number of TB deaths among HIV-positive people equates to a best estimate of 26 deaths per 100 000 population. Figures have not been updated for this report.5 million) among women. range. India alone accounts for an estimated one fifth (21%) of all TB cases worldwide. 2006.5 million). The latest estimates are for 2008.45 million) among incident TB cases that were HIV-positive (data not shown).32 million–0. These numbers are slightly lower than those reported in previous years. range.4 The 27 countries (15 in the European Region) that account for 86% of all such cases have been termed the 27 high MDR-TB burden countries (see also 7)'8-32 ). the European Region (4%) and the Region of the Americas (3%). Defined as females aged ≥15 years old. India (99 000. Oxford University Press and The World Bank. 0. as published in March 2010 in: Multidrug and extensively drug-resistant TB (M/XDR-TB): 2010 global report on surveillance and response.55 million) and Indonesia (0.  1SFWBMFODF There were an estimated 14 million prevalent cases (range. at least.2 million–1.3 million cases (range.4 million). an update to the Global Burden of Disease study.6–2. 0.35–0. approximately 1.1 million (12%) (8%&0). these deaths are classified as HIV deaths in the 10th revision of the International Classification of Diseases (ICD-10). prevalence is a robust indicator of the burden of disease caused by TB when it is directly 8)03&1035 (-0#"-56#&3$6-04*4$0/530-  measured in a nationwide survey. an estimated 1. estimates of the prevalence of TB and trends in rates of TB prevalence will improve.1 million–3.5 million) occurred among HIV-negative cases of TB (8%&0) ).7 million people died of TB in 2009.59 million). Most of the estimated number of cases in 2009 occurred in Asia (55%) and Africa (30%).5 million).0–1. Of these HIV-positive TB cases. approximately 80% were in the African Region. Global burden of disease and risk factors.e. the Russian Federation (38 000.3 million deaths (range. including 0. 30 000–45 000) and South Africa (13 000. Geneva.%35#BOE9%35# There were an estimated 440 000 cases of multi-drug resistant TB (MDR-TB) in 2008 (range.4 million deaths (range. 390 000– 510 000). equivalent to 200 cases per 100 000 population. In those countries where surveys are done and repeated at periodic intervals (see 7)'8-32). one second-line injectable agent (amikacin. Nigeria (0. 79 000–120 000). New York. with a best estimate of 1.2 million (11–13%) were HIV-positive. . Thus in total.PSUBMJUZ In 2009.5 1 2 3 4 5 This study is an update to Lopez AD et al.1 These indicate that women2 account for an estimated 3. As explained in %22)< . reflecting better estimates (based on more direct measurements as documented in %22)<) as well as reductions in HIV prevalence in the general population. Africa means the WHO African Region.  . it is difficult to estimate its absolute level and trend.1–1.3 million–0. South Africa (0. World Health Organization. 2010 (WHO/HTM/TB/2010. *-+96)). Estimates of the numbers of TB cases among women and children need to be improved through more reporting and more analysis of notification data disaggregated by age and sex. XDR-TB is defined as resistance to isoniazid and rifampicin (i. 58 countries and territories had reported at least one case of extensively drug-resistant TB (XDR-TB).3).40–0. China (1. The 22 HBCs that have received particular attention at the global level since 2000 account for 81% of all estimated cases worldwide (8%&0)).38 million deaths (range.4 million incident cases in 2009. In addition. The five countries with the largest number of incident cases in 2009 were India (1. Of the 9. The four countries that had the largest number of estimated cases of MDR-TB in absolute terms in 2008 were China (100 000. 3.3 smaller proportions of cases occurred in the Eastern Mediterranean Region (7%).  . kanamycin and/or capreomycin). This is equivalent to 20 deaths per 100 000 population.52 million). Asia here means the WHO regions of South-East Asia and the Western Pacific. 12 million–16 million) of TB in 2009 (8%&0)).37– 0. 79 000–120 000). 1.

and (vi) enable and promote research. The Global Plan to Stop TB.EPXERHFIKMRXSVIZIVWIXLIMRGMHIRGISJ QEPEVMEERHSXLIVQENSVHMWIEWIW *OEJDBUPS-RGMHIRGITVIZEPIRGIERHHIEXLVEXIW EWWSGMEXIH[MXL8& *OEJDBUPS4VSTSVXMSRSJ8&GEWIWHIXIGXIHERH GYVIHYRHIV(387 45015#1"35/&34)*15"3(&54 4&5'03"/% #Z6IHYGITVIZEPIRGIERHHIEXLVEXIWF]  GSQTEVIH[MXLXLIMVPIZIPWMR Achievements in TB control in the years following implementation of DOTS and the Stop TB Strategy. The additional targets set by the Stop TB Partnership are to halve TB prevalence and death rates by 2015. notification and treatment of approximately 7 million cases. the plan was updated. and communities through partnership. which covers the five years from 2011 to 2015.35). The Global Plan to Stop TB. 2006 (WHO/HTM/STB/2006. Currently. . World Health Organization. as the mid-point of the original 10-year plan approached. and prospects for the further gains that could be made up to 2015. In 2010. #Z6IHYGIXLIKPSFEPMRGMHIRGISJEGXMZI8& GEWIWXS GEWITIVQMPPMSRTSTYPEXMSRTIV]IEV 1 2 3 The Stop TB Strategy: building on and enhancing DOTS to meet the TBrelated Millennium Development Goals. This updated version of the plan. The six major components of the strategy are: (i) pursue high-quality DOTS expansion and enhancement.  5IF(MPCBM1MBOUP4UPQ5# The Stop TB Partnership’s Global Plan to Stop TB. 2006– 2015. It set out the scale at which the interventions included in the Stop TB Strategy need to be implemented to achieve the 2015 targets. most attention is given to the targets set for 2015.3 billion per year for research and development related to new drugs. Geneva. plus around US$ 1. N HIV testing of 100% of TB patients. compared with their levels in 1990. 2011–2015. World Health Organization.%&7&-01. N enrolment of all patients with a confirmed diagnosis of MDR-TB on treatment consistent with international guidelines. as well as testing of any new TB patients considered at high risk of having MDR-TB (estimated globally at around 20% of all new TB patients).2). N provision of isoniazid preventive therapy (IPT) to all people living with HIV who are attending HIV care services and are considered eligible for IPT. World Health Organization. MDR-TB. (iii) contribute to health-system strengthening based on primary health care. N mobilization of US$ 7 billion per year to finance implementation of the Stop TB Strategy. 2006–2015: actions for life towards a world free of tuberculosis."-"3*"  "/%05)&3%*4&"4&4 5BSHFUD.2 was launched in January 2006. Geneva. (v) empower people with TB. N testing of 100% of previously treated TB patients for MDR-TB. The target set within the context of the MDGs is to halt and reverse the incidence of TB by 2015. new diagnostics and new vaccines.    +PSFEPXEVKIXWXLI7XST8&7XVEXIK] ERHXLI+PSFEP4PERXS7XST8&  (MPCBMUBSHFUTGPS5#DPOUSPM + lobal targets for reducing the burden of disease caused by TB have been set for 2015 and 2050 (&3<).  5IF4UPQ5#4USBUFHZ The Stop TB Strategy1 is the approach recommended by WHO to reduce the burden of TB in line with global targets set for 2015. N enrolment of 100% of HIV-positive TB patients on co-trimoxazole preventive therapy (CPT) and antiretroviral therapy (ART).#"5)*7"*%4 . N a treatment success rate among sputum smearpositive cases of 90%.368).3 The major targets for 2015 in this updated plan have been defined as follows: N diagnosis. (ii) address TB/HIV. Geneva. and the needs of poor and vulnerable populations. 2010 (WHO/HTM/STB/2010. 2006 (WHO/HTM/TB/2006. The strategy is summarized in &3<.&/5(0"-4 4&5'03 N (0"-$0. (iv) engage all care providers. #09 (PBMT UBSHFUTBOEJOEJDBUPSTGPS5#DPOUSPM )&"-5)*/5)&. are highlighted in &3<.*--&//*6. includes an updated set of targets.

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community TB care and research (components 5 and 6 of the strategy) are not discussed because there are limitations in the available data.8 million cases of TB (new cases and relapse cases) were notified to NTPs. the Russian Federation (31%)..-:TSWMXMZI8&TEXMIRXW IZIRQSVIPMZIWGSYPHFIWEZIH   %WWYQMRKXLIXVIEXQIRXWYGGIWWVEXIMRMWQEMRXEMRIH MR   )\GPYHMRKHIEXLWEZIVXIHEQSRK. Pakistan (42%).IWXIVR4EGM´G6IKMSRLEZIEPVIEH]EGLMIZIHXLI 1 XEVKIXSJLEPZMRKXLIQSVXEPMX]VEXI1SVXEPMX]VEXIW EVIJEPPMRKMREPP. additional efforts to compile better data on these topics will be needed. Such engagement is essential to ensure high levels of case detection and treatment success.3VIKMSRW *ODJEFODF+PSFEPP]MRGMHIRGIVEXIWTIEOIHMR8LMW QIERWXLEXXLI[SVPHMWSRXVEGOXSEGLMIZI1(+8EVKIX GEWEVI´ZISJ. All four topics are closely related to health-system strengthening (component 3 of the Stop TB Strategy) as well as DOTS and the engagement of all care providers. including 2. 0. ACSM. both of which fall under component 2 of the Stop TB Strategy. and compares progress with the targets included in the Global Plan to Stop TB.-:TSWMXMZITISTPI. #09 "DIJFWFNFOUTJO5#DPOUSPMEVSJOHUIFQFSJPE°BOEQSPTQFDUTGPS° 8LI(387WXVEXIK][EWHIZIPSTIHEWXLIMRXIVREXMSREPP] VIGSQQIRHIHETTVSEGLXS8&GSRXVSPMRXLIQMHW (387 MW EPWS XLI JSYRHEXMSR SJ XLI 7XST 8& 7XVEXIK] PEYRGLIH F] .PSUBMJUZ+PSFEPP]8&QSVXEPMX]LEWJEPPIRF]QSVIXLER EXLMVHWMRGI8LI6IKMSRSJXLI%QIVMGEWERHXLI . Boxes are used to feature four topics – laboratory strengthening.    4VSKVIWWMRMQTPIQIRXMRKXLI7XST8& 7XVEXIK]ERHXLI+PSFEP4PERXS7XST8& 8 his section examines the latest data on implementation of the Stop TB Strategy.  $BTFOPUJ¾DBUJPOT In 2009.3 IJJSVXW XS W]WXIQEXMGEPP] QSRMXSV TVSKVIWW MR 8& GSRXVSPSRERERRYEPFEWMWMRGSMRGMHIH[MXLKPSFEP TVSQSXMSR ERH I\TERWMSR SJ XLI (387 WXVEXIK] HEXE GSQTMPIHWMRGIXLIREPPS[EWWIWWQIRXSJEGLMIZIQIRXW MR 8& GSRXVSP FIX[IIR  ERH  ERH TVSNIGXMSRW SJ [LEX JYVXLIV KEMRW GSYPH FI QEHI YT XS  /I] VIWYPXWEVIWYQQEVM^IHFIPS[[MXLJYVXLIVHIXEMPWTVS ZMHIHMR7)'8-32 1BUJFOUT USFBUFE BOE DVSFE  ° % XSXEP SJ  QMPPMSR TEXMIRXW [IVI XVIEXIH MR (387 TVSKVEQQIW SJ [LSQQMPPMSR[IVIWYGGIWWJYPP]XVIEXIH-RXLI XVIEXQIRX WYGGIWW VEXI VIEGLIH   [SVPH[MHI ERH  MRLMKLFYVHIRGSYRXVMIW . 5. 57% of global notifications were sputum smear-positive.MXL I\TERWMSR SJ XVIEXQIRX JSV 1(68& ERH MRXIVZIRXMSRWWYGLEW%68JSV..who.0 million new cases of sputum smear-negative pulmonary TB (including cases for which smear status was unknown). treatment success rates for sputum smear-positive TB patients and case detection rates for all forms of TB.6 million new cases of sputum smear-positive pulmonary TB. Among the 22 HBCs. HRD.3 million relapse cases (8%&0)).3 MR  XS KYMHI 8& GSRXVSP IJJSVXW HYVMRK XLI  ]IEVW JVSQ  XS  8LI WXEVX SJ . the percentage of notified cases of pulmonary TB that were sputum smear-positive was relatively low in Zimbabwe (29%). The data that are currently available as well as data for all other topics covered in the 2010 data collection form can be viewed and downloaded on the WHO web site (www.3«WWM\VIKMSRW -JWFTTBWFE°9TXSQMPPMSRPMZIW[IVIWEZIH XLVSYKLMQTPIQIRXEXMSRSJ(387ERHXLI7XST8&7XVEX IK] -JWFTUIBUDPVMECFTBWFEGSPN°%JYVXLIVQMP PMSRPMZIWGSYPHFIWEZIHMJGYVVIRXIJJSVXWMR8&GSRXVSP EVI WYWXEMRIH MRGPYHMRK EVSYRH  QMPPMSR [SQIR ERH GLMPHVIR .int/tb/ data).9 million new cases of extrapulmonary TB and 0. The first three topics covered are case notifications.1 Among pulmonary cases. In future. 2011–2015 where applicable. These all illustrate progress in implementing DOTS – the foundation of the Stop TB Strategy. The fourth topic is the engagement of the full range of care providers in TB control (component 4 of the strategy) through PPM.. 2.. strengthened surveillance and rational use of anti-TB medicines. The next two sections cover collaborative TB/ HIV activities and the diagnosis and treatment of drugresistant TB.

the WHO data collection form has made no distinction between notifications in DOTS and non-DOTS programmes. .-:VEXLIVXLER8&MR-'(    'SQTEVIH [MXL E GSYRXIVJEGXYEP WGIREVMS HI´RIH EW XLI WXERHEVH SJ GEVI ERH GEWI RSXM´GEXMSR VEXIW QEMRXEMRIH EX PIZIPW No distinction is made between DOTS and non-DOTS programmes. virtually all (more than 99%) notified cases were reported to WHO as treated in DOTS programmes.GPEWWM ´IHEWHIEXLWEXXVMFYXEFPIXS. This is because by 2007. Since 2009.

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13 reached the 85% target. the South-East Asia Region and the Western Pacific Region. Kenya (46%) and Ethiopia (46%). Among WHO regions. demonstrating that countries in which there is a high prevalence of HIV among TB patients are able to achieve this target. but the term “rate” has become standard terminology in this context of this indicator. especially the European Region. it is calculated as the number of notified cases of TB in one year divided by the number of estimated incident cases of TB in the same year.RSXHMWTPE]IHMRXLMWXEFPI  Myanmar (45%). The considerable attention given to the CDR was in line with the two principal global targets (case detection and treatment success rates) set for TB control during the period 1991 to 2005. three met or exceeded the 85% target: the Eastern Mediterranean Region.  5SFBUNFOUPVUDPNFT  $BTFEFUFDUJPOSBUFT Globally. Of the 22 HBCs. of the Americas and 66% in the European Region (where death and failure rates are comparatively high). A comparatively high proportion of notified cases were sputum smear-positive in Bangladesh (81%). 77% in the Region The case detection rate (CDR)1 has been a much-used indicator of national progress in TB control since the mid-1990s. This included Kenya and the United Republic of Tanzania. . the rate of treatment success for new sputum smear-positive cases of pulmonary TB who were treated in the 2008 cohort was 86% (8%&0) ). the Democratic Republic of the Congo (85%) and Viet Nam (73%). The targets of reaching a CDR of ≥70% and a treat1 The CDR is actually a ratio rather than a rate. This is the second successive year that the target of 85% (first set in 1991) has been exceeded globally. and expressed as a percentage. The treatment success rate was 80% in the African Region. Efforts to increase treatment success rates are warranted in these regions. For a given country.

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with the target year subsequently reset to 2005. compared with past reports (and this will be true of future reports on global TB control as well). this report places less emphasis on the CDR. Given uncertainty in estimates of TB incidence. The best estimate of the CDR of all forms of TB in 2009 was 63% (range. In particular. this report (for the first time in the series of reports published since 1997) does not include estimates of the CDR for sputum smear-positive cases of pulmonary TB (&3<). 60–67%) (8%&0)). The highest rates of case detection in 2009 are estimated to be in the Euro- SJREXMSREPERHMRXIVREXMSREPIJJSVXWXSGSRXVSP 8&EVI HI´RIH MR XIVQW SJ VIHYGXMSRW MR XLI HMWIEWI FYVHIR .&3< [LMGLEVIRS[XLIJSGYW ment success rate of 85% among sputum smear-positive cases of pulmonary TB by 2000 were set by the Fortyfourth World Health Assembly in 1991.

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74–85%).YRI  ERH 3GXSFIVF]ERI\TIVXKVSYTGSRZIRIHF]XLI.. 64–78%). The African Region has the lowest estimated rate of case detection (best estimate 50%. . South Africa. Kenya. 48–53%). Among the HBCs. range. the Russian Federation. the lowest rate is in Nigeria. range. While estimated rates of TB incidence are falling slowly. range.%22)<   GSRHYGXIH FIX[IIR . the highest rates of case detection in 2009 are estimated to be in Brazil. the United Republic of Tanzania and China. 74–85%) and the Region of the Americas (best estimate 79%. notification rates are increasing in the African Region and (particularly since around the year 2000) the Eastern Mediterranean and South-East Asia regions. range.3 +PSFEP 8EWO *SVGI SR 8& -QTEGX 1IEWYVIQIRX %QSRK SXLIV´RHMRKWXLMWVIZMI[MHIRXM´IHVIEWSRW[L]IWXM QEXMRK XLI '(6 JSV WTYXYQ WQIEVTSWMXMZI 8& MW QSVI HMJ´GYPX XLER TVIZMSYWP] XLSYKLX GSQTEVIH [MXL XLI '(6JSVEPPJSVQWSJ8& *GFTUJNBUFTPGUIF$%3GPSTNFBSQPTJUJWF5#BSFOFFEFE GPSSFQPSUJOHQVSQPTFT UIFSFBSFUXPPQUJPOT5IF¾STUJT UP BTTVNF UIBU UIF TNFBSQPTJUJWF $%3 JT TJNJMBS UP UIF $%3GPSBMMGPSNTPG5#*GUIJTJTOPUTBUJTGBDUPSZ DPVO USJFTBOEPSJOUFSOBUJPOBMBHFODJFTTIPVMEDPOUBDU8)0 BOESFRVFTUTGPSTFQBSBUFFTUJNBUFTPGUIF$%3GPSTNFBS QPTJUJWF5#XJMMCFIBOEMFEPOBDBTFCZDBTFCBTJT *U TIPVME CF FNQIBTJ[FE UIBU UIF TUBOEBSE PG DBSF GPS 5#EJBHOPTJTSFDPNNFOEFECZ8)0JT J TQVUVNTNFBS NJDSPTDPQZGPSBMMDBTFTBOE JJ FYQBOTJPOPGUIFVTFPG DVMUVSFUPEJBHOPTFBMMCBDUFSJPMPHJDBMMZQPTJUJWF OPUKVTU TNFBSQPTJUJWF DBTFT UPXBSETUIFVMUJNBUFHPBMPGVTJOH DVMUVSF PS FRVJWBMFOUT TVDI BT NPMFDVMBS UFTUT  JO UIF EJBHOPTJTPGBMMDBTFT   -RXLIKPSFEPVITSVXTYFPMWLIHMR(IGIQFIVXLI'(6JSV WQIEVTSWMXMZIGEWIW[EWIWXMQEXIHEW¦ [MXLEFIWX IWXMQEXISJ 2I[GEWIWMRGPYHIVIPETWIGEWIW   MI WQIEVTSWMXMZI ERH WQIEVRIKEXMZI GEWIW SJ TYPQSREV] 8&ERHI\XVETYPQSREV]GEWIW   % W]WXIQEXMG VIZMI[ SJ XLI TVSTSVXMSR SJ EPP 8& GEWIW [MXL WTYXYQWQIEVTSWMXMZI8&MWSJTEVXMGYPEVVIPIZERGIERHMW HMWGYWWIHMRWIGXMSRSJ%22)< pean Region (best estimate 80%. followed by the Western Pacific Region (best estimate 70%.

-+. For people in this category. here. establishing links with the full range of health-care providers and stronger enforcement of legislation regarding notification of cases (where this is mandated by law) will help.  .-+. and financial barriers to diagnosis (and subsequently treatment) need to be mitigated or removed.-+. strengthening surveillance systems. This will be necessary to move towards the 7 million notifications targeted in the Global Plan for 2015 (and eventually.46                                                                         (MPCBM             )JHICVSEFODPVOUSJFT ¦ -RHMGEXIWHEXERSXEZEMPEFPI E  )WXMQEXIWJSVEPP]IEVWEVIVIGEPGYPEXIHEWRI[MRJSVQEXMSRFIGSQIWEZEMPEFPIERHXIGLRMUYIWEVIVI´RIHWSXLI]QE]HMJJIVJVSQXLSWITYFPMWLIH TVIZMSYWP]-JRSXM´GEXMSRHEXEJVSQEGSYRXV]LEHRSXFIIRVIGIMZIHF].  8)03&1035 (-0#"-56#&3$6-04*4$0/530- 5"#-& &TUJNBUFTPGUIFDBTFEFUFDUJPOSBUFGPSBMMDBTFT  °B  &)78 F 03. reasons could include not recognizing any symptoms of TB and/or no access (financial and/or geographical) to health-care services. This could mean better laboratory capacity as well as more knowledgeable and better trained staff. %22)<). To reach cases in this category. to achieve early detection of all cases). Despite difficulties with estimating the case detection rate (&3<. 8%&0)%).-+.  . notifications increased sharply between 2002 and 2006. which accounts for almost 70% of incident cases in this region (8%&0)). For people in this category. efforts to increase the percentage of TB cases that are diagnosed and treated according to international guidelines are clearly of major importance. especially in peripheral-level health-care facilities. In the Western Pacific Region. N Cases seek care but are not diagnosed. &)78 03.  %JKLERMWXER ¦ ¦ ¦         &ERKPEHIWL             &VE^MP             'EQFSHME             'LMRE             (6'SRKS             )XLMSTME             -RHME             -RHSRIWME           /IR]E               1S^EQFMUYI             1]ERQEV              2MKIVME            4EOMWXER                    4LMPMTTMRIW      6YWWMER*IHIVEXMSR  7SYXL%JVMGE                       8LEMPERH              9KERHE             968ER^ERME             :MIX2EQ             >MQFEF[I                         %*6 %16 )16 )96 7)%6 .  .YRIXLIRSXM´GEXMSRVEXIMR[EWEWWYQIHXSFIXLIWEQIEWMR )WXMQEXIWJSVXLI4LMPMTTMRIW[MPPFIVIEWWIWWIHMRPEXI F  &IWXPS[ERHLMKLMRHMGEXIFIWXIWXMQEXIWJSPPS[IHF]PS[IVERHYTTIVFSYRHW8LIPS[IVERHYTTIVFSYRHWEVIHI´RIHEWXLIXLERHXL GIRXMPIWSJSYXGSQIHMWXVMFYXMSRWTVSHYGIHMRWMQYPEXMSRW7II%22)<JSVJYVXLIVHIXEMPW indicating that case detection is improving (see *-+96)  in 7)'8-32). patterns are strongly influenced by China. . &)78 03. . There are three main reasons why incident cases of TB may not be notified (see also %22)<. better diagnostic capacity is needed. N Cases do not seek care. health systems need to be strengthened so that basic health-care services are available to more people. These are: N Cases are diagnosed but not reported. For people in this category. but have since stabilized. &)78 03.

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corporate and private providers through Public-Private Mix (PPM) approaches. substantial progress in engaging non-NTP care providers through PPM can be documented for an increasing number of countries. which demonstrate the major contribution that PPM can make to case notifications. voluntary. Despite this recording and reporting challenge. This has been accompanied by maintenance of high rates of treatment success (data not shown). First. NTPs have used a variety of approaches to engage non-NTP care providers.IEPXL WYGGIIHIH MR HIZIPSTMRK E TVSHYGXMZI GSPPEFSVEXMSR FIX[IIR LSWTMXEPW ERH 8& HMWTIRWEVMIW *VSQXSXLITVSTSVXMSRSJ8&WYWTIGXWERH GEWIWVIJIVVIHJVSQLSWTMXEPWERHEVVMZMRKMR8&HMWTIR WEVMIW MRGVIEWIH WYFWXERXMEPP] JVSQ   XS   8LI GSRXVMFYXMSRSJLSWTMXEPWXSGSR´VQIHGEWIWSJWTYXYQ WQIEVTSWMXMZI TYPQSREV] 8& HSYFPIH JVSQ   XS  . demonstrating this progress is not always possible. Unfortunately. in the geographical areas in which PPM has been implemented. is provided in &3<. As also illustrated in 8%&0).  1VCMJD°QSJWBUFBOEQVCMJD°QVCMJDNJY 11.WIZIVIEGYXIVIWTMVEXSV]W]RHVSQI ITMHIQMG XLI KSZIVRQIRX IWXEFPMWLIH E [IFFEWIH GSQQYRMGE FPIHMWIEWIWVITSVXMRKW]WXIQXLVSYKLSYXXLIGSYRXV] -XFIGEQIQERHEXSV]XSVITSVXMRJIGXMSYWHMWIEWIW MRGPYHMRK8&[MXLMRLSYVW&]XLIIRHSJXLMW W]WXIQGSZIVIHEPPGSQQYRMGEFPIHMWIEWIGIRXVIW  SJLSWTMXEPWEXGSYRX]PIZIPSVEFSZIERH SJXS[R WLMTPIZIPGPMRMGW8LIW]WXIQMWYWIHF]YTXS JEGMPMXMIW IZIV] HE] ERH EFSYX   GEWIW SJ MRJIG XMSYWHMWIEWIEVIVITSVXIHIEGLHE] 8LVSYKL GSPPEFSVEXMSR XS LIPT MQTPIQIRX XLI 8& GSQ TSRIRX SJ XLI [IFFEWIH VITSVXMRK W]WXIQ XLI 1MR MWXV] SJ . beyond those which fall under the direct responsibility of the NTP (termed “non-NTP providers” in this report). Efforts to engage all care providers through PPM initiatives. one or both conditions are not yet met. and N promotion of the International Standards for Tuberculosis Care through PPM initiatives. it requires that systematic *YVXLIV HIXEMPW EFSYX XLI [IFFEWIH WYVZIMPPERGI W]W XIQEVITVSZMHIHMR&3< recording and reporting of the source of referral and place of TB treatment is being done. . which illustrates how strengthening surveillance can lead to increased notifications of TB cases and an increase in the CDR. a web-based system for mandatory reporting of TB cases by all providers in China 1 WHO recommends that the source of referral and the place of treatment should be routinely recorded and reported. one of the best ways to increase case detection is for NTPs to establish collaboration with the full range of health-care providers. Second. respectively.   JOJUJBUJWFT In many countries. are summarized in 8%&0) . New and compelling data compiled from 15 countries (including nine HBCs) in 2010. the contribution of PPM initiatives typically ranges from between about one fifth to one third of total notifications.MXLXLI[IFFEWIHVITSVXMRKW]WXIQWIVZMRKEW ERMRWXVYQIRXXSTYXTSPMG]MRXSTVEGXMGILSWTMXEPWRS[ GSRXVMFYXI EFSYX E XLMVH SJ EPP RSXM´GEXMSRW SJ WTYXYQ WQIEVTSWMXMZITYPQSREV]8&MR'LMRE (SGXSVWMREPPLIEPXLJEGMPMXMIWMRGPYHMRKLSWTMXEPWYWI XLMW W]WXIQ XS VITSVX MRJSVQEXMSR SR TISTPI [MXL 8& WMKRWERHW]QTXSQWERHVIJIVXLIQXSXLIRIEVIWX8& A case study from China. and its two subcomponents are: N involvement of all public. In these 15 countries. it requires that data reported at the local level are aggregated. These include incentivebased schemes for individual and institutional providers in India and Myanmar.1 Often. according to the local context. are being introduced and scaled up in many countries. analysed and reported at the national level. Strengthening of laboratory capacity and human resource development are discussed in &3< and &3<. This is component 4 of the Stop TB Strategy (&3<). Engagement of all care providers is discussed in the next section.

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 %RKSPE (MZIVWITYFPMGERHTVMZEXITVSZMHIVW 'SYRXV][MHI  'EQFSHME 4LEVQEGMIWTVMZEXIGPMRMGWERHLSWTMXEPW 'SYRXV][MHI   'LMRE +IRIVEPTYFPMGLSWTMXEPW 'SYRXV][MHI   +LERE (MZIVWITYFPMGERHTVMZEXITVSZMHIVW 'SYRXV][MHI -RHME (MZIVWITYFPMGTVMZEXIERH2+3TVSZMHIVW -RHSRIWME 4YFPMGERHTVMZEXILSWTMXEPW   PEVKIGMXMIW .

QMPPMSRTSTYPEXMSR   SJRI[WQIEV TSWMXMZIGEWIW 'SYRXV][MHI   'SYRXV][MHI   'SYRXV][MHI -WPEQMG6ITYFPMG (MZIVWITYFPMGERHTVMZEXITVSZMHIVW SJ-VER /E^EOLWXER 4VMWSRLIEPXLWIVZMGIW 1I\MGS 7SGMEPWIGYVMX]SVKERM^EXMSRW 1]ERQEV 4VMZEXITVEGXMXMSRIVWXLVSYKLXLI TVSJIWWMSREPQIHMGEPEWWSGMEXMSR    SJXLIIGSRSQMGEPP] EGXMZITSTYPEXMSR .

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scaling up PPM. will yield a higher number of notifications. Further progress in implementing collaborative TB/ HIV activities was made in 2009.4 million in 2008 (*-+ 96) ). they are responsible for referring HIV-positive TB patients to ART services. involving front-line health workers such as community-based informal providers.  2ITEP (MZIVWITYFPMGERHTVMZEXITVSZMHIVW 'SYRXV][MHI   2MKIVME 4VMZEXIGPMRMGWERHLSWTMXEPW 'SYRXV][MHI   4EOMWXER 4VMZEXITVEGXMXMSRIVW2+3WERHLSWTMXEPW 'SYRXV][MHI   QMPPMSRTSTYPEXMSR   SJRI[WQIEV TSWMXMZIGEWIW 'SYRXV][MHI   4LMPMTTMRIW 4VMZEXIGPMRMGWERHLSWTMXEPW 9RMXIH6ITYFPMG SJ8ER^ERME 4VMZEXIERH2+3LSWTMXEPW E  (EXEJVSQI\GITX[LIVIWTIGM´IH     'SRXVMFYXMSRXSEPPRSXM´GEXMSRWJOUIFHFPHSBQIJDBMBSFBTDPWFSFECZ11. should aim to systematically map and engage all relevant care providers in TB care and control. in the Philippines. . respectively (8%&0)). when care conforms with agreed-upon standards.6 million TB patients knew their HIV status in 2009 (26% of notified cases). public hospitals in China and Indonesia.  $PMMBCPSBUJWF5#)*7BDUJWJUJFT Collaborative TB/HIV activities are essential to ensure that HIV-positive TB patients are identified and treated appropriately. social security organizations in Mexico and prison services in Kazakhstan. 53% and 41% of TB patients knew their HIV status. At the same time. infection control in health-care and congregate settings. which consolidated the achievements documented in previous reports. private practitioners and pharmacies – who are often the first point of contact for people with symptoms of TB – can help to reduce diagnostic delays and the out-of-pocket expenditures of TB patients. it is not surprising that NTPs often give first priority to engaging institutional providers with whom establishing collaborative links may be less demanding and. private hospitals in Nigeria. where 86%. In general.1). Geneva. in phases if not at once. Just over 1. For these reasons. This includes pharmacies in Cambodia. including 16 African countries (*-+96) ). and reimbursement for TB care delivered by private providers through health insurance.MWWLS[RI\GITX[LIVIWTIGM´IH F (&3<). The highest rates of HIV testing were reported in the European Region. national HIV programmes are usually responsible for initiating intensified case-finding among HIV-positive people and provision of IPT to those without active TB. and to prevent TB in HIV-positive people. up from 1. For this reason. only a small proportion of targeted care providers collaborate actively with NTPs and contribute to TB case notifications in most countries. at least 75% of TB patients knew their HIV status. WHO/ HTM/HIV/2004. HIV testing of TB patients and – for those TB patients infected with HIV – CPT and ART. and intensified TB case-finding among people living with HIV followed by IPT for those without active TB.1 These activities include establishing mechanisms for col- laboration between TB and HIV programmes. It is also noticeable that countries have prioritized different types of care providers. 2004 (WHO/HTM/TB/2004. for a given amount of effort. In 55 countries. Testing TB patients for HIV and providing CPT for HIV-positive TB patients are typically the responsibility of NTPs. When NTPs do not provide ART directly.330. the African Region and the Region of the Americas. up from 50 countries in total and 11 in the African 1 Interim policy on collaborative TB/HIV activities. Provision of ART to HIV-positive TB patients is often the responsibility of national HIV programmes. but may also be done by NTPs. World Health Organization.

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397%2(7 %*6       %16       )16      )96       7)%6   .46   (MPCBM                291&)63*.8.-48 .-8.-: 437-8-:)4)340) 463:-()(.

5% 12% 2005 131 (81%) 2006 146 (90%) 20% 22% 2007 169 (98%) 2008 167 (98%) 26% E 0 2009 143 (98%)  8LIRYQFIVWYRHIVIEGL]IEVWLS[XLI RYQFIVSJGSYRXVMIWVITSVXMRKHEXESR.8.2% 2003 92 (43%) 2004 84 (47%) 8.-: XIWXMRKJSPPS[IHF]XLITIVGIRXEKISJXSXEP IWXMQEXIH.-:WXEXYWMWMRHMGEXIHEFSZIXLIKVI]FEVWE 7 Cases (millions) 6 5 4 3 2 1 4.397%2(7        '*(63& )*7UFTUJOHGPS5#QBUJFOUT BMMDPVOUSJFT °8LIRYQFIVSJRSXM´IHRI[ERHVIXVIEXQIRXGEWIWMWWLS[RMRFPYI ERHXLIRYQFIVSJGEWIWJSV[LMGLXLI.-:WXEXYW[EWVIGSVHIHMRXLI8&VIKMWXIVMWWLS[RMRKVI]8LITIVGIRXEKISJ RSXM´IH8&GEWIW[MXLORS[R.2% 3.-:TSWMXMZI8&GEWIWEGGSYRXIHJSV F]VITSVXMRKGSYRXVMIW '*(63& )*7UFTUJOHGPS5#QBUJFOUT  Percentage of notified TB cases with known HIV status 0–14 15–49 50–74 ≥75 No data .

This remains a small fraction of the estimated number of TB patients who have MDR-TB (eighth column from right. compared with 2009 (*-+96) ). mostly by European countries and South Africa (*-+96). This represents 12% of the estimated number of cases of MDR-TB among all notified cases of pulmonary TB in 2009 (8%&0)). Further efforts are needed to reach the Global Plan target of starting 100% of HIVpositive TB patients on both CPT and ART by 2015. Country plans suggest that. Screening for TB among HIV-positive people and providing IPT to those without active TB have steadily increased.7 million HIV-positive people were screened for TB and close to 80 000 of those without active TB were enrolled on IPT. particularly since 2007 (*-+96). Intensified efforts are needed to approach the Global Plan target of providing IPT to all those attending HIV care services who are eligible for it by 2015. Substantial increases in the numbers of patients diagnosed with MDR-TB and started on treatment are expected in the three countries where the estimated number of cases is highest: China. especially since 2005 (*-+96)). about 10% of the people living with HIV who are estimated to be in need of ART and about 5% of the estimated total number of HIV-positive people worldwide. in which patients are known to be receiving treatment according to international guidelines. In 2009. 8%&0)). overall. The numbers started on IPT are less than 1% of the estimated number of people living with HIV. The number reached around 11 000 in 2009. the numbers of patients diagnosed with MDR-TB and started on treatment will almost double in 2010 and 2011. The numbers screened are equivalent to about one third of the people living with HIV who are on ART. and is expected to rise to over 30 000 in 2011 (approximately 60% of all notifications of MDR-TB that are projected by countries in that year). By 2009.BOBHFNFOUPGESVHSFTJTUBOU5# 0 Percentage of HIV-positive TB patients  2004 2005 2006 2007 2008 2009 24 (25%) 47 (55%) 69 (64%) 93 (85%) 109 (96%) 89 (80%)  2YQFIVWYRHIV]IEVWWLS[XLIRYQFIVSJGSYRXVMIWVITSVXMRKHEXE JSPPS[IHF]XLITIVGIRXEKISJXSXEPIWXMQEXIH.  . 8%&0)). *-+96)). National data on treatment outcomes among cohorts . Almost 80% of TB patients who were known to be HIV-positive were started on CPT and almost 40% were enrolled on ART (*-+96) . just over 30 000 cases of MDR-TB were notified to WHO in 2009. 8)03&1035 (-0#"-56#&3$6-04*4$0/530- '*(63& $PUSJNPYB[PMFQSFWFOUJWFUIFSBQZBOEBOUJSFUSPWJSBM UIFSBQZGPS)*7QPTJUJWF5#QBUJFOUT ° Number of TB patients (thousands) 500 Tested HIV-positive 400 300 CPT 200 ART 100 0 2003 2004 2005 2006 2007 2008 2009 '*(63& $PUSJNPYB[PMFQSFWFOUJWFUIFSBQZGPS)*7QPTJUJWF 5#QBUJFOUT °B Percentage of HIV-positive TB patients 100 80 CPT 60 40 20 2003 2004 2005 2006 27 (30%) 24 (29%) 39 (53%) 55 (64%) 2007 2008 73 (92%) 86 (93%) 2009 63 (75%) E  2YQFIVWYRHIV]IEVWWLS[XLIRYQFIVSJGSYRXVMIWVITSVXMRKHEXE JSPPS[IHF]XLITIVGIRXEKISJXSXEPIWXMQEXIH. almost 300 000 HIV-positive TB patients were started on CPT and almost 140 000 were enrolled on ART. 1.-:TSWMXMZI8&GEWIW EGGSYRXIHJSVF]VITSVXMRKGSYRXVMIW '*(63& "OUJSFUSPWJSBMUIFSBQZGPS)*7QPTJUJWF5#QBUJFOUT  °B 100 80 60 ART 40 20 0 2003 47 (9%) E Region in 2008.-:TSWMXMZI8&GEWIW EGGSYRXIHJSVF]VITSVXMRKGSYRXVMIW Globally. The number of HIV-positive TB patients enrolled on CPT and ART has been increasing in recent years. *-+96) ). Much more rapid expansion of diagnosis and treatment – within and outside projects and programmes approved by the GLC – is needed to approach the targets for MDR-TB that are included in the Global Plan (*-+96)). There has been an impressive increase in the share of notified cases enrolled on treatment in projects or programmes approved by the Green Light Committee (GLC). India and the Russian Federation (8%&0)).

%35# ° BOEQSPKFDUFE OVNCFSTPGQBUJFOUTUPCFFOSPMMFEPOUSFBUNFOU ° JOUIFDPVOUSJFTJODMVEFEJOUIF(MPCBM 1MBO HSFZ BOEUBSHFUTJODMVEFEJOUIF(MPCBM1MBO ° B CMVF 2YQFIVWEVIJSVWQIEVERHSVGYPXYVI TSWMXMZIGEWIWSJ1(68& non-GLC 50 52 50 GLC 300 40 30 30 20 19 29 31 23 10 0 2005 (100) 2006 (107) 2007 (110) Notified 2008 (128) 2009 (91) 2010 (83) 2011 (74) Projected Number of patients (thousands) Number of patients (thousands) 60 250 200 150 100 50 0 E  2YQFIVWYRHIV]IEVWWLS[XLIRYQFIVSJGSYRXVMIWVITSVXMRKHEXE E 2007 2008 2009 2010 2011 2012 2013 2014 2015  8LIYTHEXIHZIVWMSRSJXLI+PSFEP4PERGSZIVMRKXLI]IEVW¦ [EWPEYRGLIHF]XLI7XST8&4EVXRIVWLMTMR3GXSFIV .-:TSWMXMZITISTPI EGGSYRXIHJSVF]VITSVXMRKGSYRXVMIW '*(63& '*(63& /PUJ¾FEDBTFTPG.-:TSWMXMZI TISTPI[LS[IVIWGVIIRIHJSV8&MWWLS[REFSZIXLI PMRIE *15QSPWJTJPOBNPOH)*7QPTJUJWFQFPQMF °B 5.1 2005 10 (21%) E 0 2005 14 (35%) 0. 8)03&1035 (-0#"-56#&3$6-04*4$0/530-  '*(63& '*(63& *OUFOTJ¾FE5#DBTF¾OEJOHBNPOH)*7QPTJUJWFQFPQMF  °8LITIVGIRXEKISJIWXMQEXIH.-:TSWMXMZITISTPI [MXLSYXEGXMZI8&EGGSYRXIHJSVF]VITSVXMRKGSYRXVMIW E  2YQFIVWYRHIV]IEVWWLS[XLIRYQFIVSJGSYRXVMIWVITSVXMRKHEXE JSPPS[IHF]XLITIVGIRXEKISJXSXEPIWXMQEXIH.3 2006 44 (49%) 2007 72 (59%) 2008 82 (66%) 2009 78 (71%) 2006 25 (26%) 2007 42 (44%) 2008 43 (51%) 2009 41 (48%)  2YQFIVWYRHIV]IEVWWLS[XLIRYQFIVSJGSYRXVMIWVITSVXMRKHEXE JSPPS[IHF]XLITIVGIRXEKISJXSXEPIWXMQEXIH.4% 1200 800 2.2 0 1.0% 0.4 0.2% 1600 4.6% 0.0% 400 Percentage of HIV-positive people without active TB Number of people screened (thousands) 2000 0.%35# ° BOE QSPKFDUFEOVNCFSTPGQBUJFOUTUPCFFOSPMMFEPO USFBUNFOU ° B /PUJ¾FEDBTFTPG.

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of at least 200 patients are currently limited to nine
countries: Brazil, Kazakhstan, Peru, the Philippines, the
Republic of Moldova, Romania, South Africa, Turkey and
Uzbekistan (*-+96)). Rates of treatment success are
variable, ranging from below 40% to almost 80%. High
rates of default are a common problem (with a median
value of 17%).
One of the most important constraints to rapid expansion of diagnostic and treatment services for MDR-TB is
laboratory capacity. Without greater capacity to diagnose
MDR-TB, the number of cases diagnosed and treated will
remain low. Diagnostic testing for drug susceptibility, or
DST, among new cases of TB remains almost entirely
confined to the European Region and the Region of the
Americas (*-+96) ). Even in these regions, however,
the percentage of previously treated patients who were
tested for drug resistance was less than 40%, far below
the target of testing all previously treated patients by
2015 that is included in the Global Plan.
Recent efforts to strengthen laboratory services,
under the umbrella of the Global Laboratory Initiative,
are highlighted in &3<.
While efforts to improve the diagnosis and treatment
of MDR-TB are urgently needed, the existence of MDR-TB
and XDR-TB also highlights the paramount importance
of preserving the efficacy of the few anti-TB medicines
currently used in TB treatment (&3<).
Limiting the number of cases of MDR-TB (and drugsusceptible TB) also requires that proper measures for
infection control are in place. These measures include
personal protection (for example, masks), administrative controls (for example, in waiting areas for people
attending outpatient services) and environmental measures such as ventilation systems. The best indicator to
assess the quality of infection control is the ratio of the
notification rate of TB among health-care workers to
the notification rate among the general population. This
ratio should be approximately 1. The data required to
calculate this indicator are requested on the WHO data
collection form, but to date the availability of reliable
data is limited. Collection and reporting of data on this
indicator need to be improved.
A total of 64 countries reported that training related
to infection control was done in 2009. For 35 countries,
this included training in tertiary (referral) hospitals.
Among 80 countries that provided data, 55 (69%) reported having a focal point for infection control related to TB
in at least one of their tertiary hospitals. Of 75 countries
that provided data, 36 (48%) had performed an assessment of the status of infection control for TB in at least
part of their network of tertiary hospitals in 2009.

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5 3.5 TB/HIV 1.9 2.    *MRERGMRKJSV8&GSRXVSP  )JHICVSEFODPVOUSJFT '*(63& 8 'VOEJOHBWBJMBCMFGPS5#DPOUSPMCZMJOFJUFN IJHI CVSEFODPVOUSJFT ° 1 The first round was completed in 2003.2 OR/surveys/other 1.5 2.5 2.5 2.0 MDR-TB DOTS 0. Round 9 was completed (including decisions on which proposals would be approved for funding) in 2009.8 General healthcare services: MDR-TBa General healthcare services: DOTSa 2. US$ billions (constant 2010 US$)b 3.0 2.5 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 E  8LIWIX[SGEXIKSVMIWWLS[JYRHMRKJSVSYXTEXMIRXZMWMXWERHMRTEXMIRX GEVITVSZMHIHMRKIRIVEP.0 2.0 1.5 1.6 2.0 3.6 PPM/PAL/ ACSM/CBC 1.

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5 billion per year. Trends in funding for the 22 HBCs as a whole conceal important variations among countries (8%&0).5 2. Indonesia and Mozambique.5 US$ billions (constant 2010 US$)b he funding available for TB control in the 22 HBCs has increased year-on-year since 2002. funding gaps have persisted in most African countries as well as Cambodia. In 2011. *-+96) .0 1. In some countries.3–0.2 1.0 1. Most of this funding has been used to support DOTS implementation. ranging from around 3.5 2. with the exception of a small dip in 2009.6 1. India. 61% of the funding expected in 2011 is accounted for by just two countries: the Russian Federation and South Africa (*-+ 96)).5 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 E  9RORS[RWSYVGIETTPMIWSRP]XSETSVXMSRSJXLIFYHKIXJSV1(68& LSWTMXEPWMR7SYXL%JVMGE  7IIJSSXRSXIFSJ*-+96)ERH1)8. and is expected to reach US$ 327 million in 2011 (a 10% increase compared with 2010). the Russian Federation.6 2. NTP budget (excluding loans) 1. Since 2007.0 billion in 2011 (*-+96). and is expected to reach US$ 3. In contrast.0 2. the Philippines and the Russian Federation. The relatively small amount of funding reported for collaborative TB/HIV activities reflects the fact that funding for most of these interventions is channelled through national HIV programmes and nongovernmental organizations rather than via NTPs.0 3. the exceptions include Kenya. there is much greater reliance on donor funding.8 2. where funding has fallen since 2008 (*-+96)).MRµEXMSR  7IIEPWS1)8.3(7 F . Financing from the Global Fund has become increasingly important since 2004.5 2. Myanmar and Pakistan. these gaps have been in the range of US$ 0. funding gaps are anticipated for all components of the Stop TB Strategy.3(7 '*(63& 'VOEJOHBWBJMBCMFGPS5#DPOUSPMCZTPVSDFPGGVOEJOH  IJHICVSEFODPVOUSJFT ° 3. In other HBCs. general healthcare services (excluding loans) Government. National governments are the largest source of funding (*-+96) ). although the share for MDR-TB (mostly accounted for by funding in the Russian Federation and South Africa) has increased since 2007 (*-+96)). Thailand.0 0. Despite increases in funding and nine completed rounds of proposals1 to the Global Fund. *-+96) ). Brazil. In 2011. the Philippines and Viet Nam will rely primarily on domestic funding (including loans from development banks). In absolute terms. China. Other donor funding is expected to amount to approximately US$ 100 million in 2011. China. *-+96)).5 2. NTPs continue to report funding gaps (*-+96) ). including for DOTS (the basic package that underpins the Stop TB Strategy). there are still funding gaps for supplies of first-line anti-TB drugs. accounting for 85% of total expected funding in 2011.9 2. *-+96).5 Unknowna Global Fund Grants (excluding Global Fund) Loans Government. South Africa. Both NTP budgets and funding of NTPs have been increasing in most countries. Funding has been closest to keeping pace with increases in NTP budgets in Brazil.

first-line drugs 153 100 0 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 E 472 500 Russian Federation 3.5 2.5 2.0 3.2 India Brazil 1.9 2.8 South Africa 2.3(7 5"#-& /51CVEHFUT BWBJMBCMFGVOEJOH DPTUPGVUJMJ[BUJPOPGHFOFSBMIFBMUIDBSFTFSWJDFTBOEUPUBM5#DPOUSPMDPTUT         IJHICVSEFODPVOUSJFT  64NJMMJPOT B %:%-0%&0)*92(-2+ 284 &9(+)8 %JKLERMWXER +6%287 .0 US$ millions (constant 2010 US$)b US$ billions (constant 2010 US$)a  2006 2007 2008 2009 2010 2011 F  7IIJSSXRSXI SJ*-+96)ERH1)8.3(7 E  'SYRXVMIWVITSVXMRKRSKETSVERIKEXMZIKETEGVSWWEPPPMRIMXIQWEVI I\GPYHIH F  7IIJSSXRSXIFSJ*-+96)ERH1)8.0 0.6 2. 8)03&1035 (-0#"-56#&3$6-04*4$0/530- '*(63& '*(63& 'VOEJOHBWBJMBCMFGPS5#DPOUSPMCZDPVOUSZ  IJHICVSEFODPVOUSJFT ° 'VOEJOHHBQTSFQPSUFECZ/51T IJHICVSEFODPVOUSJFT B ° 3.0 1.5 1.5 China 2. excluding first-line drugs DOTS.5 OR/surveys ACSM/CBC/ PPM/PAL 411 400 TB/HIV 337 310 300 MDR-TB 270 200 DOTS.5 1.5 2.0 2.6 All other HBCs 1.

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22 HBCs

Afghanistan

2819

2536

Bangladesh

21

Brazil

63

64

45

Cambodia
38
36

59
2248
25
25

5

14

5
0

931

China

DR Congo

Ethiopia

64

394

17

9

64

3

India

39

39

Indonesia
94

147
112

31

239

71

112

208

45

19

US$ millions (constant 2010 US$)b

50

8

Kenya

Mozambique

46

Myanmar

Nigeria

Pakistan
88

63

21

32

12

45

6

31
38
14

12
5

Philippines

Russian Federation
43
43

43

South Africa
1258

1286

35

5

7

1

54

28

8

8
3

37

Thailand

413

Uganda
23

52

1227

20

4

273
14

UR Tanzania

Viet Nam

34

273

258

704

2002

Zimbabwe

30

18

21

13

10

13

2

9
2002

2005

2008

2011

2005

2008

2011

2002

2005

2008

2011

21

20

6

2

47

2002

2005

2008

2011

2002

2005

2008

2011

NTP budget
Available funding
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Internal sources

Russian Federation
Thailand
Brazil
South Africa
China
Philippines
Viet Nam
India
Indonesia
Kenya
Pakistan
Mozambique
Nigeria
Ethiopia
Afghanistan
UR Tanzania
Cambodia
Uganda
Myanmar
Zimbabwe
Bangladesh
DR Congo

Government, NTP budget
(excluding loans)
Government, general
health-care services
(excluding loans)
Loans
External sources
Grants (excluding
Global Fund)
Global Fund

0

10

20

30

40

50

60

70

80

90

100

% of total available funding

40% of available funding in India to more than 90% of
available funding in the Democratic Republic of the Congo (*-+96)).
There is also considerable variation in the estimated
cost per patient treated according to the DOTS strategy (*-+96) ). This ranges from under US$ 100 (in
Bangladesh, India, Myanmar, Pakistan and Zimbabwe)
to around US$ 750 in Thailand, US$ 1000–1500 in Brazil and South Africa and more than US$ 7 500 in the
Russian Federation. In most HBCs, the cost per patient
treated under DOTS is around US$ 150–400. As shown
in *-+96), variation in the cost per patient treated
is clearly related to income levels (for example, Brazil
and South Africa are upper-middle income countries,
where prices for inputs such as NTP staff and hospital care are higher than in low-income countries). The
major reason why the Russian Federation is an outlier
is the model of care used: high costs are associated with
a policy of lengthy hospitalization of TB patients within an extensive network of TB hospitals and sanatoria.
A further explanation for variation in costs appears to
be the scale at which treatment is provided. The countries with relatively low costs for their income level (for
example, Bangladesh, China, India, Indonesia and the
Philippines) are also the countries where the total numbers of patients treated are highest (as shown by the size
of the circles in *-+96)). A similar pattern exists for
the cost per patient successfully treated, which combines
information about both costs and effectiveness (*-+96) 
). 

)JHICVSEFODPVOUSJFTBOEPUIFSDPVOUSJFT
Besides the 22 HBCs, 81 other countries have reported
financial data to WHO since 2006 that allow assessment
of trends in funding for TB control. Combined, these 103
countries account for 96% of the world’s notified cases
of TB. Funding for TB control has grown from US$ 3.9
billion in 2006 to a projected US$ 4.7 billion in 2011
(*-+96) , *-+96) ). As in HBCs, the largest share
of funding is for DOTS implementation; an increasing
amount is for MDR-TB. National governments account
for 86% of the funding expected in 2011, followed by
the Global Fund (US$ 513 million, or 11% of total funding) and then by grants from donors besides the Global
Fund (US$ 101 million, or 2%). Loans from development
banks account for the remaining 1% of total funding. The
funding gaps reported by these 103 countries amount to
US$ 0.6 billion in 2010 and US$ 0.3 billion in 2011 (*-+
96)).
A comparison of the funding available in the countries that reported financial data with the funding
requirements set out in the Global Plan is provided, by
region and for the period 2011–2015, in *-+96).1
Overall, funding falls short of the requirements of the
Global Plan. The gap is approximately US$ 1 billion in
2011. Given the scale-up of interventions set out in the
plan, this could increase to US$ 3 billion by 2015 without intensified efforts to mobilize more resources.

1

This analysis is for the 22 HBCs and a subset of 85 other countries
that are among the 149 countries considered in the Global Plan. The
total funding available in the group of 107 countries for which data
were available was adjusted upwards according to the fraction of
cases for which they accounted, to allow direct comparison with the
group of 149 countries considered in the Global Plan. The Global
Plan excludes high-income countries.



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140
139
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92

86

52

203

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83

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4

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RUSSIAN FEDERATION

R2=0.55

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8
SOUTH AFRICA
BRAZIL
1662
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1341

858
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6

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AFGHANISTAN
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247
232
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DR CONGO
198
212
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194
192
181
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171
154
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117
PAKISTAN
INDIA
90
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91
75
MYANMAR
MOZAMBIQUE 367

CHINA

194

47

5

6

7

8

9

GNI per capita (logarithmic scale)
E 

8LIGSWXTIVWQIEVTSWMXMZITEXMIRXWYGGIWWJYPP]XVIEXIHMWFEWIHSRE]IEVEZIVEKI
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Regionally. largely explained by apparent stability in the TB incidence rate in India. The exception is the South-East Asia Region (where the incidence rate is stable). Globally. which accounts for almost 70% of incident cases in this region (8%&0)). It should be noted. following a peak at just over 140 cases per 100 000 population in 2004. prevalence and mortality are all declining (*-+96)). notifications increased sharply between 2002 and 2006. then MDG Target 6. Projections suggest that the target of halving mortality by 2015 compared with 1990 could be achieved at global level. indicating improving rates of case detection. incidence rates are declining in five of WHO’s six regions (*-+96)). As incidence falls slowly. the rate of decline varies from less than 1% per year in the Eastern Mediterranean and European regions to around 2% per year in the African Region (since 2004) and 4% per year in the Region of the Americas. As also illustrated in *-+96). indicating that the highest rates of case detection are achieved in these regions (see also 7)'8-32 ). The stability in TB incidence rates in India (which accounts for 61% of cases in this region) as well as Bangladesh. in the absence of convincing evidence to the contrary (%22)< ).c will be achieved. Myanmar and Pakistan. patterns are strongly influenced by China. Indonesia.   4VSKVIWWXS[EVHWKPSFEPXEVKIXWJSV VIHYGXMSRWMRHMWIEWIFYVHIR 4 rogress made towards achieving the impact targets set for 2015 – to halt and reverse the incidence of TB by 2015 (MDG Target 6. Indonesia and Myanmar explains the flat trend in estimated incidence in the South-East Asia Region. compared with trends in mortality (see also %22)<). '*(63& (MPCBMUSFOETJODBTFOPUJ¾DBUJPOSBUFTBOEFTUJNBUFESBUFTPGJODJEFODF NPSUBMJUZBOEQSFWBMFODF0IJX+PSFEPXVIRHW MRGEWIRSXM´GEXMSRVEXI. here. The target of halving the prevalence rate appears out of reach. In the Western Pacific Region. India.1 Progress in achieving reductions in incidence and mortality is shown for each of the 22 HBCs in *-+96) and *-+96). Trends in incidence rates are assumed to be stable in Afghanistan. Among the five regions where incidence rates are falling. Further evaluation of trends in the disease burden in India is needed. If current trends are sustained. that there is more uncertainty about trends in prevalence. and prevalence rates are also in decline. at around 1% per year. The latest assessment for the 22 HBCs suggests that incidence rates are falling or stable in all countries except South Africa (*-+96)). Mortality rates have fallen by one third since 1990. rates of incidence. Incidence rates are falling slowly. *-+96)  and *-+96) . notifications are closest to estimated incidence in the Region of the Americas and the European Region. but have since stabilized. however. and has been planned for early 2011.c). notifications are increasing in the African Region and (particularly since 2000) in the Eastern Mediterranean and South-East Asia regions. and to halve prevalence and mortality rates compared with a baseline of 1990 (the targets set by the Stop TB Partnership) – is illustrated at the global level in *-+96) and at the regional level in *-+96) . Bangladesh.

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Projections suggest that the Western Pacific and Eastern Mediterranean regions are on track to achieve the target by 2015. current forecasts suggest that the target may not be achieved. European and South-East Asia regions are close to reaching the target. Pakistan. The most impressive progress is in the Region of the Americas. . 8)03&1035 (-0#"-56#&3$6-04*4$0/530- '*(63& 5SFOETJOFTUJNBUFE5#NPSUBMJUZSBUFT°BOEGPSFDBTU5#NPSUBMJUZSBUFT ° CZ8)0SFHJPO )WXMQEXIH8&QSVXEPMX]I\GPYHIW8&HIEXLWEQSRK. four countries reached the target of halving the 1990 mortality rate by 2009 (Brazil. On current projections. Even allowing for uncertainty in these estimates. Bangladesh. Cambodia. the Stop TB Strategy (launched in 2006) have saved millions of lives since 1995. Prevalence rates are falling in all six WHO regions (*-+ 96)). The reductions in mortality associated with progress to date in implementing the DOTS strategy (1995–2006) and its successor. In the other HBCs. Cambodia. In the African Region. notifications have been getting closer to estimated incidence in recent years. both of which appear to have achieved the target already. mortality rates appear to be falling with the possible exception of Afghanistan and Uganda (*-+96) ). where the Stop TB Partnership’s target of halving the 1990 prevalence rate has been achieved. Kenya. and the European Region could get close. and could do so before 2015. The best progress towards the 2015 target of halving the 1990 mortality rate is in the Region of the Americas and the Western Pacific Region. Indonesia. South Africa and the United Republic of Tanzania (*-+96)). China and the United Republic of Tanzania). Mortality rates (excluding TB deaths among HIVpositive people) are falling in all six WHO regions. Myanmar. China.1 From 1995 to 2009. notably in Afghanistan.-:TSWMXMZITISTPI7LEHIHEVIEWVITVIWIRXYRGIVXEMRX]FERHWE 8LILSVM^SRXEPHEWLIHPMRIWVITVIWIRXXLI7XST8&4EVXRIVWLMTXEVKIXSJE VIHYGXMSRMRXLIQSVXEPMX]VEXIF] GSQTEVIH[MXL8LISXLIVHEWLIHPMRIWWLS[TVSNIGXMSRWYTXS Africa The Americas Eastern Mediterranean 10 40 60 50 8 40 6 30 20 30 4 20 Rate per 100 000 population  10 2 10 0 0 0 Europe South-East Asia Western Pacific 15 40 60 50 10 30 40 20 30 5 20 10 10 0 0 0 1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015 E  8LI[MHXLSJYRGIVXEMRX]FERHWREVVS[WEWXLITVSTSVXMSRSJVIKMSREPQSVXEPMX]IWXMQEXIHYWMRKZMXEPVIKMWXVEXMSRVIGSVHWMRGVIEWIW In most of the HBCs. following a major increase in TB incidence and mortality rates associated with the HIV epidemic throughout the 1990s and up to around 2004. The Eastern Mediterranean. Indonesia. and continued implementation could save millions more in the years up to 2015 (*-+96) ). Pakistan and the Russian Federation) have a good chance of doing so by 2015. achieving the target appears out-of-reach. and six additional countries (India. 49 1 These results are based on the following manuscript: Glaziou P et al. Among the 22 HBCs. Lives saved by tuberculosis control and prospects for achieving the 2015 global target for reductions in tuberculosis mortality (submitted for publication in May 2010). the African and South-East Asian regions will not achieve the target.

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KVI] 7LEHIHEVIEWVITVIWIRXYRGIVXEMRX]FERHW Afghanistan Bangladesh 200 150 100 50 0 DR Congo Brazil 120 100 80 60 40 20 0 300 250 200 150 100 50 0 250 Ethiopia China 150 600 100 400 50 200 0 India 500 Rate per 100 000 population Cambodia 0 Indonesia Kenya 250 500 200 400 150 300 400 400 200 300 300 150 200 200 100 100 200 100 100 50 50 100 0 0 0 0 Mozambique Myanmar 500 500 400 400 300 300 200 200 100 100 0 0 Russian Federation Nigeria 300 250 200 150 100 50 0 300 200 100 0 South Africa 0 Pakistan Thailand 400 300 200 100 0 Uganda 150 1000 100 400 50 200 0 0 Viet Nam 250 1000 200 300 600 Zimbabwe UR Tanzania 250 400 150 800 100 Philippines 500 150 200 100 50 100 50 0 0 1990 1995 2000 2005 0 1990 1995 2000 2005 1990 1995 2000 2005 800 200 600 150 100 400 50 200 0 0 1990 1995 2000 2005 E 1990 1995 2000 2005 million patients were treated. a further 5 million lives could be saved if current efforts and levels of achievement in TB control are sustained.  +ETWMRXVIRHPMRIWSJRSXM´GEXMSRVEXIWSGGYV[LIR HEXEEVIRSXVITSVXIHXS. saving up to 6 million lives. From 2010 to 2015.. as set out in the Global Plan. This includes approximately 2 million lives saved among women and children. With expansion of treatment for MDR-TB and interventions such as ART for HIV-positive TB patients in the period 2011–2015. even more lives could be saved.3 . including around 2 million women and children. of whom 41 million were successfully treated in DOTS programmes.

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2 40 100 120 100 80 60 40 20 0 1990 1995 2000 2005 2010 2015 0.4 0.20 0.0 Cambodia 15 80 60 Rate per 100 000 population Brazil 100 80 Annual number of lives saved (millions)  Total 1.05 0.8 0.15 0.2 0.8 0.0 HIV-positive 0.2 0.05 1.6 0.HEWLIH PMRIW [IVITVIHMGXIHF]´XXMRKPSKPMRIEV QSHIPWSJXMQIWIVMIWJSVXLI]IEVW¦  0.0 2000 2005 2010 2015 .10 0.6 0.4 0.00 −0.25 UR Tanzania 150 20 40 Philippines 60 50 40 30 20 10 0 Uganda 40 60 Kenya 60 50 40 30 20 10 0 80 Myanmar 200 0 Indonesia 70 60 50 40 30 20 10 0 100 China 200 Ethiopia 120 100 80 60 40 20 0 1.0 0.

estimates of the disease burden need to be further improved in the period up to 2015 (and beyond) using better surveillance systems. although funding gaps remained a major bottleneck in Kenya (dependent on the approval of funding from a Round 9 grant from the Global Fund).html.e. The most notable successes in 2009/2010 among Asian countries were the completion of nationwide surveys in Myanmar (in April 2010. The Task Force has defined a conceptual framework for this work (*-+96)) and related tools to help countries to implement it in practice. WHO/HTM/TB/2009. Preparations were relatively advanced in Kenya. As of mid-2010. TB impact measurement: policy and recommendations for how to assess the epidemiological burden of TB and the impact of TB control. Cambodia. who. The greatest challenge in terms of implementation of prevalence surveys is in the African Region. Nonetheless. . the Philippines (2007) and Viet Nam (2007) recently completed surveys. Geneva. the Philippines.    -QTVSZMRKQIEWYVIQIRXSJXLI KPSFEPFYVHIRSJ8& ) stimates of TB incidence. the WHO Global Task Force on TB Impact Measurement is thus making concerted efforts to support countries to pursue two other major strategic tracks of work (full details are available in a recent WHO Policy Paper3). This will allow assessment of the impact of TB control since 2002 i. The review is also the basis for the TB component of the forthcoming update to the Global Burden of Disease. Besides its work on reviewing and updating the methods that are used to produce estimates of the burden of disease caused by TB.2 updates to parameter values based on the results of systematic reviews. prevalence and mortality and their trend (presented in 8%&0)  and in *-+ 96)7 ¦) are based on the best available data and analytical methods. Bangladesh (2008). with particular attention to 21 “global focus” countries (*-+96) ). Nigeria. Rwanda and the United Republic of Tanzania). For example. the last nationwide and population-based surveys of the prevalence of TB disease in the African Region were undertaken between 1957 and 1961. A survey is in the advanced stages of preparation in Thailand. with the exception of Eritrea in 2005. These surveys should be carried out according to WHO guidelines and related Task Force recommendations. more extensive and in-depth analysis of available surveillance and programmatic data. up from three in the years up to 2008) and systematic documentation of uncertainty. The results of these surveys will be of major importance for gaining a better understanding of the burden of disease (both countries) and the impact of TB control in the past two decades (in China. Myanmar. five countries were in a strong position to start surveys in late 2010 or early 2011 (Ethiopia. but security concerns and other factors that affect field operations may preclude implementation. and subsequent surveys are planned close to 2015. and most notification systems are recording only around 50–70% of estimated cases. Indonesia. Malawi. the years since DOTS was implemented. Zambia and South Africa. only around 10% of TB-attributable deaths (in HIV-negative people) are recorded in vital registration systems and reported to WHO. In the Eastern Mediterranean Region. Uganda (where reprogramming of Global Fund grants is needed) and Zambia (where full funding had been secured but the subsequent suspension of a Global Fund grant now impedes progress). Uganda. much greater use of mortality data from vital registration systems (89 countries for the analyses presented in this report. As of July 2010. China. rather than for each country individually. see &3< ) and China (in July 2010). Methods were updated in 2009 following 18 months of work by an expert group convened under the umbrella of the WHO Global Task Force on TB Impact Measurement. 2009 (Stop TB policy paper no. Intensive efforts are needed to ensure that countries planning surveys in 2010 and 2011 are able to do so successfully. Thailand and Viet Nam) were on track with survey implementation. In 2009 and 2010. due for publication in 2010.int/tb/advisory_bodies/impact_measurement_taskforce/en/ index. simplification of models. Pakistan secured full funding for a survey in 2008. considerable progress was made during 2009 and 2010. there was substantial progress in 1 2 3 For further details. and in Indonesia a follow-up to the 2004 survey is planned for 2013 or 2014. following previous surveys in 1990 and 2000). N Strengthening surveillance of cases and deaths through notification and vital registration systems. Looking forwards. For example. following a previous survey in 2002. Ghana. all of the countries in the South-East Asia and Western Pacific regions where prevalence sur- veys are recommended (Bangladesh.1 Improvements to methods (full details are provided in %22)<) include systematic documentation of expert opinion and how this has been used in estimates of the burden of disease caused by TB. Despite this progress. World Health Organization. and additional survey data. see the Task Force web site at: http://www. These are: N Surveys of the prevalence of TB disease. some parameter values are now estimated only at global level or for regions. The ultimate goal is for TB incidence and mortality to be measured directly from these systems. a survey will be implemented in Cambodia in 2011.416). 2.

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There is also an urgent need to introduce electronic recording and reporting systems. Examples of aspects of data quality that are difficult or impossible to assess without case-based and electronic reporting systems include the extent to which misclassifications and duplications exist. better data from surveys and surveillance combined with better analysis of these data should be of great value in identifying where and why cases are not being detected. By July 2010.YRIERH[EWGSQTPIXIHMR%TVMP%WXLMWVITSVX[IRXXSTVIWWTVI PMQMREV]VIWYPXW[IVII\TIGXIHMRPEXI analysing surveillance and programmatic data. stored in well-managed relational databases (not Excel spreadsheets). Besides improving estimates of the disease burden caused by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n important conclusion from workshops and country missions was that there is an urgent need to strengthen vital registration systems. findings should help to identify which components of the Stop TB Strategy need to be introduced or scaled-up to improve TB control. In turn.34STYPEXMSR7IVZMGIW-RXIVREXMSREPERHXLI6IWIEVGL-RWXMXYXIJSV8&¦6-8¦MR . Examples from Cambodia. the United Republic of Tanzania and Viet Nam. Myanmar and Viet Nam are highlighted in the second edition of WHO’s guidelines on surveys of the prevalence of TB disease. the availability of electronic data. with analyses used to develop recommendations for how surveillance systems need to be strengthened and to produce updated estimates of disease burden.ETER8LITYVGLEWISJGETMXEPIUYMTQIRXERHXLIHIZIPSTQIRXSJLYQERVIWSYVGIGETEGMX]HYVMRKXLITMPSXWYVZI] MR=ERKSRLIPTIHXSPIZIVEKIJYRHMRKERHMRXIVIWXF]GSRZMRGMRK´RERGMEPERHXIGLRMGEPTEVXRIVWXLEXWSQISJXLI GVMXMGEPVIWSYVGIWERHGETEGMX][IVIEPVIEH]MRTPEGI 8LIREXMSREPWYVZI][EWMRMXMEXIHMR. . European. More widespread adoption of updated recommendations on recording and reporting is also required (for example. The guidelines were in the late stages of preparation at the time this report went to press. to ensure availability of data disaggregated by HIV status and source of referral). A workshop for 17 countries in the African Region is scheduled for December 2010. greatly facilitates data analysis. An example of experience with implementing a casebased and electronic recording and reporting system (from China) in provided in&3<.. Regional workshops to apply the Task Force framework (*-+96) ) for systematic assessment of surveillance data were held in the Eastern Mediterranean. SouthEast Asia and Western Pacific regions and the Region of the Americas. Country missions in which the framework was applied were undertaken in the Philippines. these workshops and country missions had covered a total of 70 countries (*-+96) ). In addition.ETERXLI&MPPERH1IPMRHE+EXIW*SYRHEXMSRERH97%-(7IZIVEPXIGLRMGEPTEVX RIVW[IVIMRZSPZIHMRGPYHMRK.1 1 The second edition of these guidelines (following publication of the first edition in 2007) has been produced as a major collaborative effort among technical and financial partners and lead survey investigators from Asian and African countries. with publication expected before the end of 2010. to allow better measurement of mortality (&3< ). without which it is difficult or impossible to adequately assess many aspects of data quality.

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Three regions are on track to achieve this target: the Region of the Americas.POJUPSJOHPGQSPHSFTT N 8LIQEMRMRHMGEXSVWXLEXWLSYPHFIYWIHXSQSRMXSV TVSKVIWWMR8&GSRXVSPYTXSPMROIHXSXLI1(+ERH 7XST 8& 4EVXRIVWLMT XEVKIXW EVI XVIRHW MR MRGMHIRGI TVIZEPIRGI ERH QSVXEPMX] XLI XVIEXQIRX WYGGIWW VEXI ERHXLIGEWIHIXIGXMSRVEXIJSVEPPJSVQWSJ8&9WISJ XLIGEWIHIXIGXMSRVEXIJSVWQIEVTSWMXMZI8&WLSYPHFI TLEWIHSYX N 6IGSVHMRKERHVITSVXMRKSJHEXERIIHWXSFIMQTVSZIH JSVTYFPMGTVMZEXIQM\. Five of WHO’s six regions are also on track to achieve this target (the exception is the South-East Asia Region. The treatment success rate achieved in DOTS cohorts worldwide has now exceeded the global target of 85% for two successive years. and the target of a 50% reduction by 2015 could be achieved if the current rate of decline is sustained.   'SRGPYWMSRW 8 his section summarizes the main conclusions that can be drawn from the findings included in this report. Incidence rates have been declining since 2004 at the global level. the Eastern Mediterranean Region and the Western Pacific Region. the Stop TB Strategy (launched in 2006). MDG Target 6. and if this trend is sustained. Reductions in the disease burden achieved to date follow 15 years of intensive efforts at country level to implement the DOTS strategy (1995–2005) and its successor. The global burden of TB is falling slowly. and up to 6 million lives were saved. the target of halving 1990 prevalence rates by 2015 may not be reached at global level. However.c will be achieved worldwide. Although increasing numbers of TB cases have access to high-quality treatment for TB as well as access to #09 4VNNBSZPGNBJOSFDPNNFOEBUJPOTJOUIFHMPCBM5#DPOUSPMSFQPSU &TUJNBUFTPGEJTFBTFCVSEFO N 7YVZIMPPERGI SJ GEWIW ERH HIEXLW RIIHW XS FI WXVIRKXLIRIH XS[EVHW XLI YPXMQEXI KSEP SJ QIEWYVMRK 8& GEWIW ERH 8& HIEXLW HMVIGXP] JVSQ RSXM´GEXMSR ERH ZMXEPVIKMWXVEXMSRHEXE)PIGXVSRMGW]WXIQWJSVVIGSVHMRK ERH VITSVXMRK SJ HEXE RIIH XS FI MRXVSHYGIH MR QER] GSYRXVMIW ERH ZMXEP VIKMWXVEXMSR W]WXIQW RIIH XS FI HIZIPSTIHSVWXVIRKXLIRIHMRQSVIXLERGSYRXVMIW N 4VIZEPIRGI WYVZI]W RIIH XS FI WYGGIWWJYPP] MQTPI QIRXIHMRGSYRXVMIW[LIVIXLIWILEZIFIIRTPERRIHJSV TEVXMGYPEVP]MR%JVMGERGSYRXVMIWERH´RHMRKW JVSQ WYVZI]W GSQTPIXIH MR  RIIH XS FI HMWWIQM REXIH N )WXMQEXIWSJXLIFYVHIRSJHMWIEWIMR[SQIRERHGLMP HVIRRIIHXSFIMQTVSZIHZMEQSVIEREP]WMWSJRSXM´GE XMSRERHQSVXEPMX]HEXEHMWEKKVIKEXIHF]EKIERHWI\ N %RYTXSHEXIEWWIWWQIRXSJXVIRHWMRHMWIEWIFYV HIRMR-RHMEYWMRKXLIPEXIWXWYVZIMPPERGITVSKVEQQEXMG ERHWYVZI]HEXERIIHWXSFIYRHIVXEOIR . a cumulative total of 41 million TB patients were successfully treated in DOTS programmes. Between 1995 and 2009. the mortality target could be achieved in five of WHO’s six regions. At the regional level. where the incidence rate is stable). It also draws together the main recommendations that appear in the report. in the form of a Box (&3<). the exception is the African Region (although rates of mortality are falling in this region). Mortality rates at global level fell by around 35% between 1990 and 2009. Prevalence is fall- ing globally and in all six WHO regions.

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including 2 million women and children. are needed. around 90% of patients with MDR-TB are not being diagnosed and treated according to international guidelines. despite increases in funding over the past decade and substantial financing from the Global Fund in many countries. In the five years that remain until the target year of 2015. 8)03&1035 (-0#"-56#&3$6-04*4$0/530-  Looking forwards. More than one-third of incident TB cases are not reported as treated in DOTS programmes. finance and implement the Stop TB Strategy. according to the updated targets included in the Global Plan. for the years 2011–2015. . much more remains to be done. This could save a cumulative total of 5 million lives. Funding gaps remain large at more than US$ 1 billion per year. intensified efforts to plan. many HIV-positive TB cases do not know their HIV status and most of the HIV-positive TB patients who do know their HIV status are not yet being provided with ART. related interventions such as ART. the Stop TB Partnership launched an updated version of the Global Plan to Stop TB in October 2010.

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It also explains the regions for which estimates of disease burden are produced and sources of information on population estimates. For example. Relapse cases may be true relapses or a subsequent episode of TB caused by reinfection.4 updates to parameter values based on the results of systematic reviews.html. rather than for each country individually. the Eastern Mediterranean Region. special studies (including surveys of the prevalence of disease and in-depth analyses of surveillance data). The countries for which these methods have been used are explained. 1990–2009.416). N Projections of TB incidence. according to the definitions used in the 10th revision of the International Classification of Diseases (ICD-10). These are direct measurements from vital registration (VR) data and indirect estimates based on combining estimates of TB incidence with estimates of the case fatality rate. It also discusses estimates of the incidence of sputum smear-positive cases of pulmonary TB. some parameter values are now estimated only at global level or for regions. N Estimates of TB mortality. expert opinion and consultations with countries. Two recent publications provide up-todate guidance about how TB incidence. TB impact .measurement: policy and recommendations for how to assess the epidemiological burden of TB and the impact of TB control. prevalence and mortality and the case fatality rate. Estimates of deaths caused by TB in HIV-positive cases are presented separately. simplification of models. This section explains the methods used to estimate the prevalence of HIV among incident cases of TB. much greater use of mortality data from VR systems (89 countries instead of the three from which estimates were derived up to 2008) and systematic documentation of uncertainty (hence the uncertainty intervals shown on all of the estimates of disease burden in this report).int/tb/advisory_ bodies/impact_measurement_taskforce/en/index. prevalence and mortality).com). It has eight major sections: N General approach. Measuring tuberculosis burden. 1990–2009. N Definitions. 2. Mortality is defined as the number of deaths caused by TB. prevalence and mortality. N Estimates of TB incidence. excluding deaths occurring in HIV-positive TB cases. This section provides some background information about the methods used to produce estimates of disease burden. Geneva. trends and the impact of control programmes.thelancet. prevalence and mortality) are produced annually by WHO using information gathered through surveillance systems (case notifications and death registrations). http://infection. and explains why such estimates (and related estimates of the case detection rate for sputum smear-positive cases of pulmonary TB) are not included in this report.who. html. N Uncertainty framework. World Health Organization.1. N Estimates of HIV prevalence among incident TB cases. .2 based on the work of the WHO Global Task Force on TB Impact Measurement. Improvements to methods include systematic documentation of expert opinion and how this has been used to produce estimates of disease burden.3 The methods used to estimate the burden of disease were updated in 2009 following 18 months of work by an expert group convened under the umbrella of the Task Force. 1990–2009. Prevalence is defined as the number of cases of TB disease (all forms) at a given point in time (the middle of the year).  6IKMSRW Regional analyses are generally undertaken for the six WHO regions (that is. The policy paper is available on the Task Force’s website http://www. This section explains the five main methods used to estimate TB incidence. the European Region. 2009 (Stop TB policy paper no. 1990–2009. WHO/HTM/TB/2009. These are national surveys of the prevalence of TB disease and indirect estimates based on combining estimates of incidence with estimates of the duration of TB disease. For further details. This section explains the two methods used to estimate TB mortality. Lancet Infectious Diseases (published online 16 January 2008. the Region of the Americas. The case fatality rate is defined as the risk of death from TB among people with active TB disease.  (FOFSBMBQQSPBDI Estimates of the burden of disease caused by TB (measured in terms of incidence. see the Task Force web site at: http://www. This section explains the two main methods used to estimate TB prevalence.who. Methods for estimating mortality by age and sex are also described. %F¾OJUJPOT  -RGMHIRGITVIZEPIRGIQSVXEPMX]ERH  XLIGEWIJEXEPMX]VEXI Incidence is defined as the number of new and relapse cases of TB (all forms) occurring in a given year. This section explains the general approach to including uncertainty in all estimates. 8 his annex explains the methods that were used to produce estimates of the global burden of disease caused by TB (measured in terms of incidence. the African Region. This section defines TB incidence. due for publication in 2010. prevalence and 8)03&1035 (-0#"-56#&3$6-04*4$0/530-  mortality should be measured. The review is also the basis for the TB component of the update to the Global Burden of Disease. and the countries for which they have been applied. int/tb/advisory_bodies/impact_measurement_taskforce/en/index. N Estimates of TB prevalence. Relapse cases are defined as people who have been previously treated for TB and for whom there was bacteriological confirmation of cure and/or documentation that treatment was completed. This section explains how projections up to 2015 were produced. the South-East Asia Region and 1 2 3 4 Dye C et al.

The policy paper is available on the Task Force’s website http://www. The WHO Global Task Force on TB Impact Measurement has agreed that methods for deriving incidence from the prevalence of infection are unreliable. A useful reference on capture-recapture methods is: Chao A et al. no. .int/tb/advisory_ bodies/impact_measurement_taskforce/en/index. the 2008 revision of estimates provided by the United Nations Population Division (UNPD) was used.  8)03&1035 (-0#"-56#&3$6-04*4$0/530- the Western Pacific Region). The recommendation on tuberculin surveys is provided on page 12. The Task Force has also stated that it is doubtful whether repeat tuberculin surveys provide a reliable estimate of the trend in TB incidence. incidence was estimated according to the following equation: incidence =  4STYPEXMSRIWXMQEXIW Where population sizes are needed to calculate TB indicators. sputum smear-negative pulmonary cases. case notifications proportion of cases detected The proportion of all TB cases6 detected (the case detection rate. For example. High-income countries are those with a per capita gross national income (GNI) of US$ 12 196 or more in 2009. was scheduled for December 2010. Expert opinion was elicited after in-depth analysis of notification data (including data from sub-national administrative levels) and programmatic data reflecting efforts in TB control (for example. measurements from “inventory” studies or estimation from capture-recapture modelling in which at least three sources of information were used – thus allowing adjustment for between-source dependencies. World Health Organization. &TUJNBUFTPG5#JODJEFODF ° No country has ever undertaken a nationwide survey of TB incidence because of the large sample sizes required and associated major logistic and financial challenges. data on access to health care from Demographic and Health Surveys and the overall performance of health systems (using indicators such as the infant mortality rate) were used to substantiate opinion on the proportion of cases with no or very limited access to health care (8%&0)%).416). However. 5"#-&" 4PVSDFTPGJOGPSNBUJPOBOEEBUBPO5#JODJEFODFVTFEJO SFHJPOBMXPSLTIPQTBOEDPVOUSZNJTTJPOT 4377-&0)'%8)+36-)73* -2'-()28'%7)7 7396')73*(%8% (SRSXLEZITL]WMGEP SV´RERGMEPEGGIWWXS LIEPXLGEVI (IQSKVETLMGERH LIEPXLWYVZI]W /%&4EWYVZI]W 7IIOGEVIFYX8&RSX HMEKRSWIH 7YVZI] 8&HMEKRSWIHFYXRSX VITSVXIH ¨-RZIRXSV]©WYVZI] 6ITSVXIHGEWIW 8&WYVZIMPPERGI E 'ETXYVI¦VIGETXYVI QSHIPPMRK  /%&4!ORS[PIHKIEXXMXYHIWFILEZMSYVERHTVEGXMGIW 1 2 3 4 5 6  As defined by the World Bank. data from TB surveillance systems that are linked to health systems of high coverage and performance may capture all (or almost all) incident cases of TB. It should be noted that. the performance of services and funding). the SouthEast Asia Region and the Western Pacific Region. 2003 and 2008 or 2009). at the time this report went to press. 20(20):3123–3157. the Eastern Mediterranean Region. with plausible ranges. http://esa. for three years (1997. 2 (WHO/HTM/TB/2009. The WHO Global Task Force on TB Impact Measurement is working on the development of such standards. 2009 (Stop TB policy paper.html.org/unpp/. estimates of TB incidence rely on one or more of the five methods described in 7)'8-327¦. the first workshop in this region. For countries participating in these regional workshops. incidence estimates are no longer derived from surveys of the prevalence of tuberculous infection as measured in tuberculin surveys. there are no direct measurements of the incidence of TB. See the second background paper prepared for the fourth meeting of the Global Task Force on TB Impact Measurement. with very few exceptions. following in-depth analysis of national and sub-national data. as yet no standard and widely-endorsed criteria and benchmarks for classifying TB surveillance systems are available.un. data on infrastructure. Eastern Europe (countries of the former Soviet states plus Bulgaria and Romania) as well as the group of high-income countries1 are distinguished. Theoretically. 2001. staffing. according to a framework developed by the WHO Global Task Force on TB Impact Measurement (see 7)'8-32 of the main part of this report).2 The UNPD estimates sometimes differ from those made by countries.who. Statistics in Medicine. the European Region.int/tb/advisory_bodies/impact_measurement_ taskforce/en/index. The African region was the only region where such workshops had not been held by mid-2010. and extrapulmonary cases. By mid-2010. including sputum smear-positive pulmonary cases. and initial ideas are available in a background paper. The applications of capture-recapture models to epidemiological data.html. accessed on 7 June 2010. Geneva. TB Impact Measurement: Policy and recommendations for how to assess the epidemiological burden of TB and the impact of TB control. The paper is available on the Task Force’s web site http://www. Defined as cases of all forms of TB. In addition.4  )WXMQEXMRK8&MRGMHIRGIJVSQIWXMQEXIWSJXLI  TVSTSVXMSRSJGEWIWHIXIGXIH Notification data for new and relapse cases have been analysed in combination with evidence about the coverage of the TB surveillance system5 and expert opinion in five regional workshops and three country missions held 2008–2010. For some analyses. In the absence of direct measurements. held 17–18 March 2010. or CDR) was estimated. these workshops and country missions had covered 71 countries in the Region of the Americas. As a result.who. for 17 of the 46 countries in the region.

 8)03&1035 (-0#"-56#&3$6-04*4$0/530-  5"#-&" 1BSBNFUFSFTUJNBUFTVTFEUPQSPEVDFFTUJNBUFTPG5#JODJEFODF QSFWBMFODFBOENPSUBMJUZ 13()04%6%1)8)6 (-786-&98-32 -RGMHIRGILMKLMRGSQIGSYRXVMIW &IXEE  (-786-&98-324%6%1)8)67 α=Ī Ī (1– Ī ) V  β=(1– Ī )     &IXE 0.-:RIKEXMZIGEWIWSJ8& 9RMJSVQ l = 1.-:TVIZEPIRGIEQSRKMRGMHIRX8&  F x– (1– x– ) V –1 . u = 4.LIVIx– MWXLII\TIGXIHZEPYIERHVMWKMZIRF] V= (u – l) 2 4 (YVEXMSRSJHMWIEWIRSRRSXM´IH .3 E 4 Ī (1– Ī ) V –1  2 N x– (1– x– ) –1 α=–x V β=(1– x– )   –1 [LIVIĪ[EWWIXEXXMQIWXLIRSXM´GEXMSRVEXIRSXIHNERHVMW HI´RIHF]G V= .

01.-:TSWMXMZIGEWIWSJ8& 9RMJSVQ l = 0. u = 0.]IEVW  (YVEXMSRSJHMWIEWIRSRRSXM´IH .2.

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int/tb/advisory_bodies/impact_measurement_ taskforce/en/index. N They are not necessarily symmetrical. The onion framework is described on pages 19–24). This started with a systematic assessment of data quality. The two shape parameters necessary to define the Beta distribution were computed using the method of moments. WHO/ HTM/TB/2009. Since the variance of CDR distributions tend to be large as a result of high uncertainty. These methods are documented in a workbook available on the web site of the WHO Global Task Force on TB Impact Measurement.2 Distributions of CDRs for the three years for which they were estimated were assumed to follow a Beta distribution (8%&0) %). Reasons for using Beta distributions include the following: N They are continuous and defined on the interval (0. as follows: 1 2 TB impact measurement: policy and recommendations for how to assess the epidemiological burden of TB and the impact of TB control.]IEVW  E  8LITVSFEFMPMX]HIRWMX]JYRGXMSRSJXLI&IXEHMWXVMFYXMSRMW ƒ (x. The use of truncated normal distributions may result in excess density towards one of the bounds. N They are defined with two parameters that can be estimated from available data using the method of moments. 2009 (Stop TB policy paper no 2.who. and then by assessment of the likely number of TB cases that are not notified.who. To facilitate the documentation of expert opinion. different “layers” of the onion represent distinct populations of TB cases that are not captured by national TB information systems (for example. Geneva.html.int/tb/advisory_bodies/impact_measurement_ taskforce/en/index. . 1). 1). random draws of numbers from a normal distribution would yield numbers outside the interval (0. including an assessment of the over-dispersion of count data over time and across regions/districts (or similar geographical areas). World Health Organization. β) = 1 0 x α–1 (1– x) β–1 u α–1 (1– u) β–1 du F  YERHPHIRSXIYTTIVERHPS[IVFSYRHW G  7IIWIGXMSR Data were assessed using a three-step process. α. http://www. This was followed by exploration of potential factors driving time-changes in case notifications (such as improvements in diagnostic capacity and the HIV epidemic). an “onion” framework1 was used.416. The policy paper is available on the Task Force’s website http://www. In this framework.html. cases with no access to health care and cases with access to private health-care services but not reported to NTPs – see 8%&0)%).

since active case-finding truncates the natural history of undiagnosed disease.1 If there were insufficient data to determine the factors leading to time-changes in case notifications. . noted u). to predict a value for 2009. with knots set at the three reference years. although the model does allow for stochastic fluctuations. Incidence trajectories were derived from the series of notified TB cases using Monte Carlo simulations from which expected values. time-trends were assessed using in-depth analysis of surveillance data. the variance for the distribution was taken as: V = ((u – l)/4)2 where l and u are the lower and upper bounds of the plausible range for the CDR. Vienna. using methods described in 7)'8-32. The CDR for sputum smear-positive pulmonary TB is the number of new and relapse cases of sputum smear-positive pulmonary TB notified to NTPs divided by .  8)03&1035 (-0#"-56#&3$6-04*4$0/530- First. as informed by expert opinion. previously published timeseries of TB incidence were extended by fitting a log-linear model to the estimates for 2006–2008. following a meeting in early 2009 in which consensus was reached among national experts and experts from WHO and the KNCV Tuberculosis Foundation. Mexico and South Africa). as described above. 2. All computations were conducted in the R statistical environment.R-project.  )WXMQEXMRK8&MRGMHIRGIJVSQTVIZMSYWP]  TYFPMWLIHXMQIWIVMIWSJMRGMHIRGI In all remaining countries. http://www.5th and 97.3 times the notification rate (upper uncertainty bound. For example. In the absence of country-specific data on the quality and coverage of TB surveillance systems. There are few data on the duration of disease in HIVpositive individuals. measurements of the duration of symptoms in prevalent TB cases that are detected during a preva1 R Development Core Team. The best estimate of the mean duration of disease (for smear-positive cases and smear-negative cases combined) in HIV-negative individuals is about three years. If only one prevalence survey measurement was available. the prevalence trajectory was built using cubic spline interpolation. 2009 (ISBN 3-900051-07-0. Measurements of the duration of disease in notified cases ignore the duration of disease among non-notified and untreated cases. the level of TB incidence was assumed to be distributed between the notification rate for new and relapse cases combined (lower uncertainty bound. R: a language and environment for statistical computing. incidence was assumed to follow a horizontal trend going through the most recent estimate of incidence. using the following equation: incidence = deaths proportion of incident cases that die Previously published time-series of incidence for those three countries were then extended to 2009. A cubic spline extrapolation of V and E. was used.  )WXMQEXMRKXLIMRGMHIRGISJWTYXYQ  WQIEVTSWMXMZI8&ERHXLIGEWIHIXIGXMSR  VEXIJSVWTYXYQWQIEVTSWMXMZI8& All the annual reports on global TB control published by WHO from 1997 to 2009 included estimates of the incidence of sputum smear-positive TB and the related CDR for such cases.  )WXMQEXMRK8&MRGMHIRGIJVSQQIEWYVIQIRXWSJ  QSVXEPMX]ERHIWXMQEXIWSJXLIGEWIJEXEPMX]VEXI In three countries (Brazil. lence survey are systematically biased towards lower values. noted l) and 1. Literature reviews commissioned by the WHO Global Task Force on TB Impact Measurement have provided estimates of the duration of disease in untreated TB cases from the pre-chemotherapy era (before the 1950s).5th centiles were extracted.  )WXMQEXMRK8&MRGMHIRGIJVSQHEXESR  GEWIRSXM´GEXMSRWERHI\TIVXSTMRMSRJSV  LMKLMRGSQIGSYRXVMIW For high-income countries. as described above. incidence was estimated from 1990 up to 2008 from TB mortality data. The duration of disease cannot be directly measured. R Foundation for Statistical Computing. When measurements from two prevalence surveys were available. the prevalence to incidence method was used for only one country (Viet Nam). Time series for the period 1990–2009 were built according to the characteristics of the three CDRs that were estimated. When three or more prevalence measurements were available. trends in TB incidence were derived by fitting a log-linear model to indirect estimates of TB incidence.org). Incidence is estimated as the prevalence of TB divided by the average duration of disease.  )WXMQEXMRK8&MRGMHIRGIJVSQIQTMVMGEP  QIEWYVIQIRXWSJHMWIEWITVIZEPIRGI Incidence can be estimated using measurements from national surveys of the prevalence of TB disease combined with estimates of the duration of disease. Shape 1 (noted α) and shape 2 (noted β) follow from: s = E(l – E) – l V α = sE β = s(l – E) where E is the expected value of the distribution. In this report. it was assumed that TB surveillance systems from countries in the highincome group performed similarly well. The distribution of incidence was assumed to follow a Beta distribution with shape parameters computed using the method of moments.

h is HIV prevalence among the general population (from the latest time-series provided by UNAIDS) and ρ is the incidence rate ratio (IRR) (defined as the incidence rate of TB in HIV-positive people divided by the incidence rate of TB in HIV-negative people). The CDR for sputum smear-positive pulmonary TB would then be estimated by dividing reported notifications of sputum smear-positive cases of pulmonary TB by the estimated incidence of sputum smear-positive pulmonary TB. estimates of the incidence of all forms of TB are used to produce indirect estimates of TB mortality and TB prevalence (these do not require estimates of the CDR for smear-positive TB). without any real change in the level of case detection in the country itself (since a change in the regional proportion will cause the estimated incidence of smear-positive TB in a given country. If needed for reporting purposes. &TUJNBUFTPG)*7QSFWBMFODFBNPOHJODJEFOU  5#DBTFT ° The prevalence of HIV among incident cases of TB was directly estimated from country-specific and empirical data wherever possible. use of this method will mean that. it is suggested that the CDR for smear-positive TB is assumed to be similar to the CDR for all forms of TB. the estimated number of incident cases that occurred in the same year. There are several reasons for this. for example). This was because. the starting point for estimates of the incidence of TB was an estimate of the CDR for all forms of TB. In regional workshops and country missions. A fuller explanation is provided here. For the 3785 country-year data points for which surveillance data were either not available or for which the percentage of TB patients tested for HIV was below 50%. Using data from countries where HIV prevalence 1 2 Research Institute of Tuberculosis.2 To estimate ρ from empirical data (that is. Another alternative is to assume that. up from 288 country-year data points in the previous year (for details of the source of data used for each country. suitable data (as defined in 8%&0)%) were available for a total of 440 country-year data points. for any given country. the proportion of all incident cases with sputum smear-positive pulmonary TB is equal to the proportion of all notified cases that had smear-positive pulmonary TB in the region of reference (this could be an epidemiologically-defined region or a WHO region. to go up and down even when the country’s notifications are stable). the proportion of sputum smear-positive cases of pulmonary TB among all notified cases reflects the true proportion of sputum smear-positive TB among incident cases of TB in the country. from countries that have an empirical estimate of both t and h). .1 It may appear that an alternative method is to assume that. the estimated CDR for all forms of TB and the estimated CDR for sputum smear-positive cases are the same. 5"#-&" 4PVSDFPGEBUBPO)*7QSFWBMFODFBNPOHJODJEFOU5#DBTFT (-6)'81)%796)1)283*8. and associated updates to methods used to estimate disease burden that have been applied in a series of regional workshops and country missions (7)'8-32). the findings of one of the systematic reviews conducted by the expert group have cast doubts on this approach. changes in the estimated CDR for sputum smear-positive pulmonary TB will occur from one year to the next simply because of a change in the share of regional notifications that are smear-positive. Data on HIV prevalence in the general population are unpublished data provided to WHO by UNAIDS. t is HIV prevalence among incident TB cases. In this case. This approach was used in global reports published up to December 2009. For the estimates published in this report. Subsequently.-:WIRXMRIPWYVZIMPPERGI  4VSZMHIVMRMXMEXIHXIWXMRKERHGSYRWIPPMRK [MXLEPIEWX GSZIVEKISJXIWXMRK  5PUBM  the prevalence of HIV was estimated indirectly according to the following equation: t= hρ l + h(ρ – l) In this equation.-:-28&4%8-)287 291&)63* '39286==)%67 2EXMSREPWYVZI]W  . Among the reasons noted in this box are the findings and associated recommendations from the 18-month expert review of methods used to estimate disease burden described in 7)'8-32 above. the equation was rearranged as follows: ρ= t(l – h) h(l – t) We then let logit(t) be log(t/(1-t)) and logit(h) be log(h/ (1-h)). the denominator of the CDR. for many countries. in any given 8)03&1035 (-0#"-56#&3$6-04*4$0/530-  country. Estimates of the incidence of sputum smear-positive pulmonary TB and the related CDR for these cases are not published in this report. The incidence of sputum smear-positive pulmonary TB can theoretically be estimated by multiplying the incidence of all forms of TB by the estimated proportion of all incident cases of TB that have sputum smear-positive pulmonary TB. for many countries. Tokyo 2010 (data not shown). please see the %44)2(-<). This is wrong and likely to cause confusion.)46):%0)2') 3*. A systematic review of the evidence about the proportion of TB cases that have sputum smear-positive pulmonary TB found considerable uncertainty around the best estimate of this proportion. which are summarized in the main part of the report (&3< ). However.

a linear model of logit-transformed t was fitted using logit-transformed h according to the following equation. The vector β holds estimated model parameters. and the second column holds logit(h). Furthermore. It should be noted. Models were run using Monte Carlo simulations in which h was drawn randomly from a Beta distribution with shape parameters computed as described in 7)' 8-32. Estimates of TB mortality were produced directly from VR data. Manila. Tuberculosis prevalence surveys: rationale and cost. The source of data used in each country is listed in the %44)2(-<. In countries with 1 2 Glaziou P et al. When there is no direct measurement from a national survey of the prevalence of TB disease. prevalence surveys exclude extrapulmonary cases and do not allow the diagnosis of cases of culture-negative pulmonary TB. Assumptions of the duration of disease are shown in the last four rows of 8%&0)%. however. written in matrix notation: Tˆ = Xβ where Tˆ is a vector of predicted logit(t).5th centiles. prevalence estimates should be used with great caution in the absence of direct measurements from a prevalence survey. Given their underlying uncertainty.i∈{1. World Health Organization. but there is no practical way to measure the duration of disease in patients who are not notified to NTPs. The uncertainty bounds for β were chosen as the 2. &TUJNBUFTPG5#NPSUBMJUZ  −4 −6 −8 −6 −4 −2 logit (HIV in general population) . This is because prevalence is the product of two uncertain quantities: (i) incidence and (ii) disease duration. Deaths from TB in HIVpositive people are coded under HIV-associated codes. The source of data used for each country is listed in the %44)2(-<.2 Data from such surveys are available for an increasing number of countries.j∈{1. &TUJNBUFTPG5#QSFWBMFODF ° The best way to measure the prevalence of TB is through national population-based surveys of TB disease. X is an n \ 2 matrix in which the first column holds 1s.j . d denotes the duration of disease and I is total incidence.1. 12(9):1003–1008. In the absence of measurements. Indirect estimates of prevalence were calculated according to the following equation: '*(63&" P = ∑ I i.  )WXMQEXMRK8&QSVXEPMX]JVSQHMVIGX  QIEWYVIQIRXWSJZMXEPVIKMWXVEXMSRHEXE Data from VR systems are reported to WHO by Member States and territories every year.2} 3FMBUJPOTIJQCFUXFFOUIFQSFWBMFODFPG)*7JO5#QBUJFOUT BOEUIFQSFWBMFODFPG)*7JOUIFHFOFSBMQPQVMBUJPO 0 −2 logit (HIV in TB)  where the index variable i denotes HIV+ and HIV–. we did not allow duration in notified cases to vary among countries.j d i.-:TVIZEPIRGIMRRI[P]RSXM´IH8&GEWIWEKEMRWX. . the index variable j denotes notified and non-notified cases. that measurements of prevalence are typically confined to the adult population.-:TVIZEPIRGIMRXLI KIRIVEPTSTYPEXMSREJXIVPSKMXXVERWJSVQEXMSR%XSXEPSJPMRIEV VIKVIWWMSRQSHIPW[IVI´XXIHXSVERHSQP]WIPIGXIHRYQFIVWHVE[RJVSQ PSKMXXVERWJSVQIHHMWXVMFYXMSRWSJFSXLZEVMEFPIW9RGIVXEMRX]FERHWJSV TVIHMGXIHZEPYIW[MXLFSYRHWHI´RIHEWXLIXLERHXLGIRXMPIW EVIWLS[RMRFPYI The best sources of data about deaths from TB (excluding those among HIV-positive people) are VR systems in which causes of death are coded according to ICD-10 (although the older ICD-9 and ICD-8 classification are still in use in several countries). Duration can be assessed in self-presenting patients. Assessing tuberculosis prevalence through population-based surveys. The duration of disease is very difficult to quantify because measurements from surveys of the prevalence of TB disease are not reliable (surveys truncate the natural history of disease). 2008. International Journal of Tuberculosis and Lung Disease. prevalence is the most uncertain of the three TB indicators used to measure disease burden. or indirectly from estimates of TB incidence and case-fatality rates (CFRs).2}.5th and 97. (low and high uncertainty bounds are provided by UNAIDS – also see 8%&0)%). 8)03&1035 (-0#"-56#&3$6-04*4$0/530- has been estimated by UNAIDS as an independent variable. 2007. The model was run 50 000 times using country-specific distributions for H and T (noted in capital letters to denote vectors or matrices) based on their uncertainty intervals (*-+96) %).

in conjunction with WHO estimates of distributions of TB incidence in those countries.1 These countries included four of the 22 HBCs (Brazil. Rescaling factors were defined for each country as the ratio of the mean of available VR-recorded TB mortality rates over the mean of indirectly estimated mortality. we assumed that VR measurements were more reliable than the indirect estimates. Semi-conjugate priors were set with an uninformative inverse Gamma prior on the conditional error variance: b ~ N(b i . . When people with AIDS die from TB. mortality estimates were computed by taking the product of posterior distributions of the CFR. HIV is registered as the underlying cause of death and TB is recorded as a contributory cause. and all other countries). CFRs were estimated separately for TB cases notified to NTPs and non-notified cases and.B i -2). Convergence of Markov Chains was assessed graphically and using two convergence diagnostic tests. equivalent to ICD-9: 010018). for the years covered by VR measurements. ICD-10 codes R00-R99) of <20% of all registered deaths. equivalent to 602 country-years. VR data are the best source of information about deaths from TB among people not infected with HIV. it was possible to disaggregate estimated TB deaths by age (with age groups defined as 0–4 years. there was an average of 6. However. Within each case category 1990–2009.σ2 ~ IG(5. smooth mortality trend lines. Counting the dead and what they died from: an assessment of the global status of cause of death data. CFRs were estimated such that they gave the best fit to the VR-recorded TB death rates (within their uncertainty ranges) across the 602 country-years of data from the 89 countries with functioning VR systems. within these two groups. and (ii) ill-defined causes of death (ICD-9 code B46. This statistical fitting used Bayesian linear models and was done separately for three groups of countries (high-income. we could not use the VR data on TB deaths from South Africa because large numbers of HIV deaths were miscoded as TB deaths. We re-scaled the indirectly estimated TB mortality values to ensure. The models used normal errors and Gibbs sampling: y = (I – N)β1 + Nβ2 + ε. since ill-defined causes are typically observed in higher proportions in rural areas with a low population density where the risk of TB is lower. VR data usually cannot be used to estimate the number of TB deaths in HIV-positive people. Bulletin of the World Health Organization. 2005. 4–8) of VR data on TB mortality between 1991 and 2009 that met the above criteria. the CFR. assumed to be time-independent (8%&0) %). increasing with decreasing VR coverage and with increasing rates of ill-defined causes of death.  )WXMQEXMRK8&QSVXEPMX]JVSQMRHMVIGXIWXMQEXIW  SJGEWIJEXEPMX]VEXIWERH8&MRGMHIRGI For the years in which VR data of sufficient quality and coverage were not available for the 89 countries defined above plus the 124 countries without any VR data. N denotes TB notifications excluding people living with HIV. separate estimates were made for HIV-positive TB cases and HIV-negative TB cases (8%&0)%).10 -4) Priors b and their precision B were defined based on literature reviews and the country-year CFR parameters used by WHO for the years 1999–2008 (8%&0) %). I denotes TB incidence excluding people living with HIV. We assumed errors in measurement (due to misclassifications) and assumptions (redistributions) to be log-normally distributed with a standard deviation on a log scale given by σ = 0. where μ is the VR recorded TB mortality rate. on average. Where this occurred. 90 countries had well-functioning VR systems according to the following definition: (i) coverage of at least 70% of the population. the Russian Federation and South Africa).σ2) where y is TB mortality from VR. For consistency with VR-based mortality estimates. ε ~ N(0. the Philippines. and country-year specific distributions of estimated incidence. the combination of using VR data for some years and indirect estimates (based on incidence and CFRs) for others sometimes led to implausible differences between adjacent time-points. we assumed that the proportion of deaths attributable to TB was half of the observed proportion in recorded deaths. 5–14 years. 25–34 years.05μ / (ν – s/2). among cases excluding those infected with HIV. 8)03&1035 (-0#"-56#&3$6-04*4$0/530-  functioning VR systems in which causes of death are coded according to the two latest revisions of the International Classification of Diseases (underlying cause of death: ICD-10 A15-A19. We assumed that the proportion of TB deaths among deaths not recorded by the VR system was the same as the proportion of TB deaths in VR-recorded deaths. to account for differences in the ratio of reported TB mortality to TB notification rates among these three groups (data not shown).  )WXMQEXMRK8&QSVXEPMX]JVSQHMWEKKVIKEXIH  IWXMQEXIWSJ8&HIEXLWF]EKIERHWI\ For countries with VR data. Incomplete coverage and ill-defined causes introduce uncertainty in measurements μ. In 2009. 15–24 years.10 -4 . The standard deviation of μ was based on the assumption that uncertainty intervals of μ spanned at least ±10% of the measurement μ. v the coverage of the VR system and s the rate of ill-defined causes. and parameters β1 and β2 denote the CFR in non-notified and notified cases respectively. 83:171–177. eastern Europe. mortality was estimated as the product of TB incidence and 1 Mathers CD et al. Since one third of countries with VR systems report to WHO only the underlying causes of death and not contributory causes.5. For VR-recorded deaths with ill-defined causes. Among the remaining 89 countries. Among the 89 countries.2 years (interquartile range.

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It is therefore generally unclear when bumps in notifications are most likely reflecting reporting errors. for those cases where corrections appear necessary. misclassification of relapse cases in the category of new cases is common). Projections for the years 2010–2015 were made using log-linear regression models fitted to rates from 2006–2009. 55–64 years. but may sometimes reflect abrupt changes in TB epidemiology (for example. step 4 may be done before or after step 3). in extrapolations used to impute missing data.  1SPKFDUJPOTPGJODJEFODF QSFWBMFODFBOE  NPSUBMJUZVQUP Projections of TB incidence. 95% confidence intervals are reported. Cases may be underreported (missing quarterly reports from remote administrative areas are not uncommon). TB deaths in HIVpositive people were not disaggregated by age and sex due to limited data from countries with functional VR systems. Notification data are of uneven quality. We used fixed population values from the UNPD. resulting from a rapid influx of migrants from countries with a high-burden of TB. When uncertainty was established with the use of observed or other empirical data. ≥65 years) and sex. The general approach to uncertainty analyses was to draw values from specified distributions for every . Missing national aggregates of new and relapse cases were imputed by cubic spline interpolation. By design. Throughout this report. (4) estimation of prevalence. misclassified (in particular. uncertainty in estimates of incidence rates and rates of HIV prevalence among both incident and notified TB cases. We did not account for any uncertainty in these values. regional and country levels. ranges with upper and lower bounds defined by these centiles are provided for all estimates established with the use of simulations. Attempts to obtain corrections for historical data are made every year. The model used the following sequence: (1) incidence estimation.5th centiles of outcome distributions. prevalence and mortality. In countries with no functional VR system. 45–54 years. as well as estimates of the burden of HIVassociated TB and MDR-TB. in parameter values. the total number of estimated TB deaths was redistributed into the different age and sex strata according to the disaggregation of the combined population of countries with VR data (with standardization against the individual country’s age and sex distribution). Unless otherwise specified. Mortality estimates incorporated the following sources of uncertainty: sampling uncertainty in the underlying measurements of TB mortality rates from data sources. some steps were independent from each other (for example. and parameter uncertainty in the Bayesian model. uncertainty bounds and ranges were defined as the 2. prevalence and mortality rates up to 2015 enable assessment of whether global targets set for 2015 are likely to be achieved at global. Time-series of TB mortality were generated for each country through Monte Carlo simulations.     35–44 years. (2) estimation of HIV-positive TB incidence. or over-reported as a result of duplicated entries in TB information systems. notification trajectories were not automatically smoothed over time to avoid introducing systematic errors in countries where time-changes are reflecting true changes in the epidemiology of TB. However. Future regional workshops will include a systematic effort to correct for such data deficiencies using expert opinion. or from rapid improvement in casefinding efforts). (3) estimation of mortality. &TUJNBUJPOPGVODFSUBJOUZ There are many potential sources of uncertainty associated with estimates of TB incidence. in line with the way in which deaths are reported. Sudden changes in notifications over time are often the result of errors or inconsistencies in reporting. but only rarely do countries provide appropriate data corrections.5th and 97. with the assumption that recent trends would continue. These include uncertainties in input data. The latter two issues can only be addressed efficiently in countries with case-based nationwide TB databases that include patient identifiers. and in the model used.

Summaries of quantities of interest were obtained by extracting the 2. As a result. Two sets of simulations were run. with the number of simulation runs set so that they were sufficient to ensure stability in the outcome distributions. These summary estimates are the result of simulations based on nonsymmetric distributions. and errors were assumed to be time-dependent within countries (thus generating autocorrelation in time-series). The country-specific 8)03&1035 (-0#"-56#&3$6-04*4$0/530-  estimates produced using the just-described simulations were then used as the building blocks for further simulations. from which aggregated summaries at global and regional levels for incidence. . Regional parameters were used in some instances (for example. parameter (except for notifications and population values) in Monte Carlo simulations. best estimates for regions do not necessarily sum to the best estimate for the world. for CFRs).5th centiles of posterior distributions. the first to produce aggregates at regional level and the second to produce aggregates at global level.5th. The same random generator seed was used for every country. prevalence and mortality were drawn. 50th and 97.

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. Estimated rates are shown rounded to three significant figures unless the value is under 100. so they may differ from those published in previous reports in this series. Data shown in the main part of the report were taken from the database on 17 June 2010. The lower and upper bounds are defined as the 2.who.5th centiles of outcome distributions produced in simulations.int/tb/data. data in this annex may differ slightly from those in the main part of the report. See %22)< for further details. in which case rates are shown rounded to two significant figures.5th and 97. As a result. (SBQIT Graphs where displayed show data from all years within the range stated. Data can be downloaded from www. Estimates published in previous global TB control reports should no longer be used. Estimates for all years are recalculated as new information becomes available and techniques are refined. %BUBTPVSDF Data shown in this annex are taken from the WHO global TB database on 31 August 2010. Estimated numbers are shown rounded to two significant figures.  8)03&1035 (-0#"-56#&3$6-04*4$0/530- &TUJNBUFTPGNPSUBMJUZ QSFWBMFODFBOEJODJEFODF Estimated values are shown as best estimates followed by lower and upper bounds.

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5th centiles of outcome distributions produced in simulations. Data shown in the main part of the report were taken from the database on 17 June 2010. Estimated rates are shown rounded to three significant figures unless the value is under 100.  8)03&1035 (-0#"-56#&3$6-04*4$0/530- &TUJNBUFTPGNPSUBMJUZ QSFWBMFODFBOEJODJEFODF Estimated values are shown as best estimates followed by lower and upper bounds. Estimates published in previous global TB control reports should no longer be used. . Data can be downloaded from www.5th and 97. data in this annex may differ slightly from those in the main part of the report. in which case rates are shown rounded to two significant figures. As a result. Estimates for all years are recalculated as new information becomes available and techniques are refined. so they may differ from those published in previous reports in this series. The lower and upper bounds are defined as the 2. Estimated numbers are shown rounded to two significant figures. %BUBTPVSDF Data shown in this annex are taken from the WHO global TB database on 31 August 2010.who.int/tb/data. (SBQIT Graphs where displayed show data from all years within the range stated. See %22)< for further details.

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Estimates published in previous global TB control reports should no longer be used. %BUBTPVSDF Data shown in this annex are taken from the WHO global TB database on 31 August 2010.who. so they may differ from those published in previous reports in this series. As a result. data in this annex may differ slightly from those in the main part of the report. Estimated rates are shown rounded to three significant figures unless the value is under 100. in which case rates are shown rounded to two significant figures. See %22)< for further details.  8)03&1035 (-0#"-56#&3$6-04*4$0/530- &TUJNBUFTPGNPSUBMJUZ QSFWBMFODFBOEJODJEFODF Estimated values are shown as best estimates followed by lower and upper bounds.int/tb/data. Estimated numbers are shown rounded to two significant figures. Data shown in the main part of the report were taken from the database on 17 June 2010. Data can be downloaded from www. The lower and upper bounds are defined as the 2. . Estimates for all years are recalculated as new information becomes available and techniques are refined. (SBQIT Graphs where displayed show data from all years within the range stated.5th and 97.5th centiles of outcome distributions produced in simulations.

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so they may differ from those published in previous reports in this series. The lower and upper bounds are defined as the 2. Estimates published in previous global TB control reports should no longer be used. Data shown in the main part of the report were taken from the database on 17 June 2010. . (SBQIT Graphs where displayed show data from all years within the range stated. As a result. data in this annex may differ slightly from those in the main part of the report.5th and 97. pending an in-depth and up-to-date analysis of surveillance and programmatic data with the NTP. Data can be downloaded from www.int/tb/data. Estimated rates are shown rounded to three significant figures unless the value is under 100.5th centiles of outcome distributions produced in simulations. Estimated numbers are shown rounded to two significant figures.  8)03&1035 (-0#"-56#&3$6-04*4$0/530- &TUJNBUFTPGNPSUBMJUZ QSFWBMFODFBOEJODJEFODF $PVOUSZOPUFT Estimated values are shown as best estimates followed by lower and upper bounds. %BUBTPVSDF Data shown in this annex are taken from the WHO global TB database on 31 August 2010. Estimates for all years are recalculated as new information becomes available and techniques are refined.who. See %22)< for further details. in which case rates are shown rounded to two significant figures. 4ETYE2I[+YMRIE Estimates of incidence. prevalence and mortality as well as the case detection rate are provisional. A reassessment of the epidemiological burden of TB will be undertaken following finalization and dissemination of survey results. 'LMRE China completed a survey of the prevalence of TB disease in 2010.

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