Global Tuberculosis Report -- 2012.pdf

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BOX 2.6Efforts by the Task Force to support TB prevalence surveys and build “AA” collaborationThe WHO Global Task Force on TB Impact Measurement has strongly recommended national TB prevalence surveys in 22 global focuscountries: 13 in Africa and 9 in Asia. The African countries are Ethiopia, Ghana, Kenya, Malawi, Mali, Mozambique, Nigeria, Rwanda,Sierra Leone, South Africa, Uganda, the United Republic of Tanzania and Zambia. The Asian countries are Bangladesh, Cambodia, China,Indonesia, Myanmar, Pakistan, the Philippines, Thailand and Viet Nam.Since 2008, the Task Force has made substantial efforts to support countries to design, implement, analyse and report on surveys. TheTask Force subgroup on TB prevalence surveys, led by WHO, has been very active and activities have included:■ close collaboration with the Global Fund to help secure full funding for surveys through reprogramming of grants (several surveys wereinitially under-budgeted);■ workshops to develop protocols and expert reviews of protocols by at least two Task Force partners not directly involved in the survey;■ production of a second edition of a WHO handbook on TB prevalence surveys (also known as “the lime book”), which providescomprehensive theoretical and practical guidance on all aspects of surveys. 1 The book was produced as a major collaborative effortinvolving 15 agencies and institutions and 50 authors in 2010, and was widely disseminated in 2011;■ training courses for survey coordinators without prior experience of survey implementation, including opportunities to observe fi e ldoperations in ongoing surveys;■ training courses to build a group of junior international consultants who can provide technicalassistance to countries;■ country missions by experts from the Task Force, mostly funded by the US government through theTB-TEAM mechanism (see Box 5.2 in Chapter 5).The concept of Asia–Asia, Asia–Africa and Africa–Africa (“AA”) collaboration has been stronglypromoted. This involves building collaboration among countries implementing surveys such that surveycoordinators and other staff can learn from and help each other, with the result that capacity toimplement prevalence surveys is built at country, regional and global levels. Examples of AA collaborationare survey coordinators from Asian countries providing guidance and support to those leading surveysin African countries where no recent experience exists; survey staff from Ethiopia providing support toAfrican countries planning surveys in 2012 and 2013; exchange visits and study tours; workshops toobserve central and fi eld operations hosted by Cambodia and Thailand; and mid-term reviews in whichsurvey coordinators visit other countries where survey operations are underway.Besides WHO, technical partners that are actively engaged in prevalence surveys include the Centers for Disease Control and Prevention,USA; the KNCV Tuberculosis Foundation in the Netherlands; the London School of Hygiene and Tropical Medicine, UK; and the ResearchInstitute for Tuberculosis, Japan.1TB prevalence surveys: a handbook. Geneva, World Health Organization, 2011 (WHO/HTM/TB/2010.17).www.who.int/tb/advisory_bodies/impact_measurement_taskforce/resources_documents/thelimebookis already unprecedented. As this report went to press,surveys were nearing completion in the Gambia, Nigeria,Rwanda, Thailand and the United Republic of Tanzania,with results expected in the first half of 2013.In late 2011 and early 2012, results from surveys completedin Ethiopia (June 2011) and Cambodia (September2011) were disseminated. The Ethiopian survey found alower prevalence of TB than was previously estimated,with most cases in young adults. As this report went topress, dissemination of results from surveys in the LaoPeople’s Democratic Republic and Pakistan was expectedby early 2013.Cambodia is only the third high-burden country toimple ment a repeat national prevalence survey in thepast 20 years (following China and the Philippines).The results provide an excellent example of the value ofnational TB prevalence surveys for measuring diseaseburden, evaluating the impact of TB control and identifyingways to improve TB care and control in future(Box 2.7).GLOBAL TUBERCULOSIS REPORT 2012 27
BOX 2.7Reducing the burden of TB disease: a success story from CambodiaFor the last two decades, Cambodia has been known to have one of the highest levels of TB burden (in terms of rates per 100 000population) in the world. TB control in Cambodia was reinstated in 1994 following decades of civil confl ict and economic hardship. TBservices were fi rst limited to provincial and district hospitals. Decentralization of TB control services to the health centre level was initiatedin the early 2000s, with nationwide expansion achieved in 2005, contributing to rapidly increasing case notifi cations (depicted with asolid black line in Figure B2.7.1).At the early stage of DOTS expansion to health centres, the National TB Programme decided to directly measure the burden of TB througha nationwide prevalence survey, completed in 2002. A total of 22 160 people aged ≥15 years participated in the survey, grouped in 42geographically determined clusters. The survey identifi ed 81 smear-positive TB cases (63% were symptomatic) and 190 smear-negativeculture-positive cases. After adjustment for unconfi rmed TB and forFIGURE B2.7.1Case notification and estimated incidence rates inCambodia, 1990–2011Rate per 100 000 population per year700600500400300200100Estimated incidence rateCase notification rate1990 1995 2000 2005 2010FIGURE B2.7.2Estimated TB prevalence (all forms) in Cambodia,1990–2011Rate per 100 000 population200015001000Survey 150% reduction target1990 1995 2000 2005 2010Survey 2childhood TB, the prevalence rate for all forms of TB was estimated at1511 (range 1244–1803) per 100 000 population, one of the highestprevalence rates observed in the world in recent history.A second nationally representative survey was conducted in 2011. Intotal, 39 680 people aged ≥15 years were sampled from 62 clusters.95 smear-positive TB cases (46% were symptomatic) and 218 smearnegativeculture-positive TB cases were identifi ed. After adjustmentfor unconfi rmed TB and for childhood TB, the prevalence rate for allforms of TB was estimated at 817 (range 690–954) per 100 000population, showing a statistically signifi cant reduction since the fi rstsurvey.Most bacteriologically-confi rmed prevalent cases did not reportsymptoms listed in the screening criteria. The proportion of peoplereporting TB symptoms listed in the screening criteria amongbacteriologically-confi rmed cases declined from 30% in 2002 to 22%in 2011. This highlights the need to revise criteria for TB screening inself-reporting patients, in favour of more sensitive criteria than thetraditional but insensitive criteria of a cough of ≥2weeks. There wasa signifi cant decline in prevalence rates for all age groups but thebiggest reduction was observed in younger age groups. The 2011survey also highlighted the need for more sensitive diagnostics thansputum smear microscopy.The repeat survey provides robust evidence of a decline in TBburden in Cambodia, following DOTS expansion in 2002 (FigureB2.7.2). Results indicate a 45% reduction in the prevalence ofbacteriologically-confi rmed cases since the fi rst national prevalencesurvey conducted in 2002, that is, over a period of only 9 years.The Cambodia results provide a major success story for TB control.28 GLOBAL TUBERCULOSIS REPORT 2012
Page 2 and 3: GLOBALTUBERCULOSISREPORT2012
Page 4 and 5: ContentsAbbreviationsivAcknowledgem
Page 6 and 7: AcknowledgementsThis report on glob
Page 8 and 9: WHO Western Pacific RegionShalala A
Page 10 and 11: Executive SummaryThe World Health O
Page 12 and 13: CHAPTER 1IntroductionBOX 1.1Basic f
Page 14 and 15: TABLE 1.1 Targets for the scale-up
Page 16 and 17: TABLE 1.2 Reporting of data in the
Page 18 and 19: BOX 2.1Uncertainty in estimates of
Page 20 and 21: TABLE 2.2 Estimated burden of disea
Page 22 and 23: FIGURE 2.5 Estimated TB incidence r
Page 24 and 25: FIGURE B2.2.1Reporting of notificat
Page 26 and 27: FIGURE 2.8Estimated TB incidence ra
Page 28 and 29: FIGURE 2.11 Countries (in blue) for
Page 30 and 31: FIGURE 2.12 Trends in estimated TB
Page 32 and 33: ● producing and widely disseminat
Page 34 and 35: FIGURE 2.16 Progress in global cove
Page 38 and 39: CHAPTER 3TB case notificationsand t
Page 40 and 41: BOX 3.1 1Definitions of TB casesDef
Page 42 and 43: TABLE 3.3 Contribution of public-pr
Page 44 and 45: BOX 3.4Integrating community-based
Page 46 and 47: TABLE 3.4 Estimates of the case det
Page 48 and 49: TABLE 3.5 Treatment success for new
Page 50 and 51: CHAPTER 4Drug-resistant TBKEY FACTS
Page 52 and 53: FIGURE 4.2 Percentage of new TB cas
Page 54 and 55: BOX 4.1Frequencies of resistance to
Page 56 and 57: FIGURE 4.6 Number of MDR-TB cases e
Page 58 and 59: FIGURE 4.7Notified cases of MDR-TB
Page 60 and 61: egimens globally, providing more su
Page 62 and 63: 5.1 Funding for TB care and control
Page 64 and 65: TABLE 5.2 NTP budgets, available fu
Page 66 and 67: FIGURE 5.5Trends in domestic and do
Page 68 and 69: FIGURE 5.6Domestic funding as a per
Page 70 and 71: FIGURE 5.8Cost per TB patient succe
Page 72 and 73: FIGURE 5.10 Total cost and unit cos
Page 74 and 75: ● The 14 countries not included i
Page 76 and 77: on public health by an external Exp
Page 78 and 79: evised as a result of the introduct
Page 80 and 81: TABLE 6.2 Incorporation of WHO poli
Page 82 and 83: FIGURE 6.3The Supranational Referen
Page 84 and 85: of TB disease by 65%, irrespective
Page 86 and 87:
FIGURE 7.3Percentage of TB patients
Page 88 and 89:
BOX 7.1Accelerating progress in pro
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TABLE 7.2 Assumptions used to estim
Page 92 and 93:
FIGURE 8.1 The development pipeline
Page 94 and 95:
sputum specimens and TB isolates fr
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cal trial sites and building labora
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new TB vaccine candidate. A Phase I
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This annex explains the methods tha
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2011. On average, 15 data points we
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may suffer from biases. These biase
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TABLE A1.3Parameter estimates used
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5. Estimates of TB prevalence, 1990
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the Republic of Moldova, Romania, t
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AFGHANISTANPopulation 2011 32 milli
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BRAZILPopulation 2011 197 millionHI
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CHINAPopulation 2011 1 348 millionH
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ETHIOPIAPopulation 2011 85 millionH
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INDONESIAPopulation 2011 242 millio
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MOZAMBIQUEPopulation 2011 24 millio
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NIGERIAPopulation 2011 162 millionH
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PHILIPPINESPopulation 2011 95 milli
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SOUTH AFRICAPopulation 2011 50 mill
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UGANDAPopulation 2011 35 millionHIG
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VIET NAMPopulation 2011 89 millionH
Page 138:
ANNEX 3Regional profiles
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WHO REGION OF THE AMERICASPopulatio
Page 143 and 144:
WHO EUROPEAN REGIONPopulation 2011
Page 145 and 146:
WHO WESTERN PACIFIC REGIONPopulatio
Page 148 and 149:
SUMMARY BY WHO REGIONTable A4.1 Est
Page 150 and 151:
MORTALITY (EXCLUDING HIV) PREVALENC
Page 152 and 153:
NEW AND RELAPSENOTIFICATION RATE aY
Page 154 and 155:
-% OF TB PATIENTS WITHKNOWN HIV STA
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AFRICAN REGIONTable A4.1 Estimates
Page 158 and 159:
Page 160 and 161:
Page 162 and 163:
INCIDENCE (INCLUDING HIV) INCIDENCE
Page 164 and 165:
NEW AND RELAPSENOTIFICATION RATE aY
Page 166 and 167:
NEW AND RELAPSENOTIFICATION RATE a1
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TREATMENT SUCCESS (%) a1995-2010YEA
Page 170 and 171:
Page 172 and 173:
Page 174 and 175:
Page 176 and 177:
YEARTOTALCONFIRMEDCASES OFMDR-TB aE
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MALEYEAR 0-14 15-24 25-34 35-44 45-
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REGION OF THE AMERICASTable A4.1 Es
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Page 184 and 185:
Page 186 and 187:
Page 188 and 189:
Page 190 and 191:
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% OF COHORTTREATMENT SUCCESS (%) a1
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Page 196 and 197:
Page 198 and 199:
Page 200 and 201:
Page 202 and 203:
MALEFEMALEYEAR 0-14 15-24 25-34 35-
Page 204 and 205:
EASTERN MEDITERRANEAN REGIONTable A
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Page 208 and 209:
Page 210 and 211:
Page 212 and 213:
Page 214 and 215:
Page 216 and 217:
Page 218 and 219:
Page 220 and 221:
EUROPEAN REGIONTable A4.1 Estimates
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Page 224 and 225:
Page 226 and 227:
Page 228 and 229:
Page 230 and 231:
Page 232 and 233:
Page 234 and 235:
Page 236 and 237:
Page 238 and 239:
Page 240 and 241:
Page 242 and 243:
Page 244 and 245:
Page 246 and 247:
Page 248 and 249:
SOUTH-EAST ASIA REGIONTable A4.1 Es
Page 250 and 251:
Page 252 and 253:
Page 254 and 255:
Page 256 and 257:
Page 258:
SMEAR LABS % OF SMEARPER 100K LABS
Page 261 and 262:
Estimates of mortality, prevalence
Page 263 and 264:
YEARPOPULATION(MILLIONS)MORTALITY (
Page 265 and 266:
YEARPOPULATION(MILLIONS)INCIDENCE (
Page 267 and 268:
YEARPOPULATION(MILLIONS)INCIDENCE (
Page 269 and 270:
Page 271 and 272:
Page 273 and 274:
Page 275 and 276:
Page 277 and 278:
Page 279 and 280:
Page 281 and 282:
SMEAR LABS % OF SMEARPER 100K LABS
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