Global Tuberculosis Report -- 2012.pdf

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CHAPTER 4Drug-resistant TBKEY FACTS AND MESSAGES By the end of 2012, representative surveillance data onlevels of MDR-TB will be available from all 27 high MDR-TB and 22 high TB burden countries, and from 135 of194 Member States. Globally, 3.7% (2.1–5.2%) of newcases and 20% (13–26%) of previously treated casesare estimated to have MDR-TB. There were an estimated 310 000 (range, 220 000–400 000) MDR-TB cases among notifi ed TB patientswith pulmonary TB in 2011. Almost 60% of these caseswere in India, China and the Russian Federation. Extensively drug-resistant TB, or XDR-TB, has beenidentifi ed in 84 countries; the average proportion ofMDR-TB cases with XDR-TB is 9.0% (6.7–11.2%). Levels of MDR-TB remain worryingly high in some partsof the world, notably countries in eastern Europe andcentral Asia. In several of these countries, 9–32% of newcases have MDR-TB and more than 50% of previouslytreated cases have MDR-TB. There has been progress in the detection and treatmentof MDR-TB in the last two years. Globally, almost 60 000cases of MDR-TB were notifi ed to WHO in 2011, mostlyby European countries and South Africa. The number ofcases reported by the 27 high MDR-TB burden countriesalmost doubled between 2009 and 2011. Despite progress, the number of MDR-TB cases notifi edin 2011 represented only 19% of the estimated 310 000cases of MDR-TB among reported TB patients withpulmonary TB, and less than 10% in the two countrieswith the largest number of cases, China and India.Achieving universal access to treatment requires a boldand concerted drive on many fronts of TB care, andincreased fi nancing. Major efforts are needed to improve treatment successrates among patients with MDR-TB. The Global Plantarget of ≥75% by 2015 was reached by only 30 of 107countries that reported treatment outcome data forpatients with MDR-TB.Drug-resistant TB (DR-TB) threatens global TB controland is a major public health concern in several countries.The first part of this chapter summarizes the latest statusof progress in global surveillance of anti-TB drug resistance,using the most recent data on multidrug-resistantTB (MDR-TB), extensively drug-resistant TB (XDR-TB)and resistance to fluoroquinolones gathered from specialsurveys and continuous surveillance (Section 4.1). Thesecond part of the chapter (Section 4.2) assesses nationalprogress in diagnosing and treating MDR-TB, using dataon diagnostic testing for DR-TB, enrolment on treatmentwith second-line drugs for those found to have MDR-TBand treatment outcomes.4.1 Surveillance of drug-resistant TB4.1.1 Progress in the coverage of drug resistancesurveillanceSince the launch of the Global Project on Anti-tuberculosisDrug Resistance Surveillance in 1994, data on drugresistance have been systematically collected and analysedfrom 135 countries worldwide (70% of WHO’s 194Member States). This includes 63 countries that have continuoussurveillance systems based on routine diagnosticdrug susceptibility testing (DST) of all TB patients and72 countries that rely on special surveys of representativesamples of patients.During the past 4 years, most of the 27 high MDR-TBand 22 high TB burden countries (a total of 36 countries)have expanded coverage of surveillance of drug resistanceto obtain more accurate estimates of the burden of MDR-TB (Figure 4.1). In 2008, 16 of these 36 countries had nonationally representative drug resistance surveillancedata (including 8 countries with data only from subnationalareas) and only 3 countries (the Baltic States) hada nationwide routine surveillance system for monitoringdrug resistance. By the end of 2012 when the survey concludesin Pakistan, baseline representative informationabout the burden of drug resistance will be available fromall 27 high MDR-TB and 22 high TB burden countries.Countries such as Afghanistan (Central region), Bangladesh,Belarus, Bulgaria, Nigeria, Uganda and thecentral Asian republics of Kyrgyzstan, Tajikistan andUzbekistan, which previously had no or very limitedinformation on drug resistance, concluded surveys in2010–2011. Data for Afghanistan could not be disaggregatedby history of treatment (% of MDR among all formsGLOBAL TUBERCULOSIS REPORT 2012 41
FIGURE 4.1Progress in implementing surveys foranti-TB drug-resistance in the 27 highMDR-TB and 22 high-TB burden countries2008 2012Afghanistan No data Completed in 2010Bangladesh No data Completed in 2011Belarus No data Completed in 2011Bulgaria No data Completed in 2010Kyrgyzstan No data Completed in 2011Nigeria No data Completed in 2011Pakistan No data OngoingTajikistan No data Completed in 2011DR Congo 1999 No more recent dataIndia 9 States 1 additional StateIndonesia 2 Provinces1 additional Provincein 2010Russian Federation 4 Oblasts 17 additional OblastsAzerbaijan 2007 Planned for 2013Uganda 1997 Completed in 2011Ukraine 2006 Planned for 2013Uzbekistan 2005 Completed in 2011Brazil 1996 OngoingCambodia 2007 No more recent dataChina 2007 Planned for 2013Ethiopia 2005 OngoingKenya 1995 OngoingMozambique 2007 No more recent dataMyanmar 2007 Planned for 2013Philippines 2004 OngoingSouth Africa 2002 OngoingThailand 2006 No more recent dataUR Tanzania 2007 No more recent dataViet Nam 2006 OngoingZimbabwe 1995 Planned for 2013Armenia 2007Moving towardsroutine surveillanceGeorgia 2007 Routine surveillanceKazakhstan 2001 Routine surveillanceRepublic of Moldova 2006 Routine surveillanceEstonia Routine surveillance Routine surveillanceLatvia Routine surveillance Routine surveillanceLithuania Routine surveillance Routine surveillanceSurvey/surveillance at subnational levelNationwide surveyNationwide routine surveillanceof TB: 6.3%; range 3.7–10.0). Six countries (Azerbaijan,the Democratic Republic of the Congo, India, Indonesia,the Russian Federation and Ukraine) still rely on drugresistance surveillance data gathered from limited subnationalareas. In the Democratic Republic of the Congo,logistic issues have prevented the implementation of anationwide survey. In Indonesia, after two surveys at provinciallevel, the national TB control programme (NTP)has opted to work towards establishing a nationwide sentinelsystem to monitor drug resistance. Concrete plansexist in Azerbaijan and Ukraine to start nationwide surveysin 2012. Drug resistance surveys are ongoing inBrazil, Ethiopia, Kenya, Pakistan, the Philippines, SouthAfrica and Viet Nam.By the end of 2011, India and the Russian Federation,which combined with China contribute to almost 60%of the estimated global burden of MDR-TB, had producedreliable data only at subnational level. These countriesshould consider conducting nationwide drug resistancesurveys in the short term to better understand the burdenof MDR-TB and properly plan diagnostic and treatmentservices.Routine surveillance represents the best approach formeasuring drug resistance and monitoring trends. Amongthe 27 high MDR-TB and 22 high TB burden countries,Georgia, Kazakhstan, the Republic of Moldova and theBaltic States now have proper routine surveillance systemsto monitor drug resistance.A group of countries – Benin, Bolivia, Chile, Colombia,El Salvador, Lebanon, Sri Lanka, Mongolia, Nicaraguaand Rwanda – that relied on special surveys to monitordrug resistance have established a routine surveillancesystem for all previously treated cases. This is the firststep towards routine drug susceptibility testing for all TBpatients.Central and Francophone Africa remain the regionswhere drug resistance surveillance data are most lacking,largely as a result of the scarce laboratory infrastructure.4.1.2 Percentage of new and previously treated TBcases that have MDR-TBGlobally, 3.7% (2.1–5.2%) of new cases and 20% (13–26%) of previously treated cases are estimated to haveMDR-TB (Chapter 2).The proportions of new TB cases with MDR-TB at countrylevel are shown in Figure 4.2. Proportions ranged from0% to 32.3% and were highest in Belarus (32.3%), Estonia(22.9%), Kazakhstan (30.3%), Kyrgyzstan (26.4%;preliminary results), the Republic of Moldova (19.4%)and Uzbekistan (23.2%). Although the average proportionof patients with MDR-TB in the Russian Federationis lower than in these countries, the proportion is high inseveral oblasts (with Arkhangelsk Oblast at the highestlevel: 35.1% in 2010).The proportion of previously treated TB cases with42 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 36 and 37: BOX 2.6Efforts by the Task Force to
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 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
Page 90 and 91: 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
Page 96 and 97: cal trial sites and building labora
Page 98: new TB vaccine candidate. A Phase I
Page 102 and 103:
This annex explains the methods tha
Page 104 and 105:
2011. On average, 15 data points we
Page 106 and 107:
may suffer from biases. These biase
Page 108 and 109:
TABLE A1.3Parameter estimates used
Page 110 and 111:
5. Estimates of TB prevalence, 1990
Page 112:
the Republic of Moldova, Romania, t
Page 116 and 117:
AFGHANISTANPopulation 2011 32 milli
Page 118 and 119:
BRAZILPopulation 2011 197 millionHI
Page 120 and 121:
CHINAPopulation 2011 1 348 millionH
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ETHIOPIAPopulation 2011 85 millionH
Page 124 and 125:
INDONESIAPopulation 2011 242 millio
Page 126 and 127:
MOZAMBIQUEPopulation 2011 24 millio
Page 128 and 129:
NIGERIAPopulation 2011 162 millionH
Page 130 and 131:
PHILIPPINESPopulation 2011 95 milli
Page 132 and 133:
SOUTH AFRICAPopulation 2011 50 mill
Page 134 and 135:
UGANDAPopulation 2011 35 millionHIG
Page 136 and 137:
VIET NAMPopulation 2011 89 millionH
Page 138:
ANNEX 3Regional profiles
Page 141 and 142:
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
Page 156 and 157:
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
Page 168 and 169:
TREATMENT SUCCESS (%) a1995-2010YEA
Page 170 and 171:
Page 172 and 173:
Page 174 and 175:
Page 176 and 177:
YEARTOTALCONFIRMEDCASES OFMDR-TB aE
Page 178 and 179:
MALEYEAR 0-14 15-24 25-34 35-44 45-
Page 180 and 181:
REGION OF THE AMERICASTable A4.1 Es
Page 182 and 183:
Page 184 and 185:
Page 186 and 187:
Page 188 and 189:
Page 190 and 191:
Page 192 and 193:
% OF COHORTTREATMENT SUCCESS (%) a1
Page 194 and 195:
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
Page 206 and 207:
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
Page 222 and 223:
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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