Global Tuberculosis Report -- 2012.pdf

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FIGURE 5.8Cost per TB patient successfully treated with first-line drugs, a 22 high TB burden countries, bCost per patient successfully treated (constant 2012 US$), log scale10000500020001000500200100502006 and 2011 c AFTZETCDMZUGBDTHKHNGIDCNZW KEPKMMINRUZABRVN PH100 200 500 1000 2000 5000 10000GDP per capita (constant 2012 US$), log scale The size of the green circle is proportional to the number ofpatients treated in 2011.— The green tail attached to each circle depicts the change incost per patient successfully treated and GDP per capitabetween 2006 and 2011. The grey area depicts the 95% confi dence interval for theprediction (= white line) of the unweighted log–log regressionof cost per patient successfully treated on GDP per capitain 2011.— The red line marks where cost per patient successfully treatedequals GDP per capita.aCosts include fi rst-line drugs, NTP staff, programmemanagement and supervision, laboratory equipment andsupplies, collaborative TB/HIV activities, PPM, PAL, ACSM,CBC, operational research, surveys, hospital stays and clinicvisits.bAF Afghanistan; BD Bangladesh; BR Brazil; CN China; CDDemocratic Republic of the Congo; ET Ethiopia; ID Indonesia;IN India; KE Kenya; KH Cambodia; MM Myanmar; MZMozambique; NG Nigeria; PK Pakistan; PH Philippines; RURussian Federation; TH Thailand; TZ United Republic ofTanzania; UG Uganda; VN Viet Nam; ZA South Africa; ZWZimbabwe.cCosts per patient treated are case-weighted three-yearaverages, 2004–2006 and 2009–2011, to minimizedistortions associated with non-annual expenses on itemssuch as buildings, equipment and buffer stocks of drugs. Notime trend is provided for South Africa and Thailand, due tolack of data.FIGURE 5.9 Cost per TB patient successfully treated with first-line drugs a (US$), average 2009–2011< 100100–499500–9991000–49995000–9999≥ 10 000No dataNot applicableaCosts include fi rst-line drugs, NTP staff, programme management and supervision, laboratory equipment and supplies, collaborative TB/HIV activities, PPM, PAL, ACSM,CBC, operational research, surveys, hospital stays and clinic visits.GLOBAL TUBERCULOSIS REPORT 2012 61
BOX 5.3Cost effectiveness of interventions for TB care and controlNational TB control programmes have provided good value for the US$ 23 billion they received in the years 2006–2011. A total of 34million TB cases were detected and treated over the same period. Treatment success rates have risen (Table 3.5, Table 3.6) while unitcosts have remained low relative to income levels (Figure 5.8). The cost effectiveness of core interventions for TB care and control isstrongly supported by reviews and meta-analyses of economic evaluations, as summarized in Table B5.3.1.The disability adjusted life year (DALY) is a commonly-used metric for measuring and comparing health outcomes across interventions.Applied to TB treatment, a DALY averted is approximately equal to a year of life saved. For patients with smear-positive pulmonary TBthat is sensitive to fi rst-line drugs, a short course of chemotherapy for 6 months costs as little as US$ 5–50 per year of life saved. Treatingsmear-negative forms of drug-sensitive TB costs somewhat more, at US$ 60–200 per year of life saved (refl ecting a lower case fatality ratein the absence of treatment and less transmission). TB that is resistant to both isoniazid and rifampicin (MDR-TB) requires longer and moreexpensive treatment with second-line drugs and costs US$ 200–800 per year of life saved.TABLE B5.3.1Summary of the available evidence on the cost effectiveness of interventions for TB care and control 1,2,3,4POPULATION INTERVENTION COST PER DALY AVERTED (US$) aPatients with smear-positive TB First-line treatment under DOTS 5–50Patients with smear-negative or extrapulmonary TB First-line treatment under DOTS 60–200Patients with MDR-TB 18–24 months of second-line treatment under WHO guidelines 200–800People living with HIV, infected with TB Isoniazid preventive therapy 15–300People living with HIV, with TB disease First-line drugs under DOTS plus ART 100–365People in whom TB is suspected Diagnosis of TB using Xpert MTB/RIF as an add-on to smear 40–200aFor those unfamiliar with the DALY, this column may be interpreted as the cost per year of life saved.WHO defi nes an intervention as “highly cost effective” if the cost per DALY averted is less than the GDP per capita of the country in whichit is being implemented. According to this benchmark, interventions for TB care and control are highly cost effective even in the lowestincomecountries. The high cost effectiveness of TB care and control was recognized by the Disease Control Priorities Project in 2006: TBtreatment was listed as one of the “best buys” in public health. 5 More recently, the Copenhagen Consensus included the expansion of TBtreatment among its top fi ve investments, out of some 40 proposals designed by experts to address urgent global challenges includingarmed confl ict, climate change, education, hunger and control of infectious diseases. 61Dye C, Floyd K. Tuberculosis. In: Disease control priorities in developing countries, 2nd ed. New York, Oxford University Press, 2006:289–312.2Baltussen, R, Floyd K, Dye C. Achieving the millennium development goals for health: cost effectiveness analysis of strategies for tuberculosis control indeveloping countries. BMJ, 2005, 331:1364–1368.3Fitzpatrick C, Floyd K. A Systematic Review of the Cost and Cost Effectiveness of Treatment for Multidrug-Resistant Tuberculosis. Pharmacoeconomics,2012, 30:63–80.4Vassall A et al. Rapid diagnosis of tuberculosis with the Xpert MTB/RIF assay in high burden countries: a cost-effectiveness analysis. PLoS Medicine,2011, 8(11):e1001120 (doi:10.1371/journal.pmed.1001120).5www.dcp2.org/main/Home.html6Nobel laureates: more should be spent on hunger, health: top economists identify the smartest investments for policy-makers and philanthropists [pressrelease dated 14 May 2012]. Denmark, Copenhagen Consensus, 2012 (available at www.copenhagenconsensus.com/Projects/CC12/Outcome.aspx;accessed July 2012).5.7 Projections of potential funding fromdomestic sources and fundingrequirements specified in the Global PlanThe Global Plan to Stop TB 2011–2015 was published by theStop TB Partnership in 2010. 1 It sets out what needs tobe done to achieve the global targets for TB control setfor 2015 in 149 low- and middle-income countries, 2 andthe associated funding requirements (Table 5.3). The total1The Global Plan to Stop TB, 2011–2015. Geneva, World HealthOrganization, 2010 (WHO/HTM/STB/2010.2).2For a summary of the targets set in the plan, see Chapter 1.requirement over five years amounts to US$ 47 billion.Excluding research and development for new TB drugs,diagnostics and vaccines (Chapter 8), which are not theresponsibility of NTPs, the total is US$ 37 billion.Funding needs for TB care and control in the GlobalPlan (i.e. amounts excluding those for research) wereestimated to grow from around US$ 6 billion in 2011 toUS$ 8 billion in 2015. Diagnosis and treatment with firstlinedrugs for drug-susceptible TB following the DOTSapproach account for the largest single share of funding– US$ 4 billion in 2011 increasing to around US$ 5 billionin 2015. The second largest component is diagnosis and62 GLOBAL TUBERCULOSIS REPORT 2012
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GLOBALTUBERCULOSISREPORT2012
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ContentsAbbreviationsivAcknowledgem
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AcknowledgementsThis report on glob
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WHO Western Pacific RegionShalala A
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Executive SummaryThe World Health O
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CHAPTER 1IntroductionBOX 1.1Basic f
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TABLE 1.1 Targets for the scale-up
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TABLE 1.2 Reporting of data in the
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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 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 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
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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
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ANNEX 3Regional profiles
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WHO REGION OF THE AMERICASPopulatio
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WHO EUROPEAN REGIONPopulation 2011
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WHO WESTERN PACIFIC REGIONPopulatio
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SUMMARY BY WHO REGIONTable A4.1 Est
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MORTALITY (EXCLUDING HIV) PREVALENC
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NEW AND RELAPSENOTIFICATION RATE aY
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-% OF TB PATIENTS WITHKNOWN HIV STA
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AFRICAN REGIONTable A4.1 Estimates
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INCIDENCE (INCLUDING HIV) INCIDENCE
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NEW AND RELAPSENOTIFICATION RATE aY
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NEW AND RELAPSENOTIFICATION RATE a1
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TREATMENT SUCCESS (%) a1995-2010YEA
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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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% OF COHORTTREATMENT SUCCESS (%) a1
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MALEFEMALEYEAR 0-14 15-24 25-34 35-
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EASTERN MEDITERRANEAN REGIONTable A
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EUROPEAN REGIONTable A4.1 Estimates
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SOUTH-EAST ASIA REGIONTable A4.1 Es
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SMEAR LABS % OF SMEARPER 100K LABS
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Estimates of mortality, prevalence
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YEARPOPULATION(MILLIONS)MORTALITY (
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YEARPOPULATION(MILLIONS)INCIDENCE (
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YEARPOPULATION(MILLIONS)INCIDENCE (
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SMEAR LABS % OF SMEARPER 100K LABS
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