GTBR13_cover M_spine20_5 91355 9789241564656 Eng

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Warning: This report is out-of-date. In particular, entire

time-series of TB disease burden estimates are updated

every year. For the latest data and analysis, please see

the most recent edition of the global TB report.

Global

tuberculosis

report

2013

WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail:

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the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning

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Cover design by Tom Hiatt, Western Pacic Regional Oce and Irwin Law, WHO headquarters. e front cover illustrates the latest status of

global progress for ve indicators that are part of the Millennium Development Goals framework. ese are the incidence rate of tuberculosis

disease per 100 000 population per year, the prevalence of tuberculosis disease per 100 000 population, the tuberculosis mortality rate per 100

000 population per year, the case detection rate (the number of cases detected and reported to national tuberculosis programmes divided by

the estimated incidence) and the treatment success rate for new TB patients started on treatment. Each pair of shapes represents both the most

recent level of the indicator and a baseline year against which progress is measured. For incidence (green and dark orange), prevalence (grey and

pink) and mortality (light orange and light blue), the top of the combined height of each pair of shapes shows the level in 1990. e lower of the

two shapes in each pair shows the level in 2012. For the case detection rate, the combined height of each pair of shapes (dark blue and brown)

shows the level in 2012 and the lower of the two shapes (dark blue) illustrates the level in 1995. For the treatment success rate (red and yellow),

the combined height of each pair shows the level in 2011 and the lower of the two shapes (red) shows the level in 1995. More information about

these indicators and progress towards global targets are provided in Chapter 2 and Chapter 3 of the Global Tuberculosis Report 2013.

Printed in France

WHO/HTM/TB/2013.11

WHO Library Cataloguing-in-Publication Data

Global tuberculosis report 2013.

1.Tuberculosis – epidemiology. 2.Tuberculosis, Pulmonary – prevention and control. 3.Tuberculosis – economics.

4.Tuberculosis, Multidrug-Resistant. 5.Annual reports. I.World Health Organization.

ISBN 978 92 4 156465 6 (NLM classication: WF 300)

iiiGLOBAL TUBERCULOSIS REPORT 2013

Contents

Abbreviations iv

Acknowledgements v

Executive summary ix

Chapter 1. Introduction 1

Chapter 2. The burden of disease caused by TB 6

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Chapter 4. Drug-resistant TB 45

Chapter 5. Diagnostics and laboratory strengthening 59

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Chapter 7. Financing 75

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Annexes

1. Methods used to estimate the global burden of disease caused by TB 99

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4. Key indicators for the world, WHO regions and individual countries 145

iv GLOBAL TUBERCULOSIS REPORT 2013

Abbreviations

ACSM Advocacy, Communication and Social

Mobilization

ACTG AIDS Clinical Trials Group

ADR adverse drug reactions

AFB acid-fast bacilli

AIDS acquired immunodeciency syndrome

ARI annual risk of infection

ART antiretroviral therapy

BCG Bacille-Calmette-Guérin

BRICS Brazil, Russian Federation, India, China,

South Africa

CDR case detection rate

CEM cohort event monitoring

CFR case fatality rate

CFU colony-forming units

CPT co-trimoxazole preventive therapy

CBC community-based care

DOTS the basic package that underpins the Stop

TB Strategy

DR-TB drug-resistant tuberculosis

DRS drug resistance surveillance

DST drug susceptibility testing

DS-TB drug-susceptible tuberculosis

DTLC District TB and Leprosy Coordinator

EBA early bactericidal activity

ECDC European Centre for Disease Prevention and

Control

ERR electronic recording and reporting

EU European Union

FDA Food and Drug Administration

FIND Foundation for Innovative New Diagnostics

GDP gross domestic product

GLC Green Light Committee

GLI Global Laboratory Initiative

GNI gross national income

HBC high-burden country

HIV human immunodeciency virus

HR Hazard ratio

ICD-10 International Classication of Diseases

(10th revision)

IDRI Infectious Disease Research Institute

IGRA interferon-gamma release assay

IPAQT Initiative for Promoting Aordable, Quality

TB Tests

IPT isoniazid preventive therapy

IRR incidence rate ratio

LED light-emitting diode

LPA line-probe assay

LTBI latent TB infection

MDG Millennium Development Goal

MDR-TB multidrug-resistant tuberculosis

MNCH maternal, newborn and child health

NAAT nucleic acid amplication test

NAP national AIDS programme

NFM new funding model

NTP national tuberculosis [control] programme

OECD Organisation for Economic Co-operation and

Development

OR Operational research

PAL Practical Approach to Lung health

PCR polymerase chain reaction

PDA personal digital assistant

PEPFAR US President’s Emergency Plan for AIDS Relief

POC point of care

PPM public–private mix

QMS quality management system

rGLC Regional Green Light Committee

RNTCP Revised National TB Control Programme

[India]

rRNA ribosomal ribonucleic acid

RR relative risk

RR-TB rifampicin-resistant tuberculosis

SD standard deviation

SITT Integrated Tuberculosis Information System

SRL supranational reference laboratory

STAG-TB Strategy and Technical Advisory Group for TB

TAG Treatment Action Group

TB tuberculosis

TB-MAC TB Modelling and Analysis Consortium

TB-TEAM Tuberculosis Technical Assistance Mechanism

TBVI Tuberculosis Vaccine Initiative

TFM transitional funding mechanism

TST tuberculin skin test

UHC universal health coverage

UN United Nations

UNAIDS Joint United Nations Programme on HIV/AIDS

UNITAID international facility for the purchase of

diagnostics and drugs for diagnosis and

treatment of HIV/AIDS, malaria and TB

USAID United States Agency for International

Development

UNPD United Nations Population Division

VR vital registration

WHO World Health Organization

XDR-TB extensively drug-resistant tuberculosis

ZN Ziehl Neelsen

vGLOBAL TUBERCULOSIS REPORT 2013

Acknowledgements

is global tuberculosis (TB) report was produced by a core

team of 15 people: Annabel Baddeley, Anna Dean, Han-

nah Monica Dias, Dennis Falzon, Katherine Floyd, Inés

Garcia, Philippe Glaziou, Tom Hiatt, Irwin Law, Christian

Lienhardt, Linh Nguyen, Charalambos Sismanidis, Hazim

Timimi, Wayne van Gemert and Matteo Zignol. e team

was led by Katherine Floyd. Overall guidance was provided

by the Director of the Global TB Programme, Mario Ravi-

glione.

e data collection forms (long and short versions)

were developed by Philippe Glaziou and Hazim Timimi,

with input from sta throughout the WHO Global TB

Programme. Hazim Timimi led and organized all aspects

of data management. Inés Garcia and Andrea Pantoja

conducted all review and follow-up of nancial data. e

review and follow-up of all other data was done by a team

of reviewers. is included Annabel Baddeley, Annemieke

Brands, Andrea Braza, Katsura Danno, Anna Dean, Han-

nah Monica Dias, Dennis Falzon, Wayne van Gemert, Soleil

Labelle, Knut Lönnroth, Linh Nguyen, Salah Ottmani,

Hazim Timimi, Fraser Wares and Matteo Zignol at WHO

headquarters; Amal Bassili from the Eastern Mediterra-

nean Regional Oce; and Suman Jain, Sai Pothapregada,

Nino Mdivani, Eliud Wandwalo and Mohammed Yassin

from the Global Fund. Data for the European Region were

collected and validated jointly by the WHO Regional Oce

for Europe and the European Centre for Disease Preven-

tion and Control (ECDC); we thank in particular Encarna

Gimenez, Vahur Hollo and Csaba Ködmön from ECDC for

providing validated data les and Andrei Dadu from the

WHO Regional Oce for Europe for his substantial con-

tribution to follow-up and validation of data for all Euro-

pean countries. Review of TB/HIV data was undertaken in

collaboration with Michel Beusenberg, Chika Hayashi, Lisa

Nelson and Michelle Williams from the WHO HIV depart-

ment. Victoria Bendaud, Josephine Dy, and Taavi Erkkola

from UNAIDS managed the process of data collection from

national AIDS programmes, provided a TB/HIV dataset

and worked closely with WHO sta to review and validate

TB/HIV data.

Philippe Glaziou and Charalambos Sismanidis prepared

estimates of TB disease burden and associated gures and

tables (Chapter 2), with support from Tom Hiatt. Particular

thanks are due to Carel Pretorius (Futures Institute), who

worked closely with Philippe Glaziou on analyses and relat-

ed estimates of TB mortality among HIV-positive people,

as well as to Dennis Falzon for coordinating a systematic

review that was used to produce estimates of mortality

related to multidrug-resistant TB (MDR-TB) and to Harish

Nair and Luciana Brondi from the University of Edinburgh

for conducting this review. Tom Hiatt prepared all gures

and tables on TB notication and treatment outcome data

(Chapter 3). Anna Dean, Dennis Falzon and Matteo Zignol

analysed data and prepared the gures and tables related to

drug-resistant TB (Chapter 4), with input from Charalam-

bos Sismanidis. Tom Hiatt and Wayne van Gemert prepared

gures and tables on laboratory strengthening and the roll-

out of new diagnostics (Chapter 5). Annabel Baddeley, Kat-

sura Danno, Tom Hiatt and Linh Nguyen analysed TB/HIV

programmatic data and prepared the associated gures and

tables (Chapter 6). Inés Garcia and Andrew Siroka analysed

nancial data, and prepared the associated gures and

tables (Chapter 7). Christian Lienhardt, Christopher Gilpin

and Karin Weyer prepared the gures on the pipelines for

new TB drugs, diagnostics and vaccines (Chapter 8), with

input from the respective Working Groups of the Stop TB

Partnership. Tom Hiatt coordinated the nalization of all

gures and tables and was the focal point for communica-

tions with the graphic designer.

e writing of the main part of the report was led by

Katherine Floyd, with contributions from Dennis Falzon,

Philippe Glaziou, Irwin Law, Ikushi Onozaki, and Charalam-

bos Sismanidis (Chapter 2); Hannah Monica Dias, Wayne

van Gemert, Haileyesus Getahun, omas Joseph, Mukund

Uplekar and Lana Tomaskovic (Chapter 3); and Inés Gar-

cia and Christian Gunneberg (Chapter 7). Chapter 4, on

drug-resistant TB, was prepared by Anna Dean, Dennis Fal-

zon and Matteo Zignol, with input from Katherine Floyd,

Philippe Glaziou and Charalambos Sismanidis. Chapter 5,

on diagnostics and laboratory strengthening, was prepared

by Wayne van Gemert, with input from Christopher Gilpin,

Fuad Mirzayev and Karin Weyer. Chapter 6 was prepared by

Annabel Baddeley, Haileyesus Getahun, Linh Nguyen and

Katherine Floyd. Chapter 8, on research and development,

was led by Christian Lienhardt, with inputs from Chris-

topher Gilpin, Karin Weyer and Katherine Floyd. Chapter

8 was carefully reviewed by the chairs and secretariats of

the Working Groups of the Stop TB Partnership. Particular

thanks are due to Michael Brennan, Uli Fruth and Jennifer

Woolley (new vaccines); Daniela Cirillo (new diagnostics);

and Barbara Laughon and Mel Spigelman (new TB drugs).

e report team is also grateful to Emily Bloss (US Centers

for Disease Control and Prevention) and Hillary Kipru-

to (WHO Country Oce, Kenya) for their contributions

to content related to strengthening of TB surveillance in

Chapter 2, including a case study of the introduction of

vi GLOBAL TUBERCULOSIS REPORT 2013

electronic recording and reporting in Kenya; to Rajendra

Yadav and Masami Fujita (WHO Country Oce, Cambodia)

for their contribution to an analysis of the integration of

TB, HIV and mother and child health services in Cambodia

(Chapter 6); and to various internal and external reviewers

for useful comments and suggestions on advanced drafts

of chapter text.

e special supplement on the “Countdown to 2015” that

accompanies the global report was prepared by Anna Dean,

Hannah Monica Dias, Katherine Floyd, Irwin Law, Mario

Raviglione, Diana Weil and Karin Weyer, with valuable

inputs from many people at global, regional and country

levels. We thank in particular Sai Pothapregada and Eliud

Wandwalo from the Global Fund, who facilitated discus-

sions with and inputs from many Fund Portfolio Managers.

Annex 1, which explains methods used to produce esti-

mates of the burden of disease caused by TB, was written

by Philippe Glaziou and Charalambos Sismanidis with

very helpful input from Carel Pretorius. We thank Colin

Mathers of the WHO Mortality and Burden of Disease team

for his careful review. e country proles that appear in

Annex 2 and the regional proles that appear in Annex 3

were prepared by Hazim Timimi. Annex 4, which contains

a wealth of global, regional and country-specic data from

the global TB database, was prepared by Tom Hiatt and

Hazim Timimi.

We thank Pamela Baillie in the Global TB Programme’s

monitoring and evaluation team for impeccable admin-

istrative support, Doris Ma Fat from the WHO Mortality

and Burden of Disease team for providing TB mortality

data extracted from the WHO Mortality Database, and

Peter Ghys, Mary Mahy and Karen Stanecki (UNAIDS) for

providing epidemiological data that were used to estimate

HIV-associated TB mortality.

e entire report was edited by Tim France (Inis Com-

munication). We thank him for his excellent work. We also

thank, as usual, Sue Hobbs for her excellent work on the

design and layout of this report. Her contribution, as in

previous years, was greatly appreciated.

e principal source of nancial support for WHO work

on global TB monitoring and evaluation is the United States

Agency for International Development (USAID), without

which it would be impossible to produce the Global Tuber-

culosis Report. Production of the report was also supported

by the governments of Japan and the Republic of Korea. We

acknowledge with gratitude their support.

In addition to the core report team and those mentioned

above, the report beneted from the input of many sta

working in WHO regional and country oces and hundreds

of people working for national TB programmes or within

national surveillance systems who contributed to the

reporting of data and to the review of report material prior

to publication. ese people are listed below, organized by

WHO region. We thank them all for their invaluable contri-

bution and collaboration, without which this report could

not have been produced.

Among the WHO sta not already mentioned above, we

thank in particular Khurshid Alam Hyder, Daniel Kibuga,

Rafael López Olarte, André Ndongosieme, Wilfred Nkhoma

and Henriette Wembanyama for their major contribution

to facilitation of data collection, validation and review.

9*1staHHinregionalandcoWntr[oHßces

WHO African Region

Harura Adamu, Boubacar Ould Abdel Aziz, Esther Aceng,

Inacio Alvarenga, Balde Amadou, Ayodele Awe, Sanni Baba-

tunde, Bazie Babou, Nayé Bah, Marie Barouan, Abera Bekele,

Norbert Bidounga, Gaël Claquin, Augusto da Cruz Claudi-

na, Peter Clement, Noel Djemadji, Ismael Hassen Endris,

Amos Omoniyi Fadare, Louisa Ganda, Boingotlo Gasen-

nelwe, Patrick Hazangwe, Joseph Imoko, Michael Jose,

Joel Kangangi, Katherine Lao, Nzuzi Katondi, Bah Keita,

Daniel Kibuga, Hillary Kipruto, Désiré Aristide Komangoya

Nzonzo, Sharmila Lareef-Jah, Frank Lule, Mwendaweli

Maboshe, Mbemba Leonard, Richard Mbumba, Julie Mug-

abekazi, André Ndongosieme, Denise Nkezimana, Wilfred

Nkhoma, Nicolas Nkiere, Ghislaine Nkone Asseko, Ishmael

Nyasulu, Laurence Nyiramasarabwe, Samuel Ogiri, Daniel

Olusoti, Amos Omoniyi, Chijioke Osakwe, Felicia Owu-

su-Antwi, Philips Patrobas, Kalpeshsinh Rahevar, Bacary

Sambou, Kefas Samson, Neema Simkoko, Desta Tiruneh,

Alexis Tougordi, Henriette Wembanyama.

WHO Region of the Americas

Monica Alonso Gonzalez, Angel Manuel Alvarez, Luis

Gerardo Castellanos, Gerardo de Cossio, Rachel Eersel,

Marcos Espinal, Ingrid García, Mirtha Del Granado, Rosa-

linda Hernández, Vidalia Lesmo, Rafael López Olarte,

Wilmer Marquiño, ais dos Santos, Alfonso Tenorio, Jorge

Victoria, Anna Volz.

WHO Eastern Mediterranean Region

Mohamed Abdel Aziz, Ali Akbar, Samiha Baghdadi, Amal

Bassili, Najwa El Emam, Hamida Khattabi, Aayid Munim,

Ghulam Nabi Kazi, Ali Reza Aloudel, Gabriele Riedner,

Karam Shah, Sindani Ireneaus Sebit, Bashir Suleiman,

Rahim Taghizadeh.

WHO European Region

Martin van den Boom, Brenda van den Bergh, Andreea

Cassandra Butu, Silvu Ciobanu, Pierpaolo de Colombani,

Andrei Dadu, Irina Danilova, Masoud Dara, Jamshid

Gadoev, Gayane Ghukasyan, Sayohat Hasanova, Arax Hov-

hannesyan, Saliya Karymbaeva, Mehmet Kontas, Kristin

Kremer, Dmitriy Pashkevich, Valiantsin Rusovich, Bog-

dana Shcherbak-Verlan, Javahir Suleymanova, Szabolcs

Szigeti, Melita Vujnovic.

WHO South-East Asia Region

Mohammad Akhtar, Vikarunnesa Begum, Erwin Coore-

man, Deki, Khurshid Alam Hyder, Navaratnasingam

Janakan, Kim Tong Hyok, La Win Maung, Jorge Luna, Par-

tha Mandal, Amaya Maw-Naing, Giampaolo Mezzabotta,

viiGLOBAL TUBERCULOSIS REPORT 2013

Bo Myint, Ye Myint, Eva Nathanson, Rajesh Pandav, Razia

Pendse, Sri Prihatini, K Rezwan, Rim Kwang Il, Hwang Kum

Ryong, Mukta Sharma, Aminath Shenalin, Achuthan Nair

Sreenivas, Chawalit Tantinimitkul, Wangchuk Lungten.

9*19GUVGTP2CEKßE4GIKQP

Shalala Ahmadova, Niño Dayanghirang, Asaua Faasino,

Salu Failauga, Ogtay Gozalov, Cornelia Hennig, Tom Hiatt,

Tauhid Islam, Narantuya Jadambaa, Ridha Jebeniani, Sung

Hye Kim, Miwako Kobayashi, Woo-Jin Lew, Katsunori

Osuga, Khanh Pham, Fabio Scano, Jacques Sebert, Cathari-

na van Weezenbeek, Rajendra Yadav, Dongbao Yu.

National respondents who contributed to

reporting and verißcation oH data

WHO African Region

Abdou-Salam Abderemane, Ouédraogo Adama, Abdelra-

him Barka Abderramane, Jean Louis Abena Foe, Soane

Alihalassa, Arlindo Amaral, Kouamé Amenan, Séverin

Anagonou, Younoussa Assoumani, Georges Bakaswa, Ada-

ma Marie Bangoura, Jorge Noel Barreto, Ballé Boubakar,

Victor Bonkoungou, Frank Adae Bonsu, Miguel Camara,

Evangelista Chisakaitwa, Ernest Cholopray, Nkemdilim

Chukwueme, Catherine Cooper, Swasilanne da Silva, B. de

Sousa Bandeira, Isaias Dambe, Davi Kokou Mawulé, Serge

Diagbouga, Aicha Diakité, Awa Helene Diop, Sicelo Dlami-

ni, emba Dlamini, addée Ndikumana, Oumou Fofana,

Susan Gacheri, Evariste Gasana, Michel Gasana, Sandile

Ginindza, Martin Gninafon, Nii Nortey Hanson-Nortey,

Adama Jallow, Saa Kamara, Madou Kane, Henry Kanyer-

ere, Nathan Kapata, Biruck Kebede, Kerram Aziza, Deogra-

tias Kibambazi, Patrick Konwuloh, Jacquemin Kouakou,

Popaul Kulonga, Rossin Lebeke, Lillian Ishengoma, Llang

Bridget Maama-Maime, Marcel Lougue, Maxime Lunga,

Ghislaine Mabeluanga Tshitenge, Jocelyn Mahoumbou,

Angelo Makpenon, David Mametja, Ivan Manhiça, Tseliso

Marata, Farai Mavhunga, Mba Bekolo Frenk José Mathieu,

Salem Salem Mohameden, Louine Morel, Youwaoga Isidore

Moyenga, James Mpunga, Frank Mugabe, Kenneth Mugi-

sha, Cliord Munyandi, Lindiwe Mvusi, Aboubacar Mzem-

baba, Ronald Ncube, Fulgence Ndayikengurukiye, Yvon

Martial Ngana, Antoine Ngoulou, Lourenço Nhocuana,

Blasdus Franz Njako, Emmanuel Nkiligi, M Nkou, Josh-

ua Obasanya, Davidson Ogunade, Hermann Ongouo,

Abdelhadi Oumar, Issoufou Ousmane, Maria Conceição

Palma, Victor Pereira, ato Raleting, Sahondra Jeanine

Randriambeloson, Rujeedawa Mohammed Fezul, Samey

Agbenyegan, Charles Sandy, Kebba D Sanneh, Marie Sarr

Diouf, Mineab Sebhatu, Mamie Shoma, Angele Shoma

Matota, René Simalo, Joseph Sitienei, Nicholas Siziba,

Philippe Takongo, Celstino Francisco Teixeira, Mohamed

Abdallahi Traoré, Nassiama Traoré, Kassim Traoré, Alie

Wurie, Eucher Dieudonné Yazipo, Ranivomahefa Myrienne

Bakoliarisoa Zanajohary, Abbas Zezai, Eric Ismaël Zoun-

grana.

WHO Region of the Americas

Christian Acosta, Shalauddin Ahmed, Valentina Antonie-

ta Alarcon Guizado, Xochil Alemán de Cruz, Kiran kumar

Alla, Valeria Almanza Torrez, Mirian Alvarez, Raúl Álva-

rez, Aisha Andrewin, A. Alister Antoine, Chris Archibald,

Carlos Alberto Marcos Ayala Luna, Wiedjaiprekash Bale-

sar, Draurio Barreira, Patricia Bartholomay, Soledad Bel-

trame, María del Carmen Bermúdez, Lynrod Brooks, Marta

Calona de Abrego, Martín Castellanos Joya, Jorge Castillo

Carbajal, Kenneth Castro, Judith Cazares, Gemma Chery,

Carlos Cuadra, Ofelia Cuevas, D’Auvergne Cleophas, Jose

Davy, Cecilia de Arango, Eva de Weever-Lista, Camille Dele-

veaux, Dy-Juan De Roza, Roger Duncan, España Cedeño

Mercedes, Manuel Salvador España Rueda, Fernandez

Hugo, Cecilia Figueroa Benites, Victor Gallant, Julio Garay

Ramos, Sarita Aguirre García, Izzy Gerstenbluth, Margar-

ita Godoy, Roscio Gómez, Ilse Maria Góngora Rivas, Sil-

vino González, Yaskara Halabi, Kevin Harvey, Dorothea

Hazel, Maria Henry, Tania Herrera, Carla Jeries, Dihad-

enys Lemus Molina, Athelene Linton, Maria Josefa Llanes

Cordero, Marvin Andres Maldonado Rivera, Maldonado

Saavedra Andrea, Marcelino Belkys, Eva Martìnez, María

de Lourdes Martínez Olivares, Zeidy Mata Azofeifa, Joan

McLeod-Simon, Timothy McLaughlin-Munroe, Roque

Miramontes, Leilawatie Mohammed, Jeetendra Mohanlall,

Ernesto Moreno, Francis Morey, Willy Morose, Michael

Owen, Cheryl Peek-Ball, Janelle Pickering, Tomasa Por-

tillo, Irad Potter, Manohar Singh Rajamanickam, Dottin

Ramoutar, Anna Esther Reyes Godoy, Paul Ricketts, Jorge

Rodriguez De Marco, Myrian Román, Nilda de Romero,

Carolyn Russell, Wilmer Salazar, Deborah Stijnberg, Sutton

Jackurlyn, Torres Clarita, Maribelle Tromp, William Turn-

er, Melissa Valdez, Daniel Vázquez, Nestor Vera, Michael

Williams, David Yost, Oritta Zachariah.

WHO Eastern Mediterranean Region

Fadhil Abbas, Mohammad S Abouzeid, Khaled Abu Ruh-

man, Nadia Abu Sabra, Ahmadi Shahnaz, Mohamed Redha

Al Lawati, Al Saidi Fatmah, Samia Ali Alagab, Abdelbary

Abdullah Ahmed Al-Hammadi, Abdullatif Al-Khal, Saeed

Al Saar, Kifah Alshaqeldi, Bahnasy Samir, Bennani Ken-

za, Kinaz Cheikh, Walid Daoud, Mohamed Furjani, Amal

Galal, Dhikrayet Gamara, Assia Haissama Mohamed, Hiba

Kamal Hamad Elneel, Kaalthoom Hassan, Hawa Hassan

Guessod, Lou Joseph, Onwar Otien Jwodh Chol, Basharat

Khan, Joseph Lasu, Sayed Daoud Mahmoodi, Khadi-

ga Adam Mohammed, Mokhtar Alaa, Mulham Mustafa,

Nasehi Mahshid, Ejaz Qadeer, Mohammad Khalid Seddiq,

Sghiar Mohammed, Mohemmed Tabena, Tamara Tayeb,

Najib Abdul aziz Abdullah abit, Seddik Walha, Yaacoub

Hiam.

WHO European Region

Abildaev Tleukhan Shildebaevich, Mokhonim Abdulloeva,

Ibrahim Abubakar, Rag Abuzarov, Nurhan Albayrak,

Natavan Alikhanova, Avtandil Alisherov, Ewa Augustynowicz-

viii GLOBAL TUBERCULOSIS REPORT 2013

Kopeć, Ekkehardt Altpeter, Laura Anderson, Delphine

Antoine, Trude Margrete Arnesen, Rusudan Aspindzelash-

vili, Andrei Astrovko, Elizabeta Bachiyska, Anna Ivanovna

Barbova, Yana Besstraschnova, Venera Lazarevna Bismil-

da, Oktam Ikramovich Bobokhojaev, Olivera Bojovic, Eric

C. Böttger, Bonita Brodhun, Noa Cedar, Daniel Chemtob,

Domnica Ioana Chiotan, Ana Ciobanu, Nico Cioran, Andra

Cirule, ierry Comolet, Radmila Curcic, Manfred Danilo-

vitš, Edita Davidaviciene, Hayk Davtyan, Pava Dimitrijevic,

António Diniz, Francis Drobniewski, Raquel Duarte, Mlad-

en Duronjic, Connie Erkens, Jennifer Fernandez Garcia,

Lyalya Gabbasova, Viktor Gasimov, Lárus Jón Guðmunds-

son, Gennady Gurevich, Walter Haas, Hasan Hazi, Evg-

eny Hanyukov, Armen Hayrapetyan, Peter Helbling, Sven

Honer, Daniela Homorodean, Jahongir Jurakhonovich

Ismoilov, Mamuka Japaridze, Vincent Jarlier, Soledad

Jiménez Pajares, Jerker Jonsson, Abdullat Kadyrov, Gul-

mira Kalmambetova, Dmitry Klymuk, Maria Korzeniewska-

Kosela, Ainura Koshoeva, Košnik Mitja, Gabor Kovacs,

Tiina Kummik, Nino Lomtadze, Stevan Lučić, Jasminka

Maglajllic, Turid Mannsåker, Mathys Vanessa, Rafail Meh-

diyev, Rukije Mehmeti, Donika Mema, Vladimir Milanov,

Alvard Mirzoyan, Gjyle Mulliqi, Gulnora Murmusaeva,

Seher Musaonbasioglu, Ucha Nanava, Zdenka Novakova,

Joan O’Donnell, Analita Pace Asciak, Clara Palma Jordana,

Elena Pavlenko, Olga Pavlova, Monique Perrin, Edita Pim-

kina, Monika Polanova, Georgeta Gilda Popescu, Gordana

Radosavljevic Asic, Bozidarka Rakocevic, omas Rendal,

Vija Riekstina, Jerome Robert, Elena Rodríguez Valín, Tom

Rogers, Elena Romancenco, Kazimierz Roszkowski-Sliz,

Sabine Rüsch-Gerdes, Branislava Savic, Gérard Scheiden,

Hasia Kaidar Shwartz, Anabela Silva, Girts Skenders, Cath-

rine Slorbak, Erika Slump, Hanna Soini, Ivan Solovic, Dick

van Soolingen, Flemming Stenz, Sergey Sterlikov, Jana

Svecova, Svetina Šorli Petra, Silva Tafaj, Talevski Stefan,

Odorina Tello Anchuela, Mirzagaleb Tillyashaykhov, Aida

Ustamujic, Gulnoz Uzakova, Tonka Varleva, Piret Viiklepp,

Cveta Vragoterova, Gerard de Vries, Jiri Wallenfels, Wan-

lin Maryse, Pierre Weicherding, Aysegul Yildirim, Zakoska

Maja, Oksana Zalutskaya, Ilona Zemanová, Manca Žolnir

Dovč, Hasan Zutic.

WHO South-East Asia Region

Shina Ahmed, Aminath Aroosha, Choe Kum Song,

Emdadul Hoque, RS Gupta, Sirinapha Jittimanee, Suksont

Jittimanee, Niraj Kulshrestha, Constantino Lopes, an-

dar Lwin, Dyah Erti Mustikawati, Tin Zar Naing, Chawet-

san Namwat, Md Nuruzzaman Haque, Nirupa Pallewatta,

Rajendra Prasad Pant, Kiran Rade, Dyah Armi Riana, Che-

wang Rinzin, Sudath Samaraweera, Gamini Senevirathne,

Janaka ilakarathne, Sabino Viegas, Bimal Kumar Yadav.

9*19GUVGTP2CEKßE4GIKQP

Paul Aia, Cecilia Teresa T. Arciaga, Nemia Bainivalu, Chris-

tina Bareja, Risa J. Bukbuk, Cheng Shiming, Phonenaly

Chittamany, Chou Kuok Hei, Nese Ituaso Conway, Du

Xin, Mayleen J. Ekiek, Fanai Saen, Rangiau Fariu, Ludovic

Floury, Louise Fonua, Jiloris Frederick Dony, Anna Marie

Celina Garn, Go Un-Yeong, Shakti Gounder, Anie Hary-

ani Hj Abdul Rahman, Noel Itogo, Tom Jack, Seiya Kato,

Khin Mar Kyi Win, Lamar Daniel, Leo Lim, Liza Lopez,

Sakiusa Mainawalala, Henri-Pierre Mallet, Tan Eang Mao,

Markleen Tagaro, Sera Moa, Suzana Mohd Hashim, Nguy-

en Binh Hoa, Nguyen Viet Nhung, Nou Chanly, Ochirbat

Batbayar, Connie Bieb Olikong, Park Yoon-Sung, Nukutau

Pokura, Waimanu Pulu, Purev Nasanjargal, Rabauliman

Marcelina, Bereka Reiher, Bernard Rouchon, Temilo Seono,

Tokuaki Shobayashi, Vita A. Skilling, Grant Storey, Phan-

nasinh Sylavanh, Kenneth Reuee Tabutoa, Tam Cheuk

Ming, Kyaw u, Tieng Sivanna, Tong Ka Io, Rosalind Vian-

zon, Wang Yee Tang, Wang Lixia.

ixGLOBAL TUBERCULOSIS REPORT 2013

Executive summary

Tuberculosis (TB) remains a major global health problem.

In 2012, an estimated 8.6 million people developed TB and

1.3 million died from the disease (including 320000 deaths

among HIV-positive people).1 e number of TB deaths is

unacceptably large given that most are preventable.

Nearly 20 years after the WHO declaration of TB as a

global public health emergency, major progress has been

made towards 2015 global targets set within the context

of the Millennium Development Goals (MDGs). Two years

ahead of the deadline, the Global Tuberculosis Report 2013

and accompanying supplement Countdown to 2015 assess

progress towards the 2015 targets and the top priority

actions needed to achieve and/or move beyond them.

C17N6&19N 61  key ßndings

On track:

e rate of new TB cases has been falling worldwide for

about a decade, achieving the MDG global target. TB

incidence rates are also falling in all six WHO regions.

e rate of decline (2% per year) remains slow.

Globally by 2012, the TB mortality rate had been reduced

by 45% since 1990. e target to reduce deaths by 50%

by 2015 is within reach.

Two WHO regions have already achieved the 2015 tar-

gets for reduced incidence, prevalence and mortality: the

Region of the Americas and the Western Pacic Region.

Of the 22 high TB burden countries (HBCs) that account

for about 80% of the world’s TB cases,2 seven have met

all 2015 targets for reductions in TB incidence, preva-

lence and mortality. Four more HBCs are on track to do

so by 2015.

Off track:

By 2012, the level of active TB disease in the community

(prevalence) had fallen by 37% globally since 1990. e

target of a 50% reduction by 2015 is not expected to be

achieved.

e African and European regions are currently not on

track to achieve the mortality and prevalence targets.

Among the 22 HBCs, 11 are not on track to reduce inci-

dence, prevalence and mortality in line with targets.

Reasons include resource constraints, conict and insta-

bility, and generalized HIV epidemics.

Progress towards targets for diagnosis and treatment

of multidrug-resistant TB (MDR-TB) is far o-track.

Worldwide and in most countries with a high burden of

MDR-TB, less than 25% of the people estimated to have

MDR-TB were detected in 2012.

Many countries have made considerable progress to

address the TB/HIV co-epidemic. However, global-

level targets for HIV testing among TB patients and

provision of antiretroviral therapy (ART) to those who

are HIV-positive have not been reached.

Five priority actions required to accelerate progress

towards 2015 targets:

1. Reach the missed cases. About 3 million people who

developed TB in 2012 were missed by national notica-

tion systems. Key actions needed to detect people with

the illness and ensure that that they get the right treat-

ment and care include: expanded services (including

rapid tests) throughout health systems bolstered by the

support of nongovernmental organizations, community

workers and volunteers to diagnosis and report cases;

intensied collaboration with public hospitals and pri-

vate health facilities who are treating patients but not

reporting; instituting mandatory notication of cases in

more countries; and better data compilation.

2. Address MDR-TB as a public health crisis. In high

MDR-TB burden countries, increased capacity to diagnose

MDR-TB must be matched with supplies of quality drugs

and scaled-up country capacity to deliver eective treat-

ment and care. is will require high-level political will

and leadership and more collaboration among partners,

including drug regulatory authorities, donor and techni-

cal agencies, civil society and the pharmaceutical industry.

3. Accelerate the response to TB/HIV. e top prior-

ity is to increase coverage of ART for HIV-positive TB

patients towards the 100% target. Expanded coverage of

TB preventive treatment among people living with HIV

is the second priority.

4. Increase nancing to close all resource gaps. An

estimated US$7–8 billion per year is required for a full

response to the TB epidemic in low- and middle-income

countries in 2014 and 2015 (excluding research and

development for new TB diagnostics, drugs and vac-

cines). Funding in 2013 is about US$6 billion. Increas-

es in both domestic and donor nancing are needed to

close the gap of up to US$ 2 billion per year, including

via the full replenishment of the Global Fund in 2013.

Progress remains fragile and could be reversed without

adequate funding.

5. Ensure rapid uptake of innovations. e fast uptake

of new tools and strategies for better diagnosis, treat-

ment and prevention of all forms of TB can be accelerated

by country-specic operational research and translation

of ndings into policy and practice.

xGLOBAL TUBERCULOSIS REPORT 2013

ADDITIONAL FINDINGS

e report is based primarily on data provided by WHO’s

Member States. In 2013, data were reported by 178 Mem-

ber States and a total of 197 countries and territories that

collectively have more than 99% of the world’s TB cases.

Burden of disease

e current global picture of TB shows continued

progress, but not fast enough.

An estimated 1.1 million (13%) of the 8.6 million peo-

ple who developed TB in 2012 were HIV-positive. About

75% of these cases were in the African Region.

Globally in 2012, an estimated 450 000 people devel-

oped MDR-TB and there were an estimated 170 000

deaths from MDR-TB .

Most TB cases and deaths occur among men, but TB

remains among the top three killers of women world-

wide. ere were an estimated 410 000 TB deaths among

women in 2012, including 160 000 among HIV-positive

women. Half of the HIV-positive people who died from

TB in 2012 were women. Of the estimated 8.6 million new

TB cases worldwide in 2012, 2.9 million were women.

ere were an estimated 530 000 TB cases among

children (under 15 years of age) and 74000 TB deaths

(among HIV-negative children) in 2012 (6% and 8% of

the global totals, respectively).

e majority of cases worldwide in 2012 were in the

South-East Asia (29%), African (27%) and Western Pacif-

ic (19%) regions. India and China alone accounted for

26% and 12% of total cases, respectively.

e TB incidence rate at country level ranges substan-

tially, with around 1000 or more cases per 100 000 peo-

ple in South Africa and Swaziland, and fewer than 10

per 100000 population in parts of the Americas, several

countries in western Europe, Japan, Australia and New

Zealand.

TB detection and treatment outcomes

Millions of people access eective TB care each year

but “missed cases” hold back gains.

Between 1995 and 2012, 56 million people were success-

fully treated for TB in countries that had adopted WHO’s

global TB strategy, saving 22 million lives.

In 2012, 6.1 million cases of TB were notied to national

TB programmes (NTPs). Of these, 5.7 million were peo-

ple newly diagnosed in 2012 and 0.4 million were previ-

ously diagnosed TB patients whose treatment regimen

was changed.

In 2011, the treatment success rate continued to be high

at 87% among all new TB cases.

Notications of TB cases have stabilized globally. In

2012, about 66% (5.7 million) of the estimated 8.6 mil-

lion people who developed TB were notied as newly

diagnosed cases.

About 75% of the estimated 2.9 million missed cases

– people who were either not diagnosed or diagnosed but

not reported to NTPs – were in 12 countries. In order of

total numbers, these were India (31% of the global total),

South Africa, Bangladesh, Pakistan, Indonesia, China,

Democratic Republic of the Congo, Mozambique, Nige-

ria, Ethiopia, the Philippines and Myanmar.

Xpert® MTB/RIF, a rapid molecular diagnostic test,

is being rapidly adopted by countries to detect TB and

rifampicin-resistant TB. By end June 2013, 1402 testing

machines and 3.2 million test cartridges had been pro-

cured by 88 of the 145 countries eligible for concessional

prices.

Treatment success rates for TB remain lowest in the

European Region, where in 2011 only 72% of new cases

were successfully treated.

MDR-TB and XDR-TB detection and treatment outcomes

Undetected cases and treatment coverage gaps con-

stitute a public health crisis.

Globally in 2012, data from drug resistance surveys and

continuous surveillance among notied TB cases sug-

gest that 3.6% of newly diagnosed TB cases and 20% of

those previously treated for TB had MDR-TB. e high-

est levels of MDR-TB are found in eastern Europe and

central Asia, where in some countries more than 20%

of new TB cases and more than 50% of those previously

treated for TB have MDR-TB.

A total of 94000 TB patients eligible for MDR-TB treat-

ment were detected in 2012: 84000 people with con-

rmed MDR-TB (i.e. resistance to both rifampicin, the

most powerful TB drug, and isoniazid), plus 10 000

with rifampicin resistance detected using Xpert MTB/

RIF. is was a 42% increase in detected cases eligible

for treatment compared with 2011. e largest increases

between 2011 and 2012 were in India, South Africa and

Ukraine.

Just over 77000 people with MDR-TB were started on

second-line treatment in 2012, equivalent to 82% of

the 94 000 newly detected cases that were eligible for

treatment globally. Treatment coverage gaps for detect-

ed cases were much larger in some countries, especially

in the African Region (51% enrolled in treatment), and

widened in China, Pakistan and South Africa.

At least one case of extensively drug-resistant TB (XDR-

TB) had been reported by 92 countries by the end of

2012. On average, an estimated 9.6% of MDR-TB cases

have XDR-TB.

Globally, only 48% of MDR-TB patients in the 2010

cohort of detected cases were successfully treated,

reecting high mortality rates and loss to follow-up. A

treatment success rate of 75% or more for patients with

MDR-TB was achieved in 34 of 107 countries.

xiGLOBAL TUBERCULOSIS REPORT 2013

Addressing TB-HIV

TB-HIV collaborative services are expanding, but

global targets are not yet in sight.

e main interventions to reduce the burden of HIV in

TB patients are HIV testing and provision of ART and

cotrimoxazole preventive therapy (CPT) to those found

to be HIV-positive. e main interventions to reduce TB

among people living with HIV are regular screening for

TB among people in HIV care and provision of isoniazid

preventive therapy (IPT) to those without active TB who

meet eligibility criteria (estimated at 50% of those newly

enrolled in HIV care).

Progress in the implementation of TB/HIV interven-

tions was further consolidated in 2012. Globally, 46%

of TB patients knew their HIV status (up from 40% in

2011). In the African Region that has the highest TB/

HIV burden, 74% of TB patients knew their HIV status

(up from 69% in 2011). Among the 41 countries with the

highest TB/HIV burden, more than 85% of TB patients

knew their HIV status in 15 countries, and in 7 of these

countries over 90% of patients knew their HIV status.

e coverage of ART among TB patients who were

known to be HIV-positive reached 57% in 2012, up from

49% in 2011. As in the past few years, about 80% of HIV-

positive TB patients were treated with CPT.

In 2012, 4.1 million people enrolled in HIV care were

reported to have been screened for TB, up from 3.5 mil-

lion in 2011. Of the reported 1.6 million people newly

enrolled in HIV care in 2012, 0.5 million (31%) were

provided with IPT.

6$ßPCPEKPI

International donor funding and more domestic

investments are essential.

Of the US$ 7‒8 billion per year required in low and

middle-income countries in 2014 and 2015, about two

thirds is needed for the detection and treatment of drug-

susceptible TB, 20% for treatment of MDR-TB, 10%

for rapid diagnostic tests and associated laboratory

strengthening, and 5% for collaborative TB/HIV activ-

ities.

Growth in domestic and international donor funding

has been clearly documented since 2002. ere is capac-

ity to further increase domestic funding, especially in

BRICS (Brazil, the Russian Federation, India, China and

South Africa) that have almost 50% of global TB cases.

International donor funding reported by NTPs amount-

ed to US$ 0.8 billion in 2013, about three-quarters of

which was from the Global Fund. To close resource gaps,

at least US$1.6 billion is needed in both 2014 and 2015.

International donor funding is crucial in many coun-

tries, accounting for more than 50% of total funding in

the group of 17 HBCs excluding BRICS, and in all low-

income countries. e proportion is even higher in some

individual countries.

Research and development

New TB diagnostics, medicines and vaccines are cru-

cial to end the global TB epidemic.

More than 50 companies are involved in development of

new diagnostic tests.

10 new or repurposed TB drugs are in late phases of clin-

ical development. In late 2012, bedaquiline became the

rst novel TB drug approved in 40 years. In June 2013,

WHO issued interim guidance for its use in treatment

of MDR-TB.

ere are 10 vaccines for TB prevention and two immu-

notherapeutic vaccines in the pipeline. In early 2013,

results from a Phase IIb proof-of-concept study of one of

the preventive vaccine candidates were published. While

ecacy was not superior to the Bacille-Calmette-Guérin

(BCG) vaccine alone, the study demonstrated that a

trial of a novel TB vaccine is feasible in a high TB burden

setting.

Short, eective and well-tolerated treatments for latent

TB infection, a point-of-care diagnostic test, and an

eective post-exposure vaccine are needed to help end

the global TB epidemic.

1 e estimated number of TB deaths among HIV-positive people

in 2011 was 336000. Estimates of TB deaths among HIV-positive

people for the entire period 1990‒2012 were updated in 2013 using

the Spectrum software, which has been used for more than a decade

to produce estimates of the burden of disease caused by HIV. In

2013, a TB module in Spectrum was available for the rst time for

use in the country consultations on HIV burden estimates that are

organized by UNAIDS every two years. Estimation of the number

of TB cases living with HIV, and of the number of TB deaths among

HIV-positive people, was integrated into this process.

2 e 22 HBCs are Afghanistan, Bangladesh, Brazil, Cambodia,

China, the Democratic Republic of the Congo, Ethiopia, India,

Indonesia, Kenya, Mozambique, Myanmar, Nigeria, Pakistan, the

Philippines, the Russian Federation, South Africa, ailand, Ugan-

da, the United Republic of Tanzania, Viet Nam and Zimbabwe.

1GLOBAL TUBERCULOSIS REPORT 2013

%*#26'4

Introduction

Tuberculosis (TB) remains a major global health problem.

It causes ill-health among millions of people each year and

ranks as the second leading cause of death from an infec-

tious disease worldwide, after the human immunode-

ciency virus (HIV). e latest estimates included in this

report are that there were 8.6 million new TB cases in 2012

and 1.3 million TB deaths (just under 1.0 million among

HIV-negative people and 0.3 million HIV-associated TB

deaths). Most of these TB cases and deaths occur among

men, but the burden of disease among women is also high.

In 2012, there were an estimated 2.9 million cases and

410 000 TB deaths among women, as well as an estimat-

ed 530 000 cases and 74 000 deaths among children.1 e

number of TB deaths is unacceptably large given that most

are preventable if people can access health care for a diag-

nosis and the right treatment is provided. Short-course reg-

imens of rst-line drugs that can cure around 90% of cases

have been available for decades.

ese large numbers of cases and deaths notwithstand-

ing, 20 years on from the 1993 World Health Organization

(WHO) declaration of TB as a global public health emergen-

cy, major progress has been made. Globally, the TB mortal-

ity rate (deaths per 100 000 population per year) has fallen

by 45% since 1990 and TB incidence rates (new cases per

100 000 population per year) are falling in most parts of

the world. In the 18 years since the launch of a new inter-

national strategy for TB care and control by WHO in the

mid-1990s (the DOTS strategy) and the subsequent global

rollout of DOTS and its successor (the Stop TB Strategy,2

Box 1.2), a cumulative total of 56 million people were suc-

cessfully treated for TB between 1995 and 2012, saving

approximately 22 million lives.

e overarching goal of the Stop TB Strategy is to achieve

2015 global targets (shown in Box 1.2) for reductions in

the burden of disease caused by TB. e target set within

the United Nations (UN) Millennium Development Goals

(MDGs) is that TB incidence should be falling by 2015

(MDG Target 6.c). Besides incidence, four other TB indi-

cators are included in the MDG monitoring framework:

the prevalence rate, the mortality rate, the case detection

rate (the number of notied cases divided by the estimated

number of incident cases in the same year, expressed as a

percentage), and the treatment success rate (the percentage

BOX 1.1

Basic facts about TB

TB is an infectious disease caused by the bacillus

Mycobacterium tuberculosis. It typically affects the

lungs (pulmonary TB) but can affect other sites as well

(extrapulmonary TB). The disease is spread in the air when

people who are sick with pulmonary TB expel bacteria,

for example by coughing. In general, a relatively small

proportion of people infected with M. tuberculosis will

develop TB disease; however, the probability of developing

TB is much higher among people infected with HIV. TB is

also more common among men than women, and affects

mostly adults in the economically productive age groups.

The most common method for diagnosing TB worldwide

is sputum smear microscopy (developed more than 100

years ago), in which bacteria are observed in sputum

samples examined under a microscope. Following recent

breakthroughs in TB diagnostics, the use of rapid molecular

tests for the diagnosis of TB and drug-resistant TB is

increasing, as highlighted in Chapter 5 and Chapter 8

of this report. In countries with more developed laboratory

capacity, cases of TB are also diagnosed via culture methods

(the current reference standard).

Without treatment, TB mortality rates are high. In studies

of the natural history of the disease among sputum smear-

positive/HIV-negative cases of pulmonary TB, around 70%

died within 10 years; among culture-positive (but smear-

negative) cases, 20% died within 10 years.a

'HHGEVKXGFTWIVTGCVOGPVUYGTGßTUVFGXGNQRGFKPVJG

U6JGOQUVGHHGEVKXGßTUVNKPGCPVK6$FTWITKHCORKEKP

became available in the 1960s. The currently recommended

treatment for new cases of drug-susceptible TB is a six-

OQPVJTGIKOGPQHHQWTßTUVNKPGFTWIUKUQPKC\KFTKHCORKEKP

GVJCODWVQNCPFR[TC\KPCOKFG6TGCVOGPVUWEEGUUTCVGUQH

QTOQTGHQTPGYECUGUCTGTGIWNCTN[TGRQTVGFVQ9*1

by Member States (Chapter 3). Treatment for multidrug-

TGUKUVCPV6$/&46$FGßPGFCUTGUKUVCPEGVQKUQPKC\KFCPF

rifampicin (the two most powerful anti-TB drugs) is longer,

and requires more expensive and more toxic drugs. For most

RCVKGPVUYKVJ/&46$VJGEWTTGPVTGIKOGPUTGEQOOGPFGF

by WHO last 20 months, and treatment success rates are

much lower (Chapter 4(QTVJGßTUVVKOGKPHQWTFGECFGU

new TB drugs are starting to emerge from the pipeline and

combination regimens that include new compounds are

being tested in clinical trials, as discussed in Chapter 8.

There are several TB vaccines in Phase I or Phase II trials

(Chapter 8). For the time being, however, a vaccine that is

effective in preventing TB in adults remains elusive.

a 6KGOGTUOC'9GVCN0CVWTCNJKUVQT[QHVWDGTEWNQUKUFWTCVKQPCPF

HCVCNKV[QHWPVTGCVGFRWNOQPCT[VWDGTEWNQUKUKP*+8PGICVKXGRCVKGPVU

A systematic review. PLoS ONEG

1 e estimated number of deaths among children excludes TB

deaths in HIV-positive children, for which estimates are not yet

available. Further details are provided in Chapter 2.

2 Raviglione M, Uplekar M. WHO’s new Stop TB strategy. e Lancet,

2006, 367: 952–5.

2GLOBAL TUBERCULOSIS REPORT 2013

BOX 1.2

The Stop TB Strategy at a glance

THE STOP TB STRATEGY

VISION A TB-free world

GOAL To dramatically reduce the global burden of TB by 2015 in line with the Millennium Development Goals

(MDGs) and the Stop TB Partnership targets

OBJECTIVES ■ Achieve universal access to high-quality care for all people with TB

■ 4GFWEGVJGJWOCPUWHHGTKPICPFUQEKQGEQPQOKEDWTFGPCUUQEKCVGFYKVJ6$

■ Protect vulnerable populations from TB, TB/HIV and drug-resistant TB

■ Support development of new tools and enable their timely and effective use

■ Protect and promote human rights in TB prevention, care and control

TARGETS ■ /&)6CTIGVE*CNVCPFDGIKPVQTGXGTUGVJGKPEKFGPEGQH6$D[

■ 6CTIGVUNKPMGFVQVJG/&)UCPFGPFQTUGFD[VJG5VQR6$2CTVPGTUJKR

¿TGFWEGRTGXCNGPEGQHCPFFGCVJUFWGVQ6$D[EQORCTGFYKVJCDCUGNKPGQH

¿GNKOKPCVG6$CUCRWDNKEJGCNVJRTQDNGOFGßPGFCUECUGRGTOKNNKQPRQRWNCVKQPRGT[GCT

COMPONENTS

1. Pursue high-quality DOTS expansion and enhancement

C 5GEWTGRQNKVKECNEQOOKVOGPVYKVJCFGSWCVGCPFUWUVCKPGFßPCPEKPI

b. Ensure early case detection, and diagnosis through quality-assured bacteriology

E 2TQXKFGUVCPFCTFK\GFVTGCVOGPVYKVJUWRGTXKUKQPCPFRCVKGPVUWRRQTV

d. Ensure effective drug supply and management

e. Monitor and evaluate performance and impact

2. Address TB/HIV, MDR-TB, and the needs of poor and vulnerable populations

a. Scale up collaborative TB/HIV activities

D 5ECNGWRRTGXGPVKQPCPFOCPCIGOGPVQH/&46$

c. Address the needs of TB contacts, and of poor and vulnerable populations

3. Contribute to health system strengthening based on primary health care

C *GNRKORTQXGJGCNVJRQNKEKGUJWOCPTGUQWTEGFGXGNQROGPVßPCPEKPIUWRRNKGUUGTXKEGFGNKXGT[CPFKPHQTOCVKQP

b. Strengthen infection control in health services, other congregate settings and households

c. Upgrade laboratory networks, and implement the Practical Approach to Lung Health

F #FCRVUWEEGUUHWNCRRTQCEJGUHTQOQVJGTßGNFUCPFUGEVQTUCPFHQUVGTCEVKQPQPVJGUQEKCNFGVGTOKPCPVUQHJGCNVJ

4. Engage all care providers

a. Involve all public, voluntary, corporate and private providers through public–private mix approaches

b. Promote use of the International Standards for Tuberculosis Care

5. Empower people with TB, and communities through partnership

C 2WTUWGCFXQECE[EQOOWPKECVKQPCPFUQEKCNOQDKNK\CVKQP

b. Foster community participation in TB care, prevention and health promotion

c. Promote use of the Patients’ Charter for Tuberculosis Care

6. Enable and promote research

a. Conduct programme-based operational research

b. Advocate for and participate in research to develop new diagnostics, drugs and vaccines

GLOBAL TUBERCULOSIS REPORT 2013

of TB patients who are successfully treated).  e Stop TB

Partnership adopted the MDG target and in addition set

global targets to halve TB prevalence and death rates by

2015 compared with their levels in 1990.  e scale at which

interventions included in the Stop TB Strategy need to be

implemented to achieve the 2015 targets for reductions in

disease burden, and the associated funding requirements,

have been described in Global Plans developed by the Stop

TB Partnership.  e latest plan covers the period 2011–

2015 and has a price tag of US$47 billion.1

As the MDG target year of 2015 approaches, work on a

post-2015 development framework is assuming increasing

prominence. In June 2013, a high-level panel established

by the UN Secretary General to provide recommendations

about the content of a post-2015 development framework,

including possible goals and targets, submitted its report.2

One of the twelve proposed goals for 2030 is to “Ensure

healthy lives”, under which a suggested target is to “Reduce

the burden of disease from HIV/AIDS, TB, malaria, neglect-

ed tropical diseases and priority noncommunicable diseas-

es”. Important themes within the report are building on

the MDGs and equity, and for health speci cally the impor-

tance of steady progress towards universal health coverage

(UHC) is highlighted.

In line with the development of a post-2015 develop-

ment framework and in response to a request from Member

States, WHO began the process of developing a post-2015

global TB strategy in 2012. Following a series of consulta-

tions between June 2012 and July 2013, the draft strategy

includes the goal of ending the global TB epidemic by 2035,

with corresponding global targets for major reductions

in TB cases and deaths by 2035 and milestones for 2020,

2025 and 2030. Achieving the proposed targets is based on

three strategic pillars: integrated, patient-centred TB care

1 The Global Plan to Stop TB, 2011–2015. Geneva, World Health

Organization, 2010 (WHO/HTM/STB/2010.2). Available at

http://www.stoptb.org/assets/documents/global/plan/TB_

GlobalPlanToStopTB2011-2015.pdf

2 http://www.un.org/sg/management/beyond2015.shtml

and prevention; bold policies and supportive systems; and

intensi ed research and innovation. It is anticipated that

the strategy will be reviewed by the WHO Executive Board

in January 2014 and discussed at the World Health Assem-

bly in May 2014.

In the context of global TB strategies and targets, WHO

has published a global TB report every year since 1997

(Figure 1.1).  e main aim of the report is to provide a

comprehensive and up-to-date assessment of the TB epi-

demic and progress in prevention, diagnosis and treatment

of the disease at global, regional and country levels, based

primarily on data that are reported by countries and terri-

tories to WHO in annual rounds of global TB data collec-

tion (Box 1.3).  is 2013 global TB report is the eighteenth

in the series of annual reports, and uses data reported by a

total of 197 countries and territories including 178 Member

States that account for over 99% of the world’s estimated

cases of TB (Table 1.1). With just over two years remaining

before the end of 2015, a special feature of this 2013 global

report is that it is accompanied by a supplement focused on

the ‘Countdown to 2015’ (Box 1.4).

 e main part of the report contains seven major chap-

ters. Each chapter is intended to stand alone, but links to

other chapters are highlighted where appropriate.

Chapter 2 contains the latest estimates of the burden of

disease caused by TB and assessment of progress towards

the 2015 targets at global, regional and country levels. Esti-

mates for women and children speci cally are given par-

ticular attention. Following new analytical and modelling

work in 2013, the chapter also contains new estimates of

the number of cases of and deaths from MDR-TB and of

HIV-related TB mortality.  e latest status of e orts to

improve measurement of TB cases and deaths at country

level, with guidance and support from the WHO Global

Task Force on TB Impact Measurement, is described.

Chapter 3 presents data on the numbers of cases noti-

 ed to NTPs and reported to WHO and their treatment

outcomes, including breakdowns of TB cases by type, sex

and age. Recent progress in increasing the reporting of

cases by private sector providers through engagement of

FIGURE 1.1

Seventeen annual WHO global TB reports, 1997–2012

1997: First report:

epidemiology and

surveillance

2002: Added ﬁ nancing and

strategy for 22 high-burden

countries (HBCs)

July 2009: Online data collection introduced

December 2009: Short update to 2009 report in transition

to earlier reporting of data and report publication

2003: Financing

and strategy

(all countries)

1310_0237_PM_003.indd 31310_0237_PM_003.indd 3 28/10/13 13:1528/10/13 13:15

4GLOBAL TUBERCULOSIS REPORT 2013

large hospitals in ve countries, the contribution of com-

munity health workers and volunteers to the referral of TB

cases and treatment support in 13 countries, and strikingly

high notication rates in prisons in parts of the European

Region, are highlighted.

Chapter 4 focuses on drug-resistant TB. e rst part

of the chapter covers progress in drug resistance surveil-

lance and associated estimates of the absolute number and

proportion of TB patients that have MDR-TB and exten-

sively drug-resistant TB (XDR-TB). e second part of the

chapter presents and discusses the latest data on the pro-

BOX 1.3

Data collected in the 2013 round of global TB data collection

&CVCYGTGTGSWGUVGFQPVJGHQNNQYKPIVQRKEU6$ECUGPQVKßECVKQPUCPFVTGCVOGPVQWVEQOGUKPENWFKPIDTGCMFQYPUD[6$ECUG

type, age, sex and HIV status; an overview of services for the diagnosis and treatment of TB; laboratory diagnostic services;

drug management; monitoring and evaluation; surveillance and surveys of drug-resistant TB; management of drug-resistant TB;

collaborative TB/HIV activities; TB infection control; engagement of all care providers in TB control; the budgets of national TB

EQPVTQNRTQITCOOGU062UKPCPFWVKNK\CVKQPQHIGPGTCNJGCNVJUGTXKEGUJQURKVCNK\CVKQPCPFQWVRCVKGPVXKUKVUFWTKPI

treatment; and NTP expenditures in 2012. A shortened version of the online questionnaire was used for high-income countries (that

KUEQWPVTKGUYKVJCITQUUPCVKQPCNKPEQOGRGTECRKVCQHÜ75aaKPCUFGßPGFD[VJG9QTNF$CPMa and/or low-incidence

EQWPVTKGUFGßPGFCUEQWPVTKGUYKVJCPKPEKFGPEGTCVGQHECUGURGTaRQRWNCVKQPQTECUGUKPVQVCN

Countries reported data using an online web-based system (www.stoptb.org/tme). The system was opened for reporting on 14

/CTEJYKVJCFGCFNKPGQH/C[HQTCNN9*1TGIKQPUGZEGRVVJG4GIKQPQHVJG#OGTKECU/C[CPFVJG'WTQRGCP4GIKQP

/C[%QWPVTKGUKPVJG'WTQRGCP7PKQPUWDOKVPQVKßECVKQPFCVCVQCU[UVGOOCPCIGFD[VJG'WTQRGCP%GPVTGHQT&KUGCUG2TGXGPVKQP

and Control (ECDC). Data from the ECDC system were uploaded into the WHO online system.

Data were reviewed, and followed up with countries where appropriate, by a team of reviewers from WHO (headquarters and

TGIKQPCNQHßEGUCPFVJG)NQDCN(WPFVQ(KIJV#+&56WDGTEWNQUKUCPF/CNCTKCVJG)NQDCN(WPF8CNKFCVKQPQHFCVCD[TGURQPFGPVU

was also encouraged via a series of in-built, real-time checks of submitted data as well as a summary report of apparent

inconsistencies or inaccuracies (this report can be generated at any time within the online system). Following corrections and

updates by countries, the data used for the main part of this report were the data available in July 2013. Annex 4 was produced on

1 October, by which time additional data had been reported by a few European countries.b

Besides the data reported through the standard TB questionnaire, data about screening for TB among people living with HIV and

RTQXKUKQPQHKUQPKC\KFRTGXGPVKXGVJGTCR[+26VQVJQUGYKVJQWVCEVKXG6$YGTGEQNNGEVGFD[VJG*+8FGRCTVOGPVKP9*1CPFVJG,QKPV

United Nations Programme on HIV/AIDS (UNAIDS). The data were jointly validated and imported into the global TB database.

a. JVVRFCVCYQTNFDCPMQTICDQWVEQWPVT[ENCUUKßECVKQPU

b. For this reason, there may be slight discrepancies between the main part of the report and Annex 4.

TABLE 1.1

Reporting of data in the 2013 round of global TB data collection

9*14')+10145'61(%17064+'5

%17064+'5#0&6'44+614+'5 /'/$'456#6'5

07/$'4 07/$'46*#64'2146'&&#6# 07/$'4 07/$'46*#64'2146'&&#6#

#HTKECP4GIKQP 46 45 46 45

'CUVGTP/GFKVGTTCPGCP4GIKQP 23 23 22 22

'WTQRGCP4GIKQPa54 42 53 41

4GIKQPQHVJG#OGTKECU 46 46 35 35

5QWVJ'CUV#UKC4GIKQP 11 11 11 11

9GUVGTP2CEKßE4GIKQP 36 30 27 24

High-burden countries (HBCs)b22 22 22 22

World 216 197 194 178

a Countries that did not report by the deadlines were mostly low-incidence countries in Western Europe.

b 6JG*$%UCTG#HIJCPKUVCP$CPINCFGUJ$TC\KN%CODQFKC%JKPCVJG&GOQETCVKE4GRWDNKEQHVJG%QPIQ'VJKQRKC+PFKC+PFQPGUKC-GP[C/Q\CODKSWG/[CPOCT0KIGTKC

2CMKUVCPVJG2JKNKRRKPGUVJG4WUUKCP(GFGTCVKQP5QWVJ#HTKEC6JCKNCPF7ICPFCVJG7PKVGF4GRWDNKEQH6CP\CPKC8KGV0COCPF<KODCDYG

grammatic response to MDR-TB, including the coverage of

testing for drug resistance among new and previously treat-

ed TB patients, the number of cases detected with MDR-

TB and enrolled on treatment, and treatment outcomes.

Chapter 5, on TB diagnostics and laboratory strength-

ening, covers three topics. ese are policy developments

between mid-2012 and mid-2013, the status of laboratory

capacity and incorporation of WHO guidance into national

policy in 2012, and recent progress in strengthening labo-

ratories and associated diagnostic capacity. e latest data

on the roll out of the rapid molecular test Xpert MTB/RIF

5GLOBAL TUBERCULOSIS REPORT 2013

BOX 1.4

Special supplement on the Countdown to 2015

The MDGs were established by the UN at the turn of the

21st century, with targets set for 2015 (www.un.org/

millenniumgoals). Designed to drive progress worldwide

and endorsed by all countries, the targets have been the

focus of international and national development efforts

for more than a decade. TB was included as part of MDG

6. In addition to TB targets and indicators that are part of

the MDG framework, targets for the response needed to

CFFTGUUVJGURGEKßEEJCNNGPIGUQH/&46$CPFVJG6$*+8

co-epidemic have been set for 2015 in the Global Plan to

Stop TB 2011–2015.

With just over two years remaining before the target dead-

line of the end of 2015, this 2013 global TB report is accom-

panied by a special supplement called Countdown to 2015.

The supplement provides an overview of progress towards

the 2015 targets set within the MDG framework and for the

TGURQPUGVQ6$*+8CPF/&46$URGEKßECNN[CPFVJGVQR

priority actions needed to either move beyond or accelerate

towards these targets. Snapshots are provided globally,

TGIKQPCNN[CPFHQTVJG*$%UVJCVJCXGCDQWVQHVJG

world’s TB cases and that have received greatest attention at

the global level since 2000. The snapshots are based on the

data presented in the main chapters of the report and the

annexes, complemented by recommendations from recent

programme reviews, published literature, and discussions

with experts at global, regional and national levels.

since it was recommended in 2010 and two multinational

projects (EXPAND-TB and TBXpert) are included.

Chapter 6 contains the most recent data on progress

in implementing collaborative TB/HIV activities to joint-

ly address the epidemics of TB and HIV. ese include HIV

testing for TB patients, provision of antiretroviral therapy

(ART) to HIV-positive TB patients, intensied screening

for TB among people living with HIV and treatment for

those without active TB with IPT.

Chapter 7 assesses nancing for TB care and control.

Funding requirements for a full response to the global TB

epidemic up to 2015, which were updated in early 2013 as

part of preparatory work undertaken to inform the replen-

ishment of the Global Fund, are presented rst. Key nd-

ings from a study of long-term trends (2002–2011) using

data compiled in the WHO annual rounds of data collection

and recently published in e Lancet Global Health are then

summarized, followed by a detailed analysis of new data

reported in 2013.

Chapter 8 discusses research and development for new

TB diagnostics, drugs and vaccines. After years of stagna-

tion, considerable progress has occurred in the past decade

and the development pipelines as of mid-2013 are described

and discussed.

e report also has four annexes. Annex 1 explains the

methods used to produce estimates of the burden of disease

caused by TB. Annex 2 contains country proles for the 22

HBCs that collectively account for about 80% of the world’s

TB cases (proles for all countries are available online1).

Annex 3 contains regional proles. Annex 4 consists of

summary tables that provide data on key indicators for the

world, the six WHO regions and individual countries.

1 www.who.int/tb/data

6GLOBAL TUBERCULOSIS REPORT 2013

%*#26'4

The burden of disease caused by TB

e burden of disease caused by TB can be mea-

sured in terms of incidence (dened as the num-

ber of new and relapse cases of TB arising in a

given time period, usually one year), prevalence

(dened as the number of cases of TB at a giv-

en point in time) and mortality (dened as the

number of deaths caused by TB in a given time

period, usually one year).

is chapter presents estimates of TB inci-

dence, prevalence and mortality (absolute num-

bers and rates) between 1990 and 2012 and (for

prevalence and mortality) forecasts up to 2015

(in sections 2.1–2.3). ese data are used to

assess progress towards achieving the global

targets for reductions in TB disease burden set

for 2015: that incidence should be falling (MDG

Target 6.c) and that prevalence and death rates

should be halved by 2015 compared with 1990

(Box 1.2 in Chapter 1). Key aspects of the meth-

ods used to produce the estimates are provided

at the beginning of each section.1 Estimates of

the number of incident TB cases among people

living with HIV, the number of incident cases

of MDR-TB, mortality due to MDR-TB and TB

deaths disaggregated by HIV status are includ-

ed in the relevant sections. Estimates are pre-

sented globally, for the six WHO Regions, and

at country level with particular focus on the 22

HBCs. In response to increasing demand and

global attention, special consideration is given

to estimates of TB disease burden among wom-

en and children. Updates to data sources and

methods used to produce estimates of TB dis-

ease burden compared with those published in

2012 are highlighted in Box 2.1.

ere is uncertainty in all estimates of the

burden of disease caused by TB. Section 2.4

proles eorts to improve measurement of this

burden under the umbrella of the WHO Glob-

al Task Force on TB Impact Measurement. e

recent and unprecedented progress in imple-

menting national TB prevalence surveys is

summarized and expanding eorts to strength-

en surveillance of cases and deaths via noti-

cation and vital registration (VR) systems are

described.

KEY FACTS AND MESSAGES

■ The global burden of TB remains enormous. In 2012, there were an

GUVKOCVGFOKNNKQPKPEKFGPVECUGUQH6$CPFOKNNKQPRGQRNGFKGF

HTQOVJGFKUGCUGaFGCVJUCOQPIRGQRNGYJQYGTG*+8PGICVKXG

CPFaCOQPIRGQRNGYJQYGTG*+8RQUKVKXG#OQPIVJGUGFGCVJU

VJGTGYGTGCPGUVKOCVGFaHTQO/&46$CTGNCVKXGN[JKIJVQVCN

EQORCTGFYKVJaKPEKFGPVECUGUQH/&46$

■ Although the number of TB cases and deaths remains unnecessarily

large for a mostly curable disease, there has been major progress towards

global targets for reductions in the burden of disease. The 2015 MDG

target of halting and reversing TB incidence has been achieved, with

TB incidence falling globally for several years (2% per year in 2012).

Globally, the TB mortality rate has fallen by 45% since 1990 and the

Stop TB Partnership target of a 50% reduction by 2015 is within reach.

Mortality and incidence rates are falling in all six WHO regions and in

OQUVQHVJG*$%UVJCVCEEQWPVHQTQXGTQHVJGYQTNFÂU6$ECUGU

■ 6JKUKUVJGßTUV[GCTKPYJKEJGUVKOCVGUQH6$FGCVJUCOQPI*+8

positive people were produced using the UNAIDS Spectrum model,

leading to revisions to previously published estimates for the period

1990–2011. The estimated percentage of TB cases living with HIV

remains unchanged, at 13% globally in 2012.

■ Although most TB cases and deaths occur among men, the burden of

FKUGCUGKUJKIJCOQPIYQOGP+PCPGUVKOCVGFaYQOGP

FKGFHTQO6$aCOQPI*+8PGICVKXGYQOGPCPFaCOQPI

*+8RQUKVKXGYQOGP6JGTGYGTGCNUQCPGUVKOCVGFa6$FGCVJU

among HIV-negative children (estimates of HIV-associated mortality are

not yet available).

■ 6JG5QWVJ'CUV#UKCCPF9GUVGTP2CEKßE4GIKQPUEQNNGEVKXGN[

CEEQWPVGFHQTQHVJGYQTNFÂU6$ECUGUKP6JG#HTKECP4GIKQP

had approximately one quarter of the world’s cases, and the highest

rates of cases and deaths relative to population (255 incident cases per

aQPCXGTCIGOQTGVJCPFQWDNGVJGINQDCNCXGTCIGQH+PFKC

and China had the largest number of cases (26% and 12% of the global

VQVCNTGURGEVKXGN[5QWVJ#HTKECCPF5YC\KNCPFJCFVJGJKIJGUVKPEKFGPEG

rate per capita (about 1 new case for every 100 people each year).

■ The quality and coverage of data available to estimate TB disease

burden continues to improve. In 2012, data from vital registration

systems were used to estimate TB mortality in 121 countries (up from

EQWPVTKGUKPVJGTGJCUDGGPWPRTGEGFGPVGFRTQITGUUKPVJG

KORNGOGPVCVKQPQHPCVKQPCN6$RTGXCNGPEGUWTXG[UUKPEGCPFGHHQTVU

to improve the monitoring of TB incidence by strengthening routine

health information systems and implementing inventory studies to

measure under-reporting of diagnosed cases are expanding.

■ Five national TB prevalence surveys were implemented in 2012 (in

VJG)CODKC0KIGTKC4YCPFCVJG7PKVGF4GRWDNKEQH6CP\CPKCCPF

6JCKNCPFCPFCHWTVJGTßXGYKNNUVCTVQTDGEQORNGVGFKPKP)JCPC

+PFQPGUKC/CNCYK5WFCPCPF<CODKC6JGUGUWTXG[URTQXKFGCFKTGEV

OGCUWTGQHFKUGCUGDWTFGPQHVGPHQTVJGßTUVVKOGCPFYKNNDGWUGFVQ

WRFCVGGUVKOCVGUQHFKUGCUGDWTFGPQPEGTGUWNVUCTGßPCNK\GF6JG[CNUQ

provide rich data to inform programme policy and strategy.

1 A detailed description is provided in Annex 1.

7GLOBAL TUBERCULOSIS REPORT 2013

BOX 2.1

Updates to estimates of TB disease burden in this report and updates that are anticipated in the near future

Each year, new data become available for the estimation of TB disease burden. Periodically, new approaches to the use of

CXCKNCDNGFCVCCTGFGXGNQRGF6JKUDQZRTQXKFGUCUWOOCT[QHWRFCVGUVJCVYGTGOCFGKP7RFCVGUHQTURGEKßEEQWPVTKGU

VJCVCTGGZRGEVGFKPVJGPGCTHWVWTGRGPFKPIVJGßPCNK\CVKQPQHCPCN[UGUQHFCVCHTQOTGEGPVN[EQORNGVGFRTGXCNGPEG

surveys, are also highlighted.

UPDATES IN THIS REPORT

1. TB/HIV burden estimates

+PCPFHQTVJGßTUVVKOGGUVKOCVGU

of TB incidence among people living

with HIV and TB mortality among HIV-

positive people were generated using

the Spectrum software programme.a

Spectrum has been used for more than

a decade to produce estimates of the

burden of disease caused by HIV, to build

projections about the future course of the

HIV epidemic and to assess the potential

impact of interventions. A TB module was

developed in 2012 and 2013 through

a collaboration between the Futures

Institute, the TB Modelling and Analysis

Consortium (TB-MAC), UNAIDS and WHO.

It was initially tested in two regional

workshops held in Johannesburg, South

Africa (in March 2013) and subsequently in

a workshop for countries in western Africa.

The mathematical methods implemented

in Spectrum as well as the input data are

described in Annex 1. It is anticipated

that the TB module will be extended to

include projections of the future course of

the TB epidemic and the potential impact

of selected interventions, building on

existing estimates of TB disease burden

generated by WHO.

The updated estimates of TB

incidence among people living with HIV

published in this report are generally

very consistent with previously published

estimates, especially for countries with a

IGPGTCNK\GF*+8GRKFGOKECPFUVTQPI6$

HIV surveillance systems. The updated

time series of mortality estimates at global

NGXGNCPFHQTVJG#HTKECP4GIKQPKPFKECVG

a lower level of TB mortality among HIV-

positive people compared with estimates

published in 2012. As a result of the use of

5RGEVTWOEQWPVT[URGEKßEGUVKOCVGUQH6$

mortality among HIV-positive people that

are fully consistent with overall estimates

QH*+8OQTVCNKV[CTGCXCKNCDNGHQTVJGßTUV

time. These are shown in Annex 2 and in

QPNKPGEQWPVT[RTQßNGU

2. MDR-TB mortality and incidence

'UVKOCVGUQH/&46$OQTVCNKV[CPF

KPEKFGPEGYGTGNCUVRTQFWEGFKPCPF

published in a 2010 WHO report on the

/&46$GRKFGOKE#U[UVGOCVKENKVGTCVWTG

review of evidence about mortality

CUUQEKCVGFYKVJ/&46$YCUEQOOKUUKQPGF

by WHO in 2013. The results have been

used to produce global estimates of

/&46$KPEKFGPEGCPFOQTVCNKV[KP

6JGGUVKOCVGQHOQTVCNKV[FWGVQ/&46$

is slightly higher than before, but the

uncertainty interval greatly overlaps the

RTGXKQWUQPG6JGGUVKOCVGQH/&4

TB incidence is similar to the previous

estimate.

3. Newly reported data

There are relatively small changes to

estimates of TB incidence, mortality

and prevalence for many countries that

TGàGEVXKVCNTGIKUVTCVKQPFCVCTGRQTVGF

to WHO between mid-2012 and mid-

2013, updated WHO estimates of the

overall number of deaths (that provide

overall mortality envelopes), updates to

estimates of the burden of HIV-associated

6$CPFPGY6$PQVKßECVKQPFCVCKPENWFKPI

corrections made to historical data. In

most instances, changes are well within

the uncertainty intervals of previously

published estimates of TB burden and time

trends are generally consistent. Newly-

reported data are the reason for small

changes to estimates of the number of TB

deaths among women and children.

4. In-depth epidemiological reviews

In January 2013, estimates of TB burden

for Viet Nam were updated in close

consultation with the NTP and other

stakeholders. These resulted in changes

to estimates of the level of and trends in

TB incidence, prevalence and mortality

compared with those published in the

2012 global TB report. Updates drew on

new analyses from prevalence survey data,

GXKFGPEGCDQWVVJGKPàWGPEGQPVTGPFUKP

ECUGPQVKßECVKQPUQHKPETGCUGFTGRQTVKPIVQ

the NTP of cases diagnosed in the private

sector and prisons and new analyses of

DTQCFGTKPàWGPEGUQP6$FKUGCUGDWTFGP

such as economic growth, health system

performance and the coverage of health

insurance.

5. Inclusion of newly reported cases

without documented treatment

history in incidence estimates

+PRTGXKQWU[GCTUPQVKßGF6$RCVKGPVU

without any reported treatment history

were not considered as incident cases

(incident cases were the sum of new and

TGNCRUGECUGU+PVJKUTGRQTVPQVKßGFECUGU

for which the treatment history is unknown

are considered to be incident cases.

6JKUEJCPIGKULWUVKßGFHQTVYQTGCUQPU

ßTUVKPEQWPVTKGUHCEKPIRTQDNGOUYKVJ

incomplete documentation of treatment

history, the vast majority of such cases are

ßTUVGRKUQFGUQTTGNCRUGGRKUQFGUUGEQPF

WHO received several requests from NTPs

(or equivalent) to include all patients with

no documented treatment history in the

count of new and relapse episodes to avoid

understating the true burden of TB. This

change affects relatively few countries,

most of which are in western Europe.

UPDATES ANTICIPATED IN

THE NEAR FUTURE

Updates to estimates of disease burden

are expected in several countries that

have recently completed or will soon

complete national TB prevalence surveys.

6JGUGKPENWFGßXG*$%U+PFQPGUKC

Nigeria, Pakistan, Thailand and the United

4GRWDNKEQH6CP\CPKC#FFKVKQPCNEQWPVTKGU

KPENWFGVJG)CODKCCPF4YCPFCDQVJ

of which completed surveys in 2012,

and Ghana where a survey began in

March 2013. In addition to a prevalence

survey, an inventory study to estimate TB

underreporting was completed in Pakistan

in 2012 (see also section 2.4) and an

in-depth epidemiological review was

conducted in Thailand in August 2013.

A workshop for the six countries that had

completed surveys by July 2013

(i.e. the Gambia, Nigeria, Pakistan,

4YCPFC6JCKNCPFCPF7PKVGF4GRWDNKE

QH6CP\CPKCCUYGNNCUVJGKTVGEJPKECN

partners will be held at WHO headquarters

in November 2013, to conduct and

complete analyses of survey data.

Following this workshop, updates to

estimates of TB disease burden will be

possible. These updates will be made

CXCKNCDNGKPQPNKPGEQWPVT[RTQßNGUCPF

associated data sets.

In 2014, a thorough review of the

current epidemiological and modelling

methods used to estimate TB disease

burden will be conducted by the

WHO Global Task Force on TB Impact

Measurement. The recommendations may

result in some further updates in the 2014

global TB report.

a JVVRYYYHWVWTGUKPUVKVWVGQTIURGEVTWOCURZ

GLOBAL TUBERCULOSIS REPORT 2013

2.1 TB incidence

TB incidence has never been measured at national level

because this would require long-term studies among large

cohorts of people (hundreds of thousands) at high cost and

with challenging logistics. Notications of TB cases pro-

vide a good proxy indication of TB incidence in countries

that have both high-performance surveillance systems

(for example, there is little underreporting of diagnosed

cases) and where the quality of and access to health care

means that few cases (or a negligible number) are not diag-

nosed. In the large number of countries where these crite-

ria are not yet met, TB incidence can be estimated using

an inventory study (in which the level of underreporting

is assessed) combined with capture–recapture analysis to

estimate under-diagnosis, provided that certain assump-

tions are satised.1 To date, such studies have been under-

taken in only a few countries: examples include Egypt,

Iraq and Yemen (see section 2.4). e ultimate goal is to

directly measure TB incidence from TB notications in all

countries. is requires a combination of strengthened sur-

veillance, better quantication of underreporting (i.e. the

number of cases that are missed by surveillance systems)

and universal access to health care. A TB surveillance check-

list developed by the WHO Global Task Force on TB Impact

Measurement denes the standards that need to be met

for notication data to provide a direct measure of TB inci-

dence (further details in section 2.4).

For most countries, incidence estimates are currently

based on notication data combined with country consul-

tations in which in-depth analyses of the available surveil-

lance, survey and programmatic data are undertaken, and

expert opinion about the fraction of cases diagnosed but

not reported, or not diagnosed at all, is elicited and docu-

mented. e 96 countries (with 89% of estimated TB cases)

covered by such consultations since 2008 are shown in Fig-

ure 2.1. For remaining countries not covered in workshops

and in which notications do not provide a good proxy indi-

cation of TB incidence, estimates are based on extending

previously published time series, mortality data from VR

systems combined with evidence about the case fatality

rate, or ecological modelling (see Annex 1 for details).

In 2012, there were an estimated 8.6 million incident

cases of TB (range, 8.3million–9.0million) globally, equiv-

alent to 122 cases per 100000 population (Table 2.1, Table

2.2). e absolute number of incident cases is falling, albeit

slowly (Figure 2.2).

Most of the estimated number of cases in 2012 occurred

in Asia (58%) and the African Region (27%);2 smaller pro-

portions of cases occurred in the Eastern Mediterranean

Region (8%), the European Region (4%) and the Region of

FIGURE 2.1

Coverage of country consultations on estimates of TB disease burden, 2008–2013

1 An inventory study can be used to measure the number of cases that are diagnosed but not reported, but using results to estimate the total

number of incident cases using capture–recapture methods requires that certain conditions are met. ese are explained in a guide on inven-

tory studies recently published by WHO, which is available at: www.who.int/tb/publications/inventory_studies/en/index.html

2 Asia refers to the WHO Regions of South-East Asia and the Western Pacic.

9GLOBAL TUBERCULOSIS REPORT 2013

TABLE 2.1

Estimated epidemiological burden of TB, 2012. Numbers in thousands.a

POPULATION

/146#.+6;bHIV-POSITIVE

6$/146#.+6; 24'8#.'0%' INCIDENCE HIV-POSITIVE

INCIDENT TB CASES

BESTcLOW HIGH BEST LOW HIGH BEST LOW HIGH BEST LOW HIGH BEST LOW HIGH

Afghanistan  11 4.6 20   0.3 110 54  56 47 67 0.3 0.2 0.5

Bangladeshd154 695 70 29 130   0.1 670 340 1 100 350 290 410 0.2 0.2 0.3

$TC\KN  4.9 4.6 5.2 2.5 2.2 3 120 51 210 92 76 110 16 13 19

Cambodia  9.3 4.3 16 0.6 0.4 0.7 110 96 130 61 52 70 2.7 2.3 3.1

China 1 377 065 44 43 46 1.2 0.9 1.5 1 400 1 200 1 600 1 000  1 100 7.3 6.4 

&4%QPIQ 65 705 36 16 64 6.3 5.5   200 620 210 190 250 16 14 19

Ethiopia 91 729 16 12 21 5.6 4.6 7.3 210 170 250 230 170 290 23 17 30

Indiae 270 170 390 42 37   1 900 3 900 2 200 2 000 2 400 130 120 140

Indonesia  67 30 120 2.1  37303501 200460 540 7.5 5.6 9.7

Kenya  9.5 5.4 15 7.7 6.6  130 71 210 120 110 120 45 44 47

/Q\CODKSWG 25 203 13 1 41 45 35 53 140  340 140 96 190   110

Myanmar 52 797 25 12 44 4.6  5.3 260 200 320 200 170 230 19 16 21

Nigeria  27 1.6  19 11 25 270 43 710   310 46 21 

Pakistan 179 160 62 27 110 1.2  1.3 670 320 1 100 410 340 490  3.1 4.6

Philippines 96 707 23 22 25 0.1  0.1 450 390 500 260 210 310 0.5 0.4 0.6

4WUUKCP

Federation 143 170 19  20  1.5 2.2 170 73 320 130 110 150 9.3 7.9 11

South Africa  31 3.7   75 100 450 160  530 430 630 330 270 390

Thailand  9.2  17 2.2 1.9  110 47 190  66 95 12 10 14

Uganda 36 346 4.7  12 9.2 12 64 24 120 65 53 79 35  42

746CP\CPKC  6.1 3.2 9.9 7    45 140 79 74  32 30 34

Viet Nam 90 796  12 25 2.1  2.7 200  370 130 99 170 9.3 6.9 12

<KODCDYG 13 724 4.6 0.2 16  15 20 59 13 140 77 60 97 55 42 69

High-burden

countries 4 432 959 780 630 940 270 250 280 9 600 8 200 11 000 7 000 6 700 7 400 880 810 960

#(4  230 160 310 250 230 270 2 700 2 100 3 300 2 300 2 100 2 500  760 910

#/4 961 103 19 16 21 6.4 5.6 7.2 390 300 490  260 300 31  34

'/4 616 591 100 63 150 4.2  4.7 1 100 730 1 600 670 590 750 11 10 12

'74 904 540 36 35 36 3.9 3.4 4.4 510  650 360 340 390 19 17 21

5'#4  450 330 590 51 46 56  3 700 6 100 3 400 3 200 3 700 170 160 

924  110 96 120  4.2 5.4 2 400 2 100 2 600 1 600 1 500  24 21 27

Global 7 053 684 940 790 1 100 320 300 340 12 000 11 000 13 000 8 600 8 300 9 000 1 100 1 000 1 200

a 0WODGTUHQTOQTVCNKV[RTGXCNGPEGCPFKPEKFGPEGUJQYPVQVYQUKIPKßECPVßIWTGU6QVCNU*$%UTGIKQPCNCPFINQDCNCTGEQORWVGFRTKQTVQTQWPFKPI

b /QTVCNKV[GZENWFGUFGCVJUCOQPI*+8RQUKVKXG6$ECUGU&GCVJUCOQPI*+8RQUKVKXG6$ECUGUCTGENCUUKßGFCU*+8FGCVJUCEEQTFKPIVQ+%&CPFCTGUJQYPUGRCTCVGN[KPVJKU

table.

c Best, low and high indicate the point estimate and lower and upper bounds of the 95% uncertainty interval.

d Estimates of TB disease burden have not been approved by the NTP in Bangladesh and a joint reassessment (by the NTP and WHO) will be undertaken following completion of

the national TB prevalence survey scheduled for 2014.

e 'UVKOCVGUHQT+PFKCJCXGPQV[GVDGGPQHßEKCNN[CRRTQXGFD[VJG/KPKUVT[QH*GCNVJ(COKN[9GNHCTG)QXGTPOGPVQH+PFKCCPFUJQWNFVJGTGHQTGDGEQPUKFGTGFRTQXKUKQPCN

10 GLOBAL TUBERCULOSIS REPORT 2013

TABLE 2.2

Estimated epidemiological burden of TB, 2012. 4CVGURGTRQRWNCVKQPGZEGRVYJGTGKPFKECVGFa

POPULATION

(THOUSANDS)

/146#.+6;b*+8215+6+8'6$/146#.+6; 24'8#.'0%' INCIDENCE *+824'8#.'0%'+0

INCIDENT TB CASES (%)

BEST LOW HIGH BEST LOW HIGH BEST LOW HIGH BEST LOW HIGH BEST LOW HIGH

Afghanistan  37 15  0.3  1.1   595  156 226 0.55 0.41 

Bangladeshc154 695 45 19     434  721 225     

$TC\KN  2.5 2.3 2.6 1.3 1.1 1.5 59 25 107 46  55 17.3 17.1 17.4

Cambodia  63 29 110  2.7 4.7 764 645  411 353 474 4.34 4.21 4.44

China 1 377 065 3.2 3.1 3.3   0.1 99  113 73 64  0.73 0.73 0.73

&4%QPIQ 65 705 54 24 97 9.7  12 576 301  327  375 7.66 7.65 7.66

Ethiopia 91 729  13 23 6.1 5 224  272 247  321 10.2 10.1 10.2

Indiad 22 14 32 3.4 3 3.9 230 155 319 176 159 193 5.95 5.93 5.97

Indonesia  27 12  0.9 0.7 1.2 297 144 506  153 220 1.65 1.65 2.33

Kenya  22 13 34  15 21 299 164 475 272 261    

/Q\CODKSWG 25 203 53 3.9 163 177  209 553 111 1 340 552  753 59.7 59.6 

Myanmar 52 797  23   7.3 10  377 616 377 322 435 9.33 9.32 9.33

Nigeria  16 0.9 51 11 6.7 15 161 25 420  50  25.2  25.7

Pakistan 179 160 34 15 61 0.7 0.5  376  641 231 190 276 0.92  0.96

Philippines 96 707 24 22 26 0.1  0.1 461 405 520 265 219 316   

4WUUKCP

Federation 143 170 13 13 14 1.2 1 1.5 121 51 221 91 77 106 7.14 7.03 7.25

South Africa  59 7 164  144 192  305  1 000  1 190 63.0 62.9 63.0

Thailand  14  25 3.3 2.9 4.2 159 71  119  142 15.2 15.2 15.3

Uganda 36 346 13 2.3 33 25 22 32 175 67 334 179 145 216 53.2 52.9 53.3

746CP\CPKC  13  21 15 12 17 176 95  165 154 175 41.2 41.2 41.3

Viet Nam 90 796 20 13 27 2.4 2 2.9   410 147 109 192 6.97 6.94 6.99

<KODCDYG 13 724 33 1.2 117 132 111 147 433 92 1 030 562 434 706 70.9 70.7 71.4

High-burden

countries 4 432 959 18 14 21 6 5.6 6.4 216 186 248 159 151 166 7.37 7.35 7.40

#(4  26  35  26 30 303 239 373 255 235 275 36.6 34.7 

#/4 961 103 1.9 1.7 2.2 0.7 0.6 0.7 40 31 51 29 27 31 11.4  14.4

'/4 616 591 16 10 24 0.7 0.6    256 109 96 122  1.34 2.52

'74 904 540 3.9 3.9 4 0.4 0.4 0.5 56 42 72 40  43 5.26  6.93

5'#4  25  32  2.5 3.1 264 203 333  174 200 4.94 4.31 5.62

924   5.2 6.4 0.3 0.2 0.3  115 142   95 1.49 0.92 

Global 7 053 684 13 11 16 4.6 4.3 4.8 169 149 190 122 117 127 12.8 11.6 14.0

a Best, low and high indicate the point estimate and lower and upper bounds of the 95% uncertainty interval.

table.

c Estimates of TB disease burden have not been approved by the NTP in Bangladesh and a joint reassessment (by the NTP and WHO) will be undertaken following completion of

the national TB prevalence survey scheduled for 2014.

d 'UVKOCVGUHQT+PFKCJCXGPQV[GVDGGPQHßEKCNN[CRRTQXGFD[VJG/KPKUVT[QH*GCNVJ(COKN[9GNHCTG)QXGTPOGPVQH+PFKCCPFUJQWNFVJGTGHQTGDGEQPUKFGTGFRTQXKUKQPCN

11GLOBAL TUBERCULOSIS REPORT 2013

FIGURE 2.2

Estimated absolute numbers of TB cases and deaths

(in millions), 1990–2012

a *+8CUUQEKCVGF6$FGCVJUCTGENCUUKßGFCU*+8FGCVJUCEEQTFKPIVQ+%&

2.5

5.0

7.5

10.0

1990 1995 2000 2005 2012

Millions

All TB cases

HIV-positive TB cases

TB incidence

0.5

1.0

1.5

2.0

1990 1995 2000 2005 2012

Millions

TB deaths among HIV-negative people

TB deaths among HIV-positive peoplea

TB deaths

the Americas (3%). e 22 HBCs that have been given high-

est priority at the global level since 2000 (listed in Table

2.1 and Table 2.2) accounted for 81% of all estimated inci-

dent cases worldwide. e ve countries with the largest

number of incident cases in 2012 were India (2.0 million–

2.4 million), China (0.9 million–1.1 million), South Africa

(0.4 million–0.6 million), Indonesia (0.4 million–0.5 mil-

lion) and Pakistan (0.3 million–0.5 million); these and the

other ve countries that make up the top ten in terms of

numbers of cases are highlighted in Figure 2.3. India and

China alone accounted for 26% and 12% of global cases,

respectively. Of the 8.6 million incident cases, an estimat-

ed 0.5 million were children and 2.9 million (range, 2.7–

3.1 million) occurred among women (Box 2.2).

e 8.6 million incident TB cases in 2012 included

1.0 million–1.2 million (12–14%) among people living with

HIV, with a best estimate of 1.1 million (13%) (Table 2.1,

Table 2.2). e proportion of TB cases co-infected with HIV

was highest in countries in the African Region (Figure 2.4).

Overall, 37% of TB cases were estimated to be co-infect-

ed with HIV in this region, which accounted for 75% of TB

cases among people living with HIV worldwide. In parts of

southern Africa, more than 50% of TB cases were co-infect-

ed with HIV (Figure 2.4).

Following a systematic review of evidence about mor-

tality caused by MDR-TB (

Box 2.3), global estimates of

the burden of MDR-TB were updated in 2013 (Box 2.1).

e best estimate is that there were 450000 (range,

300 000‒600 000) new cases of MDR-TB worldwide in

2012. is total includes cases of primary and acquired

MDR-TB.

e number of incident TB cases relative to population

(the incidence rate) varies widely among countries (Fig-

ure 2.5). e lowest rates are found predominantly in

high-income countries including most countries in west-

ern Europe, Canada, the United States of America, Japan,

Australia and New Zealand. In these countries, the inci-

dence rate per 100000 population is less than 10 cases per

FIGURE 2.3

Estimated TB incidence: top-ten countries, 2012

●

Myanmar

DR Congo

Ethiopia

Philippines

Bangladesh

Pakistan

Indonesia

South Africa

China

India

a. Incidence: absolute numbers

Millions

0.5 1.0 1.5 2.0 2.5

●

Rate per 100 000 population per year

Gabon

Timor-Leste

Mozambique

Zimbabwe

Djibouti

Lesotho

Namibia

Sierra Leone

South Africa

Swaziland

400 800 1200 1600

b. Incidence: rate per 100 000 population

12 GLOBAL TUBERCULOSIS REPORT 2013

BOX 2.2

The burden of TB disease among women and children

6JGDWTFGPQH6$OQTDKFKV[CPFOQTVCNKV[COQPIYQOGPFGßPGF

CUHGOCNGUCIGFÜ[GCTUCPFEJKNFTGPFGßPGFCURGQRNG

CIGF[GCTUKUNCTIGTVJCPQHVGPTGCNKUGF6JKUKUVJGUGEQPF

consecutive year in which the WHO global TB report highlights the

DWTFGPQHFKUGCUGCOQPIEJKNFTGPCPFHQTVJGßTUVVKOGKPENWFGU

estimates of the burden among women disaggregated by region

and HIV status.

There were an estimated 2.9 million new cases of TB and

aFGCVJUHTQOVJGFKUGCUGCOQPIYQOGPKP#OQPI

EJKNFTGPVJGTGYGTGCPGUVKOCVGFaPGYECUGUKPCPF

aFGCVJUCOQPIEJKNFTGPYJQYGTG*+8PGICVKXG/GVJQFU

used to produce these estimates and further details about results

are provided below. The estimates of TB morbidity and mortality

among children are slightly higher than those published in the

INQDCN6$TGRQTVTGàGEVKPIPGYUWTXGKNNCPEGFCVCVJCVUJQY

OQTG6$ECUGUDGKPIPQVKßGFCOQPIEJKNFTGPINQDCNN[CPFPGY84

data.

The burden of TB in women: estimates of TB incidence

and mortality, 2012

Incidence

4GIKQPCNGUVKOCVGUQHVJGYQOGPOGPTCVKQHQTPGYCNNECUGV[RGU

6$ECUGPQVKßECVKQPUKPYGTGIGPGTCVGFCPFCUUWOGFVQDG

the same as the ratio among incident TB cases in 2012 (see Annex

1 for further details). The resulting global and regional estimates

of incidence are shown in Table B2.2.1. Women account for

QHVJGVQVCNQHOKNNKQPKPEKFGPVECUGUKP6JG#HTKECP

CPF5QWVJ'CUV#UKCTGIKQPUCEEQWPVHQTQHVJGECUGUCOQPI

women.

TABLE B2.2.1

6QVCNPWODGTQHPGY6$PQVKßECVKQPUCNNECUGV[RGU

and estimated incident cases among women in 2012,

disaggregated by WHO region

WHO

REGION

NUMBER OF TB CASE

NOTIFICATIONS

ESTIMATED TB INCIDENCE

BEST ESTIMATE UNCERTAINTY INTERVAL

#(4 361 645  ¿

#/4 63 626 100 000 91 000–110 000

'/4 101 910  240 000–330 000

'74 79 279 120 000 110 000–130 000

5'#4 431 470 1 100 000 990 000–1 200 000

924 392 030 510 000 460 000–550 000

Global 1 429 960 2 900 000 2 700 000–3 100 000

Mortality

In total, there were an estimated 410 000 TB deaths among

women in 2012. This includes 250 000 (range, 210 000–290 000)

TB deaths among HIV-negative women (29% of all TB deaths

among HIV-negative adults) and 160 000 (range, 150 000–

170 000) HIV-associated TB deaths (50% of all HIV-associated

TB deaths). Newly reported data and a decrease in the overall TB

mortality envelope explain the decrease in the estimated number

QH6$FGCVJUCOQPIYQOGPEQORCTGFYKVJßIWTGUTGRQTVGFKP

previous years (see also Box 2.1).

/QTVCNKV[FCVCFKUCIITGICVGFD[CIGCPFUGZHTQO84U[UVGOU

were used to produce estimates of TB deaths among HIV-negative

CFWNVUHQTEQWPVTKGU84FCVCYGTGCXCKNCDNGHQTEQWPVTKGU

but for China, age and sex-disaggregated data were not available).

TB deaths were calculated for women and men, after adjustment

HQTKPEQORNGVGEQXGTCIGCPFKNNFGßPGFECWUGUUGGAnnex 1

HQTHWTVJGTFGVCKNU(QTEQWPVTKGUYKVJQWV84FCVCCPGEQNQIKECN

statistical model was used to predict the ratio of male to female

TB mortality. The model included a set of risk factors known to be

associated with TB mortality (GDP per capita, the percentage of

PGYECUGUYKVJ/&46$*+8RTGXCNGPEGKPVJGIGPGTCNRQRWNCVKQP

and the treatment success rate). Globally, there were 2.55 (range,

¿OCNGFGCVJUCOQPI*+8PGICVKXGCFWNVUHQTGXGT[

female death (Figure B2.2.14GIKQPCNFKHHGTGPEGUCTGGXKFGPV

(Table B2.2.2), with the African and South-East Asia regions

accounting for 69% of total deaths. The main limitation in the

OGVJQFUWUGFKUVJCVVJGEQWPVTKGUTGRQTVKPIWUCDNG84FCVC

were all middle- or high-income countries. Predictions for low-

income countries had to be extrapolated from these countries.

TB deaths among HIV-positive people were disaggregated

by sex using the assumption that the male to female sex ratio

is similar to the sex ratio of AIDS deaths estimated by UNAIDS.

Globally, the numbers of HIV-associated TB deaths were similar

among men and women (Figure B2.2.2). However, there were

striking regional variations (Table B2.2.2+PVJG#HTKECP4GIKQP

more deaths occurred among women than men, while in other

regions more deaths were estimated to have occurred among men.

TABLE B2.2.2

Estimated number of TB deaths among women in 2012,

disaggregated by WHO region

HIV-NEGATIVE HIV-POSITIVE

BEST

ESTIMATE

UNCERTAINTY

INTERVAL

BEST

ESTIMATE

UNCERTAINTY

INTERVAL

#(4  53 000–110 000 140 000 130 000–150 000

#/4 5 900 5 000–6 700 2 000 1 900–2 200

'/4 32 000 ¿ 1 400 1 300–1 600

'74 10 000 9 700–10 000 1 200 1 000–1 300

5'#4 93 000 65 000–120 000  16 000–20 000

924 26 000 24 000–29 000 1 200 1 000–1 300

Global 250 000 210 000–290 000 160 000 150 000–170 000

The burden of TB in children: estimates of TB

notißcations, incidence and mortality (among those HIV-

negative), 2012

6$PQVKßECVKQPUCPFKPEKFGPEG

6JGINQDCNPWODGTQHPGY6$ECUGPQVKßECVKQPUCOQPIEJKNFTGP

CIGF[GCTUKUGUVKOCVGFCVaKPTable

B2.2.3). This includes cases reported among children and an

estimate of the number of cases among children in countries that

FKFPQVTGRQTVPQVKßECVKQPUFKUCIITGICVGFD[CIG(QTEQWPVTKGU

that did not report age-disaggregated data (Figure B2.2.3), it

YCUCUUWOGFVJCVVJGTCVKQQHEJKNFVQCFWNVPQVKßGFECUGUYCUVJG

same (for each case type) as in those countries that did report

PQVKßECVKQPUFKUCIITGICVGFD[CIGCPCNVGTPCVKXGOGVJQFWUKPI

VJGCUUWORVKQPVJCVVJGTCVKQQHEJKNFJQQFVQCFWNVPQVKßECVKQP

rates was the same gave similar results). WHO does not request

age-disaggregated data for relapse cases or those reported as of

unknown case type, and the number of children in these categories

YCUCUUWOGFVQDG\GTQ

To estimate TB incidence among children, it was assumed that

the case detection rate for all ages at the global level in 2012 (best

13GLOBAL TUBERCULOSIS REPORT 2013

estimate 66%, range 64%–69%)

was the same for adults and

children. On this basis, TB incidence

among children is estimated at

530 000 (range, 510 000–550 000)

in 2012, equivalent to about 6%

QHVJGVQVCNPWODGTQHOKNNKQP

incident cases.

Limitations of the methods used

KPENWFG

The assumption that the case

detection rate is the same for

adults and children, in the

absence of any data on levels

of underreporting of diagnosed

cases for children and adults

separately.

The assumption that reported

cases were true cases of TB. Misdiagnosis is possible, especially

IKXGPVJGFKHßEWNVKGUQHFKCIPQUKPI6$KPEJKNFTGP

The proportion of cases among children may be different in

countries for which age-disaggregated data were not available.

However, reporting of cases disaggregated by age has been

improving and the number of countries not reporting age-

disaggregated data was relatively low in 2012.

Mortality among HIV-negative children

/QTVCNKV[FCVCTGRQTVGFVQ9*1HTQO84U[UVGOUVJCVYGTG

disaggregated by age were available for 120 countries. These data

were used to calculate TB death rates per 100 000 population

for children and adults, after adjustment for incomplete coverage

CPFKNNFGßPGFECWUGUUGGAnnex 1 for further details). For

EQWPVTKGUYKVJQWV84FCVCCPGEQNQIKECNUVCVKUVKECNOQFGNYCUWUGF

to predict the ratio of childhood to adult TB mortality rates. The

total number of deaths from TB among HIV-negative children was

estimated to be 74 000 (range, 59 000–90 000), equivalent to

CDQWVQHVJGVQVCNPWODGTQHa6$FGCVJUCOQPI*+8

negative people in 2012.

An estimate of TB mortality among HIV-positive children

KUPQVKPENWFGFKPVJKUTGRQTVFWGVQVJGFKHßEWNVKGUCTKUKPI

from the miscoding of HIV deaths as TB deaths. However, age

disaggregation of HIV-associated TB mortality will be one of the

future outcomes of the TB component of Spectrum (see Box 2.1).

Steps to improve estimation of

6$ECUGUCOQPIEJKNFTGPKPENWFG

a global consultation to further

develop analytical methods and

VQFGßPGCPFRTKQTKVK\GCEVKQPU

needed to obtain new data in

September 2013;

promotion of case-based

electronic recording and

reporting systems that facilitate

compilation and analysis of age-

disaggregated data;

nationwide inventory surveys

to measure underreporting of

childhood TB;

more contact-tracing studies and

the integration of TB activities

in maternal, newborn and child

JGCNVJUGTXKEGUVQßPFEJKNFJQQF

cases that might otherwise not

be diagnosed.

●

Global

WPR

SEAR

EUR

EMR

AMR

AFR

1234

Sex Ratio (M:F)

FIGURE B2.2.1

The male:female ratio for HIV-negative

6$FGCVJUCOQPICFWNVUCIGFÜ

[GCTUINQDCNN[CPFHQT9*1TGIKQPU

●

Global

WPR

SEAR

EUR

EMR

AMR

AFR

123

Sex Ratio (M:F)

FIGURE B2.2.2

The male:female ratio for HIV-

associated TB deaths among adults

CIGFÜ[GCTUINQDCNN[CPFHQT

WHO regions

Age disaggregation

All case types disaggregated

Only smear-positive cases disaggregated

No age disaggregation

No data reported

FIGURE B2.2.3

4GRQTVKPIQHPQVKßECVKQPFCVCFKUCIITGICVGFD[CIG

TABLE B2.2.3

New TB case notißcations in 2012, by case type and

age disaggregation

SMEAR-

POSITIVE

SMEAR-

NEGATIVEa

EXTRA-

PULMONARY

Total notißcations  1 935 971 

Countries disaggregating by age 2 551 136 1 597 530 

Countries not disaggregating

by age 17 653  

VQVCNPQVKßECVKQPU

disaggregated) (99%)  

Number of countries that report-

ed notißcations disaIIreIated by

aIe number of *BCsb

204 (22)  

Total childhood notißcations from

countries disaIIreIatinI by aIe 163 477 

Total estimated childhood

notißcations amonI all countries 349 000

a This includes reported cases for whom smear results were unknown or not done.

b #PCFFKVKQPCNPKPGEQWPVTKGUTGRQTVGF\GTQ6$ECUGUHQTCPFVJTGGEQWPVTKGU

had not reported data to WHO by July 2013.

14 GLOBAL TUBERCULOSIS REPORT 2013

FIGURE 2.4

Estimated HIV prevalence in new TB cases, 2012

HIV prevalence

in new TB cases,

all ages (%)

0–4

5–19

20–49

≥50

No data

Not applicable

FIGURE 2.5

Estimated TB incidence rates, 2012

Estimated new TB

cases (all forms) per

100 000 population

per year

0–9.9

10–19

20–49

50–124

125–299

300–499

≥500

No data

Not applicable

15GLOBAL TUBERCULOSIS REPORT 2013

FIGURE 2.6

Global trends in estimated rates of TB incidence, prevalence and mortality. .GHV)NQDCNVTGPFUKPGUVKOCVGF

incidence rate including HIV-positive TB (green) and estimated incidence rate of HIV-positive TB (red%GPVTGCPFTKIJV

Trends in estimated TB prevalence and mortality rates 1990–2012 and forecast TB prevalence and mortality rates

¿6JGJQTK\QPVCNFCUJGFNKPGUTGRTGUGPVVJG5VQR6$2CTVPGTUJKRVCTIGVUQHCTGFWEVKQPKPRTGXCNGPEGCPF

mortality rates by 2015 compared with 1990. Shaded areas represent uncertainty bands. Mortality excludes TB deaths among

HIV-positive people.

Rate per 100 000 population per year

Incidence

1990 1995 2000 2005 2010

100

150

Prevalence

1990 1995 2000 2005 2010 2015

100

200

300

Rate per 100 000 population

Mortality

1990 1995 2000 2005 2010 2015

Rate per 100 000 population per year

FIGURE 2.7

Estimated TB incidence rates by WHO region, 1990–2012. 4GIKQPCNVTGPFUKPGUVKOCVGF6$KPEKFGPEGTCVGUgreen)

and estimated incidence rates of HIV-positive TB (red). Shaded areas represent uncertainty bands.

Rate per 100 000 population per year

1990 1995 2000 2005 2012 1990 1995 2000 2005 20121990 1995 2000 2005 2012

Africa The Americas Eastern Mediterranean

Europe South-East Asia Western Pacific

100

200

300

400

100

150

200

100

200

300

100

150

200

100000 population. Most countries in the Region of the

Americas have rates below 50 per 100000 population and

this is the region with the lowest burden of TB on average.

Most of the HBCs have rates of around 150‒300 cases per

100000 population (Table 2.2); HBCs with markedly lower

rates are Brazil and China, while rates are above 500 per

100000 population in Mozambique, South Africa and Zim-

babwe. Other countries in the top ten worldwide in terms of

incidence rates are mostly in Africa (Figure 2.3). In South

Africa and Swaziland, the best estimate is that at least 1 in

every 100 people (1000 or more per 100000 population)

develops TB each year.

Globally, the incidence rate was relatively stable from

1990 up to around 2001, and then started to fall (Figure

2.6), achieving the MDG target ahead of the 2015 deadline.

Between 2011 and 2012, the rate of decline was 2%. is

downward trend needs to be sustained to ensure that the

MDG target is met in 2015. Incidence rates are also declin-

16 GLOBAL TUBERCULOSIS REPORT 2013

ing in all of six WHO regions (Figure 2.7), fastest in the

European Region (6.5% per year) and slowest in the Eastern

Mediterranean and South-East Asia Regions (less than 1%

per year and 2% per year, respectively). Incidence rates have

been falling since the mid-1990s in the Eastern Mediterra-

nean Region and since around 2000 in the South-East Asia

Region; they peaked around 1997 in the European Region

and around 2002 in the African region, and have been fall-

ing since 1990 in the Region of the Americas and the West-

ern Pacic Region. e latest assessment for the 22 HBCs

suggests that incidence rates are falling in most countries

(Figure 2.8).

2.2 TB prevalence

In countries with a relatively high burden of TB (around

100 cases per 100000 population or more), the prevalence

of bacteriologically-conrmed pulmonary TB can be direct-

ly measured in nationwide population-based surveys using

sample sizes of around 50000 people. Survey results can be

FIGURE 2.8

Estimated TB incidence rates, 22 high-burden countries, 1990–2012. Trends in estimated TB incidence rates

(green) and estimated incidence rates of HIV-positive TB (red). Shaded areas represent uncertainty bands.

a Estimates of TB disease burden have not been approved by the national TB programme in Bangladesh and a joint reassessment will be undertaken following the completion

of the prevalence survey planned for 2014.

Rate per 100 000 population per year

100

200

300

100

200

300

400

500

250

500

750

1000

1250

100

150

200

100

200

300

400

250

500

750

1000

1250

250

500

750

1000

1250

100

150

200

250

500

750

1000

1250

100

200

300

200

400

600

200

400

600

100

200

300

400

200

400

600

200

400

600

800

100

200

300

100

200

300

100

200

300

400

100

200

300

400

100

150

250

500

750

1000

100

150

200

1990 1995 2000 2005 2012 1990 1995 2000 2005 2012

1990 1995 2000 2005 2012 1990 1995 2000 2005 2012 1990 1995 2000 2005 2012

Afghanistan BangladeshaBrazil Cambodia China

DR Congo Ethiopia India Indonesia Kenya

Mozambique Myanmar Nigeria Pakistan Philippines

Russian Federation South Africa Thailand Uganda UR Tanzania

Viet Nam Zimbabwe

1 TB prevalence surveys: a handbook. Geneva, World Health Organiza-

tion, 2011 (WHO/HTM/TB/2010.17). Available at www.who.int/

tb/advisory_bodies/impact_measurement_taskforce/resources_

documents/thelimebook/

used to produce a national estimate of TB prevalence that

includes all forms of TB. e cost of a survey usually rang-

es from US$1 to4 million, and comprehensive theoretical

and practical guidance on survey design, implementation,

analysis and reporting of results is available.1 Repeat sur-

veys conducted about every 10 years allow trends in disease

burden to be assessed. HBCs that have completed repeat

surveys in the last 10 years include Cambodia, China, the

Philippines and ailand, and repeat surveys are planned

in Myanmar and Viet Nam. Countries in which surveys

have been implemented or are planned in the near future

are shown in Figure 2.9. Between 2008 and 2017, an

unprecedented number of national TB prevalence surveys

have been or will be conducted (see also section 2.4).

In low- and medium-burden countries, sample sizes and

17GLOBAL TUBERCULOSIS REPORT 2013

costs become prohibitively large. If survey data are not

available, prevalence can be indirectly estimated as the

product of incidence and the average duration of disease,

but with considerable uncertainty (Annex 1). TB preva-

lence can be estimated only indirectly for most countries.

ere were an estimated 12 million prevalent cases

(range, 11million–13million) of TB in 2012 (Table 2.1),

equivalent to 169 cases per 100000 population (Table 2.2).

By 2012, the prevalence rate had fallen 37% globally since

1990. Current forecasts suggest that the Stop TB Partner-

ship target of halving TB prevalence by 2015 compared

with a baseline of 1990 will not be met worldwide (Figure

2.6). Regionally, prevalence rates are declining in all six

WHO regions (Figure 2.10). e Region of the Americas

halved the 1990 level of TB prevalence by around 2004,

well in advance of the target year of 2015, and the best

estimate suggests that the Western Pacic Region achieved

the 50% reduction target in 2012. Reaching the 50% reduc-

tion target by 2015 appears feasible in the South-East Asia

Region and also in the European Region with a relatively

small acceleration in the current rate of progress. e target

appears out of reach in the African and Eastern Mediterra-

nean Regions.

FIGURE 2.9

Countries in which national population-based surveys of the prevalence of TB disease have been

implemented using currently recommended screening and diagnostic methodsa since 1990 or are planned

in the near future: status in July 2013

a 5ETGGPKPIOGVJQFUKPENWFGßGNFEJGUV:TC[EWNVWTGKUWUGFVQEQPßTOFKCIPQUKU

b “National survey planned” means that a country has submitted at least a draft survey protocol and a budget to the WHO Global Task Force on TB Impact Measurement.

No national

survey planned

National survey

plannedb

National survey

ongoing

One national

survey completed

Repeat national survey

planned

≥1 repeat national survey

completed

Not applicable

2.3 TB mortality

TB mortality among HIV-negative people can be directly

measured using data from national VR systems, provided

that these systems have high coverage and causes of death

are accurately coded according to the latest revision of the

International classication of diseases (ICD-10). Sample VR

systems covering representative areas of the country (e.g.

as in China) provide an interim solution. Mortality surveys

can also be used to estimate deaths caused by TB. In 2012,

most countries with a high burden of TB lacked national or

sample VR systems and few had conducted mortality sur-

veys. In the absence of VR systems or mortality surveys, TB

mortality can be estimated as the product of TB incidence

and the case fatality rate, or from ecological modelling

based on mortality data from countries with VR systems.

TB mortality among HIV-positive people is hard to measure

even when VR systems are in place because deaths among

HIV-positive people are coded as HIV deaths and contribu-

tory causes (such as TB) are often not reliably recorded. For

this 2013 report, country-specic estimates of TB deaths

among HIV-positive people were produced for the rst time

using the Spectrum software that has been used for HIV

burden estimates for over a decade (Box 2.1).

Until 2008, WHO estimates of TB mortality used

VR data for only three countries. is was substantially

improved to 89 countries in 2009; however most of the

data were from countries in the European Region and the

 GLOBAL TUBERCULOSIS REPORT 2013

FIGURE 2.10

Trends in estimated TB prevalence rates 1990–2012 and forecast TB prevalence rates 2013–2015, by WHO

region. 5JCFGFCTGCUTGRTGUGPVWPEGTVCKPV[DCPFU6JGJQTK\QPVCNFCUJGFNKPGUTGRTGUGPVVJG5VQR6$2CTVPGTUJKRVCTIGVQHC

50% reduction in the prevalence rate by 2015 compared with 1990. The other dashed lines show projections up to 2015.

Rate per 100 000 population

Africa The Americas Eastern Mediterranean

Europe South-East Asia Western Pacific

200

400

100

150

100

200

400

100

200

300

400

100

200

1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015

BOX 2.3

MDR-TB mortality – methods used to produce updated estimates

#URCTVQHCINQDCNTGRQTVQPVJG/&46$GRKFGOKECPFVJGINQDCNTGURQPUGKVYCUGUVKOCVGFVJCVVJGTGYGTGaFGCVJU

TCPIGa¿aHTQO/&46$KPa6JKUYCUVJGßTUVVKOG9*1RWDNKUJGFCINQDCNGUVKOCVGQH/&46$OQTVCNKV[CPF

given limitations in the available evidence, annual updates have not been attempted.

+PVJGQT[VJGPWODGTQHFGCVJUHTQO/&46$ECPDGGUVKOCVGFCUVJGRTQFWEVQHVQVCNFGCVJUHTQO6$VJGQXGTCNNRTQRQTVKQP

QH6$ECUGUVJCVJCXG/&46$CPFVJGTGNCVKXGTKUM44QHF[KPICOQPIRGQRNGYKVJ/&46$EQORCTGFYKVJVJQUGYKVJQWV

/&46$*QYGXGTYJKNGGUVKOCVGUQHVQVCN6$OQTVCNKV[CPFVJGRTGXCNGPEGQH/&46$JCXGDGGPCXCKNCDNGHQTUGXGTCN[GCTUHTQO84

FCVCKGHQTVQVCN6$FGCVJUCPFTGRTGUGPVCVKXGUWTXGKNNCPEGQTUWTXG[FCVCHQTVJGRTQRQTVKQPQHECUGUYKVJ/&46$CPGUVKOCVG

QHVJG44YCUPQV

+P9*1EQOOKUUKQPGFCU[UVGOCVKETGXKGYQHVJG44QHF[KPIHTQO/&46$EQORCTGFYKVJ6$6YGPV[ßXGUVWFKGUVJCV

KPENWFGFFCVCCDQWVOQTVCNKV[COQPIRCVKGPVUGPTQNNGFQPVTGCVOGPVHQT/&46$CPF6$YKVJQWV/&46$FWTKPICPFCHVGT

VTGCVOGPVYGTGKFGPVKßGF6JGUGCNNQYGFECNEWNCVKQPQHCINQDCNGUVKOCVGQHVJG44QHF[KPIHTQO/&46$TCPIG¿

6JGUVWFKGUJCFCDTQCFIGQITCRJKECNEQXGTCIGCPFKPENWFGFEQWPVTKGUYKVJDQVJJKIJCPFNQYDWTFGPUQH/&46$CPF*+8DWV

YGTGKPUWHßEKGPVVQGUVKOCVGTGIKQPURGEKßE44U

$CUGFQPVJGTGUWNVUQHVJGOGVCCPCN[UKUKVKUGUVKOCVGFVJCVINQDCNN[KPVJGTGYGTGaFGCVJUTCPIGa¿

aHTQO/&46$

a MultidruI- and eZtensiXely druI-resistant TB M:&4-TB 2010 Ilobal report on surXeillance and response (WHO/HTM/TB/2010.3). Geneva, World Health

1TICPK\CVKQP#XCKNCDNGCVJVVRYYYYJQKPVVDRWDNKECVKQPUGP

19GLOBAL TUBERCULOSIS REPORT 2013

Region of the Americas, which accounted for less than 10%

of the world’s TB cases. In 2011, the rst uses of sample

VR data from China and survey data from India enabled a

further major improvement to estimates of TB mortality.

For the current report, VR data of sucient coverage and

quality were available for 121 countries. Combined with

survey data from India and Viet Nam, this means that esti-

mates of TB mortality are based on direct measurements

of TB mortality in 123 countries (shown in Figure 2.11).

Collectively, these 123 countries account for 45% of the

estimated number of TB deaths globally. e parts of the

world where there are major gaps in the availability of VR

data are the African Region and parts of the South-East

Asia Region; in the latter, Indonesia is currently building a

sample VR system.

ere were an estimated 1.3 million TB deaths in 2012

(Table 2.1, Figure 2.2): 940000 among HIV-negative peo-

ple and 320 000 among HIV-positive people (TB deaths

among HIV-positive people are classied as HIV deaths in

ICD-10).1 ese deaths included 410000 among women and

74000 among children (Box 2.2). ere were approximate-

ly 170000 deaths from MDR-TB (range, 102000‒242000):

methods used to produce this new global estimate of MDR-

TB mortality are explained in Box 2.3.

Approximately 75% of total TB deaths occurred in the

African and South-East Asia Regions in 2012 (both includ-

ing and excluding TB deaths among HIV-positive people).

India and South Africa accounted for about one-third of

global TB deaths.

e number of TB deaths per 100000 population aver-

aged 13 globally in 2012 (

Table 2.2) and 17.6 when TB

deaths among HIV-positive people are included. ere is

considerable variation among countries (Figure 2.12),

ranging from under 1 TB death per 100 000 population

(examples include most countries in western Europe, Can-

ada, the United States of America, Australia and New Zea-

land) to more than 40 deaths per 100000 population in

much of the African Region as well as three HBCs in Asia

(Bangladesh, Cambodia and Myanmar).

Globally, mortality rates (excluding deaths among

HIV-positive people)2 have fallen by 45% since 1990; the

current forecast suggests that the Stop TB Partnership

target of a 50% reduction in TB mortality by 2015 com-

pared with a baseline of 1990 will be achieved (Figure 2.6).

Mortality rates are declining in all six WHO regions (Fig-

ure 2.13). e 2015 target has already been surpassed in

the Region of the Americas (since 2004) and the Western

Pacic Region (since 2002), and may have been reached in

the Eastern Mediterranean Region. Among the other three

regions, the South-East Asia Region appears best placed

to achieve the target. Mortality rates appear to be falling

in most of the 22 HBCs (Figure 2.14), although there is

considerable uncertainty about the level of and trends in

mortality in some countries, notably Mozambique, Nigeria,

South Africa and Zimbabwe.

FIGURE 2.11

Countries (in orange) for which TB mortality is estimated using measurements from vital registration (n=121)

systems and/or mortality surveys (n=2, India and Viet Nam)

1 International statistical classication of diseases and related health

problems, 10th revision (ICD-10), 2nd ed. Geneva, World Health

Organization, 2007.

2 Trends in TB mortality rates are restricted to TB deaths among

HIV-negative people, given that TB deaths among HIV-positive

people are classied as HIV deaths in ICD-10.

20 GLOBAL TUBERCULOSIS REPORT 2013

FIGURE 2.12

Estimated TB mortality rates excluding TB deaths among HIV-positive people, 2012

Estimated TB

deaths per

100 000 population

0–0.9

1–3.9

4–9.9

10–19

20–39

≥40

No data

Not applicable

FIGURE 2.13

Trends in estimated TB mortality rates 1990–2012 and forecast TB mortality rates 2013–2015, by WHO

region. Estimated TB mortality excludes TB deaths among HIV-positive people. Shaded areas represent uncertainty bands.a

6JGJQTK\QPVCNFCUJGFNKPGUTGRTGUGPVVJG5VQR6$2CTVPGTUJKRVCTIGVQHCTGFWEVKQPKPVJGOQTVCNKV[TCVGD[

compared with 1990. The other dashed lines show projections up to 2015.

a The width of an uncertainty band narrows as the proportion of regional mortality estimated using vital registration data increases or the quality and completeness of the vital

registration data improves.

2.5

5.0

7.5

1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015

Rate per 100 000 population per year

Africa The Americas Eastern Mediterranean

Europe South-East Asia Western Pacific

21GLOBAL TUBERCULOSIS REPORT 2013

FIGURE 2.14

Trends in estimated TB mortality rates 1990–2012 and forecast TB mortality rates 2013–2015, 22 high-

burden countries. 'UVKOCVGF6$OQTVCNKV[GZENWFGU6$FGCVJUCOQPI*+8RQUKVKXGRGQRNG6JGJQTK\QPVCNFCUJGFNKPGU

represent the Stop TB Partnership target of a 50% reduction in the mortality rate by 2015 compared with 1990. The

other dashed lines show projections up to 2015.a Uncertainty is due to adjustments made to the mortality data from vital

registration systems that were reported by countries (mortality data from vital registration systems are represented by the “x”

symbol). Further explanation of methods is provided in Annex 1.

a The width of an uncertainty band narrows as the quality and completeness of vital registration

data improves.

b Estimates of TB disease burden have not been approved by the national TB programme in

Bangladesh and a joint reassessment will be undertaken following the completion of the

prevalence survey planned for 2014.

Afghanistan BangladeshbBrazil Cambodia China

DR Congo Ethiopia India Indonesia Kenya

Mozambique Myanmar Nigeria Pakistan Philippines

Russian Federation South Africa Thailand Uganda UR Tanzania

Viet Nam Zimbabwe

Rate per 100 000 population per year

100

150

100

1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015

1990 1995 2000 2005 2010 2015

100

200

100

200

300

100

2.5

5.0

7.5

100

200

300

100

150

200

100

150

2.4 Strengthening measurement of the

burden of disease caused by TB:

the WHO Global Task Force on TB Impact

Measurement

e estimates of TB incidence, prevalence and mortality

and their trend presented in sections 2.1–2.3 are based

on the best available data and analytical methods. None-

theless, there remains considerable scope to improve mea-

surement of the level of and trends in TB disease burden.

is nal section of the chapter describes the latest status

of eorts to improve measurement of the burden of dis-

ease caused by TB, under the umbrella of the WHO Global

Task Force on TB Impact Measurement. is task force was

established in 2006 and includes representatives from lead-

ing technical and nancial partners and countries with a

high burden of TB.1

At its second meeting in December 2007, the Global Task

Force on TB Impact Measurement dened three strategic

areas of work:2

strengthening surveillance towards the ultimate goal

of direct measurement of incidence and mortality from

notication and VR systems, respectively;

1 Many countries with a high burden of TB are engaged in the work of

the Task Force. Partners that are actively participating in the work

of the Task Force include the Centers for Disease Control and Pre-

vention in the USA, the European Centre for Disease Prevention

and Control, the Global Fund, Public Health England, the KNCV

Tuberculosis Foundation, the London School of Hygiene and Trop-

ical Medicine in the UK, the Research Institute for Tuberculosis in

Japan, the Union and the United States Agency for International

Development (USAID).

2 TB impact measurement: policy and recommendations for how to

assess the epidemiological burden of TB and the impact of TB control.

Geneva, World Health Organization, 2009 (Stop TB policy paper

no. 2; WHO/HTM/TB/2009.416). Available at www.who.int/tb/

publications/2009/impactmeasurementpolicy/

22 GLOBAL TUBERCULOSIS REPORT 2013

conducting surveys of the prevalence of TB disease in a

set of global focus countries that meet epidemiological

and other relevant criteria; and

periodic review and updating of the methods used to

translate surveillance and survey data into estimates of

TB incidence, prevalence and mortality.

In 2008 and 2009, methods were thoroughly reviewed and

updated by an expert group convened by the task force.

Updates were discussed and endorsed by the full task force

in March 2010. Current methods are described in detail in

Annex 1, and an updated review is planned in 2014 (Box

2.1). e following sections focus on the other two strate-

gic areas of work: strengthened surveillance and national

TB prevalence surveys. Further details are available on the

task force’s web site.1

2.4.1 Strengthening surveillance

Reasons for uncertainty in current estimates of TB inci-

dence include use of expert opinion about both the num-

ber of cases that are diagnosed but not reported to national

surveillance systems and the number of cases that are not

diagnosed at all (section 2.1). Major challenges in estimat-

ing TB mortality include the lack of VR systems of su-

cient coverage and quality in many countries, notably in

Africa and parts of Asia (Figure 2.11). e long-term goal

of directly measuring the level of and trends in TB disease

burden from routine surveillance data, using notication

data to measure TB incidence and VR data to measure TB

mortality, requires strengthened surveillance in many

countries. Countries for which more robust estimates of

mortality were available in 2012 are shown in Figure 2.11.

TB surveillance checklist of standards and benchmarks

Strengthening surveillance to move towards the goal of

direct measurement of TB incidence and mortality requires

a clear understanding of what a ‘model’ surveillance system

should look like and a method for assessing the current per-

formance of TB surveillance. Following considerable work

in 2011 and 2012, a TB surveillance checklist that denes

the standards and associated benchmarks that need to be

met for a country’s notication and VR data to be used as

a direct measure of TB incidence and mortality has been

developed (Box 2.4).

Use of the checklist began in January 2013 and it is being

applied in a growing number of countries (Figure 2.15) as

the basis for identifying what standards are already met

and the investments required to close remaining gaps.

is work is being undertaken in close collaboration with

the Global Fund so that use of the checklist is integrated

into the fund’s grant processes and ndings can inform

investments by the fund as well as national governments

and other partners (Box 2.5). With more than 100 low-

and middle-income countries receiving TB grants from the

Global Fund, this approach has great potential to make a

real dierence to TB surveillance worldwide. An initial list

of 25 priority countries has been dened.

Inventory studies to measure or estimate

TB underreporting

One of the standards in the TB surveillance checklist is

that all diagnosed cases of TB are reported to the national

surveillance system. e two benchmarks that must be sat-

ised are that TB reporting is a legal requirement, and that

≥90% of TB cases are reported to national health authori-

ties, as determined by a national-level investigation such as

an inventory study. To date, few countries have implement-

ed an inventory study but as the number doing so increas-

es, estimates of the level of and trend in TB incidence will

improve. Even when underreporting is considerable and

notication data are not a good proxy for TB incidence,

results from inventory studies can be used to quantify the

gap and obtain more precise estimates of disease burden

and provide valuable information about where eorts to

collaborate with public and private sector providers are

needed (see also Chapter 3, section 3.2.1). In 2012, the

Global Task Force on TB Impact Measurement completed a

guide on how to design and implement an inventory study,

and how to analyse and report results.2

In the past 10 years, inventory studies combined with

capture–recapture analysis have been implemented in the

Netherlands, the UK, French Guiana, Egypt, Iraq, Pakistan

and Yemen. Results from the study in Iraq are summarized

in Box 2.6.

Electronic recording and reporting of data

Several of the standards in the TB surveillance checklist

are about data quality. In all of the regional and country

workshops held between 2008 and 2013, it was evident that

it is much easier to assess the quality of TB surveillance

data in countries with case-based electronic recording and

reporting systems. Besides facilitating assessment of data

quality, electronic recording and reporting systems have

other major advantages compared to systems based solely

on paper-based recording and reporting. ese include:

Better programme and resource management, by

encouraging sta to use and act upon live data. is may

help to prevent defaulting from treatment and assist

with management of drug supplies (including avoidance

of stock-outs).

Improved surveillance by making it easier for facilities

not traditionally linked to the NTP, such as hospitals,

prisons and the private sector, to report TB cases, and by

reducing the burden of compiling and submitting data

through paper-based quarterly reports.

Analysis and use of data is facilitated, since data can be

readily imported into statistical packages. Results are

then available to decision-makers more quickly and it is

possible to detect outbreaks promptly.

1 www.who.int/tb/advisory_bodies/impact_measurement_

taskforce

2 Assessing tuberculosis underreporting through inventory studies. Gene-

va, World Health Organization, 2013 (WHO/HTM/TB/2012.12).

Available at: www.who.int/tb/publications/inventory_studies/en/

index.html

23GLOBAL TUBERCULOSIS REPORT 2013

BOX 2.4

The TB surveillance checklist of standards and benchmarks

A major goal of TB surveillance is to

provide an accurate measure of the

number of new TB cases and TB deaths

that occur each year, and to be able

to assess trends over time. In some

countries, TB surveillance already meets

the standards necessary to do this, but

in others there are important gaps. For

example, TB cases that are diagnosed

in the private sector are not reported

in many settings, and in many low- and

middle-income countries some people

with TB may not easily access health

care and therefore not be diagnosed

at all. Furthermore, a large number of

countries lack vital registration systems

with the geographical coverage and

quality required to accurately measure

deaths caused by TB (section 2.3). The

Checklist of standards and benchmarks

for TB surXeillance and Xital reIistration

systems was developed with the

HQNNQYKPIQDLGEVKXGU

To assess a national surveillance

system’s ability to accurately measure

TB cases and deaths.

To identify TB surveillance gaps in

national surveillance systems that

need to be addressed.

The outcomes of the checklist can

be used to identify countries with

surveillance systems that already provide

an accurate measure of the number of

TB cases and deaths that occur each

[GCTCPFVQFGßPGVJGCEVKQPUPGEGUUCT[

to strengthen surveillance in countries

KPYJKEJICRUCTGKFGPVKßGFa Countries

KPVJGHQTOGTECVGIQT[ECPDGEGTVKßGF

as having surveillance data that provide

a direct measure of TB incidence and/or

mortality.

The checklist was developed by a

team of experts in disease surveillance

in conjunction with expert advice

HTQOOGGVKPIUQTICPK\GFD[9*1KP

September 2011 and May 2012. The

checklist underwent two rounds of

ßGNFVGUVKPIKPGNGXGPEQWPVTKGU$TC\KN

China, Egypt, Estonia, Japan, Kenya,

the Netherlands, Thailand, Uganda, the

United Kingdom and the United States

of America.

The checklist is ten pages long

and has two parts. Part A consists of

eighteen questions that are used to

characterise the national TB surveillance

system; these provide the background

for part B, which consists of thirteen

standards and their associated

benchmarks. The standards are general

statements about the characteristics

VJCVFGßPGCJKIJRGTHQTOCPEG6$

surveillance system; nine standards

are related to the measurement of

TB cases and one is related to the

measurement of TB deaths. There are

three supplementary standards that can

be used to assess whether a country’s

surveillance system provides a direct

measure of the number of drug-resistant

TB cases, HIV-positive TB cases, and TB

cases among children. For each of the

VJKTVGGPUVCPFCTFUDGPEJOCTMUFGßPG

(in quantitative terms wherever possible)

the level of performance considered

UWHßEKGPVVQOGGVVJGTGURGEVKXG

standard. An accompanying user guide

explains the rationale for each standard

and associated benchmark(s), and the

methods that should be used to assess

whether the benchmarks and hence the

standard are met. Illustrative examples

are also provided in the user guide.

Based on a completed assessment

using the checklist, countries can

identify key actions needed to address

KFGPVKßGFICRUKPPQVKßECVKQPCPFXKVCN

registration systems. It is anticipated

that an assessment of TB surveillance

using the checklist would take place

GXGT[VJTGGVQßXG[GCTUDWVEQWNFCNUQ

be done more frequently.

Following the 2012

recommendations of the Global Fund’s

6GEJPKECN'XCNWCVKQP4GHGTGPEG)TQWR

and a collaborative agreement between

the fund and WHO, assessments of TB

surveillance using the checklist are

increasingly being integrated within

the fund’s grant mechanisms. As such,

assessments with the checklist should

be timed to coincide with programme

reviews, Global Fund grant renewals

and the development of the concept

notes required to access funding in

the fund’s new funding model (NFM)

NCWPEJGFKP4GUWNVUECPVJGPDG

used to develop or update monitoring

and evaluation investment plans that

can be supported through grants from

the Global Fund as well as by national

budgets and by other partners. This

collaborative effort with the Global

Fund has great potential to help

strengthen TB surveillance in more than

a hundred countries receiving grants

worldwide. Assessments in 15 high-

burden and high-impact countries are

DGKPIRTKQTKVK\GFKPCPF

by August 2013, a total of eleven

countries including eight of the fund’s

high-burden or high-impact countries

had completed the assessment (Figure

2.15).

The checklist and user guide

are available on the website of the

WHO Global Task Force on TB Impact

/GCUWTGOGPV

JVVRYYYYJQKPVVDCFXKUQT[ADQFKGU

KORCEVAOGCUWTGOGPVAVCUMHQTEGGP

a The checklist is not intended to assess a

U[UVGOÂUCDKNKV[VQHWNßNQVJGTRTQITCOOCVKE

requirements, e.g. patient care, delivery of

laboratory results, or drug management.

Higher quality data, since automated data quality checks

can be used and duplicate or misclassied notications

can be identied and removed (which is very dicult or

impossibleto do nationally with paper-based systems).

It is also easier to introduce new data items.

Identication of clusters of cases in space and time,

including clusters of drug-resistant cases, thus allowing

early investigation and containment of epidemics.

Countries that have national electronic case-based data-

bases of TB patients are shown in Figure 2.16. A recent

example of the implementation of a case-based electron-

ic recording and reporting system, in Kenya, is described

in Box 2.7. Recent guidance on electronic recording and

reporting for TB care and control, developed by WHO and

partners in 2011, is available on the task force’s website.1

1 Electronic recording and reporting for TB care and control. Geneva,

World Health Organization, 2013 (WHO/HTM/TB/2011.22).

Available at www.who.int/tb/publications/electronic_recording_

reporting

24 GLOBAL TUBERCULOSIS REPORT 2013

BOX 2.5

The TB surveillance checklist in Indonesia: from implementation to resource mobilization

A national assessment of the TB surveillance system in

Indonesia using the Checklist of standards and benchmarks for

TB surXeillance and Xital reIistration systems (see Box 2.4)

was undertaken in February 2013, linked to a national

programme review.

A thorough analysis of all available national, provincial

CPFFKUVTKEVNGXGNVKOGUGTKGUQH6$PQVKßECVKQPCPFQVJGT

available surveillance data was completed. A desk review of NTP

manuals, guidelines, policy and training documents, annual

reports, reporting forms and registers was conducted. Other

information was collected through interviews with NTP staff,

partners and other stakeholders.

The TB surveillance system is based on quarterly reporting

QHPQVKßGFECUGUHTQOJGCNVJHCEKNKVKGUVQFKUVTKEVUVQRTQXKPEGU

CPFßPCNN[VQVJGPCVKQPCNNGXGN+VKUEWTTGPVN[VTCPUKVKQPKPI

to a web- and case-based electronic recording and reporting

U[UVGO6$ECUGFGßPKVKQPUYGTGEQPUKUVGPVYKVJKPVGTPCVKQPCN

IWKFGNKPGU6JGTGYGTGQWVQHFKUVTKEVUKPVJGEQWPVT[

that submitted all quarterly reports to the national level in

2011. The system produced externally but not internally

consistent data. Since TB reporting is not a legal requirement,

not all TB cases were reported to the NTP, but the level of

underreporting of cases from the private to the public sector

has not been measured nationally. There have been steady

improvements in access to health care, but it is still not at

CNGXGNUWHßEKGPVVQGPUWTGVJCVCNN6$ECUGUJCXGCEEGUUVQ

FKCIPQUKUCPFECTG#PCVKQPCNN[TGRTGUGPVCVKXG84U[UVGOYKVJ

standard coding of causes of death is being developed. Only

provincial level drug resistance surveys have been conducted

so far, and while HIV testing of TB cases was improving the

coverage remains low. Finally, childhood TB was diagnosed in

limited settings.

#EVKXKVKGUVQCFFTGUUVJGICRUVJCVYGTGKFGPVKßGFHTQO

VJGKORNGOGPVCVKQPQHVJGEJGEMNKUVYGTGFGßPGFUGGTable

B2.7.1). One of the top priorities is maintenance of the sample

84U[UVGOYJKEJEQUVU75¿RGTECRKVCKPVJGUCORNGF

CTGCUGSWKXCNGPVVQCDQWV75a¿OKNNKQPRGT[GCTHQTVJG

population of 5 million to be covered). For the other activities

in Table B2.7.1, the total budget requirement was estimated

VQDG75aOKNNKQPCOQPIYJKEJQPGVQRRTKQTKV[KFGPVKßGF

in the key recommendations arising from the 2013 programme

TGXKGYKUKORNGOGPVCVKQPQHCOCPFCVQT[PQVKßECVKQPRQNKE[

Through continuous consultations between the NTP, WHO and

VJG)NQDCN(WPFVJGßPCPEKPITGSWKTGFHQTVJGKPXGUVOGPVRNCP

YCUKFGPVKßGFCPFUGEWTGF

This example shows how the checklist can be used to

EQPFWEVCUVCPFCTFK\GFCUUGUUOGPVQH6$UWTXGKNNCPEGJKIJNKIJV

progress achieved as well as remaining gaps to be addressed,

and to secure funding for an investment plan to close the gaps

with support from the Global Fund.

TABLE B2.7.1

Investment plan for strengthening surveillance in

+PFQPGUKCDCUGFQPICRUKFGPVKßGFVJTQWIJVJG

implementation of the Checklist of standards and

benchmarks for TB surveillance and vital registration

systemsVQVCNDWFIGV75aOKNNKQPGZENWFKPI84

U[UVGOHWPFGFUGRCTCVGN[

Activity

■ 8KVCNTGIKUVTCVKQP84OCKPVCKPKPICPFUECNKPIWRVJGPCVKQPCNN[

TGRTGUGPVCVKXGUCORNG84U[UVGO

■ Inventory study to measure the level of underreporting

■ Capacity building for data management and statistical analysis –

VJTQWIJCVVGPFKPIEQWTUGUCPFGZVTCUVCHßPICVVJGEGPVTCNNGXGN

■ Implementation of the SerXice #Xailability and 4eadiness

#ssessment Tool and health facility data quality assessment

■ Assessment of the Integrated Tuberculosis Information System (SITT)

Phase 2 in 2014

■ +ORNGOGPVKPIOCPFCVQT[PQVKßECVKQPRQNKE[

■ Analysis of available mortality data

■ Drug resistance survey or sentinel surveillance

■ Nationally representative survey of HIV prevalence among TB

patients

■ Corrective actions required to compile all the reports from Papua

1 TB prevalence surveys: a handbook. Geneva, World Health Organiza-

tion, 2011 (WHO/HTM/TB/2010.17). Available at www.who.int/

tb/advisory_bodies/impact_measurement_taskforce/resources_

documents/thelimebook/

2.4.2 National surveys of the prevalence of

TB disease

Before 2007, few countries had implemented nationwide

prevalence surveys. In the 1990s, national surveys were

conned to China, Myanmar, the Philippines and the

Republic of Korea. Before 2009 and with the exception of

Eritrea in 2005, the last national surveys in the African

Region were undertaken between 1957 and 1961. From

2002 to 2008, there was typically one survey per year.

In 2007, WHO’s Global Task Force on TB Impact Mea-

surement identied 53 countries that met epidemiological

and other criteria for implementing a survey. A set of 22

global focus countries were selected to receive particular

support in the years leading up to 2015. e African coun-

tries were: Ethiopia, Ghana, Kenya, Malawi, Mali, Mozam-

bique, Nigeria, Rwanda, Sierra Leone, South Africa, Uganda,

the United Republic of Tanzania and Zambia. Countries in

Asia were: Bangladesh, Cambodia, China, Indonesia, Myan-

mar, Pakistan, the Philippines, ailand and Viet Nam.

Since early 2008, substantial eorts to support countries

to design, implement, analyse and report on surveys have

been made. Examples include development of updated guid-

ance,1 coordination of technical assistance, expert reviews

of protocols, organization of study tours and mid-term sur-

vey reviews, and global and regional workshops to support

survey design and implementation and to share results and

lessons learned among countries. As part of these eorts,

25GLOBAL TUBERCULOSIS REPORT 2013

FIGURE 2.15

Countries (in orange) where the TB surveillance checklist of standards and benchmarks has been used:

status in August 2013

BOX 2.6

Inventory studies to estimate TB underreporting: an example from Iraq

Inventory studies compare the number of TB cases meeting

UVCPFCTFECUGFGßPKVKQPUKPCNNQTKPCUCORNGQHRWDNKECPF

RTKXCVGJGCNVJHCEKNKVKGUYKVJVJGTGEQTFUQH6$ECUGUPQVKßGF

to local and national authorities. This enables the level of

WPFGTTGRQTVKPIQHFKCIPQUGFECUGUVQDGSWCPVKßGF+PEGTVCKP

circumstances, the results from inventory studies can be

combined with a type of modelling called capture–recapture

analysis to estimate TB incidence. A WHO guide on the design

and implementation of inventory studies, and analysis and

reporting of results, was published in 2013.

The results from the survey in Iraq,a which was completed

in 2011, are illustrated below. The number of TB cases that

were detected by three types of health service providers

was studied during a three-month period in eight randomly

UGNGEVGFIQXGTPQTCVGUQWVQHCVQVCNQH6JGVQVCNPWODGT

QHFGVGEVGFECUGUYCU%CUGUVJCVYGTGFGVGEVGFDWVPQV

reported to the NTP accounted for 16% of total detected cases

i.e. the level of underreporting was 16%. Capture–recapture

modelling was used to estimate that an additional 473 cases

EQPßFGPEGKPVGTXCN¿JCFPQVDGGPFGVGEVGFD[

any of the three types of health providers. These results were

WUGFVQGUVKOCVGVJCVVJGTGYGTGCRRTQZKOCVGN[aKPEKFGPV

cases of TB in Iraq in 2011 (a downward revision compared with

previous estimates) and that about 60% of cases were being

detected (an upward revision from the previous best estimate

QH

The value of study results went beyond updates to estimates

QH6$KPEKFGPEG'ZCORNGUKPENWFG

NTP

(n=1673) Private

(n=649)

0 Public

(n=377)

 416 199

244 9

Updated estimates were crucial for the development of a

sound national strategic plan and to assess progress towards

the 2015 MDG target.

The national strategic plan includes interventions designed

VQCFFTGUUVJGECWUGUQHWPFGTTGRQTVKPIVJCVYGTGKFGPVKßGF

during the study.

The mapping of all health facilities delivering care to

chest-symptomatic patients in study areas (that covered

50% of the country) provided a foundation for sustained

engagement of all care providers through PPM initiatives.

a Huseynova S et al. Estimating tuberculosis burden and reporting in

TGUQWTEGNKOKVGFEQWPVTKGUCECRVWTGTGECRVWTGUVWF[KP+TCSInternational

,ournal of Tuberculosis and LunI &iseasea¿

FIGURE B2.6.1

Results from the 2011 inventory study in Iraq

26 GLOBAL TUBERCULOSIS REPORT 2013

FIGURE 2.16

Availability of national electronic case-based databases of TB patients, 2012

All TB patients

MDR-TB patients only

None

No data

Not applicable

FIGURE 2.17

Global progress in implementing national surveys of the prevalence of TB disease, actual (2002–2013)

and expected (2014–2017)

Number of surveys

Kenya



/Q\CODKSWG

South Africa

Uganda

Nigeria Ghana Bangladesh

Ethiopia Rwanda Malawi DPR Korea

Cambodia 746CP\CPKC Zambia Mongolia Myanmar

Philippines Pakistan Thailand Indonesia Nepal Philippines

Cambodia Malaysia Indonesia Eritrea Thailand Viet Nam Bangladesh Myanmar China Lao PDR Gambia Sudan Zimbabwe Viet Nam

2002 2003 2004 2005 2006 2007  2009 2010 2011 2012 2013 2014–

2015

2016–

2017

Global focus countries (GFC)

selected by WHO Global Task Force

on TB Impact Measurement

Asia – GFC Africa – GFC Non – GFC

the concept of Asia–Asia, Asia–Africa and Africa–Africa

(‘AA’) collaboration has been strongly promoted.

Following six years of substantial eort at country,

regional and global levels, unprecedented progress has

been achieved (Figure 2.17). If surveys are implemented

according to schedule, more than 20 surveys will be

implemented between 2011 and 2015. Five national TB

prevalence surveys were implemented in 2012 (Gambia,

Nigeria, Rwanda, the United Republic of Tanzania and

ailand) and a further ve w ill start or be completed in 2013

(Ghana, Indonesia, Malawi, Sudan and Zambia). ese

surveys provide an unbiased estimation of disease burden,

often for the rst time, and will be used to update estimates

of disease burden once results are nalized (Box 2.1).

Surveys are also providing a rich source of data to

inform programme policy and strategy. Although results

remain provisional pending nalization of analyses in late

2013 (Box 2.1), an excellent recent example is provided

by the 2012 survey in Nigeria (Box 2.8). For other recent

surveys, some country-specic reports are already public-

ly available (for example, from China, Cambodia, Ethiopia

and Myanmar) and others are in the pipeline. Papers for

peer-reviewed journals are also in preparation, from these

and other recent surveys.

WHO, together with countries and technical partners,

started preparing or planning global and regional synthe-

27GLOBAL TUBERCULOSIS REPORT 2013

BOX 2.7

Implementation of an innovative electronic surveillance and management system in Kenya

The NTP in Kenya has rolled out an innovative electronic

system to support surveillance and management, called TIBU

(which means cure in Swahili). In addition to running electronic

versions of its standard district TB registers, the TIBU system

makes use of the country’s extensive mobile communications

network and widespread use of mobile phones to make

RC[OGPVUVQ/&46$RCVKGPVUVJCVJGNRVQUWRRQTVVJGKT

VTGCVOGPVVJTQWIJVJGRQRWNCTaM-Pesa mobile payment system.

The system will also be used to manage drug supplies and

laboratory data and consumables.

At TIBU’s core is a national case-based database that stores

details about each individual patient episode of TB (including

ECUGUQH/&46$7UGTUCEEGUUVJGU[UVGOGKVJGTVJTQWIJCYGD

browser or by using an Android ‘app’. The NTP has given each

District TB and Leprosy Coordinator (DTLC) a tablet computer

VJCVTWPUVJG#PFTQKFQRGTCVKPIU[UVGOCPFKUßVVGFYKVJC

SIM card to connect to the internet through mobile telephone

networks. DTLCs can access the system during their regular

visits to all facilities providing TB diagnostic and treatment

services within their district and enter TB patient details into

the TIBU app during their visits to these facilities. Data are

transmitted directly to the national database via the mobile

network. Data remain stored on the tablet if no connection

is available at a facility and are subsequently transmitted to

the national database as soon as a connection is available.

TIBU automatically generates various reports, including

standard quarterly reports, charts and maps for all levels of the

administrative chain.

The NTP and developers work closely with other parts of the

Ministry of Health to ensure that TIBU complies with national

standards, such that it can communicate with the ministry’s

other health information systems.a TIBU uses Kenya’s national

facility coding scheme (JVVRYYYGJGCNVJQTMGHCEKNKVKGU

facilitytypes.aspx) and therefore the developers were able to

DWKNFCUGCONGUUNKPMVQVJGa-enya *ealth Information Systemb

VJCVRTQXKFGUFKUVTKEVRTQXKPEKCNCPFPCVKQPCNJGCNVJQHßEKCNU

YKVJKPFKECVQTUHQTOWNVKRNGJGCNVJCTGCUKPENWFKPI6$a6JKU

allows standard TB indicators to be automatically updated every

quarter in the ministry’s system.

TIBU has been developed in phases. Development was

initiated in 2007 and the original intention was to run the

system on personal digital assistants (PDAs). However, problems

with initial attempts to implement the system combined with

the rapid rise, availability and falling costs of Android-based

mobile devices, as well as the widespread adoption of mobile

phones, led to a decision to switch to the development of an

#PFTQKFaCRRaHQTWUGQPUOCTVRJQPGUCPFVCDNGVEQORWVGTU

Plans for future phases include extending coverage beyond TB

and leprosy to patients with asthma and other lung diseases,

integration with the laboratory management system and

eventually, if resources allow, roll out of tablets to over 4000

health care facilities where TB diagnostic and treatment

services are offered.

a In May 2013 the World Health Assembly adopted resolution WHA66.24 on

promoting such standardization and interoperability of health information

systems (JVVRCRRUYJQKPVIDGDYJCRFHAßNGU9*##A4GPRFHa

b Based on the open source DHIS2 platform JVVRYYYFJKUQTI

BOX 2.8

The 2012 national TB prevalence survey in Nigeria: programmatic implications

+ORNGOGPVCVKQPQHVJGßTUVGXGTPCVKQPCN6$RTGXCNGPEGUWTXG[KP0KIGTKCDGICPKP(GDTWCT[CPFßGNFCEVKXKVKGUEQXGTKPI

70 geographic clusters) were completed in October 2012. Nigeria became the second African country to successfully complete a

PCVKQPCNUWTXG[CEEQTFKPIVQEWTTGPV9*1IWKFGNKPGUHQNNQYKPI'VJKQRKCKP#VQVCNQHaRGQRNGCIGFÜRCTVKEKRCVGF

in the study.

Survey results included that 75% of previously undetected cases found during the survey had sputum smear-positive TB and

classic TB symptoms that met national screening criteria (this proportion was higher than in any other survey implemented since

%QORCTKUQPQHVJGPWODGTQHRTGXCNGPVECUGUQHURWVWOUOGCTRQUKVKXG6$YKVJPQVKßECVKQPFCVCHQTVJGUCOGCIGITQWR

UJQYGFCRTGXCNGPEGPQVKßECVKQPTCVKQQHCNUQJKIJGTVJCPKPCP[QVJGTUWTXG[KORNGOGPVGFUKPEG6JGUWTXG[CNUQ

illustrated that the burden of TB was geographically uneven, ranging from very low to extremely high levels among survey clusters.

An important conclusion already drawn from the survey results is that a top priority is to expand access to and improve the

quality of basic TB diagnostic and treatment services. If high-quality DOTS services were readily available, it would be expected that

DQVJVJGRGTEGPVCIGQHRTGXCNGPVECUGUYKVJV[RKECN6$U[ORVQOUCPFVJGRTGXCNGPEGPQVKßECVKQPTCVKQYQWNFDGOWEJNQYGT

#UGEQPFEQPENWUKQPKUVJCVURGEKßEHQEWUKUPGGFGFQPIGQITCRJKEÁJQVURQVUÂYJGTGVJGFKUGCUGDWTFGPKUJKIJGUV

ses of the main results and lessons learned from national

TB prevalence surveys in 2012. A paper that summarizes

the results and lessons learned from surveys conducted

1990–2012 in Asia is nearing completion and a similar

paper about recent surveys in Africa is planned. An overall

synthesis of the main implications of results from recent

prevalence surveys implemented in Asia and Africa for

post-2015 global TB policy and strategy is also in the pipe-

line. ese global and regional summaries will be widely

disseminated once available, starting in 2014.

 GLOBAL TUBERCULOSIS REPORT 2013

%*#26'4

TB case notißcations

and treatment outcomes

Routine recording and reporting of the numbers of TB

cases diagnosed and treated by NTPs and monitoring of

treatment outcomes was one of the ve components of

the global TB strategy (DOTS) launched by WHO in the

mid-1990s and it remains a core element of its successor,

the Stop TB Strategy (Chapter 1). With the standard de-

nitions of cases and treatment outcomes recommended by

WHO and associated recording and reporting framework

as a foundation, global monitoring of trends in case noti-

cations and treatment outcomes has been possible since

1995. e number of people diagnosed and treated for TB

and associated treatment outcomes is routinely monitored

by NTPs in almost all countries, which in turn report these

data to WHO in annual rounds of global TB data collection

(Chapter 1).

is chapter has four parts. Section 3.1 summarizes

the total number of people diagnosed with TB and noti-

ed by NTPs in 2012, including disaggregation by case

type, age and sex. e share of notications accounted for

by the prison sector in the European Region and the high

case notication rates among the prison population are

also highlighted. Section 3.2 presents and discusses the

contribution to total case notications of public–public

and public–private mix (PPM) initiatives in 29 countries

and of community-based care in 13 countries. Section 3.3

presents trends in notications between 1990 and 2012

and compares these with trends in estimated TB incidence.

Estimates of the ratio of notied:incident cases (an indica-

tor known as the case detection rate or CDR) are provided

for selected years. Section 3.4 describes the latest data on

treatment outcomes (for cases registered for treatment in

2011) as well as treatment outcomes achieved in each year

since 1995.

3.1 Case notißcations in 2012 by type

of disease, age and sex

e denitions of TB cases recommended by WHO until the

end of 2012, and that were used in the 2013 round of glob-

al TB data collection, are shown in Box 3.1. Although not

used in the global TB report this year, it should be highlight-

ed that after a two-year consultation process, WHO issued

updated guidance on denitions of cases and treatment

outcomes and an associated reporting framework in March

2013.1 ese updates were necessary to accommodate

KEY FACTS AND MESSAGES

■ +POKNNKQPECUGUQH6$YGTGPQVKßGFD[

062UCPFTGRQTVGFVQ9*1OKNNKQPYGTGKPFKXKFWCNU

newly diagnosed in 2012 and 0.4 million were previously

diagnosed TB patients whose treatment regimen was

EJCPIGF+PFKCCPF%JKPCCEEQWPVGFHQTQHPQVKßGF

cases of TB worldwide in 2012, African countries for 23%

CPFVJG*$%UHQT

■ +PVJGVTGCVOGPVUWEEGUUTCVGYCUCOQPI

CNNPGY6$ECUGUCPFCOQPIPGYECUGUQHURWVWO

smear-positive pulmonary TB (the most infectious cases).

Improvement in treatment outcomes is needed in the

'WTQRGCP4GIKQPYJGTGVJGVTGCVOGPVUWEEGUUTCVGKP

was 72% and 65% for new cases and new smear-positive

cases respectively.

■ The provision of diagnosis and treatment according

to the DOTS/Stop TB StrateIy has resulted in major

achievements in TB care and control. Between 1995 and

2012, 56 million people were successfully treated for TB

in countries that had adopted the DOTS/Stop TB StrateIy,

saving 22 million lives.

■ 0QVKßECVKQPUQH6$ECUGUJCXGUVCDKNK\GFKPTGEGPV

years, and in 2012 represented 66% (range, 64–69%) of

GUVKOCVGFKPEKFGPVECUGU6JGICRDGVYGGPPQVKßECVKQPU

and incident cases can be explained by a mixture of

underreporting of diagnosed TB cases (for example, failure

to notify cases diagnosed in the private sector) and under-

diagnosis due to poor access to health care and/or failure to

detect cases when people visit health care facilities. Major

efforts are needed to ensure that all cases are detected,

PQVKßGFVQPCVKQPCNUWTXGKNNCPEGU[UVGOUCPFVTGCVGF

according to international standards.

■ +POQUVPQVKßGF6$RCVKGPVUYGTG¿[GCTUQH

CIG%JKNFTGPCIGF[GCTUCEEQWPVGFHQTQHPQVKßGF

ECUGU6JGOCNGHGOCNGTCVKQYCUINQDCNN[TCPIKPIHTQO

1.0 to 2.1 among the six WHO regions.

1 Denitions and reporting framework for tuberculosis – 2013 revision

(WHO/HTM/TB/2013.2). Geneva, World Health Organization,

2013. (Available at www.who.int/iris/bitstream/10665/79199/1/

9789241505345_eng.pdf).

29GLOBAL TUBERCULOSIS REPORT 2013

diagnosis using Xpert MTB/RIF and other WHO-endorsed

molecular tests (Chapter 5), as well as oering an opportu-

nity to improve aspects of the existing (2006) framework,

such as inclusion of more comprehensive reporting of TB

cases among children. e updated denitions, which will

be used in WHO’s 2014 round of global TB data collection,

are summarized in Box 3.2.

In 2012, 6.1 million people with TB were notied to

NTPs and reported to WHO. Of these, 5.7 million had a new

episode of TB (shown as the total of new and relapse cases

in Table 3.1). Of these 5.7 million cases, 5.4 million had

TB for the rst time and 0.3 million were people who had a

recurrent episode of TB after being previously cured of the

disease. Besides a small number of cases whose history of

treatment was not recorded, the remaining 0.4 million had

already been diagnosed with TB but their treatment was

changed to a retreatment regimen.

Among people who were diagnosed with TB for the rst

time (new cases), 2.5 million had sputum smear-positive

pulmonary TB, 1.9 million had sputum smear-negative

pulmonary TB, and 0.8 million had extrapulmonary TB;

the remaining cases did not have a sputum smear done or

their case type was unknown (Table 3.1). India and China

accounted for 39% of the 5.7 million new and relapse cas-

es of TB that were notied in 2012 (23% and 16%, respec-

tively); the South-East Asia and Western Pacic Regions

in which these countries are respectively located together

accounted for 60% of such cases globally. African countries

TABLE 3.1

Case notißcations, 2012

TOTAL NOTIFIED

NEW CASES 4'64'#6/'06%#5'5

NEW AND

4'.#25'a

5/'#4215+6+8' 5/'#40')#6+8'

5/'#4016

DONE

':64#

27./10#4;

%#5'6;2'

UNKNOWN

27./10#4;

CASES

.#$14#614;

%10(+4/'&

2'4%'06#)'1(

27./10#4;

CASES

.#$14#614;

%10(+4/'& 4'.#25'

4'64'#6/'06

':%.4'.#25'

Afghanistan  13 319 4 740 2 665 6 906 702 13 319 62 1 049 197 

Bangladesh 173 619 106 790 24 451 0 30 549 0 106 790  3 065 4 936 

$TC\KN  40 152   10 297 11  70  7 633 75 122

Cambodia    015 290 0 64 446 73 

China  316 332 533 977 2 073 6 479 0 316 332 37  10 033 

&4%QPIQ 112 499 71 124 13 214 20 669 71 124  3 977 3 515 

Ethiopia 147 592 47 236 47 340 2 073  0 47 236 49  2 269 145 323

India   317 616 234 029 2 139 637 273 67 106 463 177 749 

Indonesia 331 424 202 319  15 697 202 319 66 5 942 2 600 

Kenya 99 149 36 937   15 934 0 36 937 50 3 419 6 162 

/Q\CODKSWG  20 951 19 797 5 542 0 20 951 51 1 451  47 741

Myanmar  42 909 73 042 0 20 661 0 42 909 37  6 979 141 170

Nigeria  52 901 32 972 4 432 52 901 62 2 513 5 035 

Pakistan 273 097 110 545 109 425 0 41 410 0 110 545 50 6 095 5 622 267 475

Philippines   115 263 0 3 270 0  45  19 409 216 199

4WUUKCP

Federation 149 921 27 467 59 019 1 039 10 017 0 41 123 47   105 753

South Africa   63 210 71 421 42 467 0  71   323 664

Thailand   17 537  b64  904 60 304

Uganda 47 211 24 916   5 143 0 24 916 65 1 334  44 663

746CP\CPKC   21 393 0 14 595 0  54 1 052 1 714 

Viet Nam 103 906 51 033 21 706  3 210 51 033 67 7 259 1 794 102 112

<KODCDYG  12 163 14 354 2 962 4 912 0 12 163 41 1 369 2 960 35 760

High-burden

countries 5 005 111 2 091 141 1 654 670 100 731 582 909 6 062 2 144 779 56 228 309 335 304 4 669 807

#(4 1 412 639 600 355 345 947 100 537 234 539 977 656 272 63 60 497 67 770 

#/4 232 695 122 606 35 606 14 564 34 400 1 669 132 070 76 9 949  

'/4  173 963 135 346  90 943 702 175 025 55  10 020 420 769

'74 337 167   6 257 39 029 30 112 577 55  67 662 269 505

5'#4 2 331 455   0 3 004 1 027 902 62 131 245 201 335 2 130 120

924 1 345 466 500 171 691 714 9 751 59 294  502 652 42 45 277 34 740 1 310 726

Global 6 090 211 2 541 283 1 913 682 139 632 796 508 9 669 2 606 498 57 283 361 395 389 5 694 822

Blank cells indicate data not reported.

a 0'9#0&4'.#25'KPENWFGUECUGUHQTYJKEJVJGVTGCVOGPVJKUVQT[KUWPMPQYP

b .#$14#614;%10(+4/'&FCVCHQT6JCKNCPFTGHGTVQUOGCTRQUKVKXGECUGUQPN[&CVCQPECUGUVJCVYGTGNCDQTCVQT[EQPßTOGFWUKPIQVJGTOGVJQFUYGTGPQVTGRQTVGF

30 GLOBAL TUBERCULOSIS REPORT 2013

accounted for 24% of new and relapse TB cases globally

(one quarter of these cases were from one country – South

Africa). e WHO Eastern Mediterranean and European

Regions and the Region of the Americas accounted for 16%

of new and relapse TB cases notied in 2012 (7%, 5% and

4%, respectively); combined, the 22 HBCs accounted for

82% of such cases.

Among the 22 HBCs, the percentage of new pulmonary

cases that were bacteriologically conrmed was highest in

Bangladesh (81%) and the Democratic Republic of the Con-

go (84%), and relatively low in China (37%), the Philippines

(45%), the Russian Federation (47%) and Zimbabwe (41%).

Almost all (96%) of the notications of new cases of

smear-positive pulmonary TB were disaggregated by age

and sex (Table 3.2); 88% were aged 15–64 years, 59% were

aged 15–45 years and 2% were children (aged <15 years).

e global male:female sex ratio was 1.9, but among HBCs

this varied from 0.5 in Afghanistan to 3.0 in Viet Nam.

Variation among countries may reect real dierences

in epidemiology as well as dierential access to or use of

health care services linked to the NTP.

Reporting of cases disaggregated by age and sex was

much less complete for new smear-negative pulmonary and

extrapulmonary cases. For example, data disaggregated by

age and sex according to the categories shown in Table 3.2

were not available for 11 HBCs. When the available data

for all new cases were combined, most cases (82%) were

aged 15–64 years, 55% were aged 15–45 years and 6% were

among children (<15 years); the male:female ratio was 1.7,

ranging from 1.0 to 2.1 among the six WHO regions. Fur-

ther eorts are needed to improve reporting of all cases dis-

aggregated by age and sex.

In the European Region, WHO and the European Cen-

tre for Disease Control and Prevention (ECDC) also request

countries to report notications in the civilian and prison

sectors separately. ese data show that notications in

the prison sector can be a considerable share of all cases,

and that case notication rates in the prison population

can be strikingly high. A summary of the latest data in the

European Region and selected countries, and an example of

success in reducing notication rates in the Russian Feder-

ation, are provided in Box 3.3.

BOX 3.1

WHO deßnitions of TB cases used until the end of 2012 (and in this global TB report)a

Deßnite case of TB A patient with Mycobacterium

tuberculosisEQORNGZKFGPVKßGFHTQOCENKPKECNURGEKOGP

either by culture or by a newer method such as molecular line

probe assay (LPA). In countries lacking laboratory capacity

to routinely identify M. tuberculosis, a pulmonary case with

one or more initial sputum specimens positive for acid-fast

DCEKNNK#($KUCNUQEQPUKFGTGFVQDGCÁFGßPKVGÂECUGRTQXKFGF

that there is functional external quality assurance with blind

rechecking.

Case of TB #FGßPKVGECUGQH6$FGßPGFCDQXGQTQPGKP

which a health worker (clinician or other medical practitioner)

has diagnosed TB and decided to treat the patient with a full

course of anti-TB treatment.

Case of pulmonary TB A patient with TB disease involving

the lung parenchyma.

Smear-positive pulmonary case of TB A patient with

one or more initial sputum smear examinations (direct smear

microscopy) AFB-positive; or one sputum examination AFB-

positive plus radiographic abnormalities consistent with active

pulmonary TB as determined by a clinician. Smear-positive

cases are the most infectious and thus of the highest priority

from a public health perspective.

Smear-negative pulmonary case of TB A patient with

pulmonary TB who does not meet the above criteria for smear-

RQUKVKXGFKUGCUG&KCIPQUVKEETKVGTKCUJQWNFKPENWFGCVNGCUV

two AFB-negative sputum smear examinations; radiographic

abnormalities consistent with active pulmonary TB; no response

to a course of broad-spectrum antibiotics (except in a patient

HQTYJQOVJGTGKUNCDQTCVQT[EQPßTOCVKQPQTUVTQPIENKPKECN

evidence of HIV infection); and a decision by a clinician to

treat with a full course of anti-TB chemotherapy. A patient with

positive culture but negative AFB sputum examinations is also a

smear-negative case of pulmonary TB.

Extrapulmonary case of TB A patient with TB of organs

other than the lungs (e.g. pleura, lymph nodes, abdomen,

genitourinary tract, skin, joints and bones, meninges).

Diagnosis should be based on one culture-positive specimen,

or histological or strong clinical evidence consistent with active

extrapulmonary disease, followed by a decision by a clinician

to treat with a full course of anti-TB chemotherapy. A patient

in whom both pulmonary and extrapulmonary TB has been

FKCIPQUGFUJQWNFDGENCUUKßGFCUCRWNOQPCT[ECUG

New case of TB A patient who has never had treatment for TB

or who has taken anti-TB drugs for less than one month.

Retreatment case of TB There are three types of retreatment

ECUGKCRCVKGPVRTGXKQWUN[VTGCVGFHQT6$YJQKUUVCTVGFQP

a retreatment regimen after previous treatment has failed

(treatment after failure); (ii) a patient previously treated for

TB who returns to treatment having previously defaulted; and

(iii) a patient who was previously declared cured or treatment

completed and is diagnosed with bacteriologically-positive

(sputum smear or culture) TB (relapse).

Case of multidrug-resistant TB (MDR-TB) TB that is

TGUKUVCPVVQVYQßTUVNKPGFTWIUKUQPKC\KFCPFTKHCORKEKP(QT

OQUVRCVKGPVUFKCIPQUGFYKVJ/&46$9*1TGEQOOGPFU

treatment for 20 months with a regimen that includes second-

line anti-TB drugs.

a See Treatment of tuberculosis Iuidelines, 4th ed. Geneva, World Health

1TICPK\CVKQP9*1*6/56$#XCKNCDNGCVJVVRYJSNKDFQE

YJQKPVRWDNKECVKQPUAGPIRFH

31GLOBAL TUBERCULOSIS REPORT 2013

BOX 3.2

WHO deßnitions of TB cases recommended for use starting in 2013 and that will be used in the 2014

global TB reporta

Bacteriologically conßrmed case of TB A patient from

whom a biological specimen is positive by smear microscopy,

EWNVWTGQT9*1CRRTQXGFTCRKFFKCIPQUVKEVGUVUWEJCU:RGTV

/6$4+(#NNUWEJECUGUUJQWNFDGPQVKßGFTGICTFNGUUQH

whether TB treatment is started.

Clinically diagnosed case of TB A patient who does not

HWNßNVJGETKVGTKCHQTDCEVGTKQNQIKECNN[EQPßTOGF6$DWVJCU

been diagnosed with active TB by a clinician or other medical

practitioner who has decided to give the patient a full course

QH6$VTGCVOGPV6JKUFGßPKVKQPKPENWFGUECUGUFKCIPQUGF

QPVJGDCUKUQH:TC[CDPQTOCNKVKGUQTUWIIGUVKXGJKUVQNQI[

CPFGZVTCRWNOQPCT[ECUGUYKVJQWVNCDQTCVQT[EQPßTOCVKQP

Clinically diagnosed cases subsequently found to be

bacteriologically positive (before or after starting treatment)

UJQWNFDGTGENCUUKßGFCUDCEVGTKQNQIKECNN[EQPßTOGF

Case of pulmonary TB #P[DCEVGTKQNQIKECNN[EQPßTOGFQT

clinically diagnosed case of TB involving the lung parenchyma

QTVJGVTCEJGQDTQPEJKCNVTGG/KNKCT[6$KUENCUUKßGFCU

pulmonary TB because there are lesions in the lungs.

Tuberculous intra-thoracic lymphadenopathy (mediastinal and/

or hilar) or tuberculous pleural effusion, without radiographic

abnormalities in the lungs, constitute a case of extrapulmonary

TB. A patient with both pulmonary and extrapulmonary TB

UJQWNFDGENCUUKßGFCUCECUGQHRWNOQPCT[6$

Case of extrapulmonary TB #P[DCEVGTKQNQIKECNN[EQPßTOGF

or clinically diagnosed case of TB involving organs other than

the lungs, e.g. pleura, lymph nodes, abdomen, genitourinary

tract, skin, joints and bones, meninges.

New case of TB A patient who has never been treated for TB

or has taken anti-TB drugs for less than 1 month.

Retreatment case of TB A patient who has been treated for

OQPVJQTOQTGYKVJCPVK6$FTWIUKPVJGRCUV4GVTGCVOGPV

ECUGUCTGHWTVJGTENCUUKßGFD[VJGQWVEQOGQHVJGKTOQUVTGEGPV

course of treatment into four categories.

1. 4elapse patients have previously been treated for TB, were

declared cured or treatment completed at the end of their

most recent course of treatment, and are now diagnosed

with a recurrent episode of TB (either a true relapse or a new

episode of TB caused by reinfection).

2. Treatment after failure patients have previously been

treated for TB and their most recent course of treatment

failed.

3. Treatment after loss to follow-up patients have previously

been treated for TB and were declared ‘lost to follow-up’

at the end of their most recent course of treatment (this

ECVGIQT[EQTTGURQPFUVQVJGÁFGHCWNVGFÂECVGIQT[FGßPGFKP

Box 3.1).

4. Other preXiously treated patients are those who have

previously been treated for TB but whose outcome after

their most recent course of treatment is unknown or

undocumented.

Case of multidrug-resistant TB (MDR-TB) #UFGßPGFKP

Box 3.1

Case of rifampicin-resistant TB (RR-TB) A patient with

TB that is resistant to rifampicin detected using phenotypic

or genotypic methods, with or without resistance to other

anti-TB drugs. It includes any resistance to rifampicin, whether

mono-resistance, multidrug resistance, polydrug resistance or

extensive drug resistance.

a &GßPKVKQPUCPFTGRQTVKPIHTCOGYQTMHQTVWDGTEWNQUKU¿TGXKUKQP9*1

*6/6$)GPGXC9QTNF*GCNVJ1TICPK\CVKQP#XCKNCDNGCV

YYYYJQKPVKTKUDKVUVTGCOAGPIRFH

3.2 Contribution of public–public and

public–private mix initiatives

and community-based TB activities to

TB case notißcations in 2012

 2WDNKE¿RWDNKECPFRWDNKE¿RTKXCVGOKZ22/

Ensuring proper diagnosis, standardized treatment and

prompt notication of all TB cases to NTPs requires collab-

oration with the full range of health care providers. Engag-

ing all care providers in TB care and control is component 4

of the Stop TB Strategy (Chapter 1). Its two subcomponents

are:

involving all public, voluntary, corporate and private

providers through PPM approaches; and

promoting the International Standards for Tuberculosis

Care.1

Many countries have scaled up PPM initiatives. Demon-

strating progress in terms of the contribution of non-NTP

providers to total case notications requires systematic

recording of the source of referral and place of TB treat-

ment locally, and reporting and analysis of aggregated data

nationally.2 In 2013, 73 countries reported summary data

to WHO, and data for 29 of these countries (including 14

HBCs) are shown in Table 3.3. In most of these countries,

PPM initiatives contributed about 10% to 40% of total noti-

cations.

Considering that the private medical sector in Africa is

much smaller compared with that in Asia, the contribution

of private-for-prot and not-for-prot providers in Ethio-

pia, Kenya, Nigeria and the United Republic of Tanzania is

noteworthy. Progress in parts of Asia is also noticeable –

almost every fourth case in Indonesia and the Philippines

was notied by non-NTP care providers in 2012. Large pub-

lic sector hospitals have contributed sizeable proportions of

cases in China and Indonesia as well as in the Philippines,

and engagement of large hospitals is one of the major strat-

egies required to improve detection and notication of TB

1 http://www.istcweb.org/ISTC_Documents.html

2 WHO recommends that the source of referral and the place of treat-

ment should be routinely recorded and reported.

32 GLOBAL TUBERCULOSIS REPORT 2013

TABLE 3.2

TB case notißcations by age and sex, 2012

0'95/'#4215+6+8'%#5'5 ALL NEW CASESa

¿;'#45 ¿;'#45 ¿;'#45 Ü;'#45

% AGED



;'#45

/#.'

FEMALE

4#6+1 ¿;'#45 ¿;'#45 ¿;'#45 Ü;'#45

% AGED



;'#45

/#.'

FEMALE

4#6+1

Afghanistan   3 106 1 156 4 0.5 15 0.6

Bangladesh 966 56 209 34 674 14 941  1.9    20 602 3 1.6

$TC\KN  25 209 11 129 3 190 1 2.3  42 306 20 056 6 322 3 2.0

Cambodia 53 6 000 6 064 2 724  1.2 – –

China 1 091  110 614 65 960  2.5 5 625 397 615    2.2

&4%QPIQ  47 722 17 066  41.3 – –

Ethiopia – – 16 1.2

India 12 957    22.2 7 –

Indonesia 1 703 116 326 70 491 13 799  1.5 27 343 172 706 100 254 22 579 1.4

Kenya 996 29 779 5 114  31.6    3 994 7 1.4

/Q\CODKSWG –– 13–

Myanmar  24 076 14 405 4 090  1.9 – –

Nigeria   10 571 2 553 2 1.6 – –

Pakistan 3 947 66 901 29 149  41.1 10 1.0

Philippines 1 032 49 736 29 617 6 943 1 2.3 – 1.9

4WUUKCP(GFGTCVKQP  17 039    2.7   26 302 5 254 4 2.2

South Africa 2 650  24 964 4 151 2 1.3     13 1.2

Thailand 117 13 525 11 435 5 921  2.4 – –

Uganda 636  4 777 914 3  ––

746CP\CPKC 490  5 257 1 536 2  91.5

Viet Nam 142 23 310    3.0 – –

<KODCDYG 293   432 2 1.3 2 911 23 541 5 954   1.2

High-burden

countries 32 952 1 172 486 604 196 205 733 2 1.9 231 674 1 724 885 894 852 343 231 6 1.7

#(4 14 340    3 1.5 97 629 571 919 167 236  91.3

#/4 2 012 61 956 27 462  2 1.7 9 646   19 974 5 1.6

'/4 5 641    31.2  133 536 53 351 21 545 10 1.0

'74 325  24 440 7 355  2.4 10 042  60 455 20 575 5 1.9

5'#4 17 116 617 926 336 069 94 741 2 2.0  739 149 397 219 112 503 6 

924 2 693 230 572 172 377   2.4 13 945   195 965 1 2.1

Global 42 127 1 451 897 710 738 241 395 2 1.9 292 295 2 171 779 1 075 428 409 559 6 1.7

Blank cells indicate data that could not be reported for the age categories shown.

– indicates values that cannot be calculated.

a Numbers in each age category are only shown if data were reported for all four age categories for each category of TB case. For this reason, there are small discrepancies

between numbers presented in this table and in the tables that appear in Box 2.2 of Chapter 2.

cases. Experience from a project that was recently complet-

ed in ve countries is proled in Box 3.4.

Approaches to engage non-NTP care providers vary

according to the local context, but there are some import-

ant cross-cutting elements. One is provision of standard-

ized care by non-NTP providers according to national

guidelines, in return for provision of free anti-TB drugs,

supervision and quality assurance, and nancial or non-

nancial incentives by NTPs. A second is the use of the Inter-

national Standards for Tuberculosis Care, which facilitates the

use of best practices in TB diagnosis and treatment among

all care providers, especially those in the private sector. In

the European Region and the Region of the Americas, con-

tributions to case notications from public sector provid-

ers outside the purview of the Ministry of Health, such as

social security organizations and prison health services, are

relatively large.

33GLOBAL TUBERCULOSIS REPORT 2013

BOX 3.3

TB and prisons

As an airborne disease, TB thrives in the crowded, poorly-

ventilated environments found in prisons in many parts of the

world. Conditions of prison life including malnutrition and stress

can also contribute to a higher risk of developing TB disease,

and inadequate or inaccessible medical care can lead to poor

treatment outcomes and acquisition of resistance. Prisoners

FKURTQRQTVKQPCVGN[EQOGHTQOOCTIKPCNK\GFUQEKQGEQPQOKE

backgrounds – including substance users, homeless people,

people with mental illness, ethnic minorities, asylum seekers and

immigrants – and therefore often enter the prison system with

an existing high prevalence of TB infection or even with active

disease. Prisons also contribute to overall TB burden in that they

CTGPQVGPVKTGN[ENQUGFU[UVGOU6$ECPDGURTGCFVQRTKUQPUVCHH

and visitors, and at some point most prisoners are released into

the general population.

6JG9*1'WTQRGCP4GIKQPKUEWTTGPVN[VJGQPN[TGIKQPVJCV

systematically collects and analyses data from Member States

on the burden of TB in prisons.a As is likely the situation in

most countries around the world, the burden of TB in prisons in

European countries is disproportionately high and often makes

CEQPUKFGTCDNGEQPVTKDWVKQPVQQXGTCNNEQWPVT[ECUGPQVKßECVKQPU

0QVKßECVKQPTCVGUQHPGY6$ECUGUKPRTKUQPUKPCNNTGRQTVKPI

countries were multiple times higher than the rates found in

VJGIGPGTCNRQRWNCVKQPTGNCVKXGTKUMUTCPIKPIHTQOVQ

CPFYGTGQXGTRGTFGVCKPGGUKP#\GTDCKLCP

)GQTIKCCPF-[TI[\UVCPCPFRGT

detainees, respectively) in 2011. Among reporting countries, case

PQVKßECVKQPUHTQORTKUQPUCEEQWPVGFHQTQXGTQHPCVKQPCN

PQVKßECVKQPUQHPGY6$ECUGUKP)GQTIKCCPFVJG4WUUKCP

Federation (11%) in 2011. Given that some countries in the region

JCXGPQVDGGPCDNGVQTGRQTVFCVCQP6$PQVKßECVKQPUKPRTKUQPU

and that limited data are available on trends, the contribution of

6$PQVKßECVKQPUKPRTKUQPUVQQXGTCNN6$PQVKßECVKQPUKPVJGTGIKQP

is uncertain.

To reduce the burden of TB in prisons, a comprehensive

package of measures is required.b,c These include early diagnosis

using systematic screeningd and rapid diagnostics, proper

infection control, improved living conditions and nutrition,

supervised and complete TB treatment with appropriate drugs,

treatment of comorbidities including HIV, diabetes, hepatitis and

substance use disorders, and continuity of care in the public sector

when a prisoner under treatment is released.

6JG4WUUKCP(GFGTCVKQPYCUUWEEGUUHWNKPKPVTQFWEKPIUGXGTCN

OGCUWTGUVJCVUKIPKßECPVN[TGFWEGFVJGDWTFGPQH6$KPKVU

penitentiary system (Figure B3.3.1).e By reinforcing systematic

screening, improving infection control measures, strengthening

treatment, and building cooperation between the Ministry of

Justice, Ministry of Health institutions, and international partners,

6$PQVKßECVKQPTCVGUFGETGCUGFUJCTRN[HTQOECUGURGT

100 000 detainees in 1999 (i.e., TB was detected in 1 of 25

FGVCKPGGUKPVQECUGURGTFGVCKPGGUKP

6JGFGETGCUGUKPEGJCUDGGPITCFWCNTGàGEVKPIVJG

continuing challenges facing TB control in the penitentiary sector,

including rising rates of TB/HIV coinfection and drug-resistant

TB, as well as the continued concentration of socioeconomically

OCTIKPCNK\GFRGQRNGGPVGTKPIVJGRTKUQPU[UVGO1HPQVGKUVJG

JKIJGTPQVKßECVKQPTCVGHQWPFKPVJGRTGVTKCNFGVGPVKQPEGPVTGU

EQORCTGFYKVJEQTTGEVKQPCNHCEKNKVKGUKPEQORCTGFYKVJ

RGTFGVCKPGGUTGURGEVKXGN[TGàGEVKPIKPRCTVVJG

underlying high prevalence of TB infection and disease among

UQEKQGEQPQOKECNN[OCTIKPCNK\GFRGQRNGYJQGPVGTVJGRTGVTKCN

detention centres from the general population.

In Eastern Europe, drug-resistant TB has been associated with

detention and in many countries prisons have had to deal with

UWDUVCPVKCNECUGNQCFUQH/&46$RCVKGPVUf–h The provision of

GHHGEVKXG/&46$ECTGHQTRTKUQPKPOCVGUKUVJGTGHQTGKORQTVCPV

The possibility of close monitoring of imprisoned patients may

also be conducive to achievement of good treatment outcomes.

(QTGZCORNGFCVCHTQOVJGRGPKVGPVKCT[UGEVQTKP#\GTDCKLCPUJQY

VTGCVOGPVUWEEGUUTCVGUKPVJGTCPIG¿KPVJG¿

patient cohorts treated in accordance with WHO-recommended

standards.i

a Tuberculosis surXeillance and monitorinI in Europe 2012. Stockholm, European

%GPVTGHQT&KUGCUG2TGXGPVKQPCPF%QPVTQN9*14GIKQPCN1HßEGHQT'WTQRG

b See Guidelines for the control of tuberculosis in prisons. Geneva, World Health

1TICPK\CVKQP9*16$

c Dara M, Chadha SS, Melchers NV, van den Hombergh J, Gurbanova E, Al-Darraji H,

van der Meer JBW. Time to act to prevent and control tuberculosis among inmates.

International ,ournal of Tuberculosis and LunI &isease,CP¿

d Systematic screeninI for actiXe tuberculosis principles and recommendations.

)GPGXC9QTNF*GCNVJ1TICPK\CVKQP9*1*6/6$

e Tuberculosis in the 4ussian (ederation 2011 an analytical reXiew of statistical

indicators used in the 4ussian (ederation and in the worldKP4WUUKCP/QUEQY

/KPKUVT[QH*GCNVJQHVJG4WUUKCP(GFGTCVKQPGVCN

f 5MTCJKPC#*WTGXKEJ*<CNWVUMC[C#GVCN/WNVKFTWITGUKUVCPVVWDGTEWNQUKUKP

$GNCTWUVJGUK\GQHVJGRTQDNGOCPFCUUQEKCVGFTKUMHCEVQTUBulletin of the World

*ealth OrIanization¿

g #GTVU#*CDQW\KV//UEJKNCF\G.GVCN2WNOQPCT[VWDGTEWNQUKUKPRTKUQPUQH

VJGGZ7554UVCVGQH)GQTIKCTGUWNVUQHCPCVKQPYKFGRTGXCNGPEGUWTXG[COQPI

sentenced inmates. International ,ournal of Tuberculosis and LunI &isease, 2000

&GE¿

h 5JKP552CUGEJPKMQX#&)GNOCPQXC+;2GTGOKVKP))5VTGNKU#-/KUJWUVKP5

GVCN6TGCVOGPVQWVEQOGUKPCPKPVGITCVGFEKXKNKCPCPFRTKUQP/&46$VTGCVOGPV

RTQITCOKP4WUUKCInternational ,ournal of Tuberculosis and LunI &isease, 2006

#RT¿

i 4eXiew of tuberculosis preXention control and care ina#zerbaiLan. Copenhagen,

9QTNF*GCNVJ1TICPK\CVKQP

TB notification rate per 100 000

detainees per year

1999 2001 2003 2005 2007 2009 2011

1000

2000

3000

4000

5000

Combined prison facilities

Correctional facilities

Pre-trial detention centres

FIGURE B3.3.1

6$PQVKßECVKQPTCVGKPVJGRTKUQPHCEKNKVKGUQHVJG

4WUUKCP(GFGTCVKQP¿QXGTCNNCPF

disaggregated by pre-trial detention centres and

correctional facilities

34 GLOBAL TUBERCULOSIS REPORT 2013

TABLE 3.3

Contribution of public-private and public-public mix (PPM) to notißcations of TB cases in 29 countries, 2012

%17064; 6;2'51(%#4'2418+&'45'0)#)'&

07/$'41(6$%#5'5

016+(+'&$;27$.+%010062

%#4'2418+&'45a

07/$'41(6$%#5'5

016+(+'&$;24+8#6'%#4'

2418+&'45b

%1064+$76+1061616#.

NOTIFICATIONS OF TB CASES

IN 2012 (%)

#(4+%#04')+10a

Ethiopia Diverse private providers – 17 133 12

Ghana Diverse non-NTP public and private providers 1 107  13

Kenya Private clinics and hospitals, and prisons  10 364 12

Lesotho Diverse private providers – 1 044 10

Nigeria Public non-NTP and NGO hospitals and private

clinics 14 096  24

5YC\KNCPF Diverse non-NTP public and private providers   33

7PKVGF4GRWDNKEQH6CP\CPKC 2TKXCVGHCEKNKVKGUCPFHCKVJDCUGFQTICPK\CVKQPU – 13 734 22

REGION OF THE AMERICASa

El Salvador Diverse non-NTP public and private providers 761 50 40

Peru 5QEKCNUGEWTKV[QTICPK\CVKQPUCPFQVJGTPQP062

public providers 6 576 – 22

EASTERN MEDITERRANEAN REGIONa

Afghanistan 2TKXCVGENKPKEUJQURKVCNUNCDQTCVQTKGUaCPF

pharmacies 1 362  12

Egypt *GCNVJKPUWTCPEGQTICPK\CVKQPU0)1UCPFQVJGT

public non-NTP providers 1 993 213 26

+TCP+UNCOKE4GRWDNKEQH *GCNVJKPUWTCPEGQTICPK\CVKQPURTKUQPUOKNKVCT[CPF

private care providers 1 205  40

Iraq Diverse non-NTP public and private providers 2 693  65

Pakistan Private clinics and hospitals 925 56 363 21

Sudan Diverse private and non-NTP public providers 450 1 475 10

5[TKCP#TCD4GRWDNKE Diverse private and non-NTP public providers 175 2 400 

;GOGP Public hospitals including university, military and

police hospitals, prisons and private hospitals  –35

EUROPEAN REGIONa

Georgia Diverse non-NTP public and private providers, and

prisons 673  

Tajikistan Diverse non-NTP public providers and prisons 1 549 – 24

SOUTH-EAST ASIA REGION

Bangladesh Diverse private, non-NTP public and NGO providers 2 429 14 934 10

IndiacDiverse private, non-NTP public and NGO providers 13 572 3 533 –

Indonesia Public and private hospitals 77 376 5 432 25

Myanmar Diverse private, non-NTP public and NGO providers   23

Nepal Diverse private providers – 5 366 15

Sri Lanka Diverse non-NTP public and private providers 5 004 445 60

Thailand Diverse non-NTP public and private providers 1 532 1 267 4.6

WESTERN PACIFIC REGION

China General public hospitals  –44

Philippines Private clinics and hospitals  36 744 24

Viet Nam Diverse non-NTP public and private providers 3 404 4 724 

a Includes all contributions from non-NTP providers, including public hospitals, public medical colleges, prisons/detention centres, military facilities, railways and public health

KPUWTCPEGQTICPK\CVKQPU

b 2TKXCVGUGEVQTRTQXKFGTUKPENWFGRTKXCVGKPFKXKFWCNCPFKPUVKVWVKQPCNRTQXKFGTUEQTRQTCVGDWUKPGUUUGEVQTRTQXKFGTUOKUUKQPJQURKVCNUPQPIQXGTPOGPVCNQTICPK\CVKQPUCPF

HCKVJDCUGFQTICPK\CVKQPU

c Data for India are for smear-positive cases of pulmonary TB in 14 cities where PPM surveillance is in place.

35GLOBAL TUBERCULOSIS REPORT 2013

BOX 3.4

Engaging hospitals to improve TB care and prevention

In 2009, WHO initiated a project to help intensify TB case

FGVGEVKQPKPßXGEQWPVTKGUKP#HTKECCPF#UKC+PVGPUKßGF

hospital engagement, mainly targeting large hospitals in urban

CTGCUYCUVJGOCKPKPVGTXGPVKQPKPCNNßXGEQWPVTKGU6JTQWIJ

a consultative process involving NTPs, departments responsible

for hospitals within the ministries of health, directors of

RCTVKEKRCVKPIJQURKVCNUCPF9*1CVQVCNQHJQURKVCNU

covering a total population of 10 million were involved. This

KPENWFGFJQURKVCNUKP-KPUJCUCKPVJG&GOQETCVKE4GRWDNKEQH

the Congo; 10 in Accra, Ghana; 17 in Manila, The Philippines;

KP5YC\KNCPFCPFVJGNCTIGUVPCVKQPCNIGPGTCNJQURKVCNU

KPVJTGGEKVKGUKP8KGVa0CO*CPQK*Q%JK/KPJ%KV[CPF*WG

The initiative was funded by the Department of Foreign Affairs,

Trade and Development of Canada.

Prior to the project, hospitals provided TB diagnosis

and treatment for many patients without following national

IWKFGNKPGUQTJCXKPIHQTOCNTGHGTTCNCPFPQVKßECVKQPTQWVKPGU

6JGURGEKßEQDLGEVKXGUQHVJGRTQLGEVYGTGVQKORTQXG6$

diagnosis and management of patients presenting to hospitals

through setting up mechanisms for internal coordination,

and to improve external networking to help intensify TB case

FGVGEVKQPCPFPQVKßECVKQP6JGOCKPCEVKXKVKGUYGTGKORTQXKPI

KFGPVKßECVKQPQHRGQRNGYKVJUWURGEVGF6$UVCPFCTFK\CVKQP

of diagnostic routines and introduction of external quality

assurance in hospital laboratories; establishing a ‘hospital

DOTS unit’; a systematic approach to internal referrals so that

cases diagnosed in hospitals would be referred to the hospital

&165WPKVHQTOCNK\CVKQPQHTQWVKPGUHQTGZVGTPCNTGHGTTCNQH

cases to health centres and feedback about referrals from

health centres; ensuring proper treatment and follow up of

patients started on treatment in hospitals; and introduction of

UVCPFCTFK\GFTGEQTFKPICPFTGRQTVKPI

After successful implementation of project activities, total

JQURKVCNPQVKßECVKQPUKPETGCUGFHTQOCDQWVRGT[GCT

CETQUUVJGßXGUKVGUDGHQTGVJGRTQLGEVVQCDQWVRGT[GCT

in 2012. The documented number of people tested for TB with

a bacteriological test increased in all sites, and the average

increase was roughly fourfold (Figure B3.4.1).

Documentation of referrals for treatment and feedback to

EQPßTOVTGCVOGPVKPKVKCVKQPFGOQPUVTCVGFVJCVVJGNQUUGUCHVGT

referral were very large at baseline in the two Asian countries

VJG2JKNKRRKPGUCPF8KGVa0CO6JGUGNQUUGUYGTGUWDUVCPVKCNN[

reduced by the end of the third project year through improved

communication between hospitals and the primary health care

facilities to which they were making referrals. Treatment success

rates among those started on treatment in hospitals were

similar to those reported by the NTP.

This project helped to describe a baseline situation in

which hospitals were not engaged. It then demonstrated that

it is possible to proactively engage hospitals and align their

services to national guidelines and in turn to improve detection

QH6$ECUGUCPFPQVKßECVKQPVQ062U#NNEQWPVTKGUJCXGGKVJGT

developed new national policies for hospital engagement or are

in the process of doing so, based on the project results. Similar

efforts are anticipated and needed in other countries.

FIGURE B3.4.1

Trends in bacteriological testing for TB and TB case

PQVKßECVKQPUKPRTQLGEVUKVGU¿

Number

20 000

40 000

60 000

80 000

100 000

2010 2011 2012

Number of bacteriological tests done

Total number of TB cases diagnosed and notified

Number of bacteriologically-positive cases diagnosed

 %QOOWPKV[EQPVTKDWVKQPUVQ6$PQVKßECVKQPU

and treatment support

Community-based TB activities can be dened as activ-

ities that are conducted outside the premises of formal

health facilities, within community-based structures (for

example, schools and places of worship) and homesteads.

Such activities can be implemented by community health

workers1 and community volunteers,2 regardless of wheth-

er they are employed and supervised by a government

department or by a nongovernmental organization, and

make an important contribution to health services includ-

ing prevention, diagnosis, improved treatment adherence,

care and support. In the specic context of TB, commu-

nity activities can help to increase case notications and

improve treatment outcomes, especially in settings where

people with TB have poor access to formal health services.

As shown in section 3.3, approximately one third of people

with TB are diagnosed but not reported to national surveil-

lance systems, or not diagnosed at all.

Accurate documentation of the contributions of commu-

nities to TB notications and treatment support has been

challenging. One reason has been the lack of standardiza-

tion of indicators that can be used for routine recording and

1 Community health workers can be dened as people with some

formal education who have been given training to contribute to

community-based health services, including TB prevention and

patient care and support. eir prole, roles and responsibilities

vary greatly among countries, and their time is often compensated

by incentives in kind or in cash.

2 Community volunteers can be dened as community members who

have been systematically sensitized about TB prevention and care,

either through a short, specic training scheme or through repeat-

ed, regular contact sessions with professional health workers.

36 GLOBAL TUBERCULOSIS REPORT 2013

BOX 3.5

The ENGAGE-TB approach

The ENGAGE-TB approacha describes the need for

PQPIQXGTPOGPVCNQTICPK\CVKQPUCPFQVJGTEKXKNUQEKGV[

QTICPK\CVKQPUVQKPVGITCVGEQOOWPKV[DCUGF6$CEVKXKVKGU

KPVQVJGKTGZKUVKPIYQTM2KNQVRTQLGEVUKPßXG#HTKECP

EQWPVTKGUVJG&GOQETCVKE4GRWDNKEQHVJG%QPIQ'VJKQRKC

-GP[C5QWVJ#HTKECCPFVJG7PKVGF4GRWDNKEQH6CP\CPKC

are showing promising results. Selected nongovernmental

QTICPK\CVKQPUKPVJGUGEQWPVTKGUJCXGUVCTVGFKPVGITCVKPI

TB services into community-based programmes for HIV,

maternal, newborn and child health (MNCH), and cancer

UETGGPKPIYKVJßPCPEKCNUWRRQTVHTQOVJG$TKUVQN/[GTU

Squibb Foundation.

NGO %17064; 241,'%6(1%75

Femmeplus Democratic

4GRWDNKEQH

the Congo

Integration of TB services into

community-based HIV activities

in two major cities (Kinshasa and

Kikwit)

AMREF Ethiopia Integration of TB/HIV services

into community-based MNCH

activities in a pastoralist region

CUAMM Ethiopia Integrated community-based TB,

HIV and cancer screening project

Save the

Children

Ethiopia Integration of community-based

TB/HIV services into MNCH

programmes in pastoralist

communities

Centre for

Positive Care

South Africa Strengthening integration of

TB into community-based HIV

activities

2CVJßPFGT 746CP\CPKC Integration of TB services into

community-based HIV services

0)1PQPIQXGTPOGPVCNQTICPK\CVKQP

The challenge is to scale up these experiences and

UKIPKßECPVN[KPETGCUGVJGPWODGTQHEQOOWPKV[DCUGF

workers and volunteers who are providing screening for TB,

referring those who might have TB for diagnosis and then

providing follow-up care and support to those diagnosed

YKVJVJGFKUGCUG9*1KUßPCNK\KPICPKORNGOGPVCVKQP

manual that will help to inform nongovernmental

QTICPK\CVKQPUCPF062UCDQWVJQYVJG[ECPYQTMVQIGVJGTVQ

implement integrated community-based TB activities, with a

RCTVKEWNCTHQEWUQPPQPIQXGTPOGPVCNQTICPK\CVKQPUYQTMKPI

on MNCH, HIV, primary health care, agriculture, livelihood

development and education services.

a ENG#GE-TB – InteIratinI community-based tuberculosis actiXities into

the work of nonIoXernmental orIanizations. Geneva, World Health

1TICPK\CVKQP

reporting. To address this challenge, WHO recently devel-

oped a minimum set of standardized indicators as part of

its ENGAGE-TB approach (Box 3.5). In 2013, these indi-

cators were used to collect standardized, comparable data

from a set of 13 countries in which data were known to be

routinely recorded and reported in at least some geograph-

ical areas.1 Data collection was undertaken separately from

the main round of global TB data collection, since most

countries are not routinely recording and reporting such

data and they are not relevant in all settings.

Among the 13 countries (Table 3.4), notied TB patients

referred from the community as a share of total notica-

tions in the areas covered by reporting ranged from 2% in

Myanmar (in 92/330 districts) to 33% in Ethiopia (in 98

out of 821 districts). It is possible that these gures are

an underestimate, pending optimization of recording and

reporting systems. Nonetheless, the nding that the con-

tribution of communities in referring people with TB was

under 10% in several countries suggests that there may

be opportunities to use untapped community resources in

TB prevention, diagnosis and treatment. In settings where

access to formal health services is limited, more emphasis

in policy and practice on the role of community referrals

of people with presumptive TB as early as possible is war-

ranted.

e share of patients receiving treatment support in the

community was generally high: for example, 50% country-

wide in India and 88% countrywide in Kenya.

Kenya also provides an interesting example of the

untapped potential of communities. While 88% of all TB

patients were reported as having received support for treat-

ment adherence, demonstrating the spread and reach of

community workers and volunteers in the country, only 5%

of TB case notications had been referred by community

members. is suggests that more could be done to increase

community engagement in and contribution to TB screen-

ing and referral.

It is evident that data on community contributions to

referrals and treatment adherence are not collected uni-

formly or systematically, even in the 13 countries shown

in Table 3.4. Only three of the 13 countries reported data

for both indicators that covered all districts in the country

(Burkina Faso, Kenya and Rwanda). e remaining coun-

tries reported data that covered only parts of the country

(sometimes very limited areas) or data were not available

for both indicators. Better understanding of the contri-

bution of communities to TB services will require more

routine collection of data; this is of greatest relevance in

settings where community contributions are considered a

necessary and integral part of TB services.

1 ere was no attempt to compile data about the contribution of

communities to programme design and implementation (including

advocacy activities at local levels). Such data are not routinely avail-

able.

37GLOBAL TUBERCULOSIS REPORT 2013

1 www.who.int/tb/data

2 e CDR is actually a ratio rather than a rate, but the term ‘rate’ has

become standard terminology in the context of this indicator.

3 It is approximate because of uncertainty in the underlying inci-

dence of TB and because notied cases are not necessarily a subset

of incident cases that occurred in the same year; see Chapter 2 for

further discussion.

TABLE 3.4

Community contributions to TB case notißcations and treatment adherence support, 2011–2012

%17064;

NOTIFIED PATIENTS

(41/%1//70+6;4'('44#.5

2#6+'0659*14'%'+8'&64'#6/'065722146+06*'%1//70+6;

%1*14670.'5552'%+(+'&

5*#4'1(616#.016+(+%#6+105+0#4'#5

(149*+%*&#6#9'4'4'2146'& )'1)4#2*+%%18'4#)'1(&#6# 5*#4'1(%1*146+0#4'#5(149*+%*

&#6#9'4'4'2146'& )'1)4#2*+%%18'4#)'1(&#6#

Burkina Faso 9% All districts 33% All districts

Côte d’Ivoire 16% FKUVTKEVU Not available

&4%QPIQ 10% 45/515 districts 3% FKUVTKEVU

Ethiopia 33% FKUVTKEVU 40%aFKUVTKEVU

India 3% 374/662 districts 50% All districts

Kenya 5% All districts  All districts

Malawi 20% FKUVTKEVU 91% FKUVTKEVU

Myanmar 2% 92/330 districts 2% 92/330 districts

Nigeria Not available 5% 36/774 districts

4YCPFC  All districts 46% All districts

Senegal 6% All districts Not available

Uganda Not available 35% All districts

746CP\CPKC 14% 63/162 districts  All districts

a Data are for the 2012 cohort.

FIGURE 3.1

Global trends in case notißcation (black) and

estimated TB incidence (green) rates, 1990–2012.

%CUGPQVKßECVKQPUKPENWFGPGYCPFTGNCRUGECUGUCNNHQTOU

1990 1995 2000 2005 2012

100

150

200

Rate per 100 000 population per year

3.3 Trends in case notißcations since 1990

and estimates of the case detection rate

Globally, the number of TB cases diagnosed and notied per

100000 population was relatively stable between 1990 and

2000, rose sharply between 2000 and 2008 and has subse-

quently started to fall slowly (Figure 3.1). Globally and in

all WHO regions, a clear gap exists between the numbers of

notied cases and the estimated numbers of incident cases,

although this has narrowed in the past decade globally and

in all six WHO regions (Figure 3.2). Trends in the 22 HBCs

are shown in Figure 3.3, and for other countries are illus-

trated in country proles that are available online.1

e case detection rate (CDR)2 for TB is an indicator

that is included within the MDGs (Chapter 1). For a giv-

en country and year, the CDR is calculated as the number

of new and relapse TB cases (see Box 3.1 for denitions)

that were notied by NTPs (Table 3.1), divided by the esti-

mated number of incident cases of TB that year. e CDR is

expressed as a percentage; it gives an approximate3 indica-

tion of the proportion of all incident TB cases that are actu-

ally diagnosed, reported to NTPs and started on treatment.

e best estimate of the CDR for all forms of TB globally

in 2012 was 66% (range, 64–69%), up from 53–59% in 2005

and 38–43% in 1995 – the year in which the DOTS strategy

began to be introduced and expanded (Table 3.5). e high-

est CDRs in 2012 were estimated to be in the Region of the

Americas (best estimate 79%; range, 74–85%), the Western

 GLOBAL TUBERCULOSIS REPORT 2013

FIGURE 3.2

Case notißcation and estimated TB incidence rates by WHO region, 1990–2012. 4GIKQPCNVTGPFUKPECUG

PQVKßECVKQPTCVGUPGYCPFTGNCRUGECUGUCNNHQTOUblack) and estimated TB incidence rates (green). Shaded areas

represent uncertainty bands.

Rate per 100 000 population per year

100

200

300

400

100

200

300

120

160

100

150

200

1990 1995 2000 2005 2012 1990 1995 2000 2005 20121990 1995 2000 2005 2012

Africa The Americas Eastern Mediterranean

Europe South-East Asia Western Pacific

Pacic Region (best estimate 81%; range, 75–89%) and the

European Region (best estimate 74%; range, 70–79%). e

other regions had estimated CDRs in the range of 55–71%,

with best estimates of around 60%. All regions have

improved their estimated CDRs since the mid-1990s, with

improvements particularly evident since 2000. Among the

22 HBCs, the highest rates of case detection in 2012 were

estimated to be in Brazil, China, Kenya, the Philippines and

the Russian Federation. e lowest rates, with best esti-

mates of around 50%, were in Afghanistan, Bangladesh,

the Democratic Republic of the Congo, Mozambique, Nige-

ria and Zimbabwe.

e gap between notications to national surveillance

systems and the true number of incident cases can be

explained by two factors. e rst is underreporting of

diagnosed TB cases, for example because private sector pro-

viders fail to notify cases. e second is under-diagnosis of

people with TB for reasons such as poor access to health

care and failure to recognize TB signs and symptoms and

test for TB when people do present to health care facilities.

Achieving the goal of universal health coverage, imple-

menting PPM initiatives such as those described in sec-

tion 3.2, and ensuring that there is an eective regulatory

framework that includes mandatory notication of cases

are essential to reduce underreporting and under-diagnosis.

A point-of-care diagnostics test would also help.

3.4 Treatment outcomes

Denitions of the categories used to report treatment out-

comes in this report are provided in Box 3.6. e updated

denitions that will be used from 2014 are explained in

Box 3.7.

3.4.1 New cases of smear-positive pulmonary TB

Data on treatment outcomes for new sputum smear-

positive cases of pulmonary TB are shown in Table 3.6 and

Figure 3.4. Globally, the rate of treatment success for the

2.6 million new cases of sputum smear-positive pulmonary

TB who were treated in the 2011 cohort was 87%. is was

the fth successive year that the target of 85% (rst set by

the World Health Assembly in 1991) was met or exceeded

globally. It is also impressive that as the size of the global

treatment cohort grew from 1.0 million in 1995 to 2.7 mil-

lion in 2009 and 2010 and 2.6 million in 2011, the treat-

ment success rate progressively improved.

Among the six WHO regions, three met or exceeded the

85% target: the Eastern Mediterranean Region, the South-

East Asia Region and the Western Pacic Region. e treat-

ment success rate was 82% in the African Region (where

there has been steady improvement since 1999), 78% in the

Region of the Americas (similar to the previous seven years)

and 65% in the European Region (where major eorts to

increase treatment success rates are needed).

Of the 22 HBCs, 16 reached or exceeded the 85% target

in 2011, including Ethiopia and Nigeria for the rst time.

Five HBCs reported lower rates of treatment success: Brazil

(76%), the Russian Federation (52%), South Africa (79%),

Uganda (77%) and Zimbabwe (81%). Nonetheless, among

these ve countries all except the Russian Federation sus-

tained their level or made progress compared with 2010.

39GLOBAL TUBERCULOSIS REPORT 2013

FIGURE 3.3

Case notißcation and estimated TB incidence rates, 22 high-burden countries, 1990–2012. Trends in case

PQVKßECVKQPTCVGUPGYCPFTGNCRUGECUGUCNNHQTOUblack) and estimated TB incidence rates (green). Shaded areas

represent uncertainty bands.

Afghanistan Bangladesh Brazil Cambodia China

DR Congo Ethiopia India Indonesia Kenya

Mozambique Myanmar Nigeria Pakistan Philippines

Russian Federation South Africa Thailand Uganda UR Tanzania

Viet Nam Zimbabwe

Rate per 100 000 population per year

100

200

300

100

200

300

400

500

250

500

750

1000

1250

100

150

200

100

200

300

400

250

500

750

1000

1250

250

500

750

1000

1250

100

150

200

250

500

750

1000

1250

100

200

300

100

200

300

400

500

600

200

400

600

100

200

300

400

200

400

600

200

400

600

800

100

200

300

100

200

300

100

200

300

400

100

200

300

400

100

150

250

500

750

1000

100

150

200

1990 1995 2000 2005 2012 1990 1995 2000 2005 2012

1990 1995 2000 2005 2012 1990 1995 2000 2005 2012 1990 1995 2000 2005 2012

FIGURE 3.4

Treatment outcomes by WHO region, 2011 cohorts

Global

WPR

SEAR

EUR

EMR

AMR

AFR

0% 20% 40% 60% 80% 100%

Global

WPR

SEAR

EUR

EMR

AMR

AFR

0% 20% 40% 60% 80% 100%

a. New smear-positive cases b. All new cases

Successfully treated Died Treatment failed Defaulted Not evaluated

40 GLOBAL TUBERCULOSIS REPORT 2013

TABLE 3.5

Estimates of the case detection rate for new and relapse cases (%), 1995–2012a

1995 2000 2005 2010 2012

BESTbLOW HIGH BEST LOW HIGH BEST LOW HIGH BEST LOW HIGH BEST LOW HIGH

Afghanistan ––– 15 22 46 39 57 52 44 63 52 44 63

Bangladesh 21 17 26 25 21 31  32 47 45  55 49 41 59

$TC\KN 79 66 97 74 62 91  72 100  69 99  69 99

Cambodia 23 19 30 27 22 34 52 44 63 64 56 75 66 57 77

China 32 27 39 33   74 65   76   79 100

&4%QPIQ 31 26  40 34  55 47 64 56 49 65 51 44 59

Ethiopia 11 7.2  33 22 55  32  66 49 93 64 49 

India 595267494555494455605466595466

Indonesia  7.1 12 20 16 25 57 47 71 66 56  72 61 

Kenya 61 56 66 72 67 77  76     79 76 

/Q\CODKSWG 23 11 73 23 13 51 30 20 53 33 25  34 25 50

Myanmar 10  13 15 13 19 53 45 63 66 57 77 71 62 

Nigeria  2.7 170 12 3.9 170 26 9.6 200 40 23  51 29 110

Pakistan 4.5 3.7 5.5 3.3  4.1 39 32  66 55  65 54 

Philippines  40  47 39 57 53 44 65 65 54 79  71 100

4WUUKCP(GFGTCVKQP 60 51 70 75 65  66 56   71   70 96

South Africa 56 47 69 59 49 72 61 50 74 70 59  62 52 75

Thailand 59 50 72 32 27 39 57  69 79 66 95 76 64 92

Uganda 23 14 41 29 20  47 36 65 60 50 75 69 57 

746CP\CPKC 59 51 69  60 77 74 69  77 72  79 74 

Viet Nam 33 25 47 56 43  63 49  70 54 95 76 59 100

<KODCDYG 55 40 79 56 45 71 50 40 63 53 43 69 46 37 60

High-burden countries 38 36 42 39 37 42 55 51 58 66 63 69 66 63 70

#(4 32 27 39 39 33  52 44 61 60 56 65 59 55 64

#/4 67 63 72 70 65 75 75 71  76 71  79 74 

'/4 23 21 26 25 22   43 54 64 57 72 63 56 71

'74 51 49 54 59 55 62 65 61 70 77 72  74 70 79

5'#4 44 40 49 41  44 50 46 53 61 56 65 62  66

924 37 32 42 39 35 44 70 63 77  73   75 

Global 40 38 43 41 39 44 56 53 59 66 63 68 66 64 69

– indicates values that cannot be calculated.

a 'UVKOCVGUHQTCNN[GCTUCTGTGECNEWNCVGFCUPGYKPHQTOCVKQPDGEQOGUCXCKNCDNGCPFVGEJPKSWGUCTGTGßPGFUQVJG[OC[FKHHGTHTQOVJQUGRWDNKUJGFRTGXKQWUN[

b $GUVNQYCPFJKIJKPFKECVGDGUVGUVKOCVGUHQNNQYGFD[NQYGTCPFWRRGTDQWPFU6JGNQYGTCPFWRRGTDQWPFUCTGFGßPGFCUVJGVJCPFVJEGPVKNGUQHQWVEQOG

distributions produced in simulations.

Data for Mozambique were not reported to WHO, but the

level in 2010 was 85%. In the Russian Federation, improve-

ment of treatment outcomes has been identied as a high

priority by the Ministry of Health and actions to improve

it have been dened. ese include ensuring earlier detec-

tion of MDR-TB and enrolment of patients on second-line

treatment, and strengthening patient support to improve

adherence to treatment (especially among the most social-

ly and economically disadvantaged patients). It is expected

that the introduction of a patient-based monitoring system

for those with MDR/XDR-TB and patients coinfected with

HIV in the near future will also help to improve the quality

of care and treatment outcomes.

3.4.2 All new cases

Data on treatment outcomes for all new cases of TB are

shown in Table 3.7 and Figure 3.4. Globally, the rate of

treatment success was 87% in 2011. Among the six WHO

regions, the highest rates were in the Eastern Mediterra-

nean Region (88%), the South-East Asia Region (89%) and

Western Pacic Region (93%). e treatment success rate

was 79% in the African Region, a big improvement from

73% in 2010. In the Region of the Americas and the Euro-

pean Region it was 75% and 72%, respectively.

Of the 22 HBCs, 15 reached or exceeded a treatment

success rate of 85% among all new cases in 2011, includ-

ing Ethiopia (following a major improvement from 77% in

41GLOBAL TUBERCULOSIS REPORT 2013

BOX 3.6

Deßnitions of treatment outcomes for drug-

susceptible TB until the end of 2012 and in this

global TB reporta

Cured A patient who was initially sputum smear-positive and

who was sputum smear-negative in the last month of treatment

and on at least one previous occasion.

Completed treatment A patient who completed treatment

DWVFKFPQVOGGVVJGETKVGTKCHQTEWTGQTHCKNWTG6JKUFGßPKVKQP

applies to sputum smear-positive and sputum smear-

negative patients with pulmonary TB and to patients with

extrapulmonary disease.

Died A patient who died from any cause during treatment.

Failed A patient who was initially sputum smear-positive

and who remained sputum smear-positive at month 5 or later

FWTKPIVTGCVOGPV#NUQKPENWFGFKPVJKUFGßPKVKQPCTGRCVKGPVU

found to have a multidrug-resistant strain at any point in time

during treatment, whether they are smear-negative or smear–

positive.

Defaulted A patient whose treatment was interrupted for two

consecutive months or more.

Not evaluated A patient whose treatment outcome is not

known.

Successfully treated A patient who was cured or who

completed treatment.

Cohort A group of patients in whom TB has been diagnosed,

CPFYJQYGTGTGIKUVGTGFHQTVTGCVOGPVFWTKPICURGEKßGFVKOG

period (e.g. the cohort of new sputum smear-positive cases

registered in the calendar year 2010). This group forms the

denominator for calculating treatment outcomes. The sum of

the above treatment outcomes, plus any cases for whom no

outcome is recorded (including those ‘still on treatment’ in the

'WTQRGCP4GIKQPCPFÁVTCPUHGTTGFQWVÂECUGUUJQWNFGSWCNVJG

number of cases registered. Some countries monitor outcomes

COQPIEQJQTVUFGßPGFD[URWVWOUOGCTCPFQTEWNVWTG

CPFFGßPGEWTGCPFHCKNWTGCEEQTFKPIVQVJGDGUVNCDQTCVQT[

evidence available for each patient.

a See Treatment of tuberculosis Iuidelines th ed. Geneva, World Health

1TICPK\CVKQP9*1*6/56$#XCKNCDNGCV

JVVRYJSNKDFQEYJQKPVRWDNKECVKQPUAGPIRFH

BOX 3.7

WHO deßnitions of treatment outcomes for

drug-susceptible TB recommended for use

starting in 2013 and that will be used in the

2014 global TB reporta

Cured A pulmonary TB patient with bacteriologically-

EQPßTOGF6$CVVJGDGIKPPKPIQHVTGCVOGPVYJQYCU

smear- or culture-negative in the last month of treatment

and on at least one previous occasion.

Completed treatment A TB patient who completed

treatment without evidence of failure but with no record

to show that sputum smear or culture results in the

last month of treatment and on at least one previous

occasion were negative, either because tests were not

done or because results are unavailable.

Died A patient who died from any cause during

treatment.

Failed A TB patient whose sputum smear or culture is

positive at month 5 or later during treatment.

Lost to follow-up A TB patient who did not start

treatment or whose treatment was interrupted for two

consecutive months or more.

Not evaluated A TB patient for whom no treatment

outcome is assigned. This includes cases ‘transferred out’

to another treatment unit as well as cases for whom the

treatment outcome is unknown to the reporting unit.

Successfully treated A patient who was cured or who

completed treatment.

Cohort #UFGßPGFKPBox 3.6. In addition, it should

be highlighted that any patient found to haXe druI-

resistant TB and placed on second-line treatment is

remoXed from the druI-susceptible TB outcome cohort.

This means that management of the standard TB register

and of the second-line TB treatment register needs to be

coordinated to ensure proper accounting of the outcomes

of treatment. (See also Box 4.4)

a &eßnitions and reportinI framework for tuberculosis – 201 reXision

9*1*6/6$)GPGXC9QTNF*GCNVJ1TICPK\CVKQP

Available at www.who.int/iris/bitstream/10665/79199/

AGPIRFH

BOX 3.8

Achievements in global TB care and control, 1995–2012

WHO began systematic monitoring of TB control progress in 1995. Data compiled on an annual basis since then allow achievements

in TB care and control to be assessed.

Between 1995 and 2012, 56 million people were successfully treated for TB in countries that had adopted the DOTS/Stop TB

StrateIy. This saved approximately 22 million lives.a

The number of lives saved is based on the estimate that in the absence of treatment, approximately one third of people with TB

would die of the disease. This estimate allows for differences in the mortality rates for smear-positive compared with other types of

TB disease (see Chapter 1), and for differences in mortality rates between HIV-negative and HIV-positive people.

a For estimates of the incremental number of lives saved by improvements in TB care associated with implementation of the DOTS and Stop TB Strategy compared

YKVJRTGUVCPFCTFUQHECTGUGG)NC\KQW2GVCN.KXGUUCXGFD[VWDGTEWNQUKUEQPVTQNCPFRTQURGEVUHQTCEJKGXKPIVJGINQDCNVCTIGVHQTTGFWEKPIVWDGTEWNQUKU

mortality. Bulletin of the World *ealth OrIanization¿

42 GLOBAL TUBERCULOSIS REPORT 2013

TABLE 3.6

Treatment success for new smear-positive cases (%) and cohort size (thousands), 1995–2011

a. Treatment success (%)

1995 1996 1997  1999 2000 2001 2002 2003 2004 2005 2006 2007  2009 2010 2011

Afghanistan – – 45 33       90     90 91

Bangladesh 71 63 73 77 79     90 91 92 92 91 92 92 92

$TC\KN 17 20 27 40  71 55  77 76 76 73 72 71 72 74 76

Cambodia 91 94 91 95 93 91 92 92 93 91 93 93 94 95 95 94 93

China 9394959595939592939494949494959695

&4%QPIQ 74  64 70 69  77         90 

Ethiopia 61 71 72 74 74  76 76 70 79       90

India 25 21  27 21 34 54 60 76        

Indonesia 91  54  50     90 91 91 91 91 91 90 90

Kenya 75 77 65 77 79   79         

/Q\CODKSWG 39 55 65 – 71 75   76 77 79  79    –

Myanmar 67 79               

Nigeria 4932737375797979 73 75 76     

Pakistan 70 – 67 23 70 74 77  79    91 90 91 91 92

Philippines 60 35  71            91 90

4WUUKCP(GFGTCVKQP 65 57 67  65  67 67 61 60    57 55 53 54

South Africa  61  72 57 63 61  67 69 71 74 74 76 73 79 79

Thailand 64    77 69 75 74 73 74 75 77     

Uganda 44 33 40 62 61 63 56 60  70 73 70 75 70 67 71 77

746CP\CPKC 73 76 77 76            90 

Viet Nam    92 92 92 93 92 92 93 92 93 92 92 92 92 93

<KODCDYG 53 32 69 70 73 69 71 67 66 54  60  74   

High-burden countries 53 50 56 62 60 67 72 75 81 84 86 87 87 87 88 88 88

#(4 60 56 64 70  71 70 73 73 74 76 75     

#/4 50 51  67 79 76 69   79 79 76 79 77 76 75 

'/4 79 66 73 57 79            

'74 67  72 63 75 75 74 74 75 71 72 70 71 70 69 67 65

5'#4 33 31 29 40 34 50 63  79        

924  72 91 92 91 90 91 90 91 91 92 92 92 92 93 93 94

Global 57 54 60 64 64 69 73 76 80 83 85 84 86 86 86 87 87

D%QJQTVUK\GVJQWUCPFU

1995 1996 1997  1999 2000 2001 2002 2003 2004 2005 2006 2007  2009 2010 2011

Afghanistan 2.0 2.9 2.0 3.1 6.3   10 10 12 13 13 12 13 14

Bangladesh 11 30 34    41 47 54 63  102 104 106 109 106 99

$TC\KN 46 45 43 30 27 34 41 29  43 42   41 41 42 43

Cambodia 4.4 9.1 12 13 16 15 14 17 19 19 21 19 19 20  17 16

China 131 175  210  214 190 194 267  473 470 466 464 449 430 377

&4%QPIQ 16 25 26 33 35 36 41 45 54 62 65 63 66 66 72 73 71

Ethiopia 5.1 11 12 15 21 30 32 37 40 41 39 37  41 45 47 41

India 265 291 293  345 349  396 420  507 553 592 616 625 630 642

Indonesia 3.0 12 21 40 46 52 54 76 93 129 159 175 161 166 169  

Kenya 6.5 13 19 22 27  31 31 34 41 40 39  37 37 36 37

/Q\CODKSWG 11 13 11 12 13 14 15 16 17    19 20 20

Myanmar 7.9 9.7 9.2 10 12 17 21 24 27 31 37 40 43 41 42 42 42

Nigeria 9.5 24 11 13 15 16 17 21  34 35 40 44 46 45 45 47

Pakistan   29 3.0 4.1 6.3 15 20 32  66  100 102 104 106

Philippines 90 126 27 21 37 50 55 59         94

4WUUKCP(GFGTCVKQP 0.05 43 0.7 0.7 1.5 3.6 4.1 5.2 6.3 26 26 31 32 32 32 30 37

South Africa  45 55 37   101 99 114 127 135 140 143 144 139 134 133

Thailand 20 0.1 3.7  14 23 20 27   30 29 30 33  30 31

Uganda 15 15  13 14 14 17 19 20 21 21 20 21 23 23 23 26

746CP\CPKC 20 21 22 24 24 24 24 24 25 26 25 25 25 24 25 24 24

Viet Nam   54 55 53 53 54 57 56  55 56 54 53 51 52 51

<KODCDYG 9.712121313141716141513161110101213

High-burden countries 739 967 879 912 1 044 1 119 1 186 1 260 1 450 1 776 1 965 2 087 2 132 2 181 2 184 2 185 2 140

#(4  233  235 323 365 409 452 491 552 564 566 577 591 606 599 579

#/4 129 134 125 111 110 111 102 105 110 121 119 132 116 109 123 126 127

'/4 46 51 60  66 64 52 76   114 132 156 167 167 170 171

'74 34 94 24  22 41 50 54 60     114 105 99 97

5'#4  360 376 399 473 512 550 604 661    974 1 011 1 022 1 045 1 065

924 296 372 294 313 353 360 346 357 439 575 663 663 661 657 641 622 560

Global 1 001 1 245 1 147 1 195 1 347 1 453 1 510 1 649 1 842 2 206 2 396 2 529 2 591 2 649 2 665 2 662 2 599

Blank cells indicate data not reported.

– indicates values that cannot be calculated.

43GLOBAL TUBERCULOSIS REPORT 2013

TABLE 3.7

Treatment success for all new cases (%) and cohort size (thousands), 1995–2011

a. Treatment success (%)

1995 1996 1997  1999 2000 2001 2002 2003 2004 2005 2006 2007  2009 2010 2011

Afghanistan – – 45 33       90      

Bangladesh 71 63 73 77 79     90 90 91 90 91 91 91 91

$TC\KN 17 20 27 40  71 55  77 72 72 69 72 69 70 72 73

Cambodia 91 94 91 95 93 91 92 92 93 91 91 92 93 94 94  94

China 9394959595939592939292929393949595

&4%QPIQ 74  64 70 69  77     60     

Ethiopia 61 71 72 74 74  76 76 70 79      77 

India 25 21  27 21 34 54 60 76        

Indonesia 91  54  50       90 90 90   

Kenya 75 77 65 77 79   79  77       

/Q\CODKSWG 39 55 65 – 71 75   76 77 79  79    –

Myanmar 67 79               

Nigeria 49 32 73 73 75 79 79 79  73 75 76     

Pakistan 70 – 67 23 70 74 77  79    90  91 90 92

Philippines 60 35  71            90 

4WUUKCP(GFGTCVKQP 65 57 67  65  67 67 61 65 67 69 69 69  66 65

South Africa  61  72 57 63 61  67 65 69 70 71 73  53 77

Thailand 64    77 69 75 74 73 71 71 75     

Uganda 44 33 40 62 61 63 56 60  70 73  72 67 64  73

746CP\CPKC 73 76 77 76             

Viet Nam    92 92 92 93 92 92 92 92 92 91 92 92 92 93

<KODCDYG 53 32 69 70 73 69 71 67 66  66 67  70 75 76 

High-burden countries 53 50 56 62 60 67 72 75 81 82 85 85 87 87 86 86 88

#(4 60 56 64 70  71 70 73 73 70 74 72 77 77 76 73 79

#/4 50 51  67 79 76 69   76 75 73  73 73 73 75

'/4 79 66 73 57 79            

'74 67  72 63 75 75 74 74 75 76 77 75 76 76 75 74 72

5'#4 33 31 29 40 34 50 63  79        

924  72 91 92 91 90 91 90 91  90 90 91 91 91 92 93

Global 57 54 60 64 64 69 73 76 80 81 84 84 85 85 85 84 87

D%QJQTVUK\GVJQWUCPFU

1995 1996 1997  1999 2000 2001 2002 2003 2004 2005 2006 2007  2009 2010 2011

Afghanistan 2.0 2.9 2.0 3.1 6.3   10 10 12 13 13 12 26 26

Bangladesh 11 30 34    41 47 54 63 119 141 144 106 156 150 

$TC\KN 46 45 43 30 27 34 41 29     47 73 75  71

Cambodia 4.4 9.1 12 13 16 15 14 17 19 30 34 34 35  39 40 37

China 131 175  210  214 190 194 267 644    932 923  

&4%QPIQ 16 25 26 33 35 36 41 45 54 62 65 92  93 106 109 92

Ethiopia 5.11112152130323740413937 139 139 152 91

India 265 291 293  345 349  396 420 1 066 1 071 1 137 1 199 1 226 1 244 1 229 1 209

Indonesia 3.0 12 21 40 46 52 54 76 93 206 244 266 263 293  296 314

Kenya 6.5 13 19 22 27  31 31 34 97  101 99 99 99 90 

/Q\CODKSWG 11 13 11 12 13 14 15 16 17    19 20 20

Myanmar 7.9 9.7 9.2 10 12 17 21 24 27 66 73   90 91 127 135

Nigeria 9.5 24 11 13 15 16 17 21  34 35 40 44 46   

Pakistan   29 3.0 4.1 6.3 15 20  117 149 191 206 212 256 255

Philippines 90 126 27 21 37 50 55 59  126  123 136 140 141 162 190

4WUUKCP(GFGTCVKQP 0.05 43 0.7 0.7 1.5 3.6 4.1 5.2 6.3 39 74 97 99 103 101 94 

South Africa  45 55 37   101 99 114 243 259 271 247 236 367  292

Thailand 20 0.1 3.7  14 23 20 27  47 49 47 47 54 43  49

Uganda 15 15  13 14 14 17 19 20 21 21 31 37 39  40 43

746CP\CPKC 20 21 22 24 24 24 24 24 25 61 59  25 59 60 59 59

Viet Nam   54 55 53 53 54 57 56 92 55 91 91 91   

<KODCDYG 9.7 12 12 13 13 14 17 16 14 54 43 43 39 40 45 46 40

High-burden countries 739 967 879 912 1 044 1 119 1 186 1 260 1 450 3 183 3 430 3 799 3 872 4 134 4 374 4 403 4 252

#(4  233  235 323 365 409 452 491   940 930  1 297 1 215 1 094

#/4 129 134 125 111 110 111 102 105 110 191  197 157  191 200 

'/4 46 51 60  66 64 52 76   226 259 307 320 331 391 

'74 34 94 24  22 42 50 55 60  221 274 276 279  250 217

5'#4  360 376 399 473 512 550 604 661 1 530 1 639    1 940  

924 296 372 294 313 353 360 346 357 439 963 1 030 1 163 1 216 1 261 1 259 1 240 1 213

Global 1 001 1 245 1 147 1 195 1 347 1 453 1 511 1 649 1 843 3 892 4 188 4 592 4 720 4 995 5 267 5 275 5 096

Blank cells indicate data not reported.

– indicates values that cannot be calculated.

44 GLOBAL TUBERCULOSIS REPORT 2013

BOX 3.9

Outcomes of TB treatment by HIV status

HIV+

(109 137)

HIV-

(925 024)

HIV+

(148 798)

HIV-

(811 586)

HIV+

(73 354)

HIV-

(370 385)

HIV+

(117 094)

HIV-

(959 174)

HIV+

(163 300)

HIV-

(845 907)

HIV+

(79 817)

HIV-

(385 748)

New smear-positive

patients (data from

88 countries)

New smear-negative

and extrapulmonary

patients (data from

72 countries)

Retreatment

patients (data from

59 countries)

100

Percentage of cohort (%)

a. Treatment success, 2011

b. Death rate among evaluated cases, 2011

Percentage (%)

New smear-positive

patients (data from

88 countries)

New smear-negative

and extrapulmonary

patients (data from

72 countries)

Retreatment

patients (data from

59 countries)

FIGURE B3.9.1

6TGCVOGPVUWEEGUUCCPFFGCVJTCVGUDCOQPI*+8

positive and HIV-negative TB patients, 2011

+PEQWPVTKGUYKVJa*+8RQUKVKXG6$

patients reported treatment outcomes for 2011 that were

disaggregated by HIV status. These countries accounted for

QHCNN*+8RQUKVKXG6$RCVKGPVUTGIKUVGTGFKPVJCV[GCT

This was a considerable increase from 2010, when countries

that reported outcomes disaggregated by HIV status

accounted for 25% of TB patients with a documented HIV-

positive test result. Much of the improvement is due to the

TGRQTVKPIQHFCVCFKUCIITGICVGFD[*+8UVCVWUHQTVJGßTUV

time by high TB/HIV burden countries such as South Africa

and Uganda. Of the 41 TB/HIV priority countries (listed in

Table 6.1 of Chapter 6), 19 reported treatment outcomes

FKUCIITGICVGFD[*+8UVCVWU$WTWPFK$WTMKPC(CUQ$TC\KN

Botswana, China, Ghana, Haiti, India, Kenya, Lesotho,

/CNK/[CPOCT0COKDKC0KIGTKC5QWVJ#HTKEC5YC\KNCPF

6JCKNCPFVJG7PKVGF4GRWDNKEQH6CP\CPKCCPF8KGV0CO

Data for 2011 show that treatment outcomes for HIV-

positive TB patients continue to be worse than those of

HIV-negative TB patients. The treatment success rate for all

PGY*+8RQUKVKXG6$RCVKGPVUYCUEQORCTGFYKVJ

among HIV-negative TB patients (Figure B3.9.1). If it is

assumed that HIV-positive TB patients who defaulted from

treatment would have died from TB, the death rate was 19%

among HIV-positive TB patients compared with 3% among

*+8PGICVKXG6$RCVKGPVU5WEJßPFKPIUCTGEQPUKUVGPVYKVJ

two autopsy studies in South Africa, which showed that

undiagnosed TB remains the main cause of death among

HIV-positive people.a,b

a /WVGXGF\K2GVCNEarly mortality followinI initiation of #4T in

rural South #frica the contribution of eZistinI co-morbidities. 20th

%QPHGTGPEGQP4GVTQXKTWUGUCPF1RRQTVWPKUVKE+PHGEVKQPU#VNCPVC

)GQTIKC75#¿/CTEJ2CRGTwww.retroconference.

org/2013b/Abstracts/46910.htm, accessed 3 June 2013).

b Martinson N et al. 7ndiaInosed infectious TB in adult home deaths

South #frica 201VJ%QPHGTGPEGQP4GVTQXKTWUGUCPF1RRQTVWPKUVKE

+PHGEVKQPU#VNCPVC)GQTIKC75#¿/CTEJ2CRGTwww.

TGVTQEQPHGTGPEGQTID#DUVTCEVUJVOCEEGUUGF,WPG).

2010 to 89% in 2011) and Nigeria for the rst time. e

six countries that reported lower rates of treatment suc-

cess were Brazil (73%), the Russian Federation (65%),

South Africa (77%), ailand (82%), Uganda (73%) and

Zimbabwe (80%). Data were not reported for Mozambique.

Treatment outcomes are worse among HIV-positive TB

patients compared with HIV-negative TB patients (Box 3.9).

Further eorts are needed to narrow the gap.

45GLOBAL TUBERCULOSIS REPORT 2013

%*#26'4

Drug-resistant TB

KEY FACTS AND MESSAGES

■ By the end of 2012, data on anti-TB drug resistance were available for 136 countries (70% of 194 WHO Member States), either

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■ 5WTXG[UWPFGTYC[KPKPVJGITQWRQHJKIJ6$CPFQT/&46$DWTFGPEQWPVTKGUCPFHTQOYJKEJTGUWNVUCTGGZRGEVGFKP

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JCXG/&46$6JGJKIJGUVNGXGNUCTGKPGCUVGTP'WTQRGCPFEGPVTCN#UKCYJGTGKPUGXGTCNEQWPVTKGUOQTGVJCPQHPGYECUGUCPF

OQTGVJCPQHRTGXKQWUN[VTGCVGFECUGUJCXG/&46$

■ 6JGTGYGTGCPGUVKOCVGFTCPIG¿PGYECUGUQH/&46$YQTNFYKFGKP#OQPIRCVKGPVUYKVJ

RWNOQPCT[6$PQVKßGFKPKGVJGITQWRQHRCVKGPVUMPQYPVQ062UCPFVJCVECPDGVGUVGFHQTFTWITGUKUVCPEGWUKPI9*1

TGEQOOGPFGFFKCIPQUVKEVGUVUVJGTGYGTGCPGUVKOCVGFaTCPIGa¿a/&46$ECUGUKP/QTGVJCPJCNH

QHVJGUGECUGUYGTGKP+PFKC%JKPCCPFVJG4WUUKCP(GFGTCVKQP

■ 'ZVGPUKXGN[FTWITGUKUVCPV6$:&46$JCUDGGPTGRQTVGFD[EQWPVTKGU1PCXGTCIGCPGUVKOCVGF%+¿

QH/&46$ECUGUJCXG:&46$

■ #VQVCNQH6$ECUGUGNKIKDNGHQT/&46$VTGCVOGPVYKVJ/&46$CPFYKVJTKHCORKEKPTGUKUVCPEGFGVGEVGF

WUKPI:RGTV/6$4+(YGTGPQVKßGFINQDCNN[KPOQUVN[D['WTQRGCPEQWPVTKGU+PFKCCPF5QWVJ#HTKEC6JKUTGRTGUGPVGF

RTQITGUUEQORCTGFYKVJYJGP/&46$ECUGUCPFTKHCORKEKPTGUKUVCPV6$ECUGUYGTGFGVGEVGFVJGNCTIGUV

increases between 2011 and 2012 were in India, South Africa and Ukraine. However, worldwide and in most countries with a high

DWTFGPQH/&46$NGUUVJCPQPGVJKTFQHVJG6$RCVKGPVUGUVKOCVGFVQJCXG/&46$YGTGCEVWCNN[FGVGEVGFKP

■ %QWPVTKGUFGVGEVKPIENQUGVQQHVJGPQVKßGF6$RCVKGPVUGUVKOCVGFVQJCXG/&46$KPKPENWFGF'UVQPKC-C\CMJUVCP

.CVXKC.KVJWCPKC5QWVJ#HTKECCPF7MTCKPG6JGNQYGUVßIWTGUYGTGKPVJG5QWVJ'CUV#UKC4GIKQPCPFVJG9GUVGTP2CEKßE

4GIKQPYJKEJEQODKPGFJCXGQHVJGYQTNFÂUECUGUQH/&46$

■ ,WUVQXGTRGQRNGYKVJ/&46$YGTGUVCTVGFQPUGEQPFNKPGVTGCVOGPVKPGSWKXCNGPVVQQHVJGPGYN[

FGVGEVGFECUGUVJCVYGTGGNKIKDNGHQTUWEJVTGCVOGPVINQDCNN[&KCIPQUVKEVTGCVOGPVICRUYGTGOWEJNCTIGTKPUQOGEQWPVTKGU

GURGEKCNN[KPVJG#HTKECP4GIKQPQHFGVGEVGFECUGUGPTQNNGFQPVTGCVOGPVCPFYKFGPGFDGVYGGPCPFKP%JKPC

Pakistan and South Africa.

■ 6JGVTGCVOGPVUWEEGUUVCTIGVQHÜUGVKPVJGGlobal Plan to Stop TB 2011–2015HQT/&46$YCUTGCEJGFD[QH

EQWPVTKGUVJCVTGRQTVGFQWVEQOGFCVCHQTVJGRCVKGPVEQJQTV*QYGXGTQXGTCNNQPN[QHRCVKGPVUYGTGUWEEGUUHWNN[VTGCVGF

■ +PVGPUKßGFINQDCNCPFPCVKQPCNGHHQTVUVQFGVGEVECUGUQH/&46$VQGPTQNVJGOQPVTGCVOGPVCPFVQKORTQXGVTGCVOGPV

outcomes are urgently required.

Drug-resistant TB (DR-TB) threatens global TB control and

is a major public health concern in several countries. is

chapter summarizes the progress made in global surveil-

lance of anti-TB drug resistance, using the most recent data

on MDR-TB and XDR-TB gathered from special surveys and

continuous surveillance systems, and summarizes global

estimates of disease burden associated with MDR-TB based

on these data (section 4.1). It also includes an assessment

of national progress in diagnosing and treating MDR-TB,

using data on diagnostic testing for DR-TB, enrolment on

treatment with second-line drugs for those found to have

MDR-TB, and treatment outcomes (section 4.2).

4.1 Surveillance of drug-resistant TB

4.1.1 Progress in the coverage of drug resistance

surveillance

Since the launch of the Global Project on Anti-tuberculosis

Drug Resistance Surveillance in 1994, data on drug resis-

tance have been systematically collected and analysed from

136 countries worldwide (70% of WHO Member States).

is includes 70 countries that have continuous surveil-

lance systems based on routine diagnostic drug suscepti-

bility testing (DST) of all TB patients and 66 countries that

rely on special epidemiological surveys of representative

samples of patients. e progress towards achieving global

coverage of drug resistance data is shown in Figure 4.1.

46 GLOBAL TUBERCULOSIS REPORT 2013

Continuous surveillance for MDR-TB, based on routine

DST of TB patients and systematic collection, collation and

analysis of data, is the most eective approach to monitor

trends in drug resistance over time. Additionally, such sys-

tems can detect outbreaks that might otherwise be unde-

tected, even during the course of a survey if the outbreak

site was not among those sites selected for patient enrol-

ment.

e number of countries that can rely on data generat-

ed by continuous surveillance systems is increasing, due to

eorts invested in scaling up the availability of culture and

DST services. Several high MDR-TB burden countries in the

European Region, including Belarus, Georgia, Kazakhstan,

Republic of Moldova, Ukraine and the Baltic States, have

put in place high quality surveillance systems to monitor

drug resistance both in new and previously treated TB cas-

es. A group of countries – Bolivia, Chile, Colombia, Costa

Rica, Ecuador, Egypt, El Salvador, Kyrgyzstan, Lebanon,

Mongolia, Nicaragua, Rwanda, Sri Lanka, Syrian Arab

Republic and Tajikistan – that previously relied on special

surveys to monitor drug resistance, have now established

routine surveillance systems for all previously treated cas-

es. is is the rst step towards achieving routine DST for

all TB patients.

Special surveys still represent the most common

approach to investigating the burden of drug resistance in

resource-limited settings where routine DST is not acces-

sible to all TB patients due to lack of laboratory capacity

or resources. Between 2010 and 2012, drug resistance

surveys were completed for the rst time in 16 countries:

Afghanistan (Central region), Albania, Bangladesh, Belar-

us, Benin, Bulgaria, Kyrgyzstan, Malawi, Nigeria, Saudi

Arabia, Somalia, Tajikistan, Tunisia, Uganda, Uzbekistan

and Yemen. In addition, Egypt, Brazil, Nepal and Zambia

completed a repeat survey.

In mid-2013, drug resistance surveys were ongoing in

12 high TB and MDR-TB burden countries. ese include

the rst nationwide surveys in Azerbaijan, India, Pakistan,

Turkmenistan, Ukraine, and repeat surveys in China, Ethi-

opia, Kenya, the Philippines, South Africa, ailand and

VietNam.

Molecular technologies are increasingly being used in

drug resistance surveys to simplify logistics and reduce

laboratory workload. GenoType® MTBDRplus (Hain Life-

science, Germany) was used in the national survey com-

pleted in 2012 in Nigeria and Xpert® MTB/RIF (Cepheid,

USA) is being used in the surveys underway in Pakistan and

Papua New Guinea. Several more countries are planning to

use Xpert MTB/RIF as a screening tool in drug resistance

surveys. ough not a complete surrogate for MDR-TB,

particularly in settings where levels of drug resistance are

low, rifampicin resistance is the most important indicator

of MDR-TB, with serious clinical implications for aected

patients. In countries where there is not yet the capacity

for culture and DST using conventional methods or where

laboratories cannot cope with the large workload generat-

ed by a drug resistance survey, Xpert MTB/RIF can play

an important role. It can be used to screen specimens for

rifampicin resistance and identify those requiring further

testing to be performed at national or supranational TB ref-

erence laboratories, also reducing the cost of initial screen-

ing by conventional commercial DST systems.

FIGURE 4.1

Progress in global coverage of data on drug resistance, 1994–2013

Year of most

recent data

1995–1999

2000–2004

2005–2009

2010–2012

Ongoing in 2013

No data

Subnational data only

Not applicable

47GLOBAL TUBERCULOSIS REPORT 2013

Five high TB and MDR-TB burden countries (Afghani-

stan, Brazil, Democratic Republic of the Congo, Indonesia

and the Russian Federation) still rely on drug resistance

surveillance data gathered from sub-national areas only.

ese countries should consider conducting nationwide

drug resistance surveys in the short term to better under-

stand the burden of MDR-TB and to guide the planning of

diagnostic and treatment services. A further six countries

(Dominican Republic, Guinea, Iran, Lesotho, Sierra Leone

and Zimbabwe) rely on drug resistance data gathered from

studies conducted in the late 1990s and should consider

implementing repeat surveys. Central and Francophone

Africa remain the parts of the world where drug resistance

surveillance data are most lacking, largely as a result of the

current weak laboratory infrastructure. Eorts should be

made to increase diagnostic and surveillance capacity in

these settings so that a drug resistance survey can be con-

ducted.

Of the 136 countries with surveillance data on drug

resistance, 35% (48 countries) have only one data point and

should consider repeating surveys to assess time trends.

Data on time trends in drug resistance were available

from 88 countries and 10 territories worldwide for a total

of 870 country-year data points. Among the 36 high TB and

high MDR-TB burden countries, 11 countries (Cambodia,

Estonia, Georgia, Latvia, Lithuania, Mozambique, Myan-

mar, Republic of Moldova, the Russian Federation (7 Fed-

eral Subjects), ailand and Viet Nam) have completed at

least two surveys at least ve years apart, allowing trends

over time to be evaluated. However, for ve of these coun-

tries (Cambodia, Mozambique, Myanmar, ailand and

Viet Nam) the most recent data are more than ve years

old. Among the six countries with recent data, in Estonia

and Latvia, surveillance data show that the rates of both

TB and MDR-TB have been declining. ese data suggest

that MDR-TB can indeed be controlled once eective policy

decisions are put into practice, and the necessary preven-

tion and control measures are implemented. In Lithuania,

Georgia, Republic of Moldova and most Federal Subjects of

the Russian Federation, MDR-TB rates appear to be stable

whereas in Ivanovo Oblast and Mary-El Republic MDR-TB

rates are increasing. Extending trend analyses to other

countries requires more data from repeat surveys or contin-

uous surveillance systems. NTPs should plan to repeat drug

resistance surveys regularly, approximately every ve years,

until capacity for continuous surveillance is established.

4.1.2 Percentage of new and previously treated

TB cases that have MDR-TB

Globally, 3.6% (95% CI: 2.1–5.1%) of new TB cases and

20.2% (95%CI: 13.3–27.2%) of previously treated cases are

estimated to have MDR-TB (Table 4.1). ese estimates are

essentially unchanged from 2011.

e proportions of new and previously treated TB cases

with MDR-TB at the country level are shown in Figure 4.2

and Figure 4.3, and for the 27 high MDR-TB burden coun-

tries in Table 4.1. Eastern European and especially central

Asian countries continue to have the highest levels of MDR-

TB. Among new cases, examples include Azerbaijan (22.3%

in 2007), Belarus (34.8% in 2012), Estonia (19.7% in 2012),

FIGURE 4.2

Percentage of new TB cases with MDR-TBa

Percentage

of cases

0–2.9

3–5.9

6–11.9

12–17.9

≥18

No data

Subnational data only

Not applicable

a Figures are based on the most recent year for which data have been reported, which varies among countries.

 GLOBAL TUBERCULOSIS REPORT 2013

TABLE 4.1

Estimated proportion of TB cases that have

MDR-TB, globally and for 27 high MDR-TB burden

countries and WHO regions

ESTIMATED

% OF NEW TB

CASES WITH

/&46$a

CONFIDENCE

+06'48#.

ESTIMATED

% OF

4'64'#6/'06

TB CASES WITH

/&46$a

CONFIDENCE

+06'48#.

Armenia 9.4 7.0–12 43 ¿

#\GTDCKLCP 22 19–27 56 50–62

Bangladesh 1.4 0.7–2.5 29 24–34

Belarus 35 33–37 69 66–71

Bulgaria 2.3 ¿ 23 17–31

China 5.7 4.5–7.0 26 22–30

&4%QPIQ 2.5 0.1–5.0 10 .5–1

Estonia 20 14–26 50 35–65

Ethiopia 1.6 ¿ 12 5.6–21

Georgia 9.2 7.9–11 31 27–35

India 2.2 1.9–2.6 15 11–19

Indonesia 1.9 1.4–2.5 12 ¿

-C\CMJUVCP 23 22–24 55 54–56

-[TI[\UVCP 26 23–31  65–72

Latvia 11 ¿ 32 23–42

Lithuania 11 9.5–14 44 39–49

Myanmar 4.2 3.1–5.6 10 6.9–14

Nigeria 2.9 2.1–4.0 14 10–19

Pakistan .5 0.1–12 2.5–5

Philippines 4.0 2.9–5.5 21 14–29

4GRWDNKEQH/QNFQXC 24 21–26 62 59–65

4WUUKCP(GFGTCVKQP 23 21–25 49 45–53

South Africa  1.4–2.3 6.7 ¿

Tajikistan 13 ¿ 56 52–61

Ukraine 14 14–15 32 31–33

7\DGMKUVCP 23 ¿ 62 53–71

Viet Nam 2.7 2.0–3.7 19 14–25

High MDR-TB

burden countries 4.2 2.1–6.2 21 12–30

#(4 2.3 0.2–4.4 11 4.4–17

#/4 2.2 1.4–3.0 14 4.7–22

'/4 3.5 0.1–11 33 12–54

'74 16 10–22 45 39–52

5'#4 2.2 ¿ 16 11–21

924 4.7 3.3–6.1 22 ¿

Global 3.6 2.1–5.1 20 13–27

a Best estimates are for the latest available year. Estimates in italics are based on

regional data.

Kazakhstan (22.9% in 2012), Kyrgyzstan (26.4% in 2011),

the Republic of Moldova (23.7% in 2012), the Russian Fed-

eration (average: 23.1%, with Yamalo-Nenets Autonomous

Area being the highest: 41.9% in 2011) and Uzbekistan

(23.2% in 2011). Among previously treated cases, exam-

ples include Azerbaijan (Baku City: 55.8% in 2007), Belar-

us (68.6% in 2012), Estonia (50.0% in 2012), Kazakhstan

(55.0% in 2012), Kyrgyzstan (68.4% in 2012), the Republic

of Moldova (62.3% in 2012), Tajikistan (56.0% in 2012) and

Uzbekistan (62.0% in 2011). In the Russian Federation,

even though the average proportion of cases with MDR-

TB does not exceed 50%, the proportion is well above 50%

in several Federal Subjects (with Ulyanovsk Oblast at the

highest level: 74.0% in 2011).1

1 Tuberculosis in the Russian Federation 2011: an analytical review of

statistical indicators used in the Russian Federation and in the world (in

Russian). Moscow: Ministry of Health of the Russian Federation et

al., 2013.

BOX 4.1

MDR-TB in children

TB in children poses a diagnostic challenge, as

paucibacillary disease is more likely. Specimens suitable

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from the youngest children who cannot expectorate sputum.

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children.

6JGTGNCVKQPUJKRDGVYGGP/&46$CPFCIGITQWR

(children aged less than 15 years versus adults aged 15

years or older) was recently assessed using representative

drug resistance surveillance data reported to WHO between

1994 and 2012. Data were analysed for 376 293 TB cases

for whom age and DST data were available. Odds ratios

were derived by logistic regression with robust standard

errors, as described in detail elsewhere.a1HVJGEQWPVTKGU

reporting data from nationwide surveys or surveillance

U[UVGOUTGRQTVGFCVNGCUVQPGRCGFKCVTKE/&46$ECUG

A child with TB was shown to be as likely as an adult

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KFGPVKßECVKQPQH/&46$KPEJKNFTGPDGUVTGPIVJGPGF

Efforts should be made to systematically conduct household

EQPVCEVKPXGUVKICVKQPQHCNNRCVKGPVUYKVJ/&46$KPENWFKPI

children. Additionally, children must be routinely included

in all drug resistance surveillance activities, including drug

resistance surveys.

a <KIPQNGVCN/WNVKFTWITGUKUVCPVVWDGTEWNQUKUKPEJKNFTGPGXKFGPEGHTQO

global surveillance. European 4espiratory ,ournal¿

More positively, levels of drug resistance among new cas-

es remain low (<3%) in many parts of the world, including

almost all countries in the Region of the Americas, most

African countries where drug resistance surveys have been

conducted, most of the South-East Asia Region, most of

western Europe, and several countries in the Western Pacif-

ic Region (examples include Australia, Cambodia, Japan,

New Zealand and VietNam).

49GLOBAL TUBERCULOSIS REPORT 2013

FIGURE 4.3

Percentage of previously treated TB cases with MDR-TBa

Percentage

of cases

0–5.9

6–11.9

12–29.9

30–49.9

≥50

No data

Subnational data only

Not applicable

a (KIWTGUCTGDCUGFQPVJGOQUVTGEGPV[GCTHQTYJKEJFCVCJCXGDGGPTGRQTVGFYJKEJXCTKGUCOQPIEQWPVTKGU6JGJKIJRGTEGPVCIGUQHRTGXKQWUN[VTGCVGF6$ECUGUYKVJ/&46$

KP$CJTCKP$QPCKTG¿5CKPV'WUVCVKWUCPF5CDC%QQM+UNCPFU+EGNCPF5CQ6QOGCPF2TKPEKRGCPF.GDCPQPTGHGTVQQPN[CUOCNNPWODGTQHPQVKßGFECUGU

4.1.3 Estimated global incidence of MDR-TB and

estimated number of MDR-TB cases among

 PQVKßGF6$RCVKGPVUKP

e data compiled from surveillance of drug resistance

among TB patients allow estimation of the total number of

incident cases of MDR-TB worldwide in 2012. e number

of incident cases includes not only cases among notied

TB patients, but also cases among people diagnosed with

TB that were not notied to NTPs (and in whom MDR-TB

may not have been detected) and cases among people not

yet diagnosed with TB. Globally in 2012, there were an

estimated 450 000 (range: 300 000‒600 000) new cases

of MDR-TB. Methods used to produce this estimate are

explained in Annex 1.

Data compiled from surveillance of drug resistance

among TB patients also allow production of global as well as

country-specic estimates of the number of MDR-TB cases

among notied TB patients with pulmonary TB. ese are

the MDR-TB cases that could be found by NTPs if all noti-

ed patients were tested for drug resistance to rifampicin

and isoniazid using WHO-recommended diagnostic tests,

and is a useful indicator for assessing country performance

in detecting cases of MDR-TB and enrolling them on treat-

ment. Globally in 2012, there were an estimated 300000

(range: 220000–380 000) MDR-TB cases among notied

TB patients. Country-specic estimates are discussed in

section 4.2.

4.1.4 Resistance to second-line drugs

Extensively drug-resistant TB (XDR-TB) had been reported

by 92 countries globally by the end of 2012 (Figure 4.4). A

total of 75 countries and 4 territories reported represen-

tative data from continuous surveillance or special sur-

veys regarding the proportion of MDR-TB cases that had

XDR-TB. Combining their data, the average proportion of

MDR-TB cases with XDR-TB was 9.6% (95% CI: 8.1%–11%),

similar to the estimate from 2011 (9.0%). irteen of these

countries reported more than 10 XDR-TB cases in the most

recent year for which data were available. Among those

countries, the proportion of MDR-TB cases with XDR-

TB was highest in Azerbaijan (Baku city: 12.8%), Belarus

(11.9%), Latvia (16.0%), Lithuania (24.8%) and Tajikistan

(Dushanbe city and Rudaki district: 21.0%).

e proportion of MDR-TB cases with resistance to u-

oroquinolones and second-line injectable agents was 16.5%

(95% CI: 12.3–20.7) and 22.7% (15.4%–30.0%), respective-

ly. A total of 32.0% (21.9%–42.1%) of patients with MDR-

TB have resistance to a uoroquinolone, a second-line

injectable agent, or both. ese patients would likely be

eligible to receive bedaquiline, the new bactericidal drug

recently approved for use in patients with MDR-TB when

options to treat using existing drugs have been exhausted

(see Box 8.2 in Chapter 8).

50 GLOBAL TUBERCULOSIS REPORT 2013

FIGURE 4.4

Countries that had notißed at least one case of XDR-TB by the end of 2012

At least one case reported

No cases reported

Not applicable

4.2 Management of drug-resistant TB

 %QXGTCIGQHFTWIUWUEGRVKDKNKV[VGUVKPI&56

e diagnosis of DR-TB requires TB patients to be tested

for susceptibility to drugs. Notication data combined with

data from drug resistance surveillance suggest that if all

notied TB patients with pulmonary TB had been tested in

2012, around 300000 cases of MDR-TB would have been

found (section 4.1.3).

Targets included in the Global Plan to Stop TB 2011–2015

are that by 2015 all new cases of TB considered at high risk

of MDR-TB (estimated to be about 20% of all new bacterio-

logically-positive TB cases globally), as well as all previously

treated cases, should undergo DST for at least the rst-line

drugs rifampicin and isoniazid. Similarly, all patients with

MDR-TB should be tested for XDR-TB.

First-line DST results were reported by just over 50%

of countries in 2012 and overall for a small proportion of

cases (Table 4.2). Globally, only 5% of new bacteriological-

ly-conrmed TB cases and 9% of those previously treated

for TB were tested for MDR-TB in 2012. e proportion of

new cases with DST results has increased slightly in recent

years but remains below the target envisaged for 2012

by the Global Plan (Figure 4.5). Coverage was highest in

the European Region, where 72% of new cases and 41% of

previously treated cases were tested for MDR-TB in 2012,

reecting the relatively better access to TB laboratory ser-

vices than elsewhere. Levels of testing were particularly

low in the African and South-East Asia Regions (0.3% and

0.1% of new bacteriologically cases and 3.1% and 0.7% of

previously treated cases, respectively).

Among the 27 high MDR-TB burden countries – which

account for >85% of estimated MDR-TB cases in the world

– the proportion of TB patients who were tested ranged

from 56 to 100% among new cases in 13 of the 14 Euro-

pean countries reporting data (17% in Tajikistan; no data

reported by Azerbaijan), and exceeded 60% among pre-

viously treated cases in nine of these countries. Among

non-European high MDR-TB burden countries, testing for

MDR-TB among new cases was highest in China (3.6%). In

previously treated cases, the coverage of testing was higher

and reached 10% in Indonesia and 12% in China and the

Philippines. In South Africa, 16% of TB cases overall were

tested for MDR-TB although DST data were not available

separately for new and previously treated cases. Five other

countries did not report data, including India, the country

estimated to have the highest number of MDR-TB cases

among notied TB patients (Table 4.2).

Among TB patients who were notied and conrmed to

have MDR-TB in 2012, 23% were reported to have DST per-

formed for both uoroquinolones and second-line injectable

drugs. Second-line DST coverage exceeded 90% in Armenia,

Bulgaria, the Democratic Republic of the Congo, Georgia

and Latvia. South Africa accounted for most of the global

cases for which second-line DST data were reported, as well

as the highest proportion observed in the African Region

(the regional gure drops from 62% to 1% when South Afri-

ca is excluded). Second-line DST reports were available for

53% of MDR-TB cases in the Western Pacic Region, 47% in

the Region of the Americas and 3–8% in the other regions.

Improving the coverage of diagnostic DST is urgently

needed to improve the detection of MDR-TB and XDR-TB.

51GLOBAL TUBERCULOSIS REPORT 2013

TABLE 4.2

DST coverage among TB and MDR-TB cases, globally and for 27 high MDR-TB burden countries and WHO

regions, 2012

0'9$#%6'4+1.1)+%#..;215+6+8'%#5'5 4'64'#6/'06%#5'5 %10(+4/'&/&46$%#5'5

07/$'49+6*

DSTa4'57.65

% OF CASES WITH

&564'57.65

07/$'49+6*

DSTa4'57.65

% OF CASES WITH

&564'57.65

07/$'49+6*

DSTb4'57.65

% OF CASES WITH

&564'57.65

Armenia  64  27 92 100

#\GTDCKLCP –––

Bangladesh 41  557 7.0 142 

Belarus 2 164 90   –

Bulgaria  71 142 45 49 100

China 11 472 3.6  12 2 042 

&4%QPIQ 12  95 1.3 65 100

Estonia 193 100 46  55 

Ethiopia 469 1.0  4.4 –

Georgia 1 931  541 45 341 99

India – – 597 3.6

Indonesia 2   10  43

-C\CMJUVCPc >100 10 443 93 –

-[TI[\UVCP  57 662 61 511 53

Latvia 666 97 100  106 96

Lithuania 1 017 100 350 100 210 77

Myanmar – –  11

Nigeria 11  94 1.2 –

Pakistan 461 0.4 154 1.3 –

Philippines 35    –

4GRWDNKEQH/QNFQXC 1 264 67 933 63 –

4WUUKCP(GFGTCVKQP 32 647 79 12 324 24 –

South Africa – – 11 046 72

Tajikistan 919 17 496 66 345 50

Ukraine  77 5 925 72 –

7\DGMKUVCP 2 703 56  30 356 21

Viet Nam – – –

High MDR-TB burden countries 77 277 3.9 42 851 7.7 16 225 21

#(4 2 216 0.3 3 969 3.1 11 303 62

#/4  22  23  47

'/4 1 990 1.1 1 617 7.6 51 3.2

'74  72 37 774 41 2 523 6.7

5'#4 1 352 0.1 2 292 0.7 1 619 

924  3.3  10 2 365 53

Global 136 630 5.1 59 267 8.7 19 245 23

Blank cells indicate data not reported.

– indicates values that cannot be calculated.

a &56KUHQTKUQPKC\KFCPFTKHCORKEKP

b &56KUHQTCàWQTQSWKPQNQPGCPFCUGEQPFNKPGKPLGEVCDNGFTWI

c #RQUUKDNGGZRNCPCVKQPHQTYJ[VJGRGTEGPVCIGHQTPGYECUGUKP-C\CMJUVCPGZEGGFUKUKPCFGSWCVGNKPMCIGUDGVYGGPENKPKECNCPFNCDQTCVQT[TGIKUVGTU

52 GLOBAL TUBERCULOSIS REPORT 2013

FIGURE 4.5

DST coverage among new cases and enrolment on MDR-TB treatment, compared with the targets in the Global

Plan to Stop TB, 2011–2015. Lines indicate the planned targets, blue squares show the situation in 2009–2012 and

orange circles the projected enrolments 2013–2015. Data on projected enrolments in 2015 were incomplete.

Number of patients

b. Enrolment on MDR-TB treatment

2009 2010 2011 2012 2013 2014 2015

50 000

100 000

150 000

200 000

250 000

300 000

Percentage of cases

2009 2010 2011 2012 2013 2014 2015

a. DST coverage among new bacteriologically-positive cases

is requires the strengthening of laboratory capacity, the

introduction of new rapid diagnostics and improved report-

ing from diagnostic centres (see Chapter 5). e identi-

cation of XDR-TB cases in countries worldwide (Box 4.2,

Figure 4.4) reects the risk of acquisition of additional sec-

ond-line drug resistance and the transmission of resistant

strains when TB care and prevention (including infection

control) are inadequate.

 0QVKßECVKQPQH/&46$ECUGUCPFGPTQNOGPV

on treatment

e low coverage of DST in many countries is one of the

main constraints limiting the detection of MDR-TB among

people diagnosed with TB. Globally, 83 715 cases of MDR-

TB were notied to WHO in 2012, with India, the Russian

Federation and South Africa reporting more than a half of

these cases (Table 4.3). In addition, just over 10 000 rifam-

picin-resistant TB (RR-TB) cases were reported to have

been detected using rapid molecular techniques.1 India,

Kyrgyzstan, the Philippines and Uzbekistan each reported

>500 of such cases.

e 83 715 reported cases of MDR-TB cases represent-

ed 28% of the 300 000 (range, 220 000–380 000) pulmo-

nary TB patients estimated to have MDR-TB in 2012 (Table

4.3), up from 20% in 2011, and 19% of the 450 000 (range:

300 000‒600 000) estimated incident MDR-TB cases in

the world in 2012. Much of the increase between 2011 and

2012 was accounted for by India (4237 to 16 588), South

Africa (10 085 to 15 419)2 and Ukraine (4305 to 6934),

although increases were reported by a total of 17 high

MDR-TB burden countries and all WHO regions with the

exception of the Region of the Americas. In the Democratic

BOX 4.2

XDR-TB in Africa

+PCENWUVGTQH:&46$RCVKGPVUKPTWTCN5QWVJ#HTKEC

made international headlines.a All of the patients from this

cluster who were tested for HIV were found to be infected.

Most of these patients died very quickly. South Africa

TGOCKPUVJGEQWPVT[VJCVTGRQTVUVJGOQUV:&46$ECUGU

KPVJGYQTNFCPFCPPWCNPQVKßECVKQPUJCXGKPETGCUGFHTQO

KPVQKP#DQWVQH/&46$ECUGU

TGRQTVGFKPVJKUEQWPVT[JCXG:&46$

FIGURE B4.2.1

Treatment outcomes for 623 TB patients with XDR-

TB in South Africa, 2010

Completed 6%

Cured 12%

Not evaluated 17%

Lost to follow-up 9%

Treatment failed 8%

Died 49%

By the end of 2012, 15 countries in the African region had

KFGPVKßGFCPFTGRQTVGFCVNGCUVQPGECUGQH:&46$Figure

4.4+PVYQJKIJ/&46$DWTFGPEQWPVTKGUKPVJG

#HTKECP4GIKQP¿VJG&GOQETCVKE4GRWDNKEQHVJG%QPIQ

CPF0KIGTKC¿GCEJTGRQTVGFVJGKTßTUV:&46$ECUG5GXGP

#HTKECPEQWPVTKGUTGRQTVGFUVCTVKPI:&46$RCVKGPVUQP

treatment in 2011 or 2012, most of them in South Africa.

Treatment outcomes reported by South Africa reveal the very

low likelihood of a favourable outcome in such patients and

the high proportion of patients lost to or not evaluated by

the health services (see Figure B4.2.1).

a )CPFJK04/QNN#5VWTO#92CYKPUMK4)QXGPFGT6.CNNQQ7GVCN

Extensively drug-resistant tuberculosis as a cause of death in patients

co-infected with tuberculosis and HIV in a rural area of South Africa. The

Lancet¿

1 ese are in addition to other rifampicin-resistant cases detected

by Xpert MTB/RIF, which were included under MDR-TB notica-

tions following subsequent testing for isoniazid resistance.

2 In South Africa, the number of cases detected was above the esti-

mated number of cases among pulmonary TB patients; this could

reect either that the estimates of the number of MDR-TB cases

among TB patients are too conservative and/or the absence of link-

ages between the clinical and laboratory registers.

53GLOBAL TUBERCULOSIS REPORT 2013

TABLE 4.3

Estimated MDR-TB cases in 2012, notißed cases of MDR-TB and enrolments on MDR-TB treatment

2009–2012, and treatment outcome reporting for 2010 cohort, globally and for 27 high MDR-TB burden

countries and WHO regions

'56+/#6'&/&46$#/10)016+(+'&

27./10#4;6$%#5'5 NOTIFIED CASES %#5'5'041..'&10/&46$64'#6/'06

/&46$%#5'5

4'2146'&9+6*

64'#6/'06176%1/'

&#6#%1*146

BEST LOW HIGH 2009 2010 2011 2012

2012

NOTIFIED /

ESTIMATED

(%)a

2009 2010 2011 2012 N %b

Armenia 250 220  156 177 79 92 37 134 154  101 132 75

#\GTDCKLCP  2 600 3 000 552  596 21  592 406 263 

Bangladesh 4 200 3 100 5 200 339 509 513 12 352 339 390 513 329 97

Belarus 2 200 2 100 2 200 1 342 1 576 1 594 1 604 73 200 1 446  1 442 91

Bulgaria 100  130 43 56 55 49 49 43 56 42 36 56 100

China 59 000 52 000 66 000 474 2 792 1 601 3 007 5.1  1 222 1 155 1 906 1 222 44

&4%QPIQ 2 900 670 5 100 91  121 65 2.2 176 191  179 105 121

Estonia 70 56   63  62   63 75 54 64 102

Ethiopia 2 100 1 200 3 000 233 140 212  14  120 199  114 

Georgia 630 570 690 369 359 475 346 55 266  737 665 504 140

India 64 000 49 000 79 000 1 660 2 967 4 237  26 1 136 2 967  14 143  74

Indonesia 6 900 5 200     6.2 20 142 260 426 140 77

-C\CMJUVCP   9 000 3 644     3 209 5 705 5 261 7 213 5 777 

-[TI[\UVCP  1 600 1 900  566   53 545 566 492 790 441 

Latvia 120 100 140 131  105 110 92 124  103 110  101

Lithuania 300 270 330 322 310 296 271 90 322 310 296 271 310 100

Myanmar 6 000 4 600 7 500  192 690  13 64 192 163 442  

Nigeria 3 600 2 700 4 500  21 95 107 3.0 0 23  125 23 110

Pakistan 11 000 0 29 000 49 444 344 1 602 15  424 344 1 045 195 44

Philippines 13 000 10 000 16 000 1 073 522  679 5.2 501  2 397   150

4GRWDNKEQH/QNFQXC 1 700 1 600  1 069  1 001  53 334 791 765  –

4WUUKCP(GFGTCVKQP 46 000 43 000 49 000  13 692  13 612 30  13 692    34

South Africa  6 900 9 400 9 070   15 419 >100 4 143 5 402 5 643 6 494  66

Tajikistan 910  1 000 319 333 604 694 76 52 245  535 245 74

Ukraine  6 500 7 000  5 336 4 305 6 934 >100   4 950 7 672 3 902 73

7\DGMKUVCP 4 000 3 700 4 300 654 1 023   43 464   1 491  61

Viet Nam  3 000 4 600 217 101 601 273 7.2 307 101  713 97 96

High MDR-TB

burden countries 270 000 180 000 350 000 40 798 47 772 52 813 75 301 28 24 521 38 942 49 663 69 320 28 793 60

#(4  14 000 62 000 10 741 9 340    5 994 7 209 7 467 9 303 6 166 66

#/4 7 100 4 500 9 600  2 661 3 474 2 967 42 3 153 3 249  3 102 2 374 

'/4  0 42 000 496   2 236 12 707 967 756 1 602 676 77

'74 74 000 60 000   33 776 34 199  50 17 169  36 313 42 399 19 496 

5'#4 90 000 71 000 110 000 2 560 3 942 6 615 19 202 21 2 040 3 901 4 597  3 113 79

924 74 000 57 000 91 000 2 059 4 295 4 394 4 473 6.0 1 429 2 210 4 946 5 070 2 456 57

Global 300 000 220 000 380 000 46 897 54 887 61 907 83 715 28 30 492 45 872 57 166 77 321 34 281 62

Blank cells indicate data not reported.

– indicates values that cannot be calculated.

a 0QVKßGFECUGUQH/&46$KPCUCRGTEGPVCIGQHVJGDGUVGUVKOCVGQH/&46$ECUGUCOQPICNNECUGUQHRWNOQPCT[6$KPVJGUCOG[GCT6JGRGTEGPVCIGOC[GZEGGF

KHGUVKOCVGUQHVJGPWODGTQH/&46$CTGVQQEQPUGTXCVKXGCPFKHNKPMCIGDGVYGGPVJGENKPKECNCPFNCDQTCVQT[TGIKUVGTUKUKPCFGSWCVG

b 6JGRGTEGPVCIGQH/&46$ECUGUQTKIKPCNN[PQVKßGFKPYKVJQWVEQOGUTGRQTVGF6JGRGTEGPVCIGOC[GZEGGFCUCTGUWNVQHWRFCVGFKPHQTOCVKQPCDQWV/&46$

ECUGUKPKPCFGSWCVGNKPMCIGUDGVYGGPPQVKßECVKQPU[UVGOUHQT6$CPF/&46$CPFVJGKPENWUKQPKPVJGVTGCVOGPVEQJQTVQHECUGUQH/&46$ECUGUHTQOC[GCTRTKQTVQ

2010.

54 GLOBAL TUBERCULOSIS REPORT 2013

Republic of the Congo, the Philippines and Viet Nam, which

detected less than 30% of their estimated burden in 2012,

MDR-TB notications decreased between 2011 and 2012.

Of the MDR-TB cases reported globally in 2012, most (82%)

were detected in either the European Region (36 708), India

(16 588) or South Africa (15 419).

Countries detecting close to 100% of the TB patients esti-

mated to have MDR-TB in 2012 included Estonia, Kazakh-

stan, Latvia, Lithuania, South Africa and Ukraine (Table

4.3). In the African and European Regions and the Region

of the Americas, about 50% of the TB patients estimated

to have MDR-TB were detected in 2012. e lowest gures

were in the two regions with the largest number of cases:

the South-East Asia region (21%) and the Western Pacic

Region (6%). India and China, the two countries estimat-

ed to have the largest numbers of TB patients with MDR-

TB (both over 50000, Figure 4.6), strongly inuence the

overall gures for the South-East Asia and Western Pacic

Regions. China and India, together with the Russian Federa-

tion – which ranks third globally in total cases of MDR-TB –

detected and reported less than one third of the TB patients

estimated to have MDR-TB (5%, 26% and 30% respectively).

e absolute numbers of TB cases started on second-line

treatment for MDR-TB increased from 30492 in 2009 to

77321 in 2012 (+154%). ere was a 40% increase in enrol-

ments between 2011 and 2012 in the 27 high MDR-TB

burden countries, which reected progress in 20 of these

countries and especially in India, Kazakhstan and Ukraine

(Table 4.3). e ratio of the numbers of patients starting

treatment with second-line drug regimens for MDR-TB,

to those notied with MDR-TB in 2012, was 92% globally

FIGURE 4.6

Number of MDR-TB cases estimated to occur among notißed pulmonary TB cases, 2012

MDR-TB cases

0–199

200–1999

2000–19 999

20 000–49 999

≥ 50 000

No data

Not applicable

(82% when RR-TB cases are included), but was lower in the

African (51%) and South-East Asia (83%) Regions (Table

4.3). Waiting lists of people requiring treatment for MDR-

TB are persisting or growing in several countries, particu-

larly when additional RR-TB cases diagnosed using Xpert

MTB/RIF are taken into account. Diagnosis:treatment

gaps of 5% or more were evident in 14 of the high MDR-

TB burden countries in 2012 (Figure 4.7), and the ratio of

MDR-TB cases diagnosed to enrolments on MDR-TB treat-

ment increased by more than 10% between 2011 and 2012

in China, Pakistan and South Africa. e number of XDR-

TB cases reported worldwide increased from 1464 to 2230

between 2011 and 2012. All the WHO regions reported

more XDR-TB cases enrolled on treatment in 2012 than in

2011, reaching 1557 globally in 2012.

Common constraints to treatment scale up include a

critical shortage of trained sta, insucient availability

of second-line medications, inadequate numbers of facili-

ties for treatment and monitoring, incomplete diagnosis

of patients and other weaknesses in the coordination of

activities required for eective programmatic management

of DR-TB. ere is a global shortfall in capacity to place peo-

ple diagnosed with MDR-TB on treatment, and increased

resources for the programmatic management of MDR-TB

are urgently required.

In a few countries, such as Georgia, the Russian Feder-

ation and Ukraine, enrolments have outstripped notica-

tions of MDR-TB in recent years. Possible explanations for

this include frequent empirical treatment of TB patients

considered at risk of having MDR-TB but for whom a labo-

ratory-conrmed diagnosis is missing, incomplete report-

55GLOBAL TUBERCULOSIS REPORT 2013

FIGURE 4.7

MDR-TB cases (orange) and additional rifampicin-resistant TB cases (blue) detected compared with

TB cases enrolled on MDR-TB treatment (green) 2009–2012, globally and in 27 high MDR-TB burden

countries, 2009–2012

Number of cases

100

150

200

400

600

800

200

400

600

1000

2000

3000

100

150

200

100

Armenia Azerbaijan Bangladesh Belarus

Bulgaria China DR Congo Estonia

100

200

300

200

400

600

800

5000

10000

15000

100

200

300

400

500

Ethiopia Georgia India Indonesia

2000

4000

6000

8000

250

500

750

1000

100

150

250

270

290

310

330

350

Kazakhstan Kyrgyzstan Latvia Lithuania

200

400

600

800

100

200

300

500

1000

1500

2000

Myanmar Nigeria Pakistan Philippines

500

1000

1500

2000

2500

300

500

700

900

1100

5000

10000

15000

20000

5000

10000

15000

200

400

600

800

Republic of Moldova Russian Federation South Africa Tajikistan

2000

4000

6000

8000

500

1000

1500

2000

200

400

600

800

2009 2010 2011 2012 2009 2010 2011 2012 2009 2010 2011 2012 2009 2010 2011 2012

Ukraine Uzbekistan Viet Nam Global

500

1000

1500

2000

2500

20 000

40 000

60 000

80 000

100 000

56 GLOBAL TUBERCULOSIS REPORT 2013

ing of laboratory data, or enrolment of ‘backlogs’ or waiting

lists of MDR-TB patients who were detected before 2012.

Among 119 countries reporting sex-disaggregated data

for enrolments, the median male:female ratio was 2. Most

countries that reported data on MDR-TB patient enrol-

ments did not report the inclusion of any children. In the

44 countries that did, the proportion of children ranged

from <1% to 33% of total enrolments.

Many countries envisage increases in the number of

patients enrolled on treatment for MDR-TB between 2013

and 2015. However, global projections remain well below

Global Plan targets, partly as a result of slow rates of

increase as well as incomplete information regarding fore-

casts, notably for China (2015) and the Russian Federation

BOX 4.3

Pharmacovigilance for TB care

2JCTOCEQXKIKNCPEGKUFGßPGFD[

9*1CUÄThe science and actiXities

relatinI to the detection assessment

understandinI and preXention of

adXerse effects or any other druI-

related problem.”

#FXGTUGFTWITGCEVKQPU#&4UECP

lead to a TB patient interrupting

treatment before completion, thus contributing to avoidable

morbidity, drug resistance, treatment failure, reduced

quality of life, or death. It is important to routinely monitor

VJGQEEWTTGPEGQH#&4UKP6$RCVKGPVUQPVTGCVOGPVKP062U

This is particularly relevant in the care of patients with

&46$CPFRCVKGPVUYJQCTG*+8RQUKVKXG

6JTGGCRRTQCEJGUVQRJCTOCEQXKIKNCPEGCTGKPWUG

Spontaneous reporting. This involves the reporting of

#&4U¿GIQVQVQZKEKV[CUUQEKCVGFYKVJCOKPQIN[EQUKFGU

– to the national pharmacovigilance centre.

Targeted spontaneous reporting. This is an extension

of spontaneous reporting that can be focused on the

UWTXGKNNCPEGQHUGTKQWUCFXGTUGGXGPVUKPURGEKßERCVKGPV

ITQWRUUWEJCURCVKGPVUYKVJ/&46$

Cohort event monitoring (CEM). This is an active form of

surveillance, similar in design and management to an

epidemiological cohort study. CEM is particularly well

suited to the post-marketing surveillance of new drugs.

In 2012, WHO produced a handbook on pharmacovigilance

for TB.a WHO offers technical assistance to countries for

the introduction and strengthening of pharmacovigilance

in their programmes. The handbook explains how

pharmacovigilance can be effectively implemented in a TB

programme through key stakeholders, including regulators

and manufacturers, and provides a step-by-step approach

to identifying signals, assessing the relationship between

an event and a drug, determination of causality, acting on

QDUGTXCVKQPUCPFEQOOWPKECVKQPQHßPFKPIU

a # practical handbook on the pharmacoXiIilance of medicines used in

the treatment of tuberculosis enhancinI the safety of the TB patient.

)GPGXC9QTNF*GCNVJ1TICPK\CVKQPwww.who.int/medicines/

RWDNKECVKQPURJCTOCEQXKIKNCPEGAVD).

(2013) (Figure 4.5b). To reach the targets set out in the

Global Plan and advance towards universal access to treat-

ment, a bold and concerted drive is still needed on many

fronts of TB care, particularly in the countries where the

burden is highest. e capacity to address this challenge has

increased in recent years as a result of the intensied tech-

nical assistance provided by international organizations.

With the reform of the Green Light Committee (GLC) struc-

ture in 2011, and the creation of regional level committees

(rGLCs) in all six WHO regions, international support to

national eorts to strengthen programmatic management

of DR-TB is now focused on devolving available resources

and technical assistance closer to countries.

4.2.3 Treatment outcomes for MDR-TB and XDR-TB

Standardized monitoring methods and indicators have

allowed countries to report MDR-TB treatment outcomes

in a comparable manner for several years. In 2013, the de-

nitions for treatment outcomes were simplied and the

reporting requirements changed to allow for the inclusion

of RR-TB cases in the MDR-TB cohort (Box 4.4).

e number of cases reported in annual MDR-TB treat-

ment outcome cohorts has tripled between 2007 and 2010,

reecting increases in all regions (Figure 4.8). All high

MDR-TB burden countries have now reported treatment

outcomes for at least one annual cohort since 2007.

A total of 107 countries reported outcomes for more

than 34000 MDR-TB cases started on treatment in 2010

(Table 4.3). is is equivalent to 62% of the number of

MDR-TB cases notied by countries in the same year. e

low proportion reects weaknesses in reporting systems to

reconcile outcome data with notications. e Global Plan

envisages that by 2015, all countries will report outcomes

for all notied MDR-TB cases. In 2010, only 71 countries

– including 13 high MDR-TB burden countries – reported

outcomes for a cohort whose size exceeded 80% of the orig-

inal number of MDR-TB notications in 2010.

Overall, the proportion of MDR-TB patients in the 2010

cohort who successfully completed treatment was 48%,

while 28% of cases were reported as lost to follow-up or had

no outcome information. Treatment success was highest in

the Eastern Mediterranean Region (56%), as well as in the

Region of the Americas (54%) where this proportion has

increased steadily since 2007 alongside a reduction in the

proportion of patients whose treatment outcome was not

evaluated. In the 2010 cohort, deaths were highest in the

African Region (17%) and the proportion of patients whose

treatment failed was highest in the European Region (11%).

e Global Plan’s target of achieving at least 75% treatment

success in MDR-TB patients by 2015 was only reached by

34/107 countries reporting outcomes for the 2010 cohort,

but included three high MDR-TB burden countries: Bangla-

desh, Ethiopia and VietNam.

Among a subset of 795 XDR-TB patients in 26 countries,

treatment success was 20% overall and 44% of patients

died; excluding South Africa, the gures were 27% and 28%

respectively (Box 4.2).

A PRACTICAL HANDBOOK

ON THE PHARMACOVIGILANCE

OF MEDICINES USED

IN THE TREATMENT OF

TUBERCULOSIS

ENHANCING THE SAFETY OF THE TB PATIENT

57GLOBAL TUBERCULOSIS REPORT 2013

FIGURE 4.8

Treatment outcomes for patients diagnosed with MDR-TB by WHO region, 2007–2010 cohorts.

The total numbers of cases with outcome data are shown beside each bar.

Africa The Americas

Eastern Mediterranean Europe

South-East Asia Western Pacific

Global

2010

2009

2008

2007

2010

2009

2008

2007

2010

2009

2008

2007

2010

2009

2008

2007

2010

2009

2008

2007

2010

2009

2008

2007

2010

2009

2008

2007

0% 20% 40% 60% 80% 100%

6 166

6 143

5 496

4 570

676

511

262

128

34 281

23 250

15 565

10 959

3 113

1 140

413

253

2 374

2 298

1 732

1 458

19 496

12 131

6 904

4 097

2 456

1 027

758

453

Cured Completed Died

Treatment failed Lost to follow-up Not evaluated

Progressing towards the target for treatment success

requires the scale up of treatment programmes globally,

enhancing the eectiveness of drug regimens, support to

patients to avoid treatment interruption and improved

data collection. In particular, countries need to analyse the

poor treatment outcomes observed in MDR-TB cases and

intensify measures to improve adherence and monitoring.

TB programmes need to apply a package of services for

MDR-TB patients that include free TB and ancillary med-

ications, free laboratory testing, enablers and social sup-

port, and the use of short treatment regimens following

current WHO policy in selected patients. e treatment of

XDR-TB patients in particular remains very unsatisfactory

and more eective regimens for this condition are urgently

required.

4.2.4 Other aspects of MDR-TB programme

management

During their illness, patients with MDR-TB may be cared

for as either outpatients or within hospitals, usually sec-

ondary or tertiary facilities. WHO recommends that, where

possible, patients with MDR-TB should be treated using

ambulatory or community-based care rather than models

of care based principally on hospitalization.

National policies and practices dier in the predominant

model of care that is employed. Among the high MDR-TB

burden countries, the lowest level of hospitalization was

reported by the Philippines (5% of MDR-TB patients),

while levels in Eastern European countries ranged between

75 and 100% but were lower in Central Asia (30–50% in

Kazakhstan, Tajikistan and Uzbekistan). In the African

Region, there is wide variation in the extent to which

 GLOBAL TUBERCULOSIS REPORT 2013

patients with MDR-TB are hospitalized, ranging from 10%

of patients (Democratic Republic of the Congo) to 100%

(Ethiopia and Nigeria). Globally, the average duration of

hospital stay ranged from 7 to 240 days (median: 84 days).

e number of visits to a health facility after diagnosis of

BOX 4.4

WHO deßnitions of treatment outcomes for

RR-TB, MDR-TB and XDR-TB

Cured Treatment completed as recommended by the

national policy without evidence of failure AND three or

more consecutive cultures taken at least 30 days apart are

negative after the intensive phase.

Treatment completed Treatment completed as

recommended by the national policy without evidence

of failure BUT no record that three or more consecutive

cultures taken at least 30 days apart are negative after the

intensive phase.

Treatment failed Treatment terminated or need for

permanent regimen change of at least two anti-TB drugs

DGECWUGQH

lack of conversion by the end of the intensive phase; or

bacteriological reversion in the continuation phase after

conversion to negative; or

evidence of additional acquired resistance to

àWQTQSWKPQNQPGUQTUGEQPFNKPGKPLGEVCDNGFTWIUQT

adverse drug reactions.

Died A patient who died for any reason during the course

of treatment.

Lost to follow-up A patient whose treatment was

interrupted for two consecutive months or more.

Not evaluated A patient for whom no treatment outcome

is assigned (this includes cases ‘transferred out’ to another

treatment unit and whose treatment outcome is unknown).

Successfully treated The sum of cured and treatment

completed.

Cohort #ITQWRQHRCVKGPVUYJGTG446$JCUDGGP

FKCIPQUGFKPENWFKPI/&46$CPF:&46$CPFYJQYGTG

UVCTVGFQPCHWNNEQWTUGQHCUGEQPFNKPG/&46$FTWI

TGIKOGPFWTKPICURGEKßGFVKOGRGTKQFGIVJGEQJQTVQH

/&46$ECUGUTGIKUVGTGFKPVJGECNGPFCT[GCT6JKU

group forms the denominator for calculating treatment

QWVEQOGU9KVJVJGTGXKUGFFGßPKVKQPUany patient found to

haXe druI-resistant TB and placed on second-line treatment

is remoXed from the druI-susceptible TB outcome cohort.

This means that management of the basic management unit

TB register and of the second-line TB treatment register

needs to be coordinated to ensure proper accounting of the

outcomes of treatment.

/QTGFGVCKNUQPVJGFGßPKVKQPQHEQPXGTUKQPTGXGTUKQPCPF

the end of the intensive phase are provided in the WHO

guidance.a

a &eßnitions and reportinI framework for tuberculosis – 201 reXision

9*1*6/6$)GPGXC9QTNF*GCNVJ1TICPK\CVKQPwww.

YJQKPVKTKUDKVUVTGCOAGPIRFH).

MDR-TB also varies markedly among countries, from 30

or less (Bangladesh, the Democratic Republic of the Con-

go, Estonia, Pakistan, and VietNam) to over 600 (Bulgaria,

Indonesia, Latvia, Tajikistan and Uzbekistan).

Palliative and end-of-life care delivered through home-

based or institutional services is fundamental to allevi-

ate the suering associated with MDR-TB, particularly in

patients with advanced disease that is not responding to

treatment. Only eleven high MDR-TB burden countries –10

in the European region plus South Africa – reported that

they provided such care within the scope of their NTPs.

When considered in the context of the poor outcomes

reported in patients with MDR-TB and especially XDR-TB,

this nding attests to the persistent, huge unmet need for

palliative care services in countries with the largest bur-

dens of drug-resistant TB.

Among 18 high MDR-TB burden countries providing

information on the quality of second-line drugs in the pub-

lic sector in 2012, two countries reported that all of the

drugs that they used conformed only to national regulatory

norms. In the other 16 countries, most reported conformi-

ty to international standards for all supplies of kanamycin

(11), capreomycin (9, with 2 other countries not using it),

levooxacin (10, with 1 other not using it), ethionamide/

prothionamide (12), cycloserine/terizidone (11) and p-ami-

nosalicylic acid (10, with 2 others not using it).

More information is required to adequately monitor TB

patients on MDR-TB treatment than is needed for drug-

susceptible TB. e denitions for monitoring of RR-TB

and MDR-TB and their outcomes were revised in 2013

(see Chapter 3 and Box 4.4). e employment of electron-

ic systems to manage patient data is therefore strongly

encouraged. One of the Global Plan’s targets is that all 27

high MDR-TB countries manage their data on treatment

of MDR-TB patients electronically by 2015. By 2012, 19

reported that national databases were in place for MDR-

TB patients (see Figure 2.16 in Chapter 2). ese systems

dier markedly from one country to another, varying

from individual patient medical records accessible online

to the periodic collation of records from registers across

the country. Before introducing electronic systems to han-

dle patient data, WHO recommends that NTPs undertake

a detailed assessment of their needs and expectations

and then try to match these with the best suited infor-

matics solution. A fragmentary approach with parallel

systems dealing with dierent programme components

(for example, management of data for patients with drug-

susceptible and drug-resistant TB in separate systems)

should be avoided. Guidance on the design and implementa-

tion of electronic systems for recording and reporting data

was produced by WHO and technical partners in 2012.1

4 Electronic recording and reporting for TB care and control. Geneva,

World Health Organization, 2013 (WHO/HTM/TB/2011.22).

59GLOBAL TUBERCULOSIS REPORT 2013

%*#26'4

Diagnostics and laboratory

strengthening

KEY FACTS AND MESSAGES

■ The conventional laboratory tests for the diagnosis of

TB, which have been used for decades, are sputum smear

microscopy and bacterial culture. Diagnosis based on

cultured specimens is the reference standard but results

take weeks to obtain. Drug susceptibility testing (DST) on

EWNVWTGUKUWUGFVQFGVGEVTGUKUVCPEGVQßTUVCPFUGEQPFNKPG

TB drugs.

■ There have been important breakthroughs in TB

FKCIPQUVKEUKPTGEGPV[GCTU+P9*1GPFQTUGFVJGßTUV

rapid molecular test that can be used to simultaneously test

HQTRWNOQPCT[6$CPFTKHCORKEKPTGUKUVCPEG:RGTV® MTB/

4+(6JGUGPUKVKXKV[QHVJGVGUVKUOWEJDGVVGTVJCPUOGCT

microscopy and is comparable to solid culture. In 2013,

a review of the 2010 policy was initiated, to examine the

substantial body of new evidence on the use and positioning

QH:RGTV/6$4+(HQTVJGFKCIPQUKUQHRWNOQPCT[

extrapulmonary and paediatric TB. Updated guidance is

expected in 2014.

■ :RGTV/6$4+(KUDGKPITCRKFN[CFQRVGFD[EQWPVTKGU

$[VJGGPFQH,WPG)GPG:RGTVOCEJKPGUCPF

OKNNKQP:RGTV/6$4+(ECTVTKFIGUJCFDGGPRTQEWTGF

D[QHVJGEQWPVTKGUGNKIKDNGHQTEQPEGUUKQPCNRTKEGU

Almost half (49%) of reporting low- and middle-income

countries and territories indicated that WHO policy

IWKFCPEGQP:RGTV/6$4+(JCFDGGPKPEQTRQTCVGFKPVQ

VJGKTPCVKQPCNIWKFGNKPGU5QWVJ#HTKECKUVJGßTUVEQWPVT[VQ

CFQRV:RGTV/6$4+(CUVJGRTKOCT[FKCIPQUVKEVGUVHQT6$

replacing smear microscopy.

■ Laboratory capacity to conduct high-quality sputum

UOGCTOKETQUEQR[TGSWKTGUUKIPKßECPVUVTGPIVJGPKPI1PN[

14 of the 22 HBCs met the target of having 1 microscopy

EGPVTGRGTaRQRWNCVKQPKPCPFQPN[GKIJV

reported a programme for external quality assessment that

covered at least 95% of all centres in the country.

■ Globally, laboratory capacity to perform DST continues

to be low and is not growing quickly enough to ensure that

6$RCVKGPVUYKVJ/&46$CTGRTQORVN[FKCIPQUGF(TQO

2009 to 2012, the percentage of new and previously treated

TB patients receiving DST increased from 4% to 5% and

HTQOVQTGURGEVKXGN[6JG':2#0&6$RTQLGEV

which started in 2009 and has entered a phase of routine

testing in 25 countries, shows how it is possible to introduce

routine testing for drug resistance and achieve considerable

KPETGCUGUKPVJGPWODGTQH/&46$ECUGUFGVGEVGF

■ The national reference laboratory of Uganda has become

the newest member of the WHO/Global Laboratory Initiative

).+5WRTCPCVKQPCN4GHGTGPEG.CDQTCVQT[54.0GVYQTM

ßNNKPICETKVKECNIGQITCRJKECNICRKP'CUV#HTKEC

e early, rapid and accurate detection of TB and drug resis-

tance relies on a well-managed and equipped laboratory

network. Laboratory conrmation of TB and drug resis-

tance is critical to ensure that people with TB signs and

symptoms are correctly diagnosed and have access to the

correct treatment as soon as possible.

e conventional laboratory tests for the diagnosis of

TB, which have been used for decades, are sputum smear

microscopy and culture. Diagnosis based on culture is the

reference standard but results take weeks to obtain. Drug

susceptibility testing (DST) on cultured specimens is the

conventional method used to detect resistance to rst- and

second-line TB drugs. Following increased investments in

TB research and development in the past decade (Chapter

8), there have been important breakthroughs in TB diag-

nostics. In 2008, rapid molecular tests (line probe assays,

or LPAs) for detection of RR-TB and MDR-TB using posi-

tive sputum specimens or cultures were recommended by

WHO. In 2010, the rst rapid molecular test that can be

used to simultaneously test for TB and rifampicin resis-

tance, Xpert® MTB/RIF (Cepheid, Sunnyvale, CA, USA),

was recommended for diagnosis of pulmonary TB and

rifampicin resistance in adults. e sensitivity of the test

is much better than smear microscopy and similar to solid

culture.1

Although laboratories play a fundamental role in TB care

and control, only 57% of the 4.6 million new pulmonary

TB patients notied globally in 2012 were bacteriologically

conrmed using a WHO-recommended diagnostic meth-

od. Low coverage of laboratory conrmation may result in

people without TB needlessly being enrolled on TB treat-

ment, while true TB cases are being missed. Furthermore,

the 5.7 million incident (new and relapse) TB patients diag-

nosed and notied to NTPs in 2012 represent only 66% of

the estimated 8.6 million incident TB cases globally. e

gap reects both underreporting of diagnosed TB cases and

failure to diagnose cases at all; the latter can be attributed

in part to weak laboratory capacity in many countries.

Detection of TB without investigating for drug resis-

tance can lead to poor treatment outcomes, additional and

unnecessary suering and costs for patients and further

spread of drug-resistant strains. While there was a small

increase between 2011 and 2012, only 5.1% of new cases

and 8.7% of previously treated cases received DST in 2012.

1 Steingart KR et al. Xpert® MTB/RIF assay for pulmonary tubercu-

losis and rifampicin resistance in adults (Review). Cochrane Data-

base of Systematic Reviews 2013, Issue 1. Art. No.: CD009593. 2013.

60 GLOBAL TUBERCULOSIS REPORT 2013

Of the 300 000 cases of MDR-TB estimated to exist among

notied TB patients with pulmonary TB in 2012 (i.e. the

group of patients known to NTPs and that could be tested

for drug resistance using WHO-recommended diagnostic

tests), only 83715 received a laboratory-conrmed diagno-

sis of MDR-TB and were notied in 2012. In addition, just

over 10 000 RR-TB cases were detected using rapid molec-

ular methods, though without results for isoniazid DST at

the time of reporting. Given the large burden of undiag-

nosed DR-TB, strengthening DST capacity is a high priority

for NTPs (see also Chapter 4).

is chapter has three parts. Section 5.1 summarizes

the key developments in WHO guidance on TB diagnostics

and laboratory strengthening during 2012–2013. Section

5.2 provides the status of laboratory capacity globally,

regionally and nationally based on data reported to WHO

by countries in 2013. e focus is on the 36 countries in

the combined list of 22 HBCs and 27 high MDR-TB burden

countries. Innovative public–private mix (PPM) laboratory

initiatives are highlighted as well. Section 5.3 describes

recent achievements in strengthening TB laboratories, cov-

ering incorporation of WHO guidance into policy and prac-

tice at country level and the latest status of progress of two

multinational projects (EXPAND-TB and TBXpert) that are

helping to introduce new diagnostics.

5.1 Developments in WHO policy guidance

on TB diagnostics and laboratory

strengthening, 2012–2013

WHO follows a systematic process for policy development

on TB diagnostics, involving synthesis of the available evi-

dence through systematic reviews and meta-analyses where

possible, assessment of the evidence by an external Expert

Group using the GRADE approach,1 and development of

policy guidance2 for dissemination to Member States and

other stakeholders.3 Policy documents are reviewed every

3–5 years, and revised as necessary when new evidence

becomes available.

e rst WHO policy guidance on the use of Xpert®

MTB/RIF was issued in December 2010. e recommen-

dations were that Xpert MTB/RIF should be used as the

initial diagnostic test in individuals at risk of having MDR-

TB or HIV-associated TB (strong recommendation), and

that Xpert MTB/RIF could be used as a follow-on test to

microscopy in settings where MDR and/or HIV is of lesser

concern, especially in smear-negative specimens (this was

a conditional recommendation, recognizing major resource

implications). e 2010 recommendations applied to the

use of Xpert MTB/RIF in sputum specimens only, as data

on its performance (sensitivity and specicity) for testing

of extrapulmonary specimens at that time were limited.

e recommendations applied to children, but only based

on generalization of data from adults.

Following rapid uptake of Xpert MTB/RIF (see section

5.2), a substantial body of new evidence had been generat-

ed by 2013.4 is included much more data about the test’s

performance characteristics (sensitivity and specicity) in

a wide range of laboratory and epidemiological settings,

additional data on test accuracy in detection of extrapul-

monary and paediatric TB, and more evidence about aord-

ability and cost-eectiveness from early implementers in

a limited number of settings. WHO therefore embarked

on a review of policy guidance in 2013. ree systematic

reviews were commissioned on the sensitivity and specic-

ity of Xpert MTB/RIF for the diagnosis of pulmonary and

extrapulmonary TB and RR-TB, in adults and children. A

review of published studies on the aordability and cost-ef-

fectiveness of Xpert MTB/RIF was also conducted.

An Expert Group convened by WHO met in May 2013

to review the expanded body of evidence, according to

GRADE procedures. Based on the outcomes of the review

and the recommendations of the Expert Group, which were

also supported by WHO’s Strategy and Technical Advisory

Group for TB (STAG-TB) in June 2013, updated WHO pol-

icy guidance was under development at the time that the

current report went to press. Upon nalization, the recom-

mendations are expected to have a major impact on further

country adoption of Xpert MTB/RIF into diagnostic and

clinical algorithms.

Several other new TB diagnostic tests are on the hori-

zon, in various stages of research and development (see

Chapter 8). Once data on their performance are available in

varying epidemiological settings, WHO will be in a position

to evaluate their performance and develop corresponding

policy guidance. A comprehensive list of existing WHO pol-

icy documents, including those on the use of microscopy,

culture, DST and non-commercial and molecular methods,

can be found at: http://www.who.int/tb/laboratory/policy_

statements

In addition to diagnostics, WHO

also develops guidance in other areas

of laboratory strengthening. In 2013,

the WHO Tuberculosis laboratory bio-

safety manual was issued, featuring a

risk-based approach that guides the

essential biosafety measures required

for performing dierent technical

procedures. e manual describes the

combination of good laboratory practices together with

administrative controls, containment principles, safety

equipment and laboratory facilities that are required to

minimize the generation of infectious aerosols and thus

prevent laboratory-acquired infections. e risk-based

approach to laboratory biosafety is framed around a three-

tiered system of ‘low’, ‘moderate’ and ‘high’ TB risk precau-

tions:

1 www.gradeworkinggroup.org

2 WHO handbook for guideline development. Geneva, World Health

Organization, 2012.

3 WHO policies on TB diagnostics are available at: www.who.int/tb/

laboratory/policy_statements

4 Weyer K et al. R apid molecular T B diagnosis: ev idence, polic y-making

and global implementation of Xpert® MTB/RIF. European Respirato-

ry Journal. November 22, 2012, doi: 10.1183/09031936.00157212

61GLOBAL TUBERCULOSIS REPORT 2013

Low TB risk precautions. ese apply to direct acid-fast

bacilli (AFB) microscopy and to Xpert MTB/RIF.

Moderate TB risk precautions. ese apply to the pro-

cessing of sputum specimens for primary culture inoc-

ulation, direct testing (i.e. on sputum smear-positive

samples) using direct non-commercial drug susceptibil-

ity assays and LPAs.

High TB risk precautions in TB containment laborato-

ries. ese apply to procedures used to manipulate cul-

tures (solid and liquid) for identication and DST, and

for indirect testing (i.e. on culture isolates) using LPA

and non-commercial DST.

5.2 Status of laboratory capacity globally,

regionally and nationally

Diagnosis of TB in most low- and middle-income countries

still relies on low-cost sputum smear microscopy, despite its

relatively low sensitivity and inability to detect drug resis-

tance. e Global Plan to Stop TB 2011–2015 includes the tar-

get that countries maintain at least one smear microscopy

centre per 100 000 population. Globally the target has been

met (1.1 centres per 100 000 population in 2012), but con-

siderable disparities remain at regional and country levels

(Table 5.1). Eight of the 22 HBCs did not meet the target in

2012: Bangladesh, China, Myanmar, Nigeria, Pakistan, the

Russian Federation, South Africa and Viet Nam. Overall,

the Western Pacic and Eastern Mediterranean Regions

had less than one centre per 100000 population.

Given the continued critical role of microscopy in

TB detection and monitoring of treatment, ensuring

high-quality performance of smear microscopy is essential.

Of the 153 countries and territories that reported data on

the number of smear microscopy centres in 2012, only 39%

indicated the existence of an external quality assessment

programme that covered all centres in the country. Among

the 22 HBCs, only three reported such a programme that

encompassed all centres in 2012 (Bangladesh, India and

Viet Nam), ve reported a programme that included at least

95% of centres (Cambodia, China, Myanmar, the Russian

Federation and South Africa), and 14 reported a programme

that included at least 80% of centres.

In 2009, WHO recommended the use of the more sensi-

tive uorescent light-emitting diode (LED) microscopy as

a replacement for traditional Ziehl–Neelsen (ZN) micros-

copy. Globally the switch to LED microscopes has been

gradual, and they were reported to be present in only 2%

of microscopy centres in 2012. Overall in 2012, the African

Region was the most advanced in rolling out LED micro-

scopes (6% of microscopy centres), led by South Africa

where 97% of microscopy centres were reported to have

them. Other HBCs in the African Region have shown sig-

nicant increases in uptake from 2011 to 2012, including

the United Republic of Tanzania (3% to 17% of microscopy

centres) and Mozambique (<1% to 9%).

e current target in the Global Plan to Stop TB 2011–

2015 for both culture and DST (to at least rifampicin and

isoniazid) capacity is one laboratory per 5 million popu-

lation. In 2012, 14 of the 27 high MDR-TB burden coun-

tries did not reach the target (Table 5.1; there were two

additional countries that did not report data). Of these 27

countries, 9 reported more than one laboratory per 5 mil-

lion population using LPAs – a high-throughput molecular

tool that can be used at central and regional levels to rapid-

ly detect resistance to rifampicin and, in some cases, isoni-

azid. e nine countries comprise eight European countries

and South Africa.

Of the 147 countries and territories that reported

numbers of laboratories with capacity to perform DST, 22

indicated that such capacity did not exist in 2012. While

countries and territories with small TB patient populations

may nd it more practical to send specimens to neighbour-

ing countries for DST than to establish national capacity,

countries with larger patient populations should aim as

a priority to build sustainable DST capacity in-country

to allow timely diagnosis of drug-resistant strains. Eight

countries reported more than 1000 notied TB cases in

2012 yet reported having no capacity to perform DST:

Afghanistan, Chad, Eritrea, Guinea-Bissau, Liberia, Papua

New Guinea, Sierra Leone and Somalia.

Quality-assured DST is critical to ensure accurate detec-

tion of drug resistance for subsequent treatment decisions

and to avoid false diagnoses. Of the high TB and MDR-TB

burden countries that reported on external quality assess-

ment coverage of DST laboratories (34 of 36), 27 (79%)

reported having a scheme that encompassed all DST lab-

oratories. Of the 117 countries globally that reported on

external quality assessment coverage of DST laboratories,

70% (82 countries) reported such a scheme.

Given its high sensitivity to detect TB and rifampicin

resistance together with its ability to be placed at relative-

ly low levels of laboratory networks, Xpert MTB/RIF has

been rapidly adopted by countries. By the end of June 2013,

3.2 million test cartridges and 1402 GeneXpert machines

(comprising 7553 machine modules) had been procured in

88 of the 145 countries eligible to purchase machines and

cartridges at concessional prices (Figure 5.1).1 e current

price per cartridge is US$9.98, following a novel nancing

agreement reached in August 2012 between the manufac-

turer and the United States Agency for International Devel-

opment (USAID), the United States President’s Emergency

Plan for AIDS Relief (PEPFAR), UNITAID and the Bill &

Melinda Gates Foundation. South Africa alone accounts

for 43% of the modules and 60% of the cartridges procured

globally, and is aiming to position Xpert MTB/RIF as a

replacement for microscopy for the diagnosis of TB. After

South Africa, leading procurers include India, Pakistan,

Zimbabwe and Nigeria.

e complete or partial replacement of microscopy

by Xpert MTB/RIF as the initial diagnostic test and the

increasing number of rifampicin-resistant cases being

detected by Xpert MTB/RIF will require adjustment of

countries’ smear, culture and DST capacities going forward.

1 http://www.who.int/tb/laboratory/mtbrifrollout/

62 GLOBAL TUBERCULOSIS REPORT 2013

TABLE 5.1

Laboratory capacity, 2012a

HIGH

$74&'0

HIGH

/&46$

$74&'0

5/'#4/+%415%12; %7.674' &47)575%'26+$+.+6;

TESTING .+0'241$'#55#; :2'46

/6$4+(

07/$'4

1(.#$14#-

614+'5

.#$14#614+'5

2'4

POPULATION

2'4%'06#)'1(

.#$14#614+'5

USING LED

/+%415%12'5

07/$'41(

.#$14#61-

4+'5

.#$14#-

614+'52'4

5 MILLION

POPULATION

07/$'4

.#$14#-

614+'5

.#$14#614+'5

2'4/+..+10

POPULATION

07/$'4

OF LABO-

4#614+'5

.#$14#614+'5

2'4/+..+10

POPULATION

07/$'4

OF SITES

Afghanistan 603 2.0 2 2 0.3 0 0 0 0 1

Armenia 30 1.0 0 1 1.7 1 1.7 1 1.7 0

#\GTDCKLCP 72  47 31.6 1 0.5 7

Bangladesh 

1 070 0.7 2 3  3 1 12

Belarus 196 2.1 2 29 15 4.3 4.3 

$TC\KN 4 000 2.0 – 220 5.5 35 0.9 0.2 13

Bulgaria 34 0.5 0 31 21 14 9.6 4 2.7 0

Cambodia 214 1.4 10 3 1.0 1 0.3 0 0 6

China 

 0.2 2 1 014 3.7 190 0.7 21  16

&4%QPIQ 

1 522 2.3  40.3 20.2 1 26

Estonia 5 0.4 10 0 2 7.7 2 7.7 2 7.7 2

Ethiopia 

2 531  050.31 50.3 7

Georgia 11 0.3 9 2 2.3 1 1.1 2 2.3 1

India 

 1.1 2 70 0.3  0.2 33 0.1 32

Indonesia 

5 566 2.3 0 46 0.9 5 0.1 2  9

-C\CMJUVCP 466 2.9 0 22  22  11 3.4 4

Kenya  4.2 2 0.2 2 0.2 2 0.2 15

-[TI[\UVCP 122 2.2 0 11 10 3 2.7 2  7

Latvia 16  0 4 9.7 1 2.4 1 2.4 2

Lithuania –– – – –

/Q\CODKSWG 300 1.2 9 3 0.6 2 0.4 0 0 12

Myanmar   0.9 14 2 0.2 2 0.2 2 0.2 3

Nigeria 

1 314  250.13 40.132

Pakistan 

   70.2 40.1 2 15

Philippines 

2 565 2.7  13 0.7 3 0.2 1  17

4GRWDNKEQH/QNFQXC –– – – –

4WUUKCP(GFGTCVKQP 

1 031 0.7 – 117 4.1 110  –

South Africa   0.4 97 15 1.4 15 1.4 15 1.4 100

Tajikistan  1.1 4 3 1.9 1 0.6 1 0.6 3

Thailand  1.6 6 65 4.9  1.3 12 0.9 14

Uganda 1 152 3.2 4 0.6 4 0.6 4 0.6 25

Ukraine   5 9.4 41 4.5 0 0 15

746CP\CPKC 945 2.0 17 4 0.4 1 0.1 3 0.3 13

7\DGMKUVCP 291 1.0 1 7 1.2 3 0.5 3 0.5 7

Viet Nam   0.9  25 1.4 2 0.1 2 0.1 22

<KODCDYG  1.3 1 2 0.7 2 0.7 0 0 17

High-burden countries – 1.0 2 – 1.8 – 0.5 – 0.1 –

High MDR-TB burden countries – 0.9 2 – 1.9 – 0.6 – 0.2 –

#(4 – 1.5 6 – 0.6 – 0.4 – 0.3 –

#/4 –2.2 –16 –  –0.2–

'/4 –  – 1.4 – 0.4 – 0.1 –

'74 –0.7 2 – –4.6– –

5'#4 – 1.2 2 – 0.5 – 0.2 – 0.1 –

924 – 0.5 2 – 3.4 – 0.6 – 0.1 –

Global – 1.1 2 – 3.8 – 0.9 – 0.3 –

Blank cells indicate data not reported.

– indicates values that cannot be calculated.

a 6JGTGIKQPCNCPFINQDCNßIWTGUCTGCIITGICVGUQHFCVCTGRQTVGFD[NQYCPFOKFFNGKPEQOGEQWPVTKGUCPFVGTTKVQTKGU&CVCHQTVJGXCTKCDNGUUJQYPKPVJGVCDNGCTGPQV

requested from high-income countries in the WHO data collection form.

;'5  NO 

63GLOBAL TUBERCULOSIS REPORT 2013

e introduction of Xpert MTB/RIF reduces the need for

culture as a diagnostic test, yet the growing number of

RR-TB cases will require culture for monitoring of treat-

ment and DST of other anti-TB drugs to guide the design of

treatment regimens. e increasing capacity of countries to

diagnose RR-TB must also be matched by increased capaci-

ty to provide appropriate treatment to the diagnosed cases

(see also Chapter 4).

One of the main reasons for low case detection rates in

many parts of the world (Chapter 3) is the existence of a

signicant private sector, in which care providers frequent-

ly diagnose people with TB but fail to notify these cases to

national authorities. e quality of diagnostic services in

the private sector is highly variable, and some private prac-

titioners continue to use tests that are not recommended by

WHO, including antibody-based serodiagnostics and inter-

feron-gamma release assays (IGRAs) for detection of active

TB. Furthermore in some settings, laboratories in the pub-

lic sector that are not under the auspices of the NTP also

diagnose TB without necessarily following recommended

guidelines and quality assurance procedures. Collaboration

between NTPs and all laboratories oering TB diagnosis is

therefore critical to ensure that national guidelines are fol-

lowed, that appropriate diagnostic tests are used, and that

patients diagnosed with TB are notied to the NTP and

receive proper care. In 2012, 20 of 36 high TB and MDR-

TB burden countries reported some level of collaboration

with laboratories in the private sector, and 25 reported

collaboration with non-NTP laboratories in the public sec-

tor. Additionally, the availability of WHO-recommended

diagnostic tests at concessional prices from manufacturers

under specied conditions has been used as leverage by new

initiatives to form innovative PPM partnerships, increas-

ing access to WHO-recommended diagnostics for people

seeking care in the private sector. Examples are provided

in Box 5.1.

5.3 Strengthening TB laboratories globally,

regionally and nationally

Advances in TB diagnostics in recent years provide an

opportunity to improve laboratory capacity to rapidly and

accurately detect TB and drug resistance. One of the main

prerequisites for eective uptake of new diagnostics is

dynamic policy reform, properly incorporating new tests

and testing methods into diagnostic algorithms. Table

5.2 presents the uptake of selected WHO policy guidance

on TB diagnostics into NTP guidelines at global, region-

al and country levels, focusing on the 36 countries in the

combined list of 22 HBCs and 27 high MDR-TB burden

countries. Overall, high burden countries have been faster

in adopting WHO TB diagnostic guidelines than the glob-

al average. All reporting high MDR-TB burden countries,

95% of HBCs and 84% of reporting countries globally had

reported incorporation of the WHO policy guidance on con-

ventional phenotypic DST into their national guidelines by

2012. ree quarters (74%) of all countries globally had

incorporated guidance on liquid culture and rapid specia-

tion. Countries in the European Region have been particu-

larly fast in adopting these policies, with 97% of countries

reporting having taken up these technologies.

Uptake of WHO policy on use of LPAs for detection of

resistance to rifampicin remains relatively modest, with

FIGURE 5.1

Progress in the roll-out of Xpert MTB/RIF, by July 2013

1–1999

2000–9999

10 000–39 999

40 000–99 999

≥ 100 000

Not eligible for preferential pricing

Not applicable

Xpert MTB/RIF

cartridges ordered

64 GLOBAL TUBERCULOSIS REPORT 2013

only 58% of countries globally adopting the policy to date.

Uptake is, however, growing. In the Region of the Ameri-

cas, for example, 61% of countries reported incorporation

of the policy in their national guidelines in 2012 compared

to only 17% in 2011.

Approximately half of low- and middle-income coun-

tries and territories globally (49%) indicated that they had

incorporated WHO guidance on Xpert MTB/RIF into their

diagnostic algorithms for people at risk of HIV-associated

and DR-TB by the end of 2012, highlighting fast uptake

of recommendations rst issued in December 2010. High

MDR-TB burden countries have been particularly quick

to adopt WHO guidance, with 84% of countries reporting

incorporation of the test into their diagnostic algorithms

for people at risk of drug-resistant TB. Funding from sourc-

es including the Global Fund, PEPFAR, USAID, TB REACH

and Médecins Sans Frontières has supported ministries of

health to rapidly establish capacity to use Xpert MTB/RIF.

ese initiatives, together with the TBXpert and EXPAND-

TB projects, will enable further roll out and scale up of the

test in targeted low- and middle-income countries, with

BOX 5.1

Innovative PPM initiatives to increase access to WHO-recommended diagnostics

Some manufacturers of rapid

diagnostics, including Becton, Dickenson

and Company (producer of the BD

MGIT™ 960 automated liquid culture

system), Hain LifeScience (Genotype®

/6$&4RNWUNKPGRTQDGCUUC[CPF

%GRJGKF:RGTV®/6$4+(QHHGTVJGKT

RTQFWEVUVQ062UCPFVJGKTPQVHQTRTQßV

partners in low- and middle-income

countries at concessional prices. Private

HQTRTQßVUGEVQTNCDQTCVQTKGUJCXG

traditionally not been included in such

arrangements, resulting in prices that

are prohibitively high for poor people

seeking care in the private sector and

encouraging use of other diagnostics

that are not recommended by WHO.

4GEGPVN[VYQRWDNKE¿RTKXCVGOKZ22/

initiatives that aim to increase access

to rapid and accurate diagnostics for

vulnerable populations in Asian settings

with vast private sector markets have

been established.

In June 2012, the government of

India took the unprecedented step

of banning the import, manufacture,

distribution and sale of antibody-based

TB serodiagnostic tests, in line with

the WHO recommendation that such

tests should not be used to diagnose

TB. Unfortunately, this ban created a

gap in the private market that allowed

other suboptimal tests to gain market

share, especially since TB diagnostics

recommended by WHO were considered

too expensive and well beyond the

reach of the typical TB patient. To

overcome this market shortcoming, the

Initiative for Promoting Affordable,

Quality TB Tests (IPAQT)a in India was

launched in March 2013. IPAQT is a

consortium of 42 private diagnostic

NCDQTCVQTKGUUWRRQTVGFD[PQVHQTRTQßV

stakeholders (examples include the

Clinton Health Access Initiative and the

McGill International TB Centre). It has

established agreements with Cepheid

Inc, Hain LifeScience, and Becton,

Dickenson and Company that allow

CEEGUUVQEQPEGUUKQPCNRTKEGUHQT:RGTV

/6$4+(ßTUVNKPGNKPGRTQDGCUUC[UCPF

liquid culture in the private sector, which

is normally excluded from negotiated

pricing agreements. Participating

laboratories must abide by several

EQPFKVKQPUVJG[PGGFVQDGCEETGFKVGF

to assure quality; they must report

EQPßTOGFECUGUVQVJG4GXKUGF0CVKQPCN

6$%QPVTQN2TQITCOOG406%2VJG[

must adhere to a ceiling price when

charging patients; and they must

refrain from using any tests that are not

TGEQOOGPFGFD[9*1QTVJG406%2

Together, the laboratories participating

in IPAQT have approximately 3000

franchisee laboratories and over 10 000

specimen collection centres across India,

thus increasing access to rapid, accurate

and affordable diagnostics for patients

seeking care in the country’s extensive

private sector.

As part of the recently launched

70+6#+&HWPFGF6$:RGTVRTQLGEVBox

5.2) and with support from the Stop TB

2CTVPGTUJKR6$4'#%*KPKVKCVKXGHWPFGF

by the Department of Foreign Affairs,

Trade and Development of Canada,

innovative social business models have

been formed in Bangladesh, Indonesia

CPF2CMKUVCPD[+PVGTCEVKXG4GUGCTEJ

and Development in cooperation with

local partners and NTPs. Based in

the megacities of Dhaka, Jakarta and

Karachi and equipped with up to 25

)GPG:RGTVKPUVTWOGPVUGCEJVJGUG

social business models will provide

:RGTV/6$4+(VGUVUTGEGKXGFHTQO

VJG6$:RGTVRTQLGEVHTGGQHEJCTIGVQ

people at high risk of TB who seek care

at private screening centres and other

partnering locations. Free treatment will

be provided to everyone diagnosed with

6$KPEQQRGTCVKQPYKVJ062U4GXGPWG

will be generated from adjunct tests and

services provided to patients, allowing

for sustainability of the businesses

beyond the duration of the three-year

6$:RGTVRTQLGEV

a www.ipaqt.org/

expected increased detection of DR-TB and HIV-associated

TB (Box 5.2).

e WHO/Global Laboratory Initiative (GLI) TB Supra-

national Reference Laboratory (SRL) Network is a driving

force in strengthening national and central level labora-

tories globally, providing long-term technical assistance

to countries under the framework of collaborative agree-

ments. e network comprises 29 laboratories covering all

six WHO regions. e newest addition to the network is the

national TB reference laboratory of Uganda; this lls a criti-

cal geographical gap that had existed in the network in East

Africa. e laboratory has already established collaborative

agreements with Somalia, South Sudan and Zambia for

provision of technical assistance. Additionally, four can-

didate SRLs are under mentorship, including the national

TB reference laboratories of Benin, Denmark and South

Africa, and the Aga Khan University of Pakistan. Pending

completion of successful mentorship and the establishment

of country partners, the new laboratories will help to widen

the geographical reach of the network, in particular in the

African and Eastern Mediterranean Regions.

65GLOBAL TUBERCULOSIS REPORT 2013

TABLE 5.2

Incorporation of WHO guidance for diagnosis of TB into national policy, 2012a

*+)*6$$74&'0

*+)*/&46$

$74&'0

CONVENTIONAL

&47)

575%'26+$+.+6;

TESTING (DST)

.+37+&%7.674'

#0&4#2+&

SPECIATION TEST

.+0'241$'#55#;

(14&'6'%6+0)

4'5+56#0%'61

4+(#/2+%+0

#.)14+6*/(14

THE DIAGNOSIS

OF TB IN PEOPLE

LIVING WITH HIV

:2'46/6$4+((14

DIAGNOSIS OF TB IN

2'45105#64+5-1(

HIV-ASSOCIATED TB

:2'46/6$4+(

(14&+#)015+51(

&47)4'5+56#06

6$+02'45105

#64+5-

Afghanistan 

Armenia 

#\GTDCKLCP  

Bangladesh 

Belarus 

$TC\KN 

Bulgaria 

Cambodia 

China 

&4%QPIQ 

Estonia 

Ethiopia 

Georgia 

India 

Indonesia 

-C\CMJUVCP 

Kenya 

-[TI[\UVCP 

Latvia 

Lithuania 

/Q\CODKSWG 

Myanmar 

Nigeria 

Pakistan 

Philippines 

4GRWDNKEQH/QNFQXC 

4WUUKCP(GFGTCVKQP 

South Africa 

Tajikistan 

Thailand 

Uganda 

Ukraine 

746CP\CPKC 

7\DGMKUVCP 

Viet Nam 

<KODCDYG 

High-burden countries 95% 77% 77% 95% 73% 77%

High MDR-TB burden countries 100% 88% 92% 96% 84% 84%

#(4  67% 54% 74% 60% 62%

#/4 91%  61%  35% 35%

'/4 77%   75% 32% 36%

'74 100% 97%   60% 56%

5'#4  73% 64%  64% 64%

924 61% 56% 39%  33% 33%

Global 84% 74% 58% 78% 49% 49%

Blank cells indicate data not reported.

requested from high-income countries in the WHO data collection form.

;'5  NO 

66 GLOBAL TUBERCULOSIS REPORT 2013

BOX 5.2

The EXPAND-TB and TBXpert projects: progress to date

.CWPEJGFKPCPFEQPVKPWKPIWPVKNVJGGPFQHVJG':2#0&6$RTQLGEVCKOUVQCEEGNGTCVGCPFGZRCPFCEEGUUVQFKCIPQUVKEUHQT

RCVKGPVUCVTKUMQH/&46$KPEQWPVTKGU':2#0&6$JCUHWNNQYPGTUJKRD[VJGOKPKUVTKGUQHJGCNVJQHVJGTGEKRKGPVEQWPVTKGUCPFYQTMU

QPCOQFGNQHDGUVRTCEVKEGUNGCTPKPID[FQKPICPFQRVKOK\KPITGUQWTEGUHQTNCDQTCVQT[UVTGPIVJGPKPICVEQWPVT[NGXGN6JGRTQLGEV

is a collaboration between WHO, the Global Laboratory Initiative (GLI), the Foundation for Innovative New Diagnostics (FIND) and the

5VQR6$2CTVPGTUJKR)NQDCN&TWI(CEKNKV[)&(CPFKUHWPFGFD[70+6#+&CPFQVJGTRCTVPGTU':2#0&6$DWKNFUQP75OKNNKQPQH

70+6#+&UWRRQTVVQOCZKOK\GTGUQWTEGUCPFVGEJPKECNCUUKUVCPEGHTQOOWNVKRNGRCTVPGTUHQTNCDQTCVQT[UVTGPIVJGPKPIKPENWFKPIVJG)NQDCN

(WPFVJG9QTNF$CPM2'2(#475#+&VJG#OGTKECP5QEKGV[HQT/KETQDKQNQI[VJG75%GPVGTUHQT&KUGCUG%QPVTQNCPF2TGXGPVKQP,QJPU

Hopkins University, the KfW Development Bank, the KNCV Tuberculosis

Foundation, Partners in Health, Project Hope, PATH, the International

%QOOKVVGGQHVJG4GF%TQUUCPF6JG7PKQP

Overcoming the challenges to establish the necessary infrastructure

for central level laboratories capable of using liquid culture and LPAs, the

':2#0&6$RTQLGEVKUUJQYKPIOCLQTRTQITGUUKPTQWVKPGFGVGEVKQPCPF

TGRQTVKPIQHFTWITGUKUVCPV6$(QTGZCORNG/&46$ECUGUYGTG

diagnosed in supported laboratories in 24 reporting countries in 2012.

6JGEWOWNCVKXGPWODGTQHFKCIPQUGFECUGUQH/&46$TGCEJGFD[

the end of 2012, equivalent to 32% of the overall project target. Several

of the countries participating in the project have reported striking

KPETGCUGUKPVJGPWODGTUQHNCDQTCVQT[EQPßTOGFECUGUQHFTWITGUKUVCPV

TB, especially in 2012 (Figure B5.2.1). The project has recently been

COGPFGFVQCFF:RGTV/6$4+(VQVJGNKUVQHRTQEWTGFFKCIPQUVKEUCNQPI

with liquid culture and LPAs. In October 2012, project partners began

to pilot a strategy for a transition from project-funded to country-

DCUGFßPCPEKPI6JGGZRGTKGPEGHTQOVJGRKNQVYKNNDGWUGFCUCOQFGN

HQTKORNGOGPVCVKQPCETQUUCNN':2#0&6$TGEKRKGPVEQWPVTKGUHQTVJG

remainder of the project, ensuring a smooth transition and sustainability

QHCEJKGXGOGPVUYJGP':2#0&6$GPFU

2TQEWTGOGPVCPFKPUVCNNCVKQPQH)GPG:RGTVKPUVTWOGPVUUVCTVGFKP

OKFHQTVJGPGY6$:RGTVRTQLGEVYJKEJYKNNRTQXKFGCRRTQZKOCVGN[

OKNNKQP:RGTV/6$4+(VGUVECTVTKFIGUCPF)GPG:RGTVOCEJKPGU

to 21 recipient low- and middle-income countries over three years. The

75OKNNKQPRTQLGEVKUHWPFGFD[70+6#+&CPFOCPCIGFD[VJG9*1

Global TB Programme and the Stop TB Partnership. To ensure country

CDUQTRVKXGECRCEKV[CPFGHHGEVKXGWUGQHVJGVGEJPQNQI[VJG6$:RGTV

project links a broad network of partners and existing initiatives for TB

laboratory strengthening and innovative approaches to expand access to

vulnerable populations in both the public and private sector (Box 5.1),

resulting in increased and rapid case detection of TB, HIV-associated TB

CPF446$6$:RGTVRTQLGEVRCTVPGTUKPENWFGVJG).+6$4'#%*VJG)&(

VJG':2#0&6$RTQLGEV+PVGTCEVKXG4GUGCTEJCPF&GXGNQROGPVCPFVJG

African Society for Laboratory Medicine.

MDR-TB cases detected

5000

10 000

15 000

20 000

2008 2009 2010 2011 2012

308 1660 2967 4237

16 588

India

MDR-TB cases detected

Belarus

500

1000

1500

2000

923

1342

1576 1594 1604

2008 2009 2010 2011 2012

MDR-TB cases detected

2008 2009 2010 2011 2012

24 43 50 30

221

100

200

300

Côte d’Ivoire

MDR-TB cases detected

Tajikistan

200

400

600

800

319 333

604

694

2008 2009 2010 2011 2012

FIGURE B5.2.1

Increase in cases of MDR-TB reported by selected

EQWPVTKGURCTVKEKRCVKPIKPVJG':2#0&6$RTQLGEV

2009–2012, compared with 2008 baseline

FIGURE B5.2.2

%QWPVTKGUKPbrownRCTVKEKRCVKPIKPVJG6$:RGTVRTQLGEV

67GLOBAL TUBERCULOSIS REPORT 2013

e SRL Network is expanding its membership to

include Centres of Excellence (SRL-CE), a new category that

recognizes laboratories that are performing well in large

low- and middle-income countries and that work primar-

ily to build in-country laboratory capacity. Countries with

laboratories currently eligible to apply for designation as

an SRL-CE include Brazil, China, India, the Russian Fed-

eration and South Africa. To be eligible for this designa-

tion, laboratories need to be nominated by their NTP to the

WHO country oce, establish a collaborative agreement

with an existing SRL, undergo a laboratory assessment

by WHO, and actively implement a quality management

system towards accreditation.

 GLOBAL TUBERCULOSIS REPORT 2013

%*#26'4

Addressing the co-epidemics

of TB and HIV

KEY FACTS AND MESSAGES

■ +POKNNKQPQHOKNNKQPRGQRNGYJQ

developed TB worldwide were HIV-positive. The African

4GIKQPCEEQWPVGFHQTQHVJGGUVKOCVGFPWODGTQH*+8

positive incident TB cases.

■ The number of people dying from HIV-associated TB has

been falling since 2003. However, there were still 320 000

deaths from HIV-associated TB in 2012 and further efforts

are needed to reduce this burden.

■ The prevalence of HIV co-infection among TB patients is

JKIJGUVKPVJG#HTKECP4GIKQP1H6$RCVKGPVUYKVJCP*+8

test result, 43% tested positive in 2012, ranging from 9.6%

KP#PIQNCCPF'VJKQRKCVQKP5YC\KNCPF

■ )NQDCNN[VJGRGTEGPVCIGQHPQVKßGF6$RCVKGPVUYKVJC

documented HIV test result was 46% in 2012, up from 40%

in 2011 and 15 times higher than the 2004 level. In the

#HTKECP4GIKQPQHPQVKßGF6$RCVKGPVUJCFCP*+8VGUV

result in 2012, a further improvement compared with 69%

in 2011. Among the 41 countries with the highest TB/HIV

DWTFGPCEJKGXGF*+8VGUVKPINGXGNUQHÜKPENWFKPI

UGXGP-GP[C/CNCYK/Q\CODKSWG4YCPFC5YC\KNCPF

6QIQCPF<CODKCCDQXG

■ 6JGTGYCUCPGPEQWTCIKPIKPETGCUGKP#46EQXGTCIG

among HIV-positive TB patients between 2011 and 2012,

from 49% worldwide in 2011 to 57% in 2012. Nonetheless,

given the WHO recommendation that all HIV-positive TB

RCVKGPVUCTGGNKIKDNGHQT#46VJGEQXGTCIGQH#46HQT*+8

positive TB patients still needs to be greatly improved.

■ +PQH*+8RQUKVKXG6$RCVKGPVUYGTGRTQXKFGF

YKVJEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26CNGXGNUKOKNCT

to recent years.

■ In 2012, 4.1 million people enrolled in HIV care were

reported to have been screened for TB, up from 3.5 million

in 2011. Of the reported 1.6 million people newly enrolled

KP*+8ECTGKPCNOQUVaYGTGRTQXKFGFYKVJ

KUQPKC\KFRTGXGPVKXGVJGTCR[+26%QXGTCIGPGGFUVQDG

increased, since about 50% of those newly enrolled in HIV

care and screened for TB are likely to be eligible for IPT.

People living with HIV who are also infected with TB are

much more likely to develop TB disease than those who are

HIV-negative.1 Starting in the 1980s, the HIV epidemic led

to a major upsurge in TB cases and TB mortality in many

countries, especially in southern and eastern Africa (Chap-

ter 2, Chapter 3).

In 2012, 1.1 million (13%) of the 8.6 million people who

developed TB worldwide were HIV-positive (Chapter 2,

Table 2.1); 75% of these HIV-positive TB cases were in

the African Region. Although the number of people dying

from HIV-associated TB has continued to fall globally and

in most regions including the African Region, there were

still 320 000 deaths from HIV-associated TB in 2012, with

approximately equal numbers among men and women (see

Chapter 2). UNAIDS and the Stop TB Partnership have set

a target of halving TB mortality rates among people who

are HIV-positive by 2015 compared with 2004.2

WHO recommendations on the interventions needed to

prevent, diagnose and treat TB in people living with HIV

have been available since 2004,3,4 and are collectively known

as collaborative TB/HIV activities. ey include establishing

and strengthening coordination mechanisms for delivering

integrated TB and HIV services, testing TB patients for HIV,

providing ART and CPT to TB patients living with HIV, pro-

viding HIV prevention services for TB patients, intensifying

TB case-nding among people living with HIV, oering IPT

to people living with HIV who do not have active TB, and

controlling the spread of TB infection in health care and

congregate settings (the latter three activities are referred

to as the ree ‘Is’ for HIV/TB). Since December 2010, the

rapid molecular test Xpert MTB/RIF has been recommend-

ed as the primary diagnostic test for TB among people living

with HIV who have TB signs and symptoms.

WHO began monitoring the implementation and expan-

sion of collaborative TB/HIV activities in 2004. is chap-

1 e probability of developing TB among people living with HIV

divided by the probability of developing TB among HIV-negative

people is the incidence rate ratio (IRR). e estimated global IRR

(all ages) in 2012 was 29.6 (uncertainty interval 27.1–32.1). Fur-

ther details are provided in Annex 1.

2 Getting to zero: 2011–2015 strategy. Geneva, Joint United Nations

Programme on HIV/AIDS, 2010.

3 Interim policy on collaborative TB/HIV activities. Geneva, World

Health Organization, 2004 (WHO/HTM/TB/2004.330; WHO/

HTM/HIV/2004.1). Available at http://whqlibdoc.who.int/hq/

2004/who_htm_tb_2004.330_eng.pdf

4 WHO policy on collaborative TB/HIV activities: guidelines for national

programmes and other stakeholders. Geneva, World Health Organi-

zation, 2012 (WHO/ HTM/TB/2012.1). Available at http://whqlibdoc.

who.int/publications/2012/9789241503006_eng_Annexes.pdf

69GLOBAL TUBERCULOSIS REPORT 2013

FIGURE 6.1

Number of TB patients with known HIV status,

2004Ų2012

FIGURE 6.2

Percentage of TB patients with known HIV status,

2004Ų2012

HIV status

Negative

Positive

TB patients (thousands)

1000

2000

3000

2004 2005 2006 2007 2008 2009 2010 2011 2012

Percentage of TB patients

2004 2005 2006 2007 2008 2009 2010 2011 2012

African region

Global

Regions outside Africa

ter presents the latest status of progress, using data for

2004 up to 2012.

6.1 HIV testing for TB patients

In 2012, the number of notied TB patients who had a doc-

umented HIV test result reached 2.8 million (Figure 6.1),

equivalent to 46% of notied TB cases (Table 6.1, Figure

6.2). is was an increase from 2.5 million and 40% respec-

tively in 2011, and 15 times the level of 3.1% reported in

2004 (Figure 6.2).

e coverage of HIV testing for TB patients was particu-

larly high in the African Region, where 74% of TB patients

had a documented HIV test result in 2012, up from 69%

in 2011 (Figure 6.2). Impressively, in 29 of 46 African

countries, ≥75% of TB patients had a documented HIV test

result in 2012 (Figure 6.3).

Overall, among the 41 countries identied as priorities

for the global TB/HIV response, (listed in Table 6.1), 53%

of TB patients notied had a documented HIV test. Of these

countries, 15 achieved testing levels of ≥85% including

seven (Kenya, Malawi, Mozambique, Rwanda, Swaziland,

Togo and Zambia) that achieved levels above 90%. In addi-

tion, although national data for China show that 34% of

TB patients were tested for HIV in 2012, coverage was 88%

in the 294 high TB/HIV burden counties in which testing

of all notied TB patients is recommended. Globally, there

were 87 countries in which ≥75% of TB patients had a docu-

mented HIV test result.

FIGURE 6.3

Percentage of patients with known HIV status by country, 2012a

Percentage of

notiﬁed TB patients

0–14

15–49

50–74

≥75

No data

Not applicable

a +PVJGEQWPVKGUKP%JKPCKFGPVKßGFHQT*+8VGUVKPICOQPIPQVKßGF6$RCVKGPVUQHPQVKßGFECUGUYGTGVGUVGFHQT*+8&CVCHQTVJG4WUUKCP

Federation are for new TB patients only excluding cases in prisons.

70 GLOBAL TUBERCULOSIS REPORT 2013

TABLE 6.1

HIV testing, treatment for HIV-positive TB patients and prevention of TB among people living with HIV,

globally and for 41 high TB/HIV burden countries and WHO regions, 2012. Numbers in thousands except

where indicated.

ESTIMATED HIV-POSITIVE INCIDENT TB CASES

07/$'41(

TB PATIENTS

WITH KNOWN

HIV STATUS

% OF

NOTIFIED

TB PATIENTS

6'56'&(14

HIV

% OF

TESTED

TB PATIENTS

HIV-POSITIVE

% OF

IDENTIFIED

HIV-POSITIVE

TB PATIENTS

56#46'&10

CPT

% OF

IDENTIFIED

HIV-POSITIVE

TB PATIENTS

56#46'&10

#46

07/$'41(

HIV-

POSITIVE

PEOPLE

5%4''0'&

(146$

07/$'4

HIV-POSITIVE

PEOPLE

2418+&'&

WITH IPT

BEST LOW HIGH

Angola 5.5 4.7 6.5 12 23 9.6 100 100 12 1.1

Botswana 5.1 4.5 5.6 6.0  63 91 66

$TC\KN 16 13 19 46 55 20 0 100

Burkina Faso 1.6 1.3  4.6  15 96 75 7.4

Burundi 2.5 2.2  5.7  19 94 55 0.2

Cambodia 2.7 2.3 3.1 32  4.4   1.1

Cameroon 19 16 23 21  37  55 12

%GPVTCN#HTKECP4GRWDNKE 5.3 4.4 6.4  46 39  20

Chad 4.1 3.4   44 20 65 1.0

China 7.3 6.4  309 34a1.9 59 295

Congo 3.6 2.9 4.3 2.0 17 33 20 23

Côte d’Ivoire  6.9 9.2 21  27 75 44

Djibouti 0.54 0.45 0.64 1.3 36 10 64 0

&4%QPIQ 16 14 19 35 31 16 61 40

Ethiopia 23 17 30 96 65 10 37  272 30

Ghana  2.4 3.1 12  24 72 37

Haiti 4.3 3.5 5.1 14  20 59 46 2.1 15

India 130 120 140  56 5.4 92 59 1 324

Indonesia 7.5 5.6 9.7 2.7    29 23

Kenya 45 44 47 93 94 39  74

Lesotho 9.9  11 10  75 97 53 21 16

Malawi 16 15 17 19 93 59   393 21

Mali 1.2 1.2 1.3 1.5   42 100

/Q\CODKSWG   110  94   55 17

Myanmar 19 16 21 19 13 27 

Namibia 7.3   9.9  47 99 72 12 12

Nigeria 46 21    23  56 140 2.3

4WUUKCP(GFGTCVKQP 9.3 7.9 11 76b

4YCPFC 2.9 2.6 3.2 6.1 99 26 99 122

Sierra Leone 3.9 3.2  12  12 26 69  1.1

South Africa 330 270 390 294  65 74 54 950 370

Sudan 4.3 3.5 5.1 3.1 15 7.5 0 17 1.3

5YC\KNCPF 13 11 15 7.4 95 77  66 69 1.9

Thailand 12 10 14 44 72 13 77 62

Togo 1.2  1.4 2.7 91 24  76

Uganda 35  42 41  50 94 49

Ukraine  3.9 5.7 34  14 94 14

746CP\CPKC 32 30 34 52  39 96 54 357

Viet Nam 9.3 6.9 12  66 7.0 73 47 5.7

<CODKC 35 32 39 45 100 54 93 60

<KODCDYG 55 42 69 34  70 26 

High TB/HIV burden countries 1 000 960 1 100 2 454 53 21 80 57 4 024 509

#(4  760 910 1 040 74 43 79 55 2 392 473

#/4 31  34 129 56 16 61 76 4.5 19

'/4 11 10 12  14 3.5 69  15 0.2

'74 19 17 21 204 60 6.3 67 74 24 

5'#4 170 160  904 39 6.2  61 1 352 

924 24 21 27 451 34 3.1 79 56  

Global 1 100 1 000 1 200 2 787 46 20 80 57 4 095 519

Blank cells indicate data not reported.

a +PVJGEQWPVKGUKP%JKPCKFGPVKßGFHQT*+8VGUVKPICOQPIPQVKßGF6$RCVKGPVUQHPQVKßGFECUGUYGTGVGUVGFHQT*+8#OQPIVJGUGYGTG

HIV-positive (1.6%).

b &CVCHQTVJG4WUUKCP(GFGTCVKQPGZENWFGTGVTGCVOGPVECUGUCPFECUGUHTQORTKUQPU

71GLOBAL TUBERCULOSIS REPORT 2013

Outside the African Region, in 2012 the percentage of

TB patients who had a documented HIV test result reached

60% in the European Region. It should be noted, how ever,

that the coverage of testing in the Russian Federation is

underestimated since the national data on HIV testing

reported to WHO are for new TB cases in the civilian sector

only (i.e. excluding prisons) while the denominator used

in calculations of coverage is all notied TB cases. e per-

centage of TB patients with a documented HIV test result

in the Region of the Americas was 56% in 2012. Brazil

(where 55% of new TB cases had a documented HIV test

result, very similar to the regional average) accounted for

more than a third of all cases tested in the region, followed

by Mexico (12%) and Haiti (10%). In other regions, where

testing rates have remained consistently low, the percent-

age ranged from 14% in the Eastern Mediterranean Region

to 39% in the South-East Asia Region.

e highest rates of HIV co-infection were reported for

TB patients in the African Region (Table 6.1), where 43%

of those with an HIV test result were positive (compared

with 46% in 2011). e percentage of TB patients found

to be HIV-positive in the 28 African countries in the list

of 41 priority countries ranged from 10% in Ethiopia and

Angola to 77% in Swaziland. In the Region of the Americas,

the percentage of TB patients with a documented HIV test

result who were HIV-positive was 16%. In the Eastern Med-

iterranean, European, South-East Asia and Western Pacic

Regions, less than 10% of TB patients with a documented

HIV test result were HIV-positive. e global average across

all regions was 20%, and 21% among the 41 high TB/HIV

burden countries.

6.2 Antiretroviral therapy and co-trimoxazole

preventive therapy for TB patients living

with HIV

ART is a critical intervention for reducing the risk of TB

morbidity and mortality among people living with HIV. It

reduces the individual risk of TB disease by 65%, irrespec-

tive of CD4 cell count,1 and when combined with IPT it can

have a signicant impact on TB prevention.2 In the latest

WHO guidelines released in July 2013,3 the threshold CD4

count at which starting ART is recommended has been

raised from a CD4 count of ≤350 to ≤500 CD4/mm3. Imple-

mentation of these guidelines on a large scale should sub-

stantially reduce morbidity and mortality resulting from

HIV-associated TB. As in previous guidelines, ART is rec-

ommended for all TB patients living with HIV, irrespective

of their CD4 cell count. CPT also helps to reduce mortality

among HIV-positive TB patients.4

e number of HIV-positive TB patients on ART has

grown from a very low level in 2004 (Figure 6.4) to reach

0.3 million in 2012. Among TB patients notied in 20125

and who had a documented HIV-positive test result, 57%

were on ART globally (Table 6.1, Figure 6.5); this is a

considerable improvement from 49% in 2011. In the Afri-

can Region, 55% of TB patients notied in 2012 who had

a documented HIV-positive test result were on ART (up

from 48% in 2011). Among the 41 high TB/HIV burden

countries, 28 reported enrolling more than 50% of notied

TB patients known to be living with HIV on ART in 2012

(Table 6.1, Figure 6.6). is important progress notwith-

standing, the WHO recommendation that all HIV-positive

TB patients are eligible for ART irrespective of their CD4

cell count also means that the coverage of ART for HIV-pos-

itive TB patients still needs to be greatly improved with the

goal of reaching the 2015 target of 100% set in the Global

Plan to Stop TB 2011–2015.

Early initiation of ART, as soon as possible within eight

weeks after initiation of TB treatment or within two weeks

for profoundly immunosuppressed patients (CD4 count

<50), is recommended. WHO also strongly recommends

the integration of ART and TB treatment services for TB

patients living with HIV either through TB or HIV treat-

ment facilities in settings with a high burden of TB and HIV.

In many settings, facilities providing TB services are more

decentralized than ART services and oer an opportunity

to scale up the delivery of integrated TB and HIV services

through task shifting and task sharing.6 A recent example

of the integration of TB services with those for HIV and

1 Suthar AB et al. Antiretroviral therapy for prevention of tuberculosis

in adults with HIV: a systematic review and meta-analysis. PLoS Med-

icine, 2012, 9(7): e1001270. (doi:10.1371/journal.pmed.1001270).

2 Samandari T et al. 6-month versus 36-month isoniazid preven-

tive treatment for tuberculosis in adults with HIV infection in

Botswana: a randomised, double-blind, placebo-controlled trial.

e Lancet. 2011 May 7;377(9777):1588-98. doi: 10.1016/S0140-

6736(11)60204-3.

3 Consolidated guidelines on the use of antiretroviral drugs for treat-

ing and preventing HIV infection. Geneva, World Health Organi-

zation, 2013. Available at http://apps.who.int/iris/bitstream/

10665/85321/1/9789241505727_eng.pdf

4 Nunn AJ et al. Role of co-trimoxazole prophylaxis in reducing mor-

tality in HIV infected adults being treated for tuberculosis: ran-

domized clinical trial. British Medical Journal. 2008, 337:a257.

5 In the annual WHO TB data collection form, countries are asked to

report the number of TB patients notied in the most recent calen-

dar year who were living with HIV and who “started or continued

on ART”.

6 Global Tuberculosis Report 2012. Geneva, World Health Organiza-

tion, 2012.

FIGURE 6.4

Number of HIV-positive TB patients enrolled

on co-trimoxazole preventive therapy (CPT) and

antiretroviral therapy (ART), 2004–2012

TB patients (thousands)

HIV-positive

CPT

ART

100

200

300

400

500

600

2004 2005 2006 2007 2008 2009 2010 2011 2012

72 GLOBAL TUBERCULOSIS REPORT 2013

FIGURE 6.5

Percentage of TB patients with known HIV status who were HIV positive, and percentage of HIV-positive TB

patients enrolled on co-trimoxazole preventive therapy (CPT) and antiretroviral therapy (ART), 2007–2012a

a The solid lines show values for countries that reported data. The shaded areas show upper and lower limits when countries that did not report data are considered.

Percentage of TB patients

2007 2008 2009 2010 2011 2012 2007 2008 2009 2010 2011 2012 2007 2008 2009 2010 2011 2012

100

% of TB patients with known

HIV status who were HIV-positive

% of HIV-positive patients on CPT % of HIV-positive patients on ART

FIGURE 6.6

Percentage of HIV-positive TB patients enrolled on antiretroviral therapy (ART), 2012

Percentage of

HIV-positive

TB patients

0–24

25–49

50–74

75–100

No data

Not applicable

maternal, new-born and child health (MNCH) services is

provided in Box 6.1.

Globally, 0.4 million TB patients living with HIV were

enrolled on CPT in 2012, up from a negligible number in

2004. e absolute number fell between 2011 and 2012,

which is at least partly explained by the decrease in the

number of HIV-positive TB cases reported between 2011

and 2012 (Figure 6.4). e coverage of CPT among TB

patients with a documented HIV-positive test result was

80% in 2012, similar to the level of 2010 and 2011 (Table

6.1, Figure 6.5). e African, South-East Asia and Western

Pacic Regions achieved particularly high levels of enrol-

ment on CPT: 79%, 89% and 79%, respectively (Table 6.1).

Of the 41 high TB/HIV burden countries, the percentage of

HIV-positive TB patients enrolled on CPT in 2012 exceeded

90% in Angola, Botswana, Burkina Faso, Burundi, Cambo-

dia, India, Kenya, Lesotho, Mozambique, Namibia, Rwan-

da, Swaziland, Uganda, the United Republic of Tanzania

and Zambia.

6.3 Intensifying TB screening and

isoniazid preventive therapy among

people living with HIV

Recording and reporting of TB screening among people liv-

ing with HIV and provision of IPT to those without active

TB is a particular challenge in many countries, and further

eorts are needed to facilitate and improve the tracking of

progress nationally and globally (Box 6.2).

73GLOBAL TUBERCULOSIS REPORT 2013

BOX 6.1

Linkages between TB, HIV and maternal, newborn and child health (MNCH) services in Cambodia

Cambodia has achieved great progress in responding to its HIV epidemic and in reducing TB prevalence and mortality. It has also

made progress in improving services for maternal, newborn and child health (MNCH). Attendance at antenatal services and the

RGTEGPVCIGQHFGNKXGTKGUCVJGCNVJHCEKNKVKGUJCXGKPETGCUGFCPFOCVGTPCNCPFWPFGTßXGOQTVCNKV[JCXGDQVJDGGPTGFWEGF/CLQT

efforts to establish and strengthen service linkages between the TB, HIV and MNCH programmes have also been made.

Linkages between TB and

HIV services

+PQHPQVKßGF6$RCVKGPVU

MPGYVJGKT*+8UVCVWUCPFQH

*+8RQUKVKXG6$RCVKGPVUYGTGQP#46

The number of people living with HIV

given IPT increased by a factor of 22

between 2006 and 2012, following

the introduction of the WHO screening

algorithm to rule out active TB (and

associated removal of the previous

requirement for a positive tuberculin

skin test before initiation of IPT).

Linkages between MNCH and

HIV services

The percentage of pregnant women

tested for HIV increased from 16% in

VQKP6JGEQXGTCIG

QH#46COQPI*+8KPHGEVGFRTGIPCPV

women increased from 11% in 2007 to

65% in 2012. The percentage of infants

born to HIV-positive women who were

RTQXKFGFYKVJ#46VQRTGXGPVOQVJGT

to-child transmission rose from 50% in

2010 to 73% in 2012.

Linkages between MNCH and

TB services

A new MNCH-TB collaborative framework

offering cross-programme referrals

between TB services and clinics

providing antenatal, growth monitoring

CPFKOOWPK\CVKQPUGTXKEGURTQOKUGUVQ

further reduce the burden of TB among

women and children.

Scaling up collaboration among

the three programmes

Collaboration among the three

programmes aims to strengthen

linkages and synergies to achieve better

outcomes. The government, with support

from WHO, has piloted efforts to set

up a collaborative project involving

the three programmes in two districts.

Lessons learned from these and other

pilot sites are helping the country to

OCZKOK\GRQVGPVKCNHQTETQUURTQITCOOG

EQNNCDQTCVKQPCPFVQQRVKOK\GVJGWUGQH

resources.

The three-programme collaborative

CEVKXKVKGUDGKPIRKNQVGFKPENWFG

 *CTOQPK\KPIVTCPURQTVCVKQPQHDNQQF

samples required for testing HIV

that are collected at sites providing

services for pregnant women, TB

patients and populations at high risk

of HIV.

 *CTOQPK\KPIKPHQTOCVKQPGFWECVKQP

and communication related to MNCH,

HIV and TB at the sites providing

MNCH, HIV and TB services.

3. Expanding cross-programme

laboratory services.

4. Strengthening the system

for referrals between the

three programmes including

UVCPFCTFK\CVKQPQHEQOOWPKECVKQP

and referral procedures.

 *CTOQPK\CVKQPQHEQOOWPKV[U[UVGO

strengthening by sharing the costs

and time spent during monthly

meetings of village health support

groups at health centres.

BOX 6.2

Improving the quality of TB/HIV data: challenges and solutions

Major efforts have been made in recent years to improve the quality of TB/HIV data. Indicators used by TB and HIV programmes have

DGGPUVCPFCTFK\GFCPFEQNNCDQTCVKQPDGVYGGP6$CPF*+8RTQITCOOGUJCUDGGPKORTQXGFYKVJENGCTFGßPKVKQPQHTGURQPUKDKNKVKGU

for data collection related to TB/HIV interventions. WHO and UNAIDS have worked intensively with countries to try to ensure

complete and consistent reporting and to reconcile any apparent discrepancies between data reported by TB and HIV programmes.

6JGUGGHHQTVUPQVYKVJUVCPFKPIEJCNNGPIGUTGOCKP

Missing or inaccurate denominators required to calculate the coverage of TB screening and IPT among people

living with HIV. There has been an increase in the number of countries capturing and reporting data on the number of people

living with HIV who are screened for TB and the number without active TB who are provided with IPT. However, many of these

countries are not reporting the corresponding denominators needed to calculate coverage (i.e. people registered in HIV care

CPFRGQRNGPGYN[TGIKUVGTGFKP*+8ECTGHQTUETGGPKPICPF+26TGURGEVKXGN[6JGTGCTGCNUQGZCORNGUQHVJGUCOGßIWTGUDGKPI

reported for both denominators.

Discrepant reporting by NTPs and National AIDS Programmes (NAPs). In some countries, the NTP and NAP report

FKHHGTGPVßIWTGUHQTVJGPWODGTQH*+8RQUKVKXG6$RCVKGPVUYJQCTGQP#46+PEQWPVTKGUVJGPWODGTUTGRQTVGFD[VJG

062CPF0#2YGTGFKHHGTGPVKPDQVJCPF#NVJQWIJUWDUGSWGPVFCVCXGTKßECVKQPCPFJCTOQPK\CVKQPGHHQTVUNGFVQ

consensus on one number in most countries, the different numbers could not be reconciled for either year in Angola, Myanmar

CPFVJG7PKVGF4GRWDNKEQH6CP\CPKC5QNWVKQPUVQCFFTGUUVJKURTQDNGOKPENWFGKORTQXKPIU[UVGOUHQTTGEQTFKPICPFTGRQTVKPI

data and further strengthening of collaboration and communication between the NAP and NTP as well as their partners.

74 GLOBAL TUBERCULOSIS REPORT 2013

In 2012, a total of 4.1 million people who were enrolled in

HIV care were screened for TB in 61 countries, an increase

from 3.5 million in 58 countries in 2011 (Figure 6.7). In

the 49 countries that reported both the number screened

for TB and the number in HIV care, the coverage of screen-

ing was 66% (3.9/5.9 million).

Among 42 countries that reported data, IPT was ini-

tiated among almost 520 000 people newly registered

in HIV care in 2012. is was an increase from less than

450000 people in 2011 (Figure 6.8). One country – South

Africa – accounted for 71% of the global total with 370000

people reported to have been provided with IPT in 2012,

followed by Ethiopia (30 000), Malawi (21000), Mozam-

1 Getahun H, et al. Development of a standardized screening rule for

tuberculosis in people living with HIV in resource-constrained set-

tings: Individual participant data meta-analysis of observational

studies. PLoS Medicine, 2011, 8(1): e1000391. doi:10.1371/journal.

pmed.1000391.

FIGURE 6.7

Intensißed TB case-ßnding among people living

with HIV, 2005–2012

Number of people screened (millions)

2005 2006 2007 2008 2009 2010 2011 2012

FIGURE 6.8

Provision of isoniazid preventive therapy (IPT)

to people living with HIV without active TB,

2005–2012

Number of HIV-positive people without

active TB (thousands)

100

200

300

400

500

600

2005 2006 2007 2008 2009 2010 2011 2012

bique (17000), Lesotho (16000), Haiti (15000), Ukraine

(14000), and Namibia (12000).

irty countries reported both the total number of peo-

ple newly enrolled in HIV care (1.6 million) and the num-

ber of people living with HIV who were started on IPT

(0.47 million) in 2012 i.e. 30% of those newly enrolled in

HIV care were initiated on IPT. If the WHO-recommend-

ed four-symptom screening algorithm is used to rule out

active TB in people living with HIV, approximately 50% of

people living with HIV would be expected to be eligible for

IPT.1 Further eorts are needed to reach the Global Plan’s

2015 target of providing IPT to all those eligible.

75GLOBAL TUBERCULOSIS REPORT 2013

%*#26'4

Financing

KEY FACTS AND MESSAGES

■ Funding required for a full response to the global TB

epidemic in low- and middle-income countries is estimated

CV75aDKNNKQPRGT[GCTD[GZENWFKPITGUGCTEJCPF

development for new TB diagnostics, drugs and vaccines).

Of this total, about two thirds is needed for the detection

and treatment of drug-susceptible TB, 20% for treatment

QH/&46$HQTTCRKFFKCIPQUVKEVGUVUCPFCUUQEKCVGF

laboratory strengthening, and 5% for collaborative TB/HIV

activities.

■ A recent long-term study using data reported to WHO

shows that TB funding in low- and middle-income countries

grew substantially between 2002 and 2011, especially in

$TC\KNVJG4WUUKCP(GFGTCVKQP+PFKC%JKPCCPF5QWVJ#HTKEC

$4+%56JGKPETGCUKPIUGNHUWHßEKGPE[QHVJGUGCPFUQOG

other countries is a success story for these countries and the

global TB community.

■ Despite growth in funding for TB, funding gaps persist

CPFCFFKVKQPCNHWPFKPIPGGFUVQDGOQDKNK\GFHTQODQVJ

domestic and international donor sources. There is capacity

to increase funding from domestic sources beyond the

75aDKNNKQPCXCKNCDNGKPGURGEKCNN[KP$4+%5

Funding required from international donor sources is

GUVKOCVGFCV75a¿DKNNKQPRGT[GCT

■ Funding from international donor sources is expected

VQTGCEJ75aDKNNKQPKPOQUVQHVJKUHWPFKPIKU

from the Global Fund and USAID. Donor funding accounts

HQTCNCTIGUJCTGÜQHVQVCNHWPFKPIKPUQOGEQWPVT[

ITQWRUPQVCDN[VJG*$%UGZENWFKPI$4+%5CPFCNNNQY

income countries, and an even higher proportion in some

individual countries. International donors have a crucial

role in sustaining and ensuring further progress in TB

prevention, diagnosis and treatment worldwide.

■ 6JGEQUVRGTRGTUQPUWEEGUUHWNN[VTGCVGFHQT6$YKVJßTUV

NKPGFTWIUKUKPVJGTCPIG75aVQ75aKPCNOQUVCNN

countries with a high burden of TB.

Progress in TB prevention, diagnosis and treatment

requires adequate funding sustained over many years.

WHO began annual monitoring of funding for TB in 2002,

and ndings have subsequently been published in global

TB reports. Particular attention has always been given to

the 22 HBCs that account for about 80% of estimated cases

(Chapter 2). Recent reports have included aggregated anal-

yses of trends since 2006 for approximately 100 countries.

In 2012, WHO conducted a comprehensive analysis of

long-term trends in TB funding in low- and middle-income

countries for the decade 2002–2011, using data reported

by countries between 2002 and 2012. e analysis was able

to include 104 out of a total of 154 countries classied by

the World Bank as low- or middle-income in 2011 (gross

national income (GNI) per capita < US$12,476). ese 104

countries had 94% of the world’s estimated cases of TB and

88% of the world’s estimated cases of MDR-TB in 2011. Lev-

els of funding in 2011 were then analysed in combination

with the most recent estimates of resource requirements

for TB prevention, diagnosis and treatment to assess the

funding that could be mobilized from domestic sources and

the balance required from international donors up to 2015.

Results from these analyses were published in an article in

the August 2013 issue of e Lancet Global Health.1

Given this very recent publication, the scope of this

nancing chapter has been adjusted compared with pre-

vious years to avoid unnecessary duplication. Section 7.1

presents the most up-to-date estimates of nancial resourc-

es required until the end of 2015 in all of the 154 countries

that were classied as low- or middle-income countries in

2011, alongside projections of the funding that could be

mobilized domestically. Section 7.2 provides a summary

of the main ndings from the analysis of trends in fund-

ing between 2002 and 2011 in 104 low- and middle-income

countries. With this background and context, the rest of

the chapter (section 7.3) contains detailed analyses of TB

funding in 2013, using data compiled in the 2013 round of

global TB data collection. Funding levels in 2013 are pre-

sented by WHO region and for other country groupings

based on income level, burden and geography, with break-

downs by source of funding (section 7.3.1) and category

of expenditure (section 7.3.2). Funding gaps reported by

countries are also illustrated and discussed (section 7.3.3).

1 Floyd K, Fitzpatrick C, Pantoja A and Raviglione M. Domestic and

donor nancing for tuberculosis care and control in low-income

and middle-income countries: an analysis of trends, 2002–11, and

requirements to meet 2015 targets. e Lancet Global Health; 1:

e105–15.

76 GLOBAL TUBERCULOSIS REPORT 2013

Further country-specic data can be found in nance pro-

les that are available online.1

7.1 Estimates of funding required up to

2015 for a full response to the global

TB epidemic

e Global Plan to Stop TB 2011–20152 sets out the actions

and funding needed for a full response to the TB epidem-

ic, based on the Stop TB Strategy.3 e overall goal of the

plan is to achieve the 2015 global targets for reductions in

cases of and deaths from TB (i.e. that incidence should be

falling and that prevalence and mortality rates should be

halved compared with their levels in 1990) (Chapter 1). Key

components of the plan include increasing the number of

patients detected and treated according to WHO’s recom-

mended strategy from 5.8 million in 2011 to 6.9 million

by 2015 (which would be equivalent to more than 80% of

projected incident cases in that year); ensuring that all pre-

viously treated patients and all new patients with known

risk factors for MDR-TB are tested for drug resistance by

2015 (including with recently endorsed rapid tests such as

Xpert MTB/RIF that are discussed in Chapter 5); enrol-

ment of all TB patients with conrmed MDR-TB (projected

to be around 300000 in 2015) on second-line treatment;

HIV testing of all patients with TB; and prompt initiation

of ART in all HIV-positive TB patients.

In 2013, the Global Plan datasets were used in combi-

nation with new country-specic planning and budgeting

work with nine high TB or high MDR-TB burden countries

to produce updated estimates of funding needs for TB

prevention, diagnosis and treatment in low- and middle-

income countries.4 e nine countries were Ethiopia, India,

Indonesia, Kazakhstan, Kenya, Nigeria, Pakistan, South

Africa and Ukraine. Analyses were conducted in the context

of estimates of funding needs and funding gaps required

for the Global Fund’s replenishment eorts in 2013.5 WHO

subsequently extended these analyses to cover all low- and

middle-income countries and not only the countries eligi-

ble to apply to the fund.6 Notable countries (in terms of TB

burden and funding requirements) that are not eligible to

apply to the Global Fund are Brazil, China and the Russian

Federation.

During the course of the work done for the rst pre-

replenishment meeting held in April 2013, it should be

highlighted that the Global Fund, WHO, UNAIDS, and

other partners agreed that funding needs for ART for HIV-

positive TB patients should be included in estimates of HIV

resource needs to avoid double-counting. For this reason,

the estimates of resource requirements for TB/HIV inter-

ventions included in the updated estimates of resource

needs for TB are lower than those published in the Global

Plan.

Funding needs were compared with the domestic fund-

ing that could be mobilized in two alternative scenarios.

e rst scenario was that TB funding could increase (from

a 2011 baseline) in line with International Monetary Fund

forecasts for growth in total government expenditures.7

e second scenario had the same assumptions as the rst,

but also assumed that countries that currently under-

perform in domestic nancing relative to their income level

(i.e. their ability to pay) and disease burden reach the lev-

el of the median performer by 2020. ese scenarios were

chosen to be fully consistent with the methods previously

used to assess the potential to mobilize domestic funding

for prevention, treatment and care of HIV.8

e main results from these analyses are summarized

in Figure 7.1. e total funding required in all low- and

middle-income countries reaches about US$ 8 billion in

2015, compared with US$6 billion in 2012 (Figure 7.2).9

Of the total funding required, about two thirds is needed

for the detection and treatment of drug-susceptible TB,

20% for treatment of MDR-TB, 10% for rapid diagnostic

tests and associated laboratory strengthening, and 5% for

collaborative TB/HIV activities (excluding ART). Funding

needed for each of these four categories increases over time.

e largest relative increases are for treatment of MDR-TB

and diagnostics/laboratory strengthening.

ere is potential to mobilize a large share of these fund-

ing needs from domestic resources in some country groups,

notably BRICS and upper middle-income countries (Figure

7.1). Elsewhere, there are relatively large gaps between

the estimated amounts of domestic funding that could be

mobilized and the total funding needed, especially in three

country groups: the 17 HBCs excluding BRICS; low-income

countries; and the African Region excluding South Africa.

In the rst scenario in which domestic funding grows from

2011 levels in line with projected growth in total govern-

ment expenditures, the total gap amounts to US$2.3 bil-

lion per year by 2015. In the second and more optimistic

scenario, the gap would be US$1.6 billion per year by 2015.

1 www.who.int/tb/data

2 e Global Plan to Stop TB, 2011–2015. Geneva, World Health Orga-

nization, 2010 (WHO/HTM/STB/2010.2).

3 Raviglione M, Uplekar M. WHO’s new Stop TB strategy. Lancet

2006; 367: 952–5.

4 Funding required for research and development for new TB diag-

nostics, drugs and vaccines was not considered. In the Global

Plan, it is estimated that about US$2 billion per year is needed for

research and development.

5 e Global Fund to Fight AIDS, Tuberculosis and Malaria fourth replen-

ishment (2014–2016): needs assessment. Geneva, Global Fund to

Fight AIDS, Tuberculosis and Malaria, 2013.

6 Floyd K, Fitzpatrick C, Pantoja A and Raviglione M. Domestic and

donor nancing for tuberculosis care and control in low-income

and middle-income countries: an analysis of trends, 2002–11, and

requirements to meet 2015 targets. e Lancet Global Health; 1:

e105–15.

7 World economic outlook database. Washington, International Mon-

etary Fund, 2012 (www.imf.org/external/pubs/ft/weo/2012/02/

weodata/index.aspx).

8 Schwartlander B, Stover J, Hallett T, et al. Towards an improved

investment approach for an eective response to HIV/AIDS. e

Lancet 2011; 377: 2031–41.

9 In Figure 7.1, country groups are not all mutually exclusive. e

global total can be calculated by adding together the totals in the

panels for BRICS, low-income countries, lower middle-income

countries (excluding China and India) and upper middle-income

countries (excluding Brazil, the Russian Federation and South

Africa).

77GLOBAL TUBERCULOSIS REPORT 2013

FIGURE 7.1

Forecast of funding that could be mobilized from domestic sources compared with total funding needed for

a full response to the global TB epidemic in nine country groups, 2012–2015. The black line shows the total

funding required. The blueDCPFTGRTGUGPVUUEGPCTKQYJKEJUJQYUFQOGUVKEHWPFKPIVJCVEQWNFDGOQDKNK\GFKHFQOGUVKE

funding increases from a 2011 baseline at the same rate of growth as International Monetary Fund forecasts of growth in total

government expenditures. The greenDCPFUJQYUCFFKVKQPCNTGUQWTEGUVJCVEQWNFDGOQDKNK\GFEQORCTGFYKVJUEGPCTKQKH

current underperformers (relative to income level and TB disease burden) improve at a consistent rate to reach the level of the

median performer by 2020. $4+%5$TC\KNVJG4WUUKCP(GFGTCVKQP+PFKC%JKPC5QWVJ#HTKEC

US$ billions

Africa excluding S

US$ billions

BRICS

Low-income countries

17 HBCs excluding BRICS

Lower-middle income countries

excluding I and C

Asia excluding I and C Rest of world excluding B and R

Upper-middle income countries

excluding B, R, S

Low-income countries excluding HBCs

US$ billions

1.0

2.0

3.0

4.0

5.0

2012 2013 2014 2015

0.5

1.0

1.5

2012 2013 2014 2015

0.10

0.20

0.30

2012 2013 2014 2015

0.2

0.4

0.6

0.8

1.0

1.2

2012 2013 2014 2015

0.2

0.4

0.6

1.2

1.4

1.6

1.8

0.8

2012 2013 2014 2015

1.0

0.2

0.4

0.6

0.8

2012 2013 2014 2015

0.2

0.4

0.6

1.0

1.2

1.4

1.6

1.8

0.8

2012 2013 2014 2015

0.2

0.4

0.6

0.8

1.0

1.2

2012 2013 2014 20152012 2013 2014 2015

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

 GLOBAL TUBERCULOSIS REPORT 2013

It should be highlighted that in the second and more

optimistic scenario, it is assumed that countries that cur-

rently underperform in terms of their levels of domestic

nancing relative to their TB burden and income level will

steadily progress to reach the level of the current median

peformer (in terms of domestic funding relative to burden

and income level) by 2020. Two countries in particular –

India and Indonesia – would need to substantially increase

their levels of domestic funding for this scenario to mate-

rialize in practice, since they account for about two-thirds

of the additional funding in Scenario 2 compared with

Scenario 1. Current trends are not in line with Scenario

2. In India, domestic funding reported for 2013 is lower

than the amount available in 2012, while in Indonesia an

increase in domestic funding between 2012 and 2013 was

reported but by a relatively small amount (see Annex 2 for

further details).

7.2 Trends in TB funding, 2002–2011:

a summary

Data reported to WHO between 2002 and 2012 allowed

analysis of trends 2002–2011 in 104 countries. ese 104

countries are shown in Table 7.1 (an additional 21 coun-

tries that could be included in analyses of funding in 2013,

described in section 7.3, are shown in bold). Among the 104

countries, there were ≥6 observations for 83 countries. For

most countries, there were between 7 and 10 observations,

including 14/22 HBCs that had 10 observations each and

5/22 HBCs for which there were 9/10 observations. Values

for country-year combinations for which data were missing

in the 104 countries were imputed using country-specic

linear regression models. Details on the criteria used to

include or exclude countries and the imputation methods

are available in an online technical appendix.1

In the 104 low- and middle-income countries with 94%

of the world’s TB cases and 88% of the world’s MDR-TB cas-

es, total funding for TB (domestic plus international donor

sources) grew in real terms (2011 US$ prices) from US$1.7

billion in 2002 to US$ 4.4 billion in 2011. e increases var-

ied among country groups, from 100% in low-income coun-

tries to 177% in upper middle-income countries. Increases

in funding were accompanied by large increases in the num-

ber of people successfully treated for TB, from 2.8 million

in 2002 to 5.0 million in 2011. A cumulative total of 43 mil-

lion people were treated between 2002 and 2011. e cost

per patient treated was in the range US$100–500 in most

of the countries with the highest burdens of TB. e size

of the patient caseload and gross domestic product (GDP)

per capita explained more than 70% of the variation among

countries in the cost per patient treated.

Domestic funding (national and local budgets, and loans)

in the 104 countries included in trend analyses rose from

US$1.5 billion in 2002 to US$3.9 billion in 2011. Loans

accounted for a small proportion (≤5%) of total domestic

funding each year. Most of the increase in total domestic

funding (US$1.7 out of US$2.4 billion [71%]) was account-

ed for by BRICS (which account for almost half of the world’s

TB cases) and other middle-income countries in Asia, Latin

America and Europe. e magnitude of domestic funding

in these country groups (69–98% of total funding per year)

and BRICS in particular (>95% of total funding per year)

meant that domestic funding dominated total funding for

TB globally (88–92% per year).

International donor funding in the 104 countries includ-

ed in trend analyses grew from US$0.2 billion in 2002 to

US$0.5 billion in 2011. ere was striking variation among

country groups in terms of the share of total funding pro-

vided from international donor sources. By 2011, donor

funding represented 39% of total funding in the 17 HBCs

excluding BRICS, which account for about one third of

the world’s TB cases; 42% of funding in African countries

excluding South Africa; and 67% of total funding in low-

income countries (25 of which are in Africa). e Global

Fund accounted for 64% of all donor funding reported by

countries during the decade 2002–2011.

Most funding was used for the diagnosis and treat-

ment of drug-susceptible TB (over 85% each year). Small

amounts were used for diagnosis and treatment of MDR-

TB, although funding started to increase in BRICS, upper

middle-income countries, and countries in Europe and

Latin America around 2006.

Despite growth in funding from domestic and interna-

tional donor sources, NTPs were not able to mobilize all the

funding that they estimated to be needed. Funding gaps

(i.e. the dierence between assessments by NTPs of funding

needs for TB prevention, diagnosis and treatment and the

actual amount of funds mobilized) persisted, and increased

from US$257 million in 2002 to US$563 million in 2011. It

should be noted that the funding gaps reported by NTPs are

sometimes based on relatively conservative assessments of

funding needs. When national strategic plans with more

FIGURE 7.2

Total funding required for a full response

to the global TB epidemic, by intervention area,

2013–2015

TB/HIV

Laboratory

strengthening/

diagnostics

MDR-TB

Drug-susceptible

US$ billions

2012 2013 2014 2015

1 Floyd K, Fitzpatrick C, Pantoja A and Raviglione M. Domestic and

donor nancing for tuberculosis care and control in low-income

and middle-income countries: an analysis of trends, 2002–11, and

requirements to meet 2015 targets. e Lancet Global Health; 1:

e105–15.

79GLOBAL TUBERCULOSIS REPORT 2013

TABLE 7.1

125 countries included in analyses of TB ßnancing in 2013a,b

LOW-INCOME

QHPQVKßGFECUGUINQDCNN[

.19'4/+&&.'+0%1/'

QHQHPQVKßGFECUGU

globally)

722'4/+&&.'+0%1/'

QHPQVKßGFECUGUINQDCNN[

$4+%5

QHPQVKßGFECUGU

globally)

*+)*$74&'0%17064+'5

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Lesotho, Mauritania,

Nigeria, Sao Tome

and Principe,

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 GLOBAL TUBERCULOSIS REPORT 2013

1 World malaria report 2012. Geneva, World Health Organization,

2012.

2 World AIDS day report 2012. Geneva, Joint United Nations Pro-

gramme on HIV/AIDS, 2012 (

www.unaids.org/en/resources/

presscentre/pressreleaseandstatementarchive/2012/november/

20121120prresults).

FIGURE 7.3

Available funding for TB care and control in

125 countries reporting 96% of global cases by

source of funding and WHO region, 2013

Global Fund

Grants (excluding

Global Fund)

Government,

general health-

care services

(inpatient and

outpatient care)

Government,

NTP budget

(including loans)

US$ billions (current 2013 US$)

0.5

1.0

1.5

2.0

2.5

3.0

EUR AFR WPR SEAR AMR EMR

FIGURE 7.4

Available funding for TB care and control in

125 countries reporting 96% of global cases by

source of funding and income group, 2013

Global Fund

Grants (excluding

Global Fund)

Government,

general health-

care services

(inpatient and

outpatient care)

Government,

NTP budget

(including loans)

US$ billions (current 2013 US$)

Upper-

middle-income

High-

income

Lower-

middle-income

Low-

income

0.5

1.0

1.5

2.0

2.5

3.0

FIGURE 7.5

Available funding for TB care and control in BRICS,

17 other HBCs and Africa excluding South Africa,

by source of funding, 2013

Global Fund

Grants (excluding

Global Fund)

Government,

general health-

care services

(inpatient and

outpatient care)

Government,

NTP budget

(including loans)

US$ billions (current 2013 US$)

0.5

1.0

1.5

2.0

2.5

3.0

3.5

BRICS Africa without

South Africa

Other HBCs

ambitious targets are developed, as was done for the nine

countries described in section 7.1, funding needs and gaps

invariably increase. e gap between the US$8 billion esti-

mated to be needed for a full response to the TB epidemic in

2015 (section 7.1) and the US$6.1 billion available in 2013

(see section 7.3 below) is US$1.9 billion.

Overall, these ndings show that TB funding increased

substantially between 2002 and 2011, resulting in impres-

sive and cost-eective gains. e increasing self-suciency

of many countries, including BRICS, which account for

almost half of the world’s TB cases, is a success story for

these countries and the global TB community. At the same

time, it is clear that international donor funding remains

crucial in many countries and needs to be continued to sus-

tain and consolidate recent gains.

7.3 TB funding in 2013

Data reported by countries to WHO in the 2013 round of

global TB data collection allowed inclusion of 122 low-

and middle-income countries (GNI per capita less than

US$12616 in 2012) in analyses of TB funding by source

of funding and category of expenditure in 2013 (Table 7.1;

the additional countries compared with those included in

analyses of trends 2002–2011 are shown in bold). An addi-

tional three high-income countries (Estonia, Latvia and

the Russian Federation) were also included in analyses

because they are in the list of 22 HBCs or 27 high MDR-

TB HBCs. Collectively, the 125 countries account for 96%

of the world’s TB cases. Methods used to compile, validate

and analyse these data are summarized in Box 7.1.

e total funding available in the 125 countries in 2013

amounts to US$6.1 billion, and US$3.1 billion excluding

the European Region (Figure 7.3). Approximately US$1.3

billion is available in the African Region, much of which

is accounted for by South Africa. In the other four WHO

regions, funding is in the range US$0.2 to US$0.7 billion.

7.3.1 Funding in 2013 by source of funding

Of the total of US$ 6.1 billion reported for 2013, 87%

(US$ 5.3 billion) is from domestic sources and 13% (US$0.8

billion) is from international donor sources (Figure 7.3,

Figure 7.4). Both fall short of amounts needed for a full

response to the TB epidemic up to 2015 (section 7.1). e

US$5.3 billion from domestic sources represents at most

67% of the total needed by 2015. e US$0.8 billion from

international donor sources is at most 50% of the US$1.6–

2.3 billion per year estimated to be required by 2015, and

remains much less than international donor funding for

malaria (US$ 1.8 billion in 2011)1 and HIV (US$8.2 bil-

lion in 2011).2 Of the international donor funding for

TB in 2013, approximately three-quarters was from the

GLOBAL TUBERCULOSIS REPORT 2013

Global Fund; the remainder was largely from USAID. Tech-

nical assistance to support countries to eectively mobilize

funding from the Global Fund and to implement grants

once approved is provided by the TB Technical Assistance

Mechanism (Box 7.2).

Breakdowns of total funding by source for dierent coun-

try groups are shown in Figure 7.4 and Figure 7.5. Find-

ings strongly reinforce those previously reported for the

decade 2002–2011 (Section 7.2). BRICS are relatively self-

sucient overall (95% of funding from domestic sources),

although India is an exception where only 64% of funding

in 2013 is from domestic sources (and as shown in Annex 1,

BOX 7.1

Methods used to compile, validate and analyse ßnancial data reported by countries to WHO

WHO began monitoring government

CPFKPVGTPCVKQPCNFQPQTßPCPEKPI

for TB in 2002. All data are stored

in the WHO global TB database. The

standard methods used to compile,

review, validate and analyse these

ßPCPEKCNFCVCJCXGDGGPFGUETKDGFKP

detail elsewhere.a,b This box provides a

summary.

Each year, WHO requests data from

low- and middle-income countries

about funding for NTPs by category

of expenditure and source of funding,

and funding gaps by category of

expenditure, in US dollars. Categories

QHGZRGPFKVWTGHQT6$EQORTKUGßTUV

line drugs; NTP staff; programme

management and supervision

activities; laboratory supplies and

equipment; advocacy, communication,

CPFUQEKCNOQDKNK\CVKQPCEVKXKVKGU

community-based care; public–private

mix approaches; collaborative TB/

HIV activities; the Practical Approach

to Lung Health; operational research

including surveys; outpatient visits;

and hospital admissions. Categories of

GZRGPFKVWTGHQT/&46$CTGUGEQPF

NKPGFTWIUQVJGTKVGOUURGEKßECNN[HQT

programmatic management of patients

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outpatient visits. Funding sources are

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NQCPUDQVJENCUUKßGFCUFQOGUVKE

funding), grants from the Global

Fund, and grants from other donors

DQVJENCUUKßGFCUKPVGTPCVKQPCNFQPQT

HWPFKPI%QWPVTKGUVJCVCTGENCUUKßGF

as high-income are asked to report data

on total funding and total expenditures

(without breakdowns by source of

funding and category of expenditure).

WHO uses methods to review and

validate data that have remained

consistent since 2002. These methods

include routine checks for plausibility

and consistency, including validation

checks that are built into the online

reporting system. Examples of validation

checks are checks for implausibly large

year-to-year changes (for example

in total reported funding by source

and by category of expenditure), or

implausibly high or low values relative

to the number of TB patients (for

GZCORNGßTUVNKPGQTUGEQPFNKPGFTWI

budgets or expenditures per patient

that greatly exceed prices quoted by

the Global TB Drug Facility). Methods

to review and validate data also include

discussions with country respondents to

resolve queries, and triangulation with

other data sources such as the detailed

budgets prepared using the WHO TB

planning and budgeting tool,c economic

evaluations that include detailed

cost data, the Global Fund and the

1TICPK\CVKQPHQT'EQPQOKE%QQRGTCVKQP

and Development (OECD) Creditor

4GRQTVKPI5[UVGO2CTVKEWNCTCVVGPVKQP

has always been given to the 22 HBCs.

In a few countries (China and the

4WUUKCP(GFGTCVKQPCTGRTQOKPGPV

examples), funding for TB reported

by NTPs includes funding for all

staff, infrastructure, and other inputs

necessary for hospital admissions and

outpatient visits during TB treatment,

DGECWUGECTGKURTQXKFGFKP6$URGEKßE

hospitals and clinics that have dedicated

budgets. In most countries, however,

the funding used for inpatient and

outpatient care for TB patients is

not captured in funding reported by

NTPs. Since detailed costing studies

of TB diagnosis and treatment in a

wide range of countries show that

JQURKVCNK\CVKQPCPFQWVRCVKGPVECTGCTG

the most important costs not captured

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VJGGUVKOCVKQPQHßPCPEKCNTGUQWTEGU

used for inpatient and outpatient care

of TB patients has always been given

considerable attention in WHO’s work

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For all countries with the exception of

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Federation, the funding used for

inpatient and outpatient care of TB

patients is estimated by multiplying

the number of outpatient visits and

days of inpatient care per patient

(reported by NTPs to WHO each year) by

EQWPVT[URGEKßEGUVKOCVGUQHVJGKTWPKV

cost available from the WHO-CHOICE

database,d and then by the reported

number of TB patients. This is done

UGRCTCVGN[HQTCRCVKGPVUYKVJFTWI

susceptible TB; and b) patients with

/&46$DCUGFQPVJGWVKNK\CVKQPFCVC

that are reported separately for these

two groups of patients on the annual

WHO TB data collection form.

a Floyd K, Pantoja A, Dye C. Financing tuberculosis

EQPVTQNVJGTQNGQHCINQDCNßPCPEKCN

monitoring system. Bulletin of the World *ealth

OrIanization¿

b (NQ[F-(KV\RCVTKEM%2CPVQLC#CPF4CXKINKQPG

/&QOGUVKECPFFQPQTßPCPEKPIHQT

tuberculosis care and control in low-income and

OKFFNGKPEQOGEQWPVTKGUCPCPCN[UKUQHVTGPFU

2002–11, and requirements to meet 2015

targets. The Lancet Global *ealthG¿

c PlanninI and budIetinI for TB control actiXities.

)GPGXC9QTNF*GCNVJ1TICPK\CVKQP

(YYYYJQKPVVDFQVURNCPPKPIADWFIGVKPIAVQQN).

d ChoosinI interXentions that are cost effectiXe

W*O-C*OICE. Geneva, World Health

1TICPK\CVKQPwww.who.int/choice/

EQWPVT[EQWPVT[AURGEKßE).

for the NTP budget specically, 37% is funded from domes-

tic sources in 2013). High-income countries are fully self-

sucient and the group of upper middle-income countries

rely on international donor funding for only a small share

(4%) of their total funding (and most is accounted for by

China). Low- and lower middle-income countries account

for most of the international donor funding (US$0.7 bil-

lion, 88%). In the group of low-income countries, it accounts

for about half of total funding. International donor fund-

ing also has a crucial role in the 17 HBCs excluding BRICS,

and in African countries excluding South Africa (Figure

7.5), where it accounts for 35% and 54% respectively of

 GLOBAL TUBERCULOSIS REPORT 2013

BOX 7.2

Technical Assistance for national TB programmes; the role of TB-TEAM

The TB Technical Assistance Mechanism (TB-TEAM) was

established to coordinate and monitor the provision of technical

assistance to NTPs. The secretariat and a dedicated websitea are

hosted by WHO’s Global TB Programme and funded by USAID.

In mid-2013, there were 34 technical partners actively engaged

in TB-TEAM. Each partner shares information about country

missions, including reports that are uploaded to the country-

URGEKßERCIGUQHVJG6$6'#/YGDUKVG

In 2012, TB-TEAM partners reported 706 missions. By

topic area, laboratory strengthening and the programmatic

OCPCIGOGPVCPFUECNGWRQH/&4CPF:&46$CEEQWPVGFHQT

one quarter of all missions. A further 30% of missions were

related to monitoring and evaluation/impact measurement,

national TB programme reviews and management of drugs and

commodities. Most missions were conducted by WHO (40%)

and KNCV Tuberculosis Foundation (20%). A further 24% were

conducted by the US Centers for Disease Control and Prevention

(CDC); the Union, and the Global TB Drug Facility (GDF).

The main focus of TB-TEAM to date has been provision of

technical assistance to support the implementation of grants

from the Global Fund. Within the context of the fund’s new

funding model (NFM) established in 2013, this is now being

extended to support the development of robust national

strategic plans and associated concept notes that are required

HQTVJGOQDKNK\CVKQPQHPGYßPCPEKCNTGUQWTEGUCUQRRQUGF

to implementation of grants that have already been secured)

from the Global Fund. The focus on support to countries that

CTGEWTTGPVQTRQVGPVKCN)NQDCN(WPFTGEKRKGPVUTGàGEVUVJGHCEV

that the fund is the main source of international donor funding

in many countries, especially in low-income countries and

several high-burden, lower-middle income countries (section

7.2). TB-TEAM partners are taking a proactive approach to

providing technical support to countries, giving particular

attention to grants that are not performing well. The TB-TEAM

UGETGVCTKCVOQPKVQTURTQITGUUKPOQDKNK\CVKQPQHHWPFKPICPF

implementation of grants using indicators such as proposal

success rates, funding for TB as a share of total grant approvals,

disbursement rates and grant performance ratings.

5VCVKUVKEUHQTVJGUGKPFKECVQTUKPECPDGUWOOCTK\GFCU

HQNNQYU

Proposal success rates. TB-TEAM helped 21 countries

VQOQDKNK\GTGUQWTEGUXKCVJG)NQDCN(WPFÂUVTCPUKVKQPCN

funding mechanism (TFM). This was put in place during

the transition to the NFM to prevent countries from

experiencing critical funding shortages that would affect

essential services. Among the three diseases supported

by the fund, TB proposals had the best recommendation

TCVGVJG6GEJPKECN4GXKGY2CPGNQHVJG)NQDCN(WPF

TGEQOOGPFGFVJCVQH6$RTQRQUCNUUJQWNFDGCRRTQXGF

compared with 79% for malaria and 62% for HIV).

TB as a share of total funding.+PVJG6(/75a

million was awarded to TB grants, equivalent to 25% of all

approved funding.

Disbursement rates. In total and across all grants in 101

EQWPVTKGU75aOKNNKQPYCUFKUDWTUGFHQT6$KP

GSWKXCNGPVVQQHVQVCNFKUDWTUGOGPVU75aDKNNKQP

D[VJG)NQDCN(WPF1HVJGTGOCKPKPIHWPFKPI75

DKNNKQPYCUFKUDWTUGFVQ*+8ITCPVU75aDKNNKQP

VQOCNCTKCITCPVUCPF75aOKNNKQPVQETQUU

cutting investments.

Grant performance ratings. At the end of 2012, TB

grants were performing relatively well (Figure B7.1.1),

YKVJKPVJGVQRVJTGGECVGIQTKGUQH#GZEGNNGPV#

(meets expectations) and B1 (adequate), compared with

53% for malaria grants and 79% for HIV grants. The other

categories are B2 (adequate but potential demonstrated)

and C (inadequate).

FIGURE B.7.1.1

Latest Global Fund performance rating by disease

HQTCNNCEVKXGITCPVU)NQDCN(WPF&CVCDCUG

CEEGUUGF,CPWCT[

Percentage (%)

100

Malaria

(110 grants)

HIV/AIDS

(183 grants)

(130 grants)

Grand Total

(423 grants)

In 2013 and 2014, Global Fund projections suggest that an

GUVKOCVGF75aDKNNKQPYKNNDGFKUDWTUGFVQ6$ITCPVU6JKU

equates to an amount per year that is approximately double the

level of 2012. TB-TEAM aims to support countries as effectively

as possible to help to ensure that these funds are disbursed and

used well.

a www.stoptb.org/countries/tbteam/

GLOBAL TUBERCULOSIS REPORT 2013

TABLE 7.2

Reported NTP budget, available funding for NTP budget by intervention area and estimated cost

of inpatient and outpatient care for drug-susceptible (DS-TB) and MDR-TB, 36 high TB or high MDR-TB

burden countries, 2013 (current US$ millions)

4'2146'&

NTP BUDGET

AVAILABLE FUNDING

INPATIENT AND

1762#6+'06%#4'

DS-TBb

INPATIENT AND

1762#6+'06%#4'

/&46$b

DS-TB /&46$ TB/HIV

PPM/PAL/ACSM/

%$%145748';5 16*'4

22 HIGH-BURDEN COUNTRIES

Afghanistan 13 6.0  00.71.32.90

Bangladesh 43 4.6 1.6 0 1.9 0.2 5.0 1.4

$TC\KN  60 6.3 2.3  020 1.4

Cambodia 24 5.3 0.6 0.2 2.2 0.7 6.7 0.2

China 359 267 25 0.2 12 0.5 0 0

&GOQETCVKE4GRWDNKEQHVJG%QPIQ 61  1.7 0.3 1.0 4.5 0.2 0

Ethiopia 145 47 6.0 3.1 12 3.6 11 0.6

India   67 0  2.1  32

Indonesia 119 39  1.3  0.6 39 2.0

Kenya 55 19 0.5 0.5 0.5  90.3

/Q\CODKSWG 11 5.6 1.1 0  05.70.1

Myanmar 36 9.1 3.5 1.6 0.4 0 5.6 1.6

Nigeria 154 17 4.6 1.6 3.6 22 6.2 1.3

Pakistan 73 26 34 0.1 1.5 5.0 11 

Philippines 149 27  0.4 6.9 2.7 109 3.4

4WUUKCP(GFGTCVKQPc1 592 1 332 129 27 0.4 104 0 0

South Africa 475 217 41 124 19 67 109 232

Thailanda44 31 3.9 0.1  03.30

Uganda 31 6.0 2.2 0.2 3.9 9.3 0.6 0

7PKVGF4GRWDNKEQH6CP\CPKC  14 0.5 2.1 0.9 1.3 1.5 0.1

Viet Nam 66 4.4 4.6 1.2 3.4  49 0.6

<KODCDYG  11 0.1 3.4 0.5 1.4 15 0.1

22 high-burden countries total 3 814 2 241 350 170 111 232 494 279

REMAINING HIGH MDR-TB BURDEN COUNTRIES

Armenia 5.4 4.5 0.6 0 0.1 0.2 7.5 1.2

#\GTDCKLCP ––

Belarusa––

Bulgaria 16 14 0.3 0 0.6 0.3 22 1.5

Estonia  0.1 0.5 0 0 0.2 0.1 0.1

Georgia 10 2.6  00 3.6 3.2

-C\CMJUVCP 242 149 70 1.0 1.7 21 192 57

-[TI[\UVCP 35 11 5.6 0.3 13 4.0 13 3.1

Latvia  3.7 1.1 0 0 0.1 20 7.3

Lithuania ––

4GRWDNKEQH/QNFQXCa35 2.6  00.615113.2

Tajikistan 46 5.0 1.1 0.6 1.1  6.6 1.1

Ukraine  21 15 0.6 0 7.9 66 40

7\DGMKUVCP 76 15 14 0 1.5 46  5.7

27 high MDR-TB burden

countries 4 011 2 312 448 164 108 325 854 400

36 high TB or high MDR-TB

burden countries 4 371 2 471 464 172 130 340 919 402

Blank cells indicate data not reported.

– indicates values that cannot be calculated.

a Based on data reported for 2013 in the 2012 round of data collection. In 2013, Thailand was not able to report funding for the sub-national level.

b 0QCOQWPVKUUJQYPHQT%JKPCCPFVJG4WUUKCP(GFGTCVKQPDGECWUG062DWFIGVKPENWFGUCNNEQUVUHQTKPRCVKGPVCPFQWVRCVKGPVECTG

c 6JGUVCHHCPFKPHTCUVTWEVWTGTGSWKTGFHQT6$ECTGCPFEQPVTQNEQWNFPQVDGFKUCIITGCVGFHQT/&46$CPF&56$UGRCTCVGN[CPFCTGUJQYPWPFGT&56$6JGHWNNCOQWPVHQTUVCHH

and other recurrent costs for TB hospitals is included in the column for DS-TB.

 GLOBAL TUBERCULOSIS REPORT 2013

FIGURE 7.6

Available funding for TB care and control in

125 countries reporting 96% of global cases by

intervention area and WHO region, 2013

Other

TB/HIV

Inpatient and

outpatient care:

MDR-TB

Inpatient and

outpatient care:

DS-TB

DS-TBb

US$ billions (current 2013 US$)

0.5

1.0

1.5

2.0

2.5

3.0

EURaAFR WPR SEAR AMR EMR

a (QT'74&56$KPENWFGUCNNQHVJGUVCHHCPFKPHTCUVTWEVWTGTGSWKTGFHQT6$ECTG

CPFEQPVTQNKPVJG4WUUKCP(GFGTCVKQPVJCVEQWNFPQVDGFKUCIITGICVGFHQT/&46$

CPF&56$UGRCTCVGN[6JGCOQWPVQHHWPFKPIUJQYPHQT/&46$KPVJG'WTQRGCP

4GIKQPKUVJWUCPWPFGTGUVKOCVG

b &TWIUWUEGRVKDNG6$&56$KPENWFGUHWPFKPICXCKNCDNGHQTßTUVNKPGFTWIU062

staff, programme management and supervision, and laboratory equipment and

supplies.

FIGURE 7.7

Available funding for TB care and control in BRICS,

17 other HBCs and Africa excluding South Africa,

by intervention area, 2013

Other

TB/HIV

Inpatient and

outpatient care:

MDR-TB

Inpatient and

outpatient care:

DS-TB

DS-TBa

US$ billions (current 2013 US$)

0.5

1.0

1.5

2.0

2.5

3.0

3.5

BRICS Africa without

South Africa

Other HBCs

a (QT$4+%5FTWIUWUEGRVKDNG6$&56$KPENWFGUCNNQHVJGUVCHHCPFKPHTCUVTWEVWTG

TGSWKTGFHQT6$ECTGCPFEQPVTQNKPVJG4WUUKCP(GFGTCVKQPVJCVEQWNFPQVDG

FKUCIITGICVGFHQT/&46$CPF&56$UGRCTCVGN[6JGCOQWPVQHHWPFKPIUJQYPHQT

/&46$KP$4+%5KUVJWUCPWPFGTGUVKOCVG   

total funding in 2013. e share is even higher in specic

countries and above 80% in four HBCs: Afghanistan, the

Democratic Republic of the Congo, Pakistan and Uganda

(Annex 2).

7.3.2 Funding in 2013 by budget category

Funding in 2013 by budget category is shown by WHO

region in Figure 7.6, for other country groups in Figure 7.7

and for HBCs and high-MDR-TB burden countries in Table

7.2. It should be highlighted that the amount of funding

shown for MDR-TB in the European Region is an underesti-

mate due to the fact that the budget category ‘Drug-suscep-

tible-TB’ (DS-TB) includes all of the sta and infrastructure

required for TB prevention, diagnosis and treatment in the

Russian Federation that could not be disaggregated for

MDR-TB and DS-TB separately. Among the 122 low- and

middle-income countries for which a breakdown could be

calculated, most of the funding available in 2013 is for

diagnosis and treatment of DS-TB.

e WHO regions in which the shares of funding

for MDR-TB are highest are the African Region (mostly

explained by South Africa), the European Region and the

South-East Asia Region. is is consistent with the distri-

bution of the burden of MDR-TB cases, which are mostly in

BRICS and the European Region, and with the latest data

on numbers of MDR-TB patients detected and enrolled on

treatment (Chapter 4). ese data show that European

countries and South Africa are enrolling the highest pro-

portion of estimated cases of MDR-TB on treatment and

that progress in scaling up treatment in India (in the South-

East Asia Region) is accelerating. e low share of funding

for MDR-TB in the Western Pacic Region, within which

most of the estimated cases of MDR-TB are in China, is

consistent with the small number of cases reported to have

been detected and started on treatment in China in 2012

(just over 3000, equivalent to 5% of the estimated number

of TB patients with MDR-TB). Among the 22 HBCs, 85% of

the available funding for MDR-TB treatment is accounted

for by BRICS (Table 7.2).

Most of the reported funding for collaborative TB/HIV

activities is accounted for by the African Region (77%),

followed by Europe (16%). is is consistent with the dis-

tribution of the burden of TB/HIV: the latest estimates are

that 75% of HIV-positive TB patients are in the African

Region (Chapter 6).

7.3.3 Reported funding gaps in 2013

In 2013, funding gaps reported by NTPs (i.e. the dierence

between assessments by NTPs of funding needs for TB pre-

vention, diagnosis and treatment and the actual amount of

funds mobilized) amount to US$1 billion. is is a consid-

erable increase from gaps in the range US$0.3–0.6 billion

that were reported during the decade 2002–2011 (section

7.2). A possible explanation may be that NTPs are devel-

oping more ambitious plans for implementation and scale

up of interventions with resulting increases in funding

gaps. African countries account for almost half of the total

(Figure 7.8a), followed by Asian countries (37% of the

total). Funding gaps were reported by countries in all

income groups with the exception of high-income countries

(Figure 7.8b), and for multiple elements of TB prevention,

diagnosis and treatment (Figure 7.8c).

GLOBAL TUBERCULOSIS REPORT 2013

Africa 48%

Asia: Low-income,

high-burden 7%

Asia: Other 30%

Rest of World 15%

FIGURE 7.8

Funding gaps reported by national TB programmes

in 125 countries with 96% of global cases, 2013

a. By region and income group

b. By income group

c. By intervention area

Low-income 36%

Lower-middle-income 44%

Upper-middle-income 20%

DS-TB, first-line

drugs 3%

DS-TB, excluding

first-line drugs 33%

ACSM/CBC/PPM/PAL/OR surveys 25%

MDR-TB 13%

TB/HIV 9%

Other 17%

 GLOBAL TUBERCULOSIS REPORT 2013

%*#26'4

Research and development

KEY FACTS AND MESSAGES

■ Efforts to develop new TB diagnostics, drugs and

XCEEKPGUJCXGKPVGPUKßGFFWTKPIVJGRCUVFGECFGCPF

considerable progress has been made.

■ More than 50 companies are involved in the development

of TB diagnostics. Although many new diagnostic

VGEJPQNQIKGUCTGCXCKNCDNGQPVJGOCTMGVCEEGNGTCVGFßGNF

evaluation of diagnostic accuracy and robustness of these

assays is needed.

■ Increased and sustained investment in new TB

diagnostics remains essential for the development of an

accurate, easy-to-use, affordable point-of-care assay for the

rapid and early diagnosis of TB.

■ There are 10 new or repurposed anti-TB drugs currently

in late phases of clinical development. In December 2012,

one of the new compounds, bedaquiline, was approved for

WUGKPVTGCVOGPVQHRCVKGPVUYKVJ/&46$D[VJG75(QQF

and Drug Administration (FDA). Interim guidance about the

WUGQHDGFCSWKNKPGKPVJGVTGCVOGPVQH/&46$YCUKUUWGF

D[9*1KP,WPG$GFCSWKNKPGKUVJGßTUVPGYFTWI

approved for TB treatment in many years.

■ 4GUWNVUHTQOVYQ2JCUG+++VTKCNUQHHQWTOQPVJTGIKOGPU

for the treatment of drug-susceptible TB are expected in late

2013. New combination regimens are also being tested in

a series of early bactericidal activity (EBA) or two-month

sputum-culture conversion Phase II studies.

■ There are 10 vaccine candidates for TB prevention

in Phase I, Phase II or Phase IIb trials and two

immunotherapeutic vaccines in Phase II or Phase III trials.

■ 4GUWNVUHTQOC2JCUG++DRTQQHQHEQPEGRVUVWF[QHVJG

XCEEKPGECPFKFCVG/8##YGTGRWDNKUJGFKP(GDTWCT[

2013. Among infants who received the vaccine as a boost

to the Bacille-Calmette-Guérin (BCG) vaccine, no additional

protection was conferred compared with BCG alone. This

study demonstrated, however, that the vaccine had an

CEEGRVCDNGUCHGV[RTQßNGKPVJKURQRWNCVKQPCPFVJCVCJKIJ

quality trial of a novel TB vaccine can be conducted and

produce robust results in a high TB burden setting.

■ 4GUGCTEJCPFFGXGNQROGPVKUQPGQHVJGVJTGGRKNNCTUQH

the WHO post-2015 global TB strategy, in recognition of its

crucial role in accelerating reductions in TB incidence and

mortality to reach post-2015 global TB targets.

e proposed goal of the post-2015 global TB strategy is

to end the global TB epidemic (Chapter 1). Despite major

progress in TB care and control since the mid-1990s (Chap-

ters 2–7), reaching this goal will require major technolog-

ical breakthroughs from the research and development

pipeline. Short, eective and well-tolerated treatments for

latent TB infection, a point-of-care diagnostic test able to

distinguish latent TB infection from active TB disease, and

an eective post-exposure vaccine are of key importance to

end the global TB epidemic.

is is the third successive year in which a chapter on

research and development has been included in the Global

tuberculosis report. e status of progress in the develop-

ment of new TB diagnostics, drugs and vaccines as of July

2013 is summarized, drawing on information provided by

the secretariats of the relevant Working Groups of the Stop

TB Partnership and recent publications. Particular atten-

tion is given to developments between August 2012 and

July 2013. e nal section of the chapter highlights key

elements of the research and development agenda post-

2015.

8.1 New diagnostics for TB

Sputum smear microscopy remains the most widely used

diagnostic test for TB, despite its relatively low sensitivity

(especially for those with paucibacillary TB such as people

living with HIV and children). e current reference stan-

dard for the bacteriological conrmation of TB is culture

in liquid media. However, culture-based diagnosis is not

widely available in most high TB burden settings because it

requires sophisticated laboratory and biosafety infrastruc-

ture, and test results take up to several weeks to obtain.

Recent breakthroughs include the development of rapid

molecular tests that can be used to diagnose TB and rifam-

picin-resistant TB at decentralized levels of health systems.

ese tests are now being rolled out worldwide (see also

Chapter 5). However, TB remains unique among the major

infectious diseases in lacking accurate and rapid point-of-

care tests, largely due to insucient progress in biomark-

er discovery despite active ongoing research. Indeed, the

most pressing priority in TB diagnostics research today

is the development of a simple, low-cost, instrument-free

rapid test using one or more reliable biomarkers that can

be implemented at the rst point of patient contact with

peripheral health services, or used as a triage test at com-

munity level to rapidly identify people who should be

referred for conrmatory testing.

e status of development and evaluation of new TB

GLOBAL TUBERCULOSIS REPORT 2013

diagnostics in July 2013 is summarized in Figure 8.1,

based on recent documentation produced by UNITAID1

and the Treatment Action Group (TAG).2 In Figure 8.1,

diagnostic tests and methods on the market are grouped

according to whether they have been evaluated by WHO

and, if so, whether they have been endorsed. Given the

rapidly evolving TB diagnostic landscape, WHO has estab-

lished a systematic process for the timely evaluation of

evidence and formulation of policy on new TB diagnostics.

is is described in Box 8.1 and further details are avail-

able elsewhere. It should also be highlighted that the list of

technologies in ‘early development’ is not necessarily com-

plete or exhaustive.3 ose listed are the ones documented

in the UNITAID and TAG reports.

Development of molecular technologies such as nucle-

ic acid amplication tests (NAATs) is most advanced i.e.

either already commercially available or in late-stage devel-

opment. e majority of tests are, however, intended for

use at reference laboratory level only, requiring dedicated

infrastructure and experienced sta. Most NAATs require

manual preparation of samples, which is technically chal-

lenging and prevents their use at more decentralized labo-

ratory levels. Testing in reference laboratories oers higher

throughput of tests and/or improved screening of samples

for drug resistance markers, but is typically relatively

expensive. e next-generation molecular tests that have

emerged since Xpert® MTB/RIF have not yet undergone rig-

orous eld trials in the settings where their use is intend-

ed, and substantial challenges with sample processing and

DNA extraction in peripheral laboratories has been report-

ed for all of them.

Technologies in the early stages of development (rst

part of Figure 8.1) include tests to detect TB, drug resis-

tance, or TB and drug resistance combined. ese include

microarray-based multiplexing diagnostic platforms for

the simultaneous detection of a large number of resistance-

conferring mutations; assays that use novel approaches to

combine nucleic acid testing with phage-based technology

to identify drug resistance in clinical isolates; a rapid colo-

rimetric culture-based method for detection of resistance

to rifampicin, isoniazid and uoroquinolones for use at

the intermediate laboratory level; second-generation Xpert

assays for the detection of resistance to drugs other than

rifampicin; and a cartridge-based point-of-care isothermal

amplication platform. In addition to technologies aimed

a This is not an exhaustive list of technologies in early development. Those listed are

the ones documented in recent (2013) publications by UNITAID and TAG.

b 7RFCVGFRQNKE[IWKFCPEGQP:RGTV/6$4+(KUWPFGTFGXGNQROGPV5GG%JCRVGT

for further details.

FIGURE 8.1

An overview of progress in the development and

evaluation of TB diagnostics, July 2013

Technologies in early developmenta

Volatile organic compounds

 $TGCVJ.KPM/GPUUCPC4GUGCTEJ75#

 2TQVQV[RGDTGCVJCPCN[\GTFGXKEG0GZV&KOGPUKQPU

Technology, USA

Molecular technologies

 Alere Q, Alere, USA

 $5/#46.CD%QTR75#

 )GPFTKXG/6$4+(+&'RKUVGO7-

 .#6'2%4$TCPFGKU7PKXGTUKV[75#

 )GPG:RGTV:&4ECTVTKFIG%GRJGKF75#

 6TW#TTC[/&46$#MMQPK75#

 INFINITIMTB Assay, AutoGenomics, USA

Culture-based technologies

 BNP Middlebrook, NanoLogix, USA

 /&4:&46$%QNQT6GUV(+0&5YKV\GTNCPF+ORGTKCN

College, UK

 64'-5GPUKVKVTG/;%16$/+%RNCVG6TGM&KCIPQUVKE

5[UVGOU6JGTOQ(KUJGT5EKGPVKßE75#

Other technologies

 6$4CRKF5ETGGP)NQDCN$KQ&KCIPQUVKEU75#

 TBDx, Signature Mapping Medical Sciences, USA

Evaluated by WHO but not yet endorsed

due to insufßcient evidence

Molecular technologies

 TB LAMP, Eiken, Japan

 )GPQV[RG/6$&4UN*CKP.KHGUEKGPEG)GTOCP[

On the market but evidence for use not yet

submitted to WHO for evaluation

Molecular technologies

 iCubate System, iCubate, USA

 TB drug resistance array, Capital Bio, China

 EasyNAT TB Diagnostic kit, Ustar Biotechnologies, China

 Truelab/Truenat MTB, Molbio/bigtec Diagnostics, India

Non-molecular technologies

 Alere Determine TB-LAM, Alere, USA

Evaluated by WHO and not recommended

 Commercial serodiagnostics (all manufacturers)

 Interferon-gamma release assays for the detection of

active TB (all settings)

Technologies endorsed by WHO

Molecular technologies

 :RGTV/6$4+(b

 Line probe assays (acid-fast bacilli smear-positive

sputum specimens or culture-positive specimens)

Microscopy

 <KGJN0GGNUGPCPFàWQTGUEGPEGOKETQUEQR[OGVJQFU

Culture-based technologies

 Commercial liquid culture systems and rapid speciation

 Non-commercial culture and drug susceptibility testing

methods

1 Tuberculosis: Diagnostics Technology and Market Landscape 2013.

Geneva, UNITAID/World Health Organization, 2013. Available

at: http://www.unitaid.eu/images/marketdynamics/publications/

TB-Dx-Landscape_1-Jul-2013.pdf

2 Clayden P. et al (on behalf of e HIV i-Base/Treatment Action

Group) 2013 Pipeline Report: HIV, Hepatitis C Virus (HCV), and

Tuberculosis (TB) Drugs, Diagnostics, Vaccines, Preventive Technolo-

gies, Research Toward a Cure, and Immune-Based and Gene erapies in

Development. New York, Treatment Action Group, 2013. Available

at: http://www.treatmentactiongroup.org/pipeline-report

3 Weyer K et al. Rapid molecular TB diagnosis: evidence, policy-mak-

ing and global implementation of Xpert® MTB/RIF European

Respiratory Journal erj01572-2012; published ahead of print 2012,

doi:10.1183/09031936.00157212.

 GLOBAL TUBERCULOSIS REPORT 2013

at diagnosis of TB and drug-resistant TB, assays for use

in monitoring patients’ response to treatment are needed

as alternatives to culture. Ribosomal RNA (rRNA)-based

amplication assays have potential to be used in this way,

given that rRNA levels per TB bacilli are much higher than

genomic DNA targets and that they are present only in

viable organisms.

Several new diagnostic technologies are on the market,

but evidence to support their use has not been provided

to WHO and thus their performance characteristics have

not been assessed and WHO cannot recommend their use.

As an alternative to real-time polymerase chain reaction

(PCR) assays (e.g. Xpert MTB/RIF) or line-probe assays for

the detection of TB and drug resistance, these technolo-

gies include PCR assays combined with DNA microarrays

(arrays), which allow the detection of a greater number

of resistance conferring alleles and may potentially oer

superior performance for the rapid detection of drug resis-

tance. e technologies include:

iCubate system (iCubate, USA). is is a multiplexed

PCR assay that detects TB, non-tuberculous mycobac-

teria and drug resistance-conferring mutations in a

single reaction. e assay allows multiple targets to be

amplied with array detection technology that simulta-

neously analyses multiple targets. e assay is currently

available for research purposes only.

Capital Bio Corporation (China) has developed a TB drug

resistance detection array kit that can detect 14 of the

most frequently found mutations in three genes asso-

ciated with resistance to rifampicin and isoniazid. e

assay is currently only appropriate for testing at refer-

ence laboratory level given the complexity of performing

the assay.

EasyNAT TB Diagnostic kit, Ustar Biotechnologies,

(China) has developed three isothermal based NAATs

for the detection of TB as well as rifampicin and isoni-

azid resistance-conferring mutations. A clinical trial

conducted in four provinces across central and northern

China showed promising preliminary results for a rapid

and easy-to-use screening tool for the diagnosis of pul-

monary TB.

A micro-PCR system developed by Truelab™ (Molbio,

India) was launched in 2013 in India. e system uses

microchips with TB-specic genetic sequences for the

quantitative detection of TB DNA in sputum samples

in a one hour reaction from sample preparation to nal

reporting of results. Battery powered equipment is used

for the steps of DNA extraction, amplication and detec-

tion. Although promising, only limited evaluation data

are currently available.

Alere Determine LAM, (Alere, USA). is is an assay for

the detection of M. tuberculosis lipoarabinomannan in

urine. e assay seems to be most useful for the diagno-

sis of TB in people living with HIV who have a low CD4

count.

BOX 8.1

Evidence required for WHO review of

new diagnostics

Phase 1: Research and Development

7RUVTGCOTGUGCTEJCPFFGXGNQROGPVVQFGßPGCPF

validate a prototype;

Laboratory validation under international standards that

culminates in a design-locked product;

WHO interacts with developers if requested to discuss

end-user requirements such as biosafety, assay

robustness and intended settings of use.

Phase 2: Evaluation and Demonstration

The performance of the new diagnostic product should

be evaluated in controlled trials at 3–5 trial sites in

high-burden TB and HIV countries;

Product registration with global and/or national

regulatory authorities;

2TQFWEVURGEKßECVKQPUCPFRGTHQTOCPEGUJQWNF

subsequently be validated in uncontrolled trials under

ßGNFEQPFKVKQPUKP¿VTKCNUKVGUKPJKIJDWTFGP6$CPF

HIV countries, and include cost-effectiveness studies.

Phase 3: Evidence Assessment

NEW TECHNOLOGIES

Submission of a dossier with Phase I and Phase II data to

WHO.

FAST-FOLLOWER

/CPWHCEVWTGFWPFGT+51UVCPFCTFU

Equivalent performance demonstrated – Supranational

4GHGTGPEG.CDQTCVQT[EQORCTKUQP

Structured evidence assessment using the Grading

QH4GEQOOGPFCVKQPU#UUGUUOGPV&GXGNQROGPVCPF

'XCNWCVKQP)4#&'CRRTQCEJ

WHO does not recommend technologies for individual

country use.

Phase 4: Phased uptake and collection of evidence

for scale-up

New diagnostic successfully implemented in routine

diagnostic services by early implementers in high-burden

countries;

Systematic assessment of proposed algorithms,

laboratory workload, operational constraints and cost-

effectiveness;

Lessons learnt by early implementers used for country

adaptation.

Phase 5: Scale-up and Policy reßnement

Scale-up of the new diagnostic, with subsequent data

WUGFVQKPHQTOCPFTGßPG9*1RQNKE[IWKFCPEGKPC

dynamic and on-going process.

GLOBAL TUBERCULOSIS REPORT 2013

Two tests are commercially available but have not been

endorsed by WHO after evaluation. e rst is a manual

molecular assay to detect TB DNA in sputum specimens

(TB-LAMP®, Eiken Chemical Co. Ltd., Japan). e evi-

dence-based process followed by WHO concluded that the

data available for the TB-LAMP assay were insucient to

proceed with the development of policy guidance. Addition-

al independent evaluation studies to investigate TB-LAMP

as a replacement test for culture are now underway in 16

countries (17 sites). e second assay evaluated by WHO

but not endorsed is a line probe assay for detecting resis-

tance to second-line anti-TB agents (GenoType® MTBDRsl,

Hain Lifescience, Germany). is cannot be recommended

as a replacement test for conventional phenotypic testing

for drug susceptibility because of suboptimal sensitivity in

detecting resistance to uoroquinolones and second-line

injectable agents. e latter group of drugs also share muta-

tions, which means that even if they are detected by the

line probe assay it is not possible to identify exactly which

drug(s) is linked to the detected mutation(s), and therefore

the test cannot be used to guide the choice of individual

injectable drugs to be used in treatment regimens for MDR-

TB. Conventional phenotypic testing for drug susceptibil-

ity to second-line drugs therefore remains necessary for

all detected strains of MDR-TB and to conrm or exclude

XDR-TB.

Two rapid molecular tests have been evaluated and

endorsed by WHO in recent years (bottom of Figure 8.1).

Line-probe assays that allow the rapid diagnosis of TB

and drug resistance within a day were endorsed in 2008.1

eir use is currently limited to acid-fast bacilli sputum

smear-positive samples or positive cultures. Xpert MTB/

RIF (Cepheid, Sunnyvale, CA, USA) was endorsed by WHO

in 2010 for the rapid diagnosis (i.e. within 2 hours) of pul-

monary TB and rifampicin-resistance in adults.2 In July

2013, the Xpert MTB/RIF assay remained the only fully

automated real-time DNA-based cartridge test that can

detect both TB and resistance to rifampicin, and the only

mature technology representing a new generation of auto-

mated molecular diagnostic platforms.

Since 2010, almost 100 articles on Xpert MTB/RIF have

been published and others are underway.3 In 2013, given

the amount of additional data, WHO commissioned three

systematic reviews of the evidence on sensitivity and

specicity of Xpert MTB/RIF as a test for pulmonary and

extrapulmonary TB, in both adults and children. Findings

were reviewed by an expert group and updated recommen-

dations are anticipated in 2014 (see Chapter 5).

e UNITAID 2013 Report: Tuberculosis: Diagnostic tech-

nology and market landscape4 describes the following four

innovations to the Xpert MTB/RIF technology, which were

made or under development in 2012 and 2013.

Assay improvements. A new prototype assay for MDR-

TB is in development. is uses new dyes and quenchers

that increase the spectral range for detection of targets

using 10 uorophores rather than the six currently used.

Remote calibration. is was made available in late

2012 and is already being used in more than 40 coun-

tries. It allows users to recalibrate the optical system,

verify the functioning of the thermal system and con-

duct a series of system-level tests to ensure full system

functionality within specications. It is anticipated that

over 90% of modules can be successfully calibrated over

the internet.

Enhancements to data management. Real-time

aggregation of geo-positioned test data (from which per-

sonal identiers have been removed) is being evaluated

in South Africa. is oers the potential to substantially

improve monitoring of the TB epidemic and the associ-

ated programmatic response.

HIV cartridges for use with the GeneXpert plat-

form. ese are planned for release in 2014. A separate

cartridge for the qualitative and quantitative detection

of HIV viral load is in development.

With over 50 companies working on TB diagnostics, there

is now considerable industry interest in TB diagnostics.

Nonetheless, a recent survey of more than 25 test devel-

opers identied several critical frequently-asked questions

for which answers are required by industry to invest in TB

diagnostic test development (www.tbfaqs.org). Test devel-

opers are particularly interested in identifying the most

important attributes on which to focus test development

eorts (examples include cost, sensitivity, specicity,

infrastructure requirements, time to result, throughput,

sputum versus other samples, manual versus automated,

point-of-care versus centralized laboratory testing, inte-

grated or reex drug resistance test and which drugs are

critical for DST). In addition, updated market analyses

are urgently needed, given that the TB diagnostics market

landscape has changed signicantly since the last global

assessment of the TB diagnostics market in 2006.5 Updat-

ed market analyses and development of target product

1 Molecular Line Probe Assay for rapid screening of patients at risk

of MDR-TB. Policy Statement. Geneva, World Health Organization,

2008. Available at http://www.who.int/tb/features_archive/policy_

statement.pdf

2 Policy Statement: Automated real-time Nucleic Acid Amplication

Technology for Rapid and Simultaneous Detection of Tuberculosis and

Rifampicin Resistance: Xpert MTB/RIF System. Geneva: World Health

Organization, 2011 (WHO/HTM/TB/2011.4). Available at http://

whqlibdoc.who.int/publications/2011/9789241501545_eng.pdf

3 Weyer K et al. Rapid molecular TB diagnosis: evidence, policy-mak-

ing and global implementation of Xpert® MTB/RIF European

Respiratory Journal erj01572-2012; published ahead of print 2012,

doi:10.1183/09031936.00157212.

4 Tuberculosis: Diagnostics Technology and Market Landscape 2013.

Geneva, UNITAID/World Health Organization, 2013. Available

at: http://www.unitaid.eu/images/marketdynamics/publications/

TB-Dx-Landscape_1-Jul-2013.pdf

5 Diagnostics for tuberculosis. Global Demand and market potential.

Geneva, Special Programme for Research and Training in Tropical

Diseases (TDR) and Foundation for Innovative New Diagnostics

(FIND), 2006. Available at: http://www.who.int/tdr/publications/

documents/tbdi.pdf

90 GLOBAL TUBERCULOSIS REPORT 2013

proles could facilitate greater engagement of test develop-

ers in TB diagnostics.

Despite good progress with the pipeline for new diagnos-

tics, much more eort and investment are needed by both

donors and manufacturers to expedite evaluations of new

technologies in dierent epidemiological settings in order

to determine their diagnostic accuracy and robustness in

the settings of intended use. Substantial additional fund-

ing and innovation for new TB diagnostic development

remain essential to ensure the availability of tests that are

reliable, easy to use, aordable, and accessible to all those

with TB. More than ever, the TB diagnostic pipeline needs

increased and sustained investment.

8.2 New drugs to treat and prevent TB

e anti-TB drugs currently used in rst-line treatments

are around 50 years old. e regimen that is currently rec-

ommended by WHO for new cases of drug-susceptible TB is

h i g h ly e c a c io us , w it h c u re ra te s o f a r ou n d 9 0 % i n H I V- ne g -

ative patients. Nonetheless, it requires six months of treat-

ment with rst-line drugs (a combination of rifampicin,

isoniazid, ethambutol and pyrazinamide for two months,

followed by a four-month continuation phase of rifampicin

and isoniazid). Regimens for treatment of MDR-TB cur-

rently recommended by WHO entail at least 20 months of

treatment with second-line drugs for most patients, and

are associated with multiple (and sometimes serious) side-

eects and lower cure rates (see Chapter 4). ere are also

interactions between anti-TB treatments and antiretro-

viral therapy (ART) for people living with HIV. New drugs

are required to shorten and simplify treatment, to improve

the ecacy and tolerability of treatment for MDR-TB and

to improve the treatment of TB among people living with

HIV.

e status of the pipeline for new anti-TB drugs in July

2013 is shown in Figure 8.2. ere are seven drugs in Phase

II (early bactericidal activity, EBA, and eight-week culture

conversion) trials and four drugs in Phase III (ecacy) tri-

als. In total, there are 10 new or repurposed drugs in Phase

II or Phase III trials; one drug (rifapentine, a rifamycin that

has a longer half-life than rifampicin) is in both Phase II

and Phase III trials, for dierent indications.

8.2.1 Phase III trials

Results from a Phase III trial (the ‘Rifaquin trial’) that eval-

uated the safety and ecacy of two regimens for patients

with drug-susceptible TB, in which moxioxacin was sub-

stituted for isoniazid in the intensive phase of treatment

and rifapentine was used in the continuation phase of

treatment, were presented in March 2013.1 A total of 827

patients with drug-susceptible TB were enrolled in Botswa-

na, South Africa, Zambia and Zimbabwe. Both new reg-

imens were well tolerated. e six-month regimen with a

weekly dose of rifapentine (1200 mg) and moxioxacin in

the continuation phase was not inferior to the currently

recommended regimen. However, the four-month regimen

with twice-weekly doses of rifapentine (900 mg) and moxi-

oxacin in the continuation phase was clearly inferior to

the currently recommended regimen.

Two Phase III trials are evaluating four-month combina-

tion regimens in which a uoroquinolone (gatioxacin in the

case of the OFLOTUB trial and moxioxacin in the case of

the ReMOX trial) is substituted for either ethambutol (in the

FIGURE 8.2

The development pipeline for new TB drugs, July 2013a

Discovery Preclinical development Clinical development

Lead

optimization Preclinical

development

Good

Laboratory

Practice

toxicity

Phase I Phase II Phase III

Cyclopeptides

Diarylquinoline

DprE Inhibitors

InhA Inhibitor

LeuRS Inhibitor

Macrolides

Mycobacterial Gyrase

Inhibitors

Pyrazinamide Analogs

Riminophenazines

Ruthenium (II)

complexes

Spectinamides

Translocase-1

Inhibitors

CPZEN-45

DC-159a

Q203

SQ609

SQ641

TBI-166

#<&

Bedaquiline

(TMC-207)

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2#

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SQ-109

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Delamanid

12%

Gatifloxacin

Moxifloxacin

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Chemical classes: àuoroSuinolone, rifamycin, oxazolidinone, nitroimidazole, diarylSuinoline, benzothiazinone

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www.newtbdrugs.org/pipeline-discovery.

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1 Jindani A et al. 2013. A Multicentre Randomized Clinical Trial to Eval-

uate High-dose Rifapentine with a Quinolone for Treatment of Pulmo-

nary TB: e RIFAQUIN Trial. Oral abstract and paper 147LB. 20th

Conference on Retroviruses and Opportunistic Infections (CROI),

March 3–6 2013, Atlanta.

91GLOBAL TUBERCULOSIS REPORT 2013

OFLOTUB trial) or ethambutol or isoniazid (in the ReMOX

trial). e results from both trials are expected in late 2013.

A new compound, delamanid (OPC-67683), is currently

being tested in a Phase III trial as an adjunct to existing

optimized regimens for treatment of MDR-TB.

8.2.2 Phase II trials – individual compounds

e safety, tolerability and antimicrobial activity of an

increased daily dose of rifapentine (at 10, 15 and 20 mg/

kg) in combination with isoniazid, pyrazinamide and

ethambutol during the rst two months of treatment are

being investigated in a Phase IIb trial (TBTC trial 29X).

Early results were reported in May 2013.1 ese showed

that rifapentine-based regimens were well-tolerated, with

no toxicity events specically related to increasing doses

of the drug. Compared with the currently recommended

six-month regimen, a higher proportion of patients who

received the regimens including rifapentine had convert-

ed to culture-negative status (both in solid and liquid

BOX 8.2

WHO interim guidance on the use of bedaquiline to treat MDR-TB

1 Moro et al. Tolerability and safety of escalating Rifapentine (RPT) dos-

es during the rst two months of tuberculosis (TB) treatment. Abstract

A6051. American oracic Society International Conference, Phila-

delphia, May 17–22, 2013

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worldwide each year (Chapter 2). Current drug regimens

TGEQOOGPFGFD[9*1HQTVTGCVOGPVQH/&46$RTGUGPVOCP[

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daily dosages of drugs that are more toxic, less effective, and

far more expensive than those used to treat drug-susceptible

TB.a)NQDCNN[QPN[CDQWVQHRCVKGPVUYJQUVCTV/&46$

therapy are treated successfully (Chapter 4).

(QTVJGßTUVVKOGKPQXGT[GCTUCPGY6$FTWIYKVJCPQXGN

mechanism of action – bedaquiline – has become available

for use. It was approved by the US FDA in December 2012,

following an accelerated approval process. There is considerable

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information remains limited, since it has only been evaluated

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WHO has issued “interim policy guidance”.b

This interim guidance provides advice on the inclusion of

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with the existing WHO guidelines for the programmatic

management of drug-resistant TB.a The interim guidance lists

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1. Effective treatment and monitoring. Treatment must be

closely monitored for effectiveness and safety, using sound

treatment and management protocols approved by relevant

national authorities.

2. Proper patient inclusion. Special caution is required

when bedaquiline is used in people aged 65 and over, and

in adults living with HIV. Its use among pregnant women

and children is not advised.

3. Informed consent. Patients must be fully aware of the

RQVGPVKCNDGPGßVUCPFTKUMUQHVJGPGYFTWICPFIKXG

documented informed consent before embarking on

treatment.

4. Adherence to WHO recommendations. All principles on

YJKEJ9*1TGEQOOGPFGF/&46$VTGCVOGPVTGIKOGPUCTG

based must be followed. In particular, four effective second-

line drugs must be part of the regimen. In line with the

general principles of TB treatment, bedaquiline should not

be introduced into a regimen in which the companion drugs

are failing to show effectiveness.

5. Active pharmacovigilance and management of

adverse events. Active pharmacovigilance measures

must be in place to ensure early detection and proper

management of adverse drug reactions and potential

interactions with other drugs.

WHO strongly recommends the acceleration of Phase III trials

to generate more comprehensive evidence that can inform

HWVWTGRQNKE[IWKFCPEGQPDGFCSWKNKPG6JGQTICPK\CVKQPYKNN

review, revise or update the interim guidance as additional

KPHQTOCVKQPQPGHßECE[CPFUCHGV[DGEQOGUCXCKNCDNG9*1

is also developing a document that will provide operational

guidance on the implementation of bedaquiline and is working

with partners to help ensure rational introduction of the drug.

a Guidelines for the proIrammatic manaIement of druI-resistant tuberculosis

– 2011 update)GPGXC9QTNF*GCNVJ1TICPK\CVKQP9*1*6/6$

2011.6).

b The use of bedaSuiline in the treatment of multidruI-resistant tuberculosis

interim policy Iuidance9QTNF*GCNVJ1TICPK\CVKQP)GPGXC5YKV\GTNCPF

2013 (WHO/HTM/TB/2013.6).

medium) after eight weeks. Among patients receiving the

regimen with the highest dose of rifapentine, 100% were

culture-negative after eight weeks of treatment (compared

with 16 weeks for those receiving the current standard of

care). e trial investigators concluded that the robust anti-

microbial activity alongside the good tolerability and safety

of the compound at increasing doses justied the assess-

ment of daily high-dose rifapentine in regimens of shorter

than six months duration in a Phase III trial.

Among other drugs tested in Phase II trials, the high-

est-prole in the past year is bedaquiline (TMC-207). e

US Food and Drug Administration (FDA) approved the use

of bedaquiline as an adjunct to existing regimens for the

treatment of MDR-TB in December 2012, under an accel-

erated procedure. Bedaquiline became the rst new TB

drug to be approved for use in 40 years. A Phase III trial,

which will investigate the safety and ecacy of bedaquiline

when used in combination with a short MDR-TB regimen,

is scheduled to start before the end of 2013. Following the

release of trial results and the FDA decision, WHO issued

interim guidance about the use of bedaquiline in the treat-

ment of MDR-TB in June 2013 (Box 8.2).

Five other individual compounds are in the Phase II

92 GLOBAL TUBERCULOSIS REPORT 2013

development phase. ese are linezolid, sutezolid, PA-824,

SQ-109 and AZD-5847.

Linezolid (a member of the oxazolidinone antibiotic

class of drugs) was approved in 2000 for the treatment of

drug-resistant, gram-positive bacterial infections. It has

good anti-mycobacterial activity in vitro and is increasingly

used ‘o-label’ for patients who have highly drug-resistant

TB. However, serious adverse events (such as peripheral

and optic neuropathies, anaemia and thrombocytopenia)

have been reported. Results from a prospective, random-

ized trial in which linezolid was used to treat patients with

XDR-TB who had not responded to other available chemo-

therapeutic options were published in late 2012.1 A total

of 41 patients were randomly assigned to linezolid therapy

(600 mg per day), which was either started immediately or

after two months without any change to the background

regimen. After conrmed sputum-smear conversion or

after four months of treatment (whichever came rst),

patients underwent a second randomization to continue

linezolid therapy at a dose of either 600 mg or 300 mg per

day for at least an additional 18 months, with close moni-

toring of toxicity.

e results showed that at four months, 15 of the 19

patients (79%) in the immediate-start group and 7 of the

20 (35%) in the delayed-start group had converted to cul-

ture-negative status (p = 0.001). Most patients (34 of 39

[87%]) had a negative sputum culture within six months

after linezolid had been added to their drug regimen. Of the

38 patients treated with linezolid, 31 (82%) had clinically

signicant adverse events that were possibly or probably

related to linezolid, including three patients who discontin-

ued therapy. Patients who received 300 mg per day after the

second randomization had fewer adverse events than those

who continued taking 600 mg per day. irteen patients

completed therapy and had not relapsed at the end of fol-

low up. Four cases of acquired resistance to linezolid were

observed. Trial investigators concluded that linezolid was

eective at achieving culture conversion among patients

with chronic XDR pulmonary TB, but warned that patients

must be monitored carefully for adverse events. Study lim-

itations include the small number of patients evaluated,

and that 10% of patients acquired resistance to linezolid.

Further data are needed to balance the long-term risks and

benets of linezolid when used as part of a combination

regimen with other eective anti-TB drugs.

Sutezolid (PNU-100480) is an oxazolidinone and an

analogue of linezolid. It has been tested in an EBA study at

doses of either 600 mg twice a day or 1200 mg once a day.

Results were presented in 2012 and showed that sutezolid

led to a signicant reduction in log colony forming units

(CFU) counts compared with the baseline level following 14

days of treatment, using both dosage options.2 e results

suggested a superior response with the 600 mg twice-daily

dose.

PA-824 is a nitroimidazole compound that is being test-

ed as part of several potential combination regimens (see

below).

SQ-109, originally synthesized as a derivative of etham-

butol, is also being tested as part of a combination regimen

(see below).

AZD-5847 is being tested in a Phase II trial.

8.2.3 Phase II trials – new regimens

Besides individual compounds, new combinations of drugs

are or will soon be tested in various Phase II trials. In the

Global tuberculosis report 2012, the results of the EBA study

of a new combination regimen (NC-001) that included moxi-

oxacin, pyrazinamide and the novel drug PA-824 were

summarized.3 ree trials of various combination regimens

are currently underway. e rst of these is NC-002, which

is building on the NC-001 study to test the same regimen in

a two-month trial. e trial is being implemented in South

Africa and the United Republic of Tanzania. e regimen

is being tested in patients with drug-susceptible TB and in

patients who have drug-resistant TB but not resistance to

the drugs included in the new regimen. e NC-002 trial

is a landmark trial, since it is the rst to simultaneously

investigate treatment of both drug-sensitive and drug-

resistant TB with the same regimen. Results are expected

at the end of 2013.4

e second trial, NC-003, is testing the EBA of various

combinations of clofazimine, bedaquiline, PA-824 and pyr-

azinamide in patients with drug-susceptible TB.5

e MAMS-TB-01 trial, conducted by the PanACEA

consortium, is evaluating new three-month combina-

tion regimens using a new adaptive study design.6 e

drugs included in the combination regimens are isoniazid,

rifampicin, pyrazinamide, ethambutol, moxioxacin and

SQ-109. e end-point of the trial is time to culture conver-

sion in liquid media. e trial started in May 2013.7

8.2.4 New developments in the treatment of latent

TB infection

New drugs are being tested for the treatment of latent TB

infection (LTBI) in people without active TB disease.

Rifapentine has been investigated as part of a combined

regimen (TBTC 26, also called PREVENT-TB), and the rst

results were published in December 2011.8 Enrolment and

1 Lee M et al. Linezolid for Treatment of Chronic Extensively

Drug-Resistant Tuberculosis. New England Journal of Medicine

2012;367:1508-18. DOI: 10.1056/NEJMoa1201964

2 Wallis R et al. Safety, tolerability and early bactericidal activity in spu-

tum of PNU-100480 (sutezolid) in patients with pulmonary tuberculo-

sis (Abstract THLBB02). 19th International AIDS Conference 2012,

July 22–27, Washington DC.

3 Diacon A H et a l. 14-day bactericida l activity of PA- 824, bedaquil ine,

pyrazinamide and moxioxacin combinations: a randomised trial.

e Lancet, 2012

4 See: http://clinicaltrials.gov/show/NCT01498419

5 See: http://clinicaltrials.gov/show/NCT01691534

6 Phillips P et al. Innovative trial designs are practical solutions for

improving the treatment of tuberculosis. Journal of Infectious Dis-

eases. 2012;205 Suppl 2:S250–7.

7 See: http://clinicaltrials.gov/show/NCT01785186

8 Sterling T et al. ree Months of Rifapentine and Isoniazid for

Latent Tuberculosis Infection. New England Journal of Medicine

2011; 365;23: 2155–66.

93GLOBAL TUBERCULOSIS REPORT 2013

follow-up for two groups of particular interest (young chil-

dren 2–11 years of age, and people living with HIV) were

extended and are scheduled to end in September 2013.Pre-

liminary results showed that the once-weekly, three month

regimen of rifapentine and isoniazid (3HP) was generally

well-tolerated and oered ‘substantial advantages’ com-

pared with the current standard of nine months of isoniazid

for treatment of LTBI in children.1Study 33, also called iAd-

here, is a follow-up Phase IV study of TBTC 26, investigating

the eectiveness of the 3HP combination (tested in PRE-

VENT-TB), either given by: (1) DOT, (2) self-administered,

or (3) self-administered with text message reminders by cell

phone.is study is expected to be completed in March 2014.

A second study is an AIDS Clinical Trials Group (ACTG)

trial of daily rifapentine and isoniazid for one month to

treat LTBI in people living with HIV. A third study to eval-

uate the eect of single and repeated administration of

rifapentine (given as a daily or weekly regimen) on steady-

state pharmacokinetic parameters of efavirenz, emtric-

itabine and tenofovir given as a xed dose combination

BOX 8.3

Raising the proßle of treatment for latent TB infection

One third of the world’s population is

estimated to be latently infected with

M. tuberculosis. People with latent TB

infection (LTBI) do not have symptoms

of TB and are not infectious, but they

are at risk of developing active disease

and becoming infectious. Studies show

that 5–20% of those infected will

develop active TB at some point in their

lifetime, with the majority developing

TB disease within 2–5 years of the initial

infection. Several factors increase the

risk of progressing from infection to

CEVKXG6$FKUGCUGKOOWPQUWRRTGUUKQP

(for example, related to HIV infection

or immunosuppressive treatment),

malnutrition, diabetes and alcohol

abuse. Preventing active TB by

addressing these risk factors as well as

proper diagnosis and treatment of LTBI

in selected risk groups is thus important

for the individual and public health.

Modelling has shown that diagnosis

and treatment of LTBI could play a

key role in TB elimination. WHO has

recently published guidelines on TB

contact investigation and on systematic

screening of active TB,a,b both of which

QHHGTCPGPVT[RQKPVVQKFGPVKßECVKQP

of risk groups for LTBI diagnosis and

treatment.

+UQPKC\KFRTGXGPVKXGVJGTCR[

(IPT) is the mainstay of current WHO

recommendations on treatment of

LTBI. Treatment is recommended for

VYQURGEKßERQRWNCVKQPITQWRURGQRNG

living with HIV, and children less than

ßXG[GCTUQNFYJQCTGJQWUGJQNFQT

close contacts of TB patients. A recent

Cochrane review showed that rifampicin-

and rifapentine-containing regimens

among HIV negative people have higher

completion rate and fewer adverse events

compared with those based on IPT only.c

Before initiating LTBI treatment, it

is essential that active TB is effectively

ruled out and the diagnosis of LBTI

reliably established. The tuberculin

skin test (TST) and interferon-gamma

TGNGCUGCUUC[U+)4#CTGFGUKIPGFVQ

detect a cellular immune response to

M. tuberculosis, but do not differentiate

between latent infection and active

disease and, if negative, do not allow

TB infection to be ruled out. Most

importantly, they cannot accurately

predict the risk of infected individuals

developing active TB disease, and their

use in routine practice poses operational

and resource challenges.

There are several unanswered

questions related to the detection

and management of LTBI that require

WTIGPVUEKGPVKßECVVGPVKQPCPF

increased research investments. There

is still limited understanding of the

fundamental biology of latency and

there are no truly adequate animal

models to study it. There is also no

diagnosis and treatment for people

who are latently infected with drug-

resistant strains of M. tuberculosis.

Expediting the discovery of robust

tools to effectively diagnose and treat

LTBI is crucially important for global

TB control. Particular emphasis needs

to be given to development of a better

understanding of the basic pathogenesis

of M. tuberculosisCPFVJGKFGPVKßECVKQP

of biomarkers that will enable reliable

diagnosis and shorter and less toxic

treatment for LTBI.

Following recent developments in the

treatment of LTBI, WHO plans to update

its guidelines on the management of

LTBI. This will entail a review of the

existing evidence with a particular focus

on risk groups that have the highest

likelihood of progression to active TB

disease following infection, and due

EQPUKFGTCVKQPVQTKUMDGPGßVCPCN[UKU

and concomitant risk factors.

a 4GEQOOGPFCVKQPUHQTKPXGUVKICVKPIEQPVCEVU

of persons with infectious tuberculosis

in low- and middle-income countries.

Available at JVVRCRRUYJQKPVKTKU

DKVUVTGCOA

eng.pdf

b Systematic screening for active tuberculosis

– Principles and recommendations. Available

at JVVRCRRUYJQKPVKTKUDKVUVTGCO

AGPIRFH

c 5JCTOC5-GVCN4KHCO[EKPUTKHCORKEKP

TKHCDWVKPCPFTKHCRGPVKPGEQORCTGFVQKUQPKC\KF

for preventing tuberculosis in HIV-negative

people at risk of active TB. Cochrane &atabase

of Systematic 4eXiews+UUWG#TV0Q

%&&1+%&

pub2.

(ATRIPLA™) started patient enrolment in September 2012

and recruitment was completed in August 2013. A fourth

study to compare the safety and eectiveness of a four-week

daily regimen of rifapentine and isoniazid with a standard

nine-month regimen of daily isoniazid among people liv-

ing with HIV started patient enrolment in May 2012 and

is expected to complete enrolment in March 2018. A fth

study to determine the safety and tolerability of a four-

month, once daily rifampicin regimen in children is being

conducted by the Canadian Institutes of Health Research

and McGill University and results are expected in 2016.2

1 Villarino et al. Tolerability among children of three months of

once-weekly rifapentine + INH (3HP) vs. 9 months of daily INH (9H)

for treatment of latent tuberculosis infection: e PREVENT TB Study

(TBTC Study 26/ACTG 5259). IDSA Conference 2012.

2 Clayden P et al, on behalf of the HIV i-Base/Treatment Action

Group. 2013 Pipeline Report: HIV, Hepatitis C Virus (HCV), and Tuber-

culosis (TB) Drugs, Diagnostics, Vaccines, Preventive Technologies,

Research Toward a Cure, and Immune-Based and Gene erapies in

Development. Available at: http://www.treatmentactiongroup.org/

pipeline-report

94 GLOBAL TUBERCULOSIS REPORT 2013

8.3 New vaccines to prevent TB

e slow decline in TB incidence globally and the growing

problem of MDR-TB highlight the critical need for new

eective TB vaccines. e BCG vaccine for the prevention

of TB is almost 100 years old, and while the vaccine pro-

tects against severe forms of TB in children (TB meningitis

and miliary TB), its ecacy in preventing pulmonary TB

in adults is highly variable. BCG is also not recommended

for use in infants known to be infected with HIV, due to

the risk of disseminated BCG disease. e development of

techniques for genetic manipulation of mycobacteria, com-

pletion of the genome sequence of M. tuberculosis in the

1990s, and recent advances in immunology provide historic

opportunities for developing a new generation of TB vac-

cines that can achieve dramatically higher levels of impact.

For the past decade, two major strategies have been used

to develop new vaccines for prevention of TB.1 One strategy

has been to develop vaccines that would have a higher e-

cacy than BCG and replace it – such as an improved version

of BCG or a new attenuated live M. tuberculosis vaccine. e

second strategy has been a ‘prime-boost’ strategy in which

BCG continues to be given to neonates (as is done current-

ly, since it prevents TB in infants and children), and a new

vaccine is given as a ‘booster’ dose to increase the ecacy

and extend the duration of protection. Modelling of the

potential public health impact of new TB vaccines in the

WHO South-East Asia Region suggested that a TB vaccine

for infants with 60% ecacy would contribute to a signif-

icant decline in TB incidence by 2050.2 Furthermore, this

modelling also indicated that if a preventive TB vaccine of

similar ecacy among adolescents and adults was deliv-

ered as part of a mass vaccination strategy, the impact on

the TB epidemic would be much larger. More recent mod-

elling of the public health impact of a new vaccine at global

level3 has reinforced this nding, indicating that an adoles-

cent and adult vaccine with 60% ecacy could potentially

avert 30‒50 million new TB cases over a 25 year period.

e much greater potential impact of an adult/adolescent

vaccine has shifted the focus of TB vaccine development

towards a new paradigm that emphasizes the development

of a diverse pipeline of new TB vaccine candidates that tar-

get the prevention of TB in this older population. Scientic

advances have also enabled the pursuit of more sophisticat-

ed approaches to vaccine design, and the global pipeline of

TB vaccine candidates in clinical trials is more robust than

at any previous period in history, now including recombi-

nant BCGs, attenuated M. tuberculosis strains, recombinant

viral-vectored platforms, protein/adjuvants combinations,

and mycobacterial extracts.

e status of the pipeline for new vaccines in July 2013

is shown in Figure 8.3. ere are 12 vaccine candidates in

clinical trials. Most are designed for prevention of TB, either

to prevent infection (pre-exposure) or to prevent primary

progression to disease or reactivation of latent TB (post-

exposure). Two are BCG replacement vaccines and two are

proposed as immunotherapeutic agents, to improve respon-

siveness to chemotherapy or prevent relapse or re-infection.

Two vaccines are in Phase IIb studies.

MVA85A is an attenuated vaccinia-vectored vaccine

candidate expressing Ag85A of M. tuberculosis. It was

designed as a booster vaccine for BCG vaccinated infants

and the rst Phase IIb trial of this vaccine was conducted

in South Africa from 2009 to 2012 with results published

in early 2013 (Box 8.4).4 An additional Phase IIb trial of

MVA85A is currently being conducted in adults living with

HIV in Senegal and South Africa; the trial has been recently

re-designed as a safety trial in which up to 650 participants

will be enrolled.

M72+AS01E is a protein subunit vaccine, formulated

in a novel adjuvant to enhance immunogenicity. It con-

tains a fusion protein of the M. tuberculosis antigens 32A

and 39A in the adjuvant AS01E. Safety and immunogenic-

ity are being tested in three dierent populations: infants

in e Gambia, people living with HIV in India and adults

with TB disease in China (Province of Taiwan) and Esto-

nia. e Phase IIb study will be the largest trial of a novel

TB vaccine in adults, aiming to enrol 4500 HIV-negative

adults in TB-endemic countries in Africa. e primary end-

point will be the protective ecacy of two doses of M72+

AS01E against pulmonary TB disease. Secondary endpoints

include safety and immunogenicity.

ere are six additional vaccines in Phase II trials.

AERAS-402/Crucell Ad35 is an adenovirus-vectored

vaccine candidate expressing three M. tuberculosis antigens:

Ag85A, Ag85B and TB10.4. It is designed as a booster vac-

cine for infants, adolescents and adults. Although started

as a Phase IIb proof-of-concept trial, based on preliminary

data the trial is now being revised to be a smaller Phase

II trial with safety and immunogenicity as primary end-

points. Of note, AERAS-402/Crucell Ad35 and MVA85A

are also being tested in combination, to try to drive a bal-

anced CD4+/CD8+ immune response. One or two doses of

AERAS-402/Crucell Ad35 followed by a dose of MVA85A

are being evaluated in a combined Phase I/Phase II trial

in adults in the United Kingdom for safety and immuno-

genicity.

ree vaccines are protein subunit adjuvanted vac-

cines, initially developed by the Statens Serum Institute in

Copenhagen, Denmark. Hybrid 1 + IC31 contains Ag85B

and ESAT-6 in an adjuvant, IC31. Hybrid 56 + IC31 con-

tains antigens 85B and ESAT6 as well as AgRv2660, which

is expressed during latency. Hybrid 4 + IC31, now being

developed with Sano Pasteur, is a fusion protein candi-

1 Evans TG, Brennan MJ, Barker L and ole J. Preventive vaccines

for tuberculosis. Vaccine. 31S (2013) B223– B226.

2 Abu-Raddad LJ, et al. Epidemiological benets of more-eective

tuberculosis vaccines, drugs, and diagnostics. Proceedings of the

National Academy of Science. 2009. 106:33; 13980–13985.

3 A model of the global public health impact of new TB vaccines was

commissioned by Aeras and developed by Applied Strategies. For-

mal publication of the model and associated results is pending.

4 Tameris MD, et al. Safety and ecacy of MVA85A, a new tuber-

culosis vaccine, in infants previously vaccinated with BCG: a

randomised, placebo-controlled phase 2b trial. e Lancet. 2013.

381:9871; 1021–1028.

95GLOBAL TUBERCULOSIS REPORT 2013

date that expresses Ag85B and TB10.4; the latter antigen is

from the same gene family as ESAT-6. All three vaccines are

being studied in Phase IIa clinical trials in Africa.

VPM 1002 is a live recombinant vaccine, derived from

the Prague strain of BCG into which the listerolysin gene

from Listeria monocytogenes has been cloned and the urease

gene deleted to improve immunogenicity. A Phase IIa trial

of this vaccine has recently been completed in South Africa.

A second Phase II trial will assess the safety and immunoge-

nicity of the vaccine in HIV exposed/unexposed newborns.

RUTI is a non-live vaccine based on fragmented M. tuber-

culosis bacteria. It is in a Phase IIa trial in Spain and is being

developed as an immunotherapeutic vaccine.

In addition to the vaccine candidates described above,

AnHui Longcom, a Chinese pharmaceutical company, is

studying Mycobacterium vaccae, a non-living preparation

from the non-pathogenic bacterium, as an adjunct to stan-

dard antimicrobial therapy. Phase III ecacy studies are

reportedly underway.

ere are three vaccine candidates in Phase I clinical

trials. ese include the rst live attenuated M. tuberculosis

vaccine, MTBVAC, as well as a new fusion protein vaccine,

ID93, formulated with a novel adjuvant GLA-SE.

MTBVAC is being developed by the University of Zara-

gosa, Institut Pasteur, BIOFABRI and the Tuberculosis

Vaccine Initiative (TBVI). It is a live M. tuberculosis strain

attenuated via deletions of the phoP and fadD26 genes. It

is the rst live attenuated M. tuberculosis vaccine to enter a

Phase I clinical trial.

ID93+GLA-SE is a recombinant fusion protein formu-

lated in the novel adjuvant, GLA-SE. It is being developed

by the Infectious Disease Research Institute (IDRI) in col-

laboration with Aeras. It expresses three M. tuberculosis

virulence antigens (Rv2608, Rv3619 and Rv3620) and one

M. tuberculosis latency antigen (Rv1813). It is beginning a

Phase 1b trial in adults in South Africa to assess safety and

immunogenicity in this population.

Ad5 Ag85A is an adenovirus serotype 5 vector express-

ing Ag85A. It has been developed by McMaster University

with support from CanSino, a Chinese biotechnology com-

pany based in Tianjin. e vaccine was recently evaluated in

a Phase I trial that demonstrated no vaccine-related serious

adverse events and showed greater immunogenicity in the

study group primed with BCG.

Research on new TB vaccines is now at a crucial juncture.

Despite the diversity that already exists in the global portfo-

lio of TB vaccine candidates in clinical trials, there is grow-

ing recognition among scientists and researchers in the eld

that there is still too much similarity in the immunological

strategies being pursued.1 In the absence of known immune

correlates for either protective immunity against TB or con-

trol of infection, the portfolio must be further diversied so

that candidates explore a dierent and novel immunological

‘space’. ere is already a robust pipeline of candidates being

evaluated pre-clinically – including nucleic acid-based (DNA

and RNA) vaccines – and these pursuits may help to broaden

the diversity of the clinical portfolio and ll the scientic

gaps that currently exist. To rationalize and streamline the

advancement of TB vaccine candidates, consensus has been

Phase I Phase II Phase III

Phase IIb

VPM 1002

Max Planck, VPM, TBVI,

Serum Institute

P B

H1+IC31

SSI, TBVI, EDCTP,

Intercell

P B PI

476+

Archivel Farma, S.L.

B PI it

*#'4#5+%

SSI, Aeras, Intercell

P B PI

*#'4#5+%

SSI, Sanofi Pasteur,

Aeras, Intercell

%TWEGNN#F#'4#5

Crucell, Aeras

P Prime B Boost PI Post-infection it Immunotherapy

#F#I#

McMaster, CanSino

P B PI

MTBVAC

TBVI, Zaragoza, Biofabri

ID93+GLA-SE

Infectious Disease

Research Institute (IDRI),

Aeras

%TWEGNN#F/8##

Crucell, Oxford, Aeras

P B

/8###'4#5

Oxford, Aeras, EDCTP

B PI it

M72+AS01

GSK, Aeras

B PI

M. Vaccae

Anhui Longcom

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-KNNGF9%QT'ZVTCEV/Y476+

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FIGURE 8.3

The development pipeline for new TB vaccines, July 2013

1 Evans TG et al. Preventive vaccines for tuberculosis. Vaccine 31S

(2013) B223– B226.

96 GLOBAL TUBERCULOSIS REPORT 2013

developed among key stakeholders on ‘stage-gating’ crite-

ria for new TB vaccines, and increased emphasis is being

placed on global coordination among key stakeholders to

advance a common research agenda.

To supplement these existing eorts, a re-prioritized

focus on early stage research is also underway. In accor-

dance with this shift in emphasis, more energy and resourc-

es will be directed towards the pursuit of novel designs, to

studies focused on immunological mechanisms and bio-

markers, and to a diversication of scientic approaches

and strategies to ensure that a more diverse pipeline of new

TB vaccine candidates moves forward into clinical trials.1

8.4 The post-2015 global TB strategy: the

critical role of research and development

Fundamental science is necessary to drive innovations in

new tools for improved TB care and control. Fundamental

research is required to better characterize M. tuberculosis

and to improve understanding of the interaction between

the bacillus and the human host, as a basis for maintain-

ing the ow of new technologies into the product pipeline.

Researchers are making great strides in redening the

1 Brennan MJ and ole J (editors). Tuberculosis vaccines: A stra-

tegic blueprint for the next decade. Tuberculosis. 2012. 92: Supple-

ment 1; S6–S13.

BOX 8.4

The MVA85A trial in South Africa

/8##KUCRQZXKTWUÄ/QFKßGF

Vaccinia Ankara”, MVA)-vectored vaccine

that expresses the immune-dominant

M. tuberculosisCPVKIGP#+VYCU

originally developed at the University

of Oxford. An infant Phase IIb proof-

of-concept trial was recently completed

in South Africa.a The study population

consisted of 2794 BCG-vaccinated,

HIV-negative infants aged 4–6 months,

with both study arms almost equally

UK\GFKPHCPVUTGEGKXGFQPGFQUG

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control arm received a placebo (Candin,

a C. albicans-derived skin test antigen).

Follow up lasted 37 months. The primary

objective of the study was to assess the

UCHGV[QH/8##KPVJGUGKPHCPVU6JG

secondary objectives were to evaluate

VJGGHßECE[QHVJGXCEEKPGCICKPUV

(a) the disease and (b) M. tuberculosis

infection, as measured by Quantiferon

conversion (this distinction is important

as infection only leads to active TB

disease in a small minority of immune-

competent individuals). Additional

objectives included the evaluation of

immunogenicity.

Conclusions drawn from the

results of the Phase IIb trial

6JKUYCUVJGßTUVENKPKECNVTKCNVQGXCNWCVG

VJGGHßECE[QHCPGY6$XCEEKPG

candidate for prevention of clinical

TB or M. tuberculosis infection, and

results were therefore of considerable

interest to the vaccine research and

public health communities. In this trial,

/8##CRRGCTGFVQDGUCHGCPFYGNN

VQNGTCVGFEQPßTOKPIUKOKNCTßPFKPIU

from previous Phase I and Phase IIa

clinical trials using this vaccine. None

of the observed serious adverse events

(or deaths) observed in the study arm

were assessed by the investigators to

be related to the vaccine, and only one

serious adverse event involving a brief

JQURKVCNK\CVKQPQEEWTTGFKPVJGRNCEGDQ

ITQWR6JGRTKOCT[GHßECE[CPCN[UKUYCU

based on the number of TB cases among

the vaccinated versus control subjects.

In the vaccine arm, there were 32 cases,

while in the placebo arm there were

39 cases. Based on this, the calculated

XCEEKPGGHßECE[YCU%+

VQHQTVJGRTKOCT[

6$ECUGFGßPKVKQPYJKEJYCUPQV

UVCVKUVKECNN[UKIPKßECPV/QTGQXGTVJGTG

was no evidence of protection against

M. tuberculosisKPHGEVKQPWUKPIVJG

Quantiferon-TB Gold assay as the read-

out. A total of 349 out of 2792 infants

DGECOGKPHGEVGFKPVJGXCEEKPGCTO

and 171 in the placebo arm), giving a

ECNEWNCVGFXCEEKPGGHßECE[QH¿

%+VQYJKEJYCU

CNUQPQVUVCVKUVKECNN[UKIPKßECPV

Implications for future studies

of this and other TB vaccine

candidates

Phase IIb proof–of-concept trials are

designed to allow ‘triage’ of vaccine

candidates and target populations, to

decrease risks before embarking on

hugely complex and resource consuming

Phase III trials. Current regulations

require a Phase IIb proof–of-concept

trial to be corroborated in larger

Phase III trials before a vaccine can be

licensed.

This study demonstrated that the

XCEEKPGJCFCPCEEGRVCDNGUCHGV[RTQßNG

in infants, and that a high quality trial

of a novel TB vaccine can be conducted

and produce robust results in a high

TB burden setting. The vaccine was

given months after all the infants had

received BCG vaccine, and it is possible

that BCG may have provided a plateau

level of protection, with very little, if any

CFFKVKQPCNRTQVGEVKQPCFFGFD[/8##

4CVGUQH6$KP5QWVJ#HTKECCPFVJG

Western Cape province in particular)

are exceptionally high in all age groups,

including young children, and this high

HQTEGQHKPHGEVKQPOC[DGFKHßEWNVVQ

address with any vaccine. It cannot be

assumed that similar results would have

been obtained in other populations. It

is also possible that adults, adolescents

and older children could be a better

VCTIGVRQRWNCVKQPHQTVJKUXCEEKPG

there is some evidence that it induces

a stronger immune response in older

age groups than in infants. Adults and

adolescents are the primary source

of transmission as they more likely to

develop the most infectious forms of the

disease and account for the largest share

of the burden of TB disease worldwide.

The vaccine is currently being evaluated

in HIV-infected adults in Senegal and

South Africa, using a two-dose regimen.

For all these reasons, the results of

the trial should not be considered as

RTQXKFKPICP[FGßPKVKXGCPUYGTVQVJG

question of whether a new TB vaccine

can provide better protection than BCG

alone. Further studies of this and other

vaccines are urgently needed. Several

of the other TB vaccine candidates in

VJGENKPKECNRKRGNKPGFKHHGTHTQO/8##

both in their antigenic composition and

in the way these antigens are delivered.

a 6COGTKU/&GVCN5CHGV[CPFGHßECE[QH

/8##CPGYVWDGTEWNQUKUXCEEKPGKPKPHCPVU

RTGXKQWUN[XCEEKPCVGFYKVJ$%)CTCPFQOK\GF

placebo-controlled phase 2b trial. The Lancet.

¿

97GLOBAL TUBERCULOSIS REPORT 2013

spectrum of TB disease and the transition from latent to

active TB, and developing a better understanding of the

behaviour of M. tuberculosis within the host. is progress

is expected to deliver better knowledge about pathogenesis

and identication of biomarkers and bio-signatures rele-

vant to new TB diagnostics. It is also expected to point to

new targets for anti-TB drugs as well as early indicators of

protective immunity, vaccine ecacy and early response to

treatment. Such developments will facilitate the selection

and testing of new interventions.

To highlight the crucial role of research in ending the

global TB epidemic, the WHO post-2015 global TB strategy

that is currently under development includes “Intensied

Research and Innovation” as one of three strategic pillars

(Chapter 1). e strategy is being developed as a successor

to the Stop TB Strategy, which covers the period 2006–2015.

In wide consultations held during 2012 and 2013, there has

been strong support for this pillar and its two main sub-

components, which are:

1. Discovery, development and rapid uptake of new tools,

interventions and strategies;

2. Research to optimize implementation and impact.

e research pillar will be essential to the success of the two

other pillars of the post-2015 global TB strategy and the

achievement of post-2015 global TB targets.

Biomedical research will need to be integrated as a crit-

ical component of the new post-2015 research strategy.

Creating connections among scientic disciplines that have

historically been inadequate or lacking (for example, bio-

medical research, epidemiology and operational research)

will depend upon close collaboration, consultation and

input from many research and public health stakeholders.

e need for more and expanded operational research

to optimize implementation and adopt innovations will

require extensive work at the country level, for example to

generate essential data on the epidemiology of TB (‘Know

your epidemic’) and universal health coverage, and to allow

adaptation of global recommendations and policies at the

national level.

#00':

Methods used to

estimate the global

burden of disease

caused by TB

101GLOBAL TUBERCULOSIS REPORT 2013

is annex explains the methods that were used to pro-

duce estimates of the global burden of disease caused by TB

(measured in terms of incidence, prevalence and mortality).

It has nine major sections:

General approach. is section provides some back-

ground information about the methods used to produce

estimates of disease burden.

Denitions. is section denes TB incidence, prev-

alence and mortality, the case fatality rate (CFR) and

the case notication rate. It also explains the regions

for which estimates of disease burden are produced and

sources of information on population estimates.

Estimates of TB mortality, 1990–2012. is section

explains the three methods used to estimate TB mor-

tality, and the countries for which they were applied.

Methods for estimating the number of HIV-associated

TB deaths and for disaggregation of TB mortality by age

and sex are also described.

Estimates of TB incidence, 1990–2012. is section

explains the main methods used to estimate TB inci-

dence, and the countries for which they were applied.

Methods to estimate the prevalence of HIV among inci-

dent TB cases are described.

Estimates of TB prevalence, 1990–2012. is sec-

tion explains the two methods used to estimate TB prev-

alence, and the countries for which they were applied.

Estimates of multidrug-resistant TB (MDR-TB)

incidence and mortality. is section explains the

main methods used to estimate MDR-TB mortality and

incidence based on drug resistance surveillance data and

parameters obtained from a recent literature review.

Projections of TB incidence, prevalence and mor-

tality. is section explains how projections from 2013

to 2015 were produced.

Uncertainty framework. is section explains the

general approach to including uncertainty in all esti-

mates.

1. General approach

Estimates of the burden of disease caused by TB (mea-

sured in terms of incidence, prevalence and mortality) are

produced annually by WHO using information gathered

through surveillance systems (case notications and death

registrations), special studies (including surveys of the

prevalence of disease, mortality surveys and in-depth anal-

yses of surveillance data), expert opinion and consultations

with countries. Two recent publications provide up-to-date

guidance about how TB incidence, prevalence and mortality

should be measured,1 based on the work of the WHO Global

Task Force on TB Impact Measurement.2 e methods used

to estimate the burden of disease were updated in 2009 fol-

lowing 18 months of work by an expert group convened by

the Task Force. ese updates were endorsed at a meeting of

the full Task Force in March 2010. Improvements to meth-

ods included systematic documentation of expert opinion

and how this has been used to produce estimates of disease

burden, simplication of models,3 updates to parameter

values based on the results of systematic reviews, much

greater use of mortality data from vital registration (VR)

systems and systematic documentation of uncertainty

(hence the uncertainty intervals shown on all of the esti-

mates of disease burden in this report).

2. Deßnitions

2.1 Incidence, prevalence, mortality, case fatality

 TCVGECUGPQVKßECVKQPTCVG

Incidence is dened as the number of new and recurrent

(relapse) episodes of TB (all forms) occurring in a given

year. Recurrent episodes are dened as a new episode of TB

in people who have had TB in the past and for whom there

was bacteriological conrmation of cure and/or documen-

tation that treatment was completed (Box 3.1, Chapter 3).

In the remainder of this Annex, relapse cases are referred

to as recurrent cases because the term is more useful when

explaining the estimation of TB incidence. Recurrent cas-

es may be true relapses or a new episode of TB caused by

reinfection. In current case denitions, both relapse cases

and patients who require a change in treatment are called

‘retreatment cases’. However, people with a continuing epi-

sode of TB that requires a treatment change are prevalent

cases, not incident cases.

Prevalence is dened as the number of TB cases (all forms)

at a given point in time.

Mortality from TB is dened as the number of deaths

caused by TB in HIV-negative people, according to the

latest revision of the International classication of diseases

(ICD-10). TB deaths among HIV-positive people are classi-

ed as HIV deaths in ICD-10. For this reason, estimates of

deaths from TB in HIV-positive people are presented sepa-

rately from those in HIV-negative people.

e case fatality rate is the risk of death from TB among

people with active TB disease.4

e case notication rate refers to new and recurrent

episodes of TB notied to WHO for a given year, expressed

per 100000 population. e case notication rate for new

and recurrent TB is important in the estimation of TB inci-

dence. In some countries, however, information on treat-

ment history may be missing for some cases. When data

on treatment history are not available, recurrent cases

cannot be distinguished from cases whose treatment was

1 TB impact measurement: policy and recommendations for how to assess

the epidemiological burden of TB and the impact of TB control. Gene-

va, World Health Organization, 2009 (Stop TB policy paper, no.

2; WHO/HTM/TB/2009.416). e policy paper is available on the

Task Force web site: www.who.int/tb/advisory_bodies/impact_

measurement_taskforce

2 For further details, see the Task Force web site at: www.who.int/tb/

advisory_bodies/impact_measurement_taskforce

3 For example, some parameter values are now estimated only at glob-

al level or for regions, rather than for each country individually.

4 Straetemans M et al. Assessing tuberculosis case fatality ratio: a

meta-analysis. PLoS One. 2011, 6(6):e20755.

102 GLOBAL TUBERCULOSIS REPORT 2013

changed, since both are registered and reported in the cat-

egory ‘retreatment’. Patients reported in the ‘unknown his-

tory’ category are considered incident TB episodes (new or

relapse). is is a change from previous years in view of past

diculties to estimate with NTPs the proportion of true

new or relapse TB episodes in this category of patients (pre-

viously, patients with unknown treatment history were not

considered new or relapse cases). is change aects rela-

tively few countries, mostly in Western Europe.

2.2 Regions

Regional analyses are generally undertaken for the six

WHO regions (that is, the African Region, the Region of the

Americas, the Eastern Mediterranean Region, the Euro-

pean Region, the South-East Asia Region and the Western

Pacic Region). For analyses related to MDR-TB and for an

ecological model used to estimate TB mortality in some

countries, nine epidemiological regions were dened. ese

were African countries with high HIV prevalence, African

countries with low HIV prevalence, Central Europe, East-

ern Europe, high-income countries,1 Latin America, the

Eastern Mediterranean Region (excluding high-income

countries), the South-East Asia Region (excluding high-

income countries) and the Western Pacic Region (exclud-

ing high-income countries). e countries in these nine

regions are listed in Appendix 1.

2.3 Population estimates

e source of population estimates needed to calculate var-

ious TB indicators was the 2012 revision of the World Pop-

ulation Prospects, which is produced by the United Nations

Population Division (UNPD).2 e UNPD estimates some-

times dier from those made by countries.

3. Estimates of TB mortality, 1990–2012

e best sources of data about deaths from TB (excluding

TB deaths 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 classication are still

in use in several countries). Deaths from TB in HIV-positive

people are coded under HIV-associated codes.

ree methods were used to estimate TB mortality

among HIV-negative people:

direct measurements of mortality from VR systems or

mortality surveys;

indirect estimates based on an ecological model that

uses data from VR systems;

indirect estimates derived from multiplying estimates

of TB incidence by estimates of the CFR.

Each method is described in more detail below. Details

on the method used for each country are available online

at www.who.int/tb/publications/global_report/gtbr13_

mortality_source.csv.

3.1 Estimating TB mortality among HIV-negative

people from vital registration data and

mortality surveys

Data from VR systems are reported to WHO by Member

States and territories every year. In countries with func-

tioning VR systems in which causes of death are coded

according to the two latest revisions of the International

classication of diseases (underlying cause of death: ICD-10

A15-A19, equivalent to ICD-9: 010-018), VR data are the

best source of information about deaths from TB among

people not infected with HIV. When people with AIDS

die from TB, HIV is registered as the underlying cause of

death and TB is recorded as a contributory cause. Since one

third of countries with VR systems report to WHO only the

underlying causes of death and not contributory causes, VR

data usually cannot be used to estimate the number of TB

deaths in HIV-positive people.

TB mortality data obtained from VR systems are essen-

tial to understanding trends in TB disease burden where

case notications have incomplete coverage or their cov-

erage is not documented through an inventory study. An

updated description of the global coverage and quality of

VR data is available in World Health Statistics 2013.3

As of May 2013, 125 countries had reported mortality

data to WHO (including data from sample VR systems and

mortality surveys), among 217 countries and territories

from which TB data were requested. ese 125 countries

included 9 of the 22 high TB burden countries (HBCs): Bra-

zil, China, India, the Philippines, the Russian Federation,

South Africa, ailand, Viet Nam and Zimbabwe. However,

the VR data on TB deaths from South Africa and Zimbabwe

were not used for this report because large numbers of HIV

deaths were miscoded as TB deaths. Improved empirical

adjustment procedures have recently been published,4 and

options for specic post-hoc adjustments for misclassi-

cation errors in the measurement of TB mortality will be

reviewed extensively by the WHO Global Task Force on TB

Impact Measurement in 2014.

Among the countries for which VR data could be used

(see Figure 2.11 in Chapter 2), there were 2087 coun-

try-year data points 1990–2012. Of these data points, 24

outliers and points obtained from systems with very low

coverage were excluded for analytical purposes. Outliers

were detected visually by plotting country-specic time

series of reported TB mortality rates. As of June 2013, 62

data points were available for 2010, 35 for 2011 and none

for 2012. On average, 16 data points were retained for anal-

ysis per country (standard deviation (SD) of 6.7) from a

total of 2063 usable data points.

1 High-income countries are dened by the World Bank as countries

with a per capita gross national income (GNI) of ≥US$12 616 in

2012.

2 http://esa.un.org/unpd/wpp/ (accessed June 2013).

3 www.who.int/gho/publications/world_health_statistics/2013/en/

(accessed July 2013) (see particularly pages 15–16).

4 Birnbaum JK, Murray CJL, Lozano R. Exposing misclassied HIV/

AIDS deaths in South Africa. Bulletin of the World Health Organiza-

tion, 2011, 89:278–285.

103GLOBAL TUBERCULOSIS REPORT 2013

Reports of TB mortality were adjusted upwards to

account for incomplete coverage (estimated deaths with no

cause documented) and ill-dened causes of death (ICD-9

code B46, ICD-10 codes R00–R99).1

It was 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. For VR-

recorded deaths with ill-dened causes, it was assumed

that the proportion of deaths attributable to TB was the

same as the observed proportion in recorded deaths.

e adjusted number of TB deaths da was obtained from

the VR report d as follows:

da =

c(1 – g)

where c denotes coverage (i.e. the number of deaths with

a documented cause divided by the total number of esti-

mated deaths) and g denotes the proportion of ill-dened

causes.

e uncertainty related to the adjustment was estimated

with standard deviation SD = d/4[1/c(1 – g) – 1]. e uncer-

tainty calculation does not account for miscoding, such as

HIV deaths miscoded as deaths due to TB.

Missing data between existing adjusted data points were

interpolated. Trailing missing values were predicted using

exponential smoothing models for time series.2 A penal-

ized likelihood method based on the in-sample t was used

for country-specic model selection. Leading missing val-

ues were similarly predicted backwards to 1990. A total of

799 country-year data points were thus imputed.

Results from mortality surveys were used to estimate

TB mortality in India and VietNam.

In 2012, 45% of global TB mortality (excluding HIV) was

directly measured from VR or survey data (or imputed from

survey or VR data from previous years). e remaining 55%

was estimated using the indirect methods described in

section 3.2 and section 3.3.

3.2 Estimating TB mortality among HIV-negative

people from an ecological model

An out-of-sample, goodness-of-t, stepwise selection

approach was used in 2012 using the series 1990–2011 to

select an ecological model that could predict TB mortality

in countries without VR data. e model was based on the

time series of VR data reported to WHO as described above,

expressed as counts of TB deaths and corrected for ill-

dened causes of deaths and VR coverage.

A population-averaged negative binomial model, with

total population as the oset converting model outputs to

rates, was used to account for the longitudinal structure of

the data as well as the observed over-dispersion of counts

of TB deaths.

Ten variables were investigated for inclusion in the

model. ese were: the infant mortality rate per 1000 live

births; gross domestic product per capita; HIV prevalence

among the general population; the percentage of the total

population aged <15 and ≥65 years; the TB treatment suc-

cess rate; the total number of newly notied TB cases per

year; whether or not a country had a high or low burden

of MDR-TB; whether a country was among the 22 HBCs or

not; and a categorical variable classifying countries in nine

groups with similar TB epidemiology (see Appendix 1).

At the univariate level, all risk factors were associated

with the outcome of TB mortality. e nal multivariate

model included the infant mortality rate per 1000 live

births, HIV prevalence among the general population, gross

domestic product per capita, the percentage of the total

population aged <15 and ≥65 years, whether a country was

in the list of 22 HBCs or not; and the categorical variable

that dened country groups with similar TB epidemiology.

Out of a total 4686 country-year observations in the

time series for 1990–2011, 802 could not be predicted

due to data not being available for any of the ten variables

included in the model.

Estimates of TB mortality predicted by the model were

used for 26 countries3 in which VR or mortality survey data

of sucient quality and coverage were not available and for

which estimates of TB incidence were judged too uncertain.

3.3 Estimating TB mortality among HIV-negative

people from estimates of case-fatality rates and

TB incidence

In 68 countries lacking VR data of the necessary coverage

and quality (in total, 94 countries lacked VR data of su-

cient coverage and quality but among 26 of them, the eco-

logical model described above was used), TB mortality was

estimated as the product of TB incidence (see section 4)

and the CFR using a model developed in 2012.

CFRs were estimated separately for TB cases notied to

NTPs and non-notied cases and, within these two groups,

separate estimates were made for HIV-negative TB cases in

high-income and other countries (Table A1.1).

TABLE A1.1

Estimates of TB case-fatality rates (HIV-negative) by

case type and country

%#5'6;2'#0&%17064;)4172 /'#056#0&#4&&'8+#6+10

0QPPQVKßGFJKIJKPEQOG

countries

0.12 (0.042)

0QPPQVKßGFQVJGTEQWPVTKGU 0.32 (0.13)

0QVKßGFJKIJKPEQOGEQWPVTKGU 0.039 (0.042)

0QVKßGFQVJGTEQWPVTKGU 0.074 (0.03)

For consistency with VR- or survey-based mortality esti-

mates, CFRs were estimated such that they gave the best t

to the directly measured TB death rates (within their uncer-

tainty ranges) in the 123 countries with VR or mortality

1 Mathers CD et al. Counting the dead and what they died from: an

assessment of the global status of cause of death data. Bulletin of the

World Health Organization, 2005, 83:171–177.

2 Hyndman R et al. Forecasting with exponential smoothing: the state

space approach. Springer Series in Statistics, 2008.

3 For the list of the 26 countries, see www.who.int/tb/publications/

global_report/gtbr13_ mortality_source.csv.

104 GLOBAL TUBERCULOSIS REPORT 2013

survey data that were retained for analysis, in conjunction

with WHO estimates of distributions of TB incidence in

those countries. is statistical tting used Bayesian linear

models and was done separately for two groups of countries

(high-income and all other countries), to account for dier-

ences in the ratio of reported TB mortality to TB notica-

tion rates among these two groups (data not shown).

e models used normal errors and Gibbs sampling:

y = (I – N)β1 + Nβ2 + ¡, ¡ ~ N(0,σ2)

where y is TB mortality from VR, I denotes TB incidence

excluding people living with HIV, N denotes TB notica-

tions excluding people living with HIV, and parameters β1

and β2 denote the CFR in non-notied and notied cases

respectively. Semi-conjugate priors were set with an unin-

formative inverse Gamma prior on the conditional error

variance:

b ~ N(bi,Bi-2), σ2 ~ IG(5.10-4,5.10-4)

For low- and middle-income countries, priors b and their

precision B were dened based on literature reviews1 and

the country-year CFR parameters used by WHO for the

years 1999–2008. For high-income countries, non-infor-

mative priors were used. Convergence of Markov Chains

was assessed graphically and using convergence diagnos-

tic tests. Within each case category 1990–2011, mortality

estimates were computed by taking the product of posteri-

or distributions of the CFR, assumed to be time-indepen-

dent (Table A1.1), and country-year specic distributions

of estimated incidence.

3.4 Estimating TB mortality among

HIV-positive people

No nationally representative measurements of HIV-associ-

ated TB mortality were available from VR systems for use

in this report. In the absence of direct measurements, TB

mortality among HIV-positive people was estimated indi-

rectly according to the following methods (also see section

4.5) implemented in the Spectrum software.2

TB mortality is calculated as the product of HIV-positive

TB incidence (see section 4.5) and case fatality ratios:

M = (I-N)Fu + NFn

where I represents incident TB cases among people living

with HIV, N represents HIV-positive cases that are notied,

(I-N) represents HIV-positive TB cases that are not notied

and M represents TB mortality among HIV-positive peo-

ple. Fn and Fu are the case fatality ratios for notied and

non-notied incident cases, respectively.

e case fatality ratios were obtained in collabora-

tion with the TB Modeling and Analysis Consortium

(TB-MAC),3,4,5 and are shown in Table A1.2.

e disaggregation of incident TB into notied and not

notied cases is based on the ratio of the point estimates

for incident and notied cases. A single CFR was used for all

bootstrapped mortality estimates.

Direct measurements of HIV-associated TB mortality

are urgently needed. is is especially the case for coun-

tries such as South Africa and Zimbabwe, where national

VR systems are already in place. In other countries, more

eorts are needed to initiate the implementation of sample

VR systems as an interim measure.

3.5 TB mortality disaggregated by age and sex

For countries with VR data, it was possible to estimate TB

deaths (excluding TB deaths among HIV-positive people)

among children (aged <15 years) and adults (aged ≥ 15 years)

separately. It was also possible to disaggregate TB deaths by

sex. For these countries, male:female and child:adult ratios

of TB deaths (expressed as rates per 100000 population)

were calculated (after correction for ill-dened causes of

deaths and VR coverage). e ecological model described in

section 3.2 was used to predict ratios for countries with no

VR data. Directly measured (i.e. based on VR data for the

latest available year) or predicted country-level ratios were

then used to estimate ratios for WHO regions. ese were

then used to estimate the global ratio which was in turn

applied to the global number of estimated TB deaths among

HIV-negative TB cases to produce age and sex-disaggregat-

ed estimates.

TB deaths among HIV-positive people were disaggregat-

ed by sex using the assumption that the male:female sex

ratio is the same as the sex ratio of AIDS deaths estimated

by UNAIDS. Further details are provided in Box 2.2, Chap-

ter 2. Disaggregation of TB deaths by age and sex will be

one of the future developments of the TB component of the

Spectrum software (also see section 3.4).

TABLE A1.2

Estimates of the case fatality ratio among

HIV-positive TB cases

NON-NOTIFIED NOTIFIED

HIV-

Mode of triangular distribution 0.43 0.03

*+8PQVTGEGKXKPI#46

Mode of triangular distribution  0.09

4GEGKXKPI#46HQTNGUUVJCPQPG[GCT

Mode of triangular distribution 0.62 0.06

4GEGKXKPI#46HQTOQTGVJCPQPG[GCT

Mode of triangular distribution 0.49 0.04

1 Straetemans M et al. Assessing tuberculosis case fatality ratio: a

meta-analysis. PLoS One. 2011, 6(6):e20755.

2 http://www.futuresinstitute.org/spectrum.aspx

3 Tiemersma EW, van der Werf MJ, Borgdor MW, Williams BG,

Nagelkerke NJ (2011) Natural history of tuberculosis: duration

and fatality of untreated pulmonary tuberculosis in HIV negative

patients: a systematic review. PLoS One 6: e17601.

4 Corbett EL, Watt CJ, Walker N, Maher D, Williams BG, et al. (2003)

e growing burden of tuberculosis: global trends and interactions

with the HIV epidemic. Archives of Internal Medicine; 163: 1009–

1021.

5 Mukadi YD, Maher D, Harries A (2001) Tuberculosis case fatality

rates in high HIV prevalence populations in sub-Saharan Africa.

AIDS; 15: 143–152.

105GLOBAL TUBERCULOSIS REPORT 2013

4. Estimates of TB incidence, 1990–2012

No country has ever undertaken a nationwide survey of

TB incidence because of the large sample sizes required

and associated major logistic and nancial challenges. As

a result, there are no direct measurements of the incidence

of TB. eoretically, data from TB surveillance systems

that are linked to health systems of high coverage and per-

formance may capture all (or almost all) incident cases of

TB. e WHO Global Task Force on TB Impact Measure-

ment has developed a set of TB surveillance standards and

benchmarks that, if met, would allow direct measurement

of TB cases and deaths from surveillance data (Chapter 2).

In the absence of direct measurements, estimates of TB

incidence for almost all countries rely on methods described

in sections 4.1–4.3.

It should be emphasized that incidence estimates are

no longer derived from surveys of the prevalence of TB

infection as measured in tuberculin surveys. e WHO

Global Task Force on TB Impact Measurement has agreed

that methods for deriving incidence from the prevalence

of infection are unreliable. e Task Force has also stated

that, with a few exceptions, repeat tuberculin surveys do

not provide a reliable estimate of the trend in TB incidence.1

4.1 Estimating TB incidence from estimates of

the proportion of cases detected

Notication data for new and recurrent cases have been

analysed in combination with evidence about the cover-

age of the TB surveillance system and expert opinion in

six regional workshops and country missions held during

the period 2009–2013, according to methods developed by

the WHO Global Task Force on TB Impact Measurement.

By May 2013, these workshops and country missions had

covered 96 countries (Figure 2.1, Chapter 2), with several

countries re-assessed multiple times.

For the 96 countries covered by these regional work-

shops and country missions, incidence was estimated

according to the following equation:

case notications

incidence =

1 – underreporting

Expert opinion about the proportion of TB cases2 that were

not reported was elicited for three reference years (1997,

2003 and, depending on when the workshop was held,

2008–2012). is was done following in-depth analysis of

notication data (including data from sub-national admin-

istrative levels), programmatic data reecting eorts in TB

care and control (for example, data on infrastructure, sta-

ing, the performance of services and funding) and (where

available) data from inventory studies.3 In addition, data

on access to health care from Demographic and Health Sur-

veys 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 (Table A1.3). Results

from inventory studies combined with capture–recapture

modelling were used to estimate the gap between notied

cases and TB incidence in three countries that participated

in regional workshops: Egypt, Iraq and Yemen.

A full description of the methods used in these work-

shops is available in a report of the workshop held for

countries in the African Region (in Harare, Zimbabwe,

December 2010).4

TABLE A1.3

Sources of information and data on TB incidence

used in regional workshops and country missions

2155+$.'%#6')14+'51(+0%+&'06%#5'5 5174%'51(&#6#

Do not have physical or

ßPCPEKCNCEEGUUVQJGCNVJECTG

Demographic and health

surveys, KABPa surveys Capture–

recapture

modelling

Seek care, but TB not

diagnosed Survey

TB diagnosed, but not

reported ‘Inventory’ survey

4GRQTVGFECUGU TB surveillance

a KABP = knowledge, attitudes, behaviour and practices.

Distributions of the proportion of cases that were not

reported in the three reference years were assumed to fol-

low a Beta distribution (Table A1.4). Reasons for using

Beta distributions include the following:

ey are continuous and dened on the interval (0, 1).

Since the variance of the proportions of cases that were

not reported tend to be large as a result of high uncer-

tainty, random draws of numbers from a normal distri-

bution would yield numbers outside the interval (0, 1).

e use of truncated normal distributions may result in

excess density towards one of the bounds.

ey are not necessarily symmetrical.

ey are dened with two parameters that can be

estimated from available data using the method of

moments.5

e shape and scale parameters necessary to dene the Beta

distribution were computed using the method of moments,

as follows:

First, 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 plau-

sible range for the proportion of incident cases that were

1 TB impact measurement: policy and recommendations for how to assess

the epidemiological burden of TB and the impact of TB control. Gene-

va, World Health Organization, 2009 (Stop TB policy paper, no. 2;

WHO/HTM/TB/2009.416).

2 Dened as cases of all forms of TB, including sputum smear-pos-

itive pulmonary cases, sputum smear-negative pulmonary cases

and extrapulmonary cases.

3 Measurements from ‘inventory’ studies can be used to quantify the

number of cases that are diagnosed but not reported to national

surveillance systems.

4 See www.who.int/tb/advisory_bodies/impact_measurement_

taskforce

5 Rényi A. Probability theory. New York, Dover Publications Inc.,

2007.

106 GLOBAL TUBERCULOSIS REPORT 2013

reported (also referred to as the case detection rate in

Chapter 3).

Shape 1 (noted α) and 2 (noted β) follow from:

α = sE

β = s(l – E)

where E is the expected value of the distribution.

Time series for the period 1990–2012 were built accord-

ing to the characteristics of the levels of underreporting

and under-diagnosis that were estimated for the three ref-

erence years. A cubic spline extrapolation of V and E, with

knots set at the reference years, was used for countries

with low-level or concentrated HIV epidemics. In countries

with a generalized HIV epidemic, the trajectory of inci-

dence from 1990 to the rst reference year (usually 1997)

was based on the annual rate of change in HIV prevalence.

Incidence trajectories were derived from the series of noti-

ed TB cases using Monte Carlo simulations from which

expected values, 2.5th and 97.5th centiles were extracted.

All computations were conducted in the R statistical envi-

ronment.1

In two countries, incidence rates were estimated to be

similar to those in a neighbouring country because infor-

mation from surveillance systems was insucient: esti-

mates for West Bank and Gaza Strip were extrapolated

from estimates for Jordan and estimates for South Sudan

were extrapolated from estimates for Sudan. e estimates

for West Bank and Gaza Strip and South Sudan should

therefore be considered as preliminary.

Trends in incidence were derived from repeat tuberculin

survey results in Bhutan, India and Yemen and for 40 coun-

tries (including countries in Eastern Europe) from trends

in mortality.

If there were insucient data to determine the factors

leading to time-changes in case notications, incidence was

assumed to follow a horizontal trend going through the

most recent estimate of incidence.

4.2 Estimating TB incidence from data on

case notißcations and expert opinion for

high-income countries

For high-income countries, the level of TB incidence was

assumed to be distributed between the notication rate

for new and recurrent cases combined, including reported

cases with undocumented treatment history as explained

in section 2.1 (lower uncertainty bound, noted l) and 1.3

times the notication rate (upper uncertainty bound, not-

ed u), as informed by expert opinion. e distribution of

incidence was assumed to follow a Beta distribution with

shape and scale parameters computed using the method of

moments, as described above.

In the absence of country-specic data on the quality

and coverage of TB surveillance systems, it was assumed

that TB surveillance systems from countries in the high-in-

come group performed similarly well, although the mod-

el does allow for stochastic uctuations. e exceptions

were the United Kingdom and the Netherlands, where the

underreporting of TB cases has been measured using inven-

tory studies and capture–recapture modelling.2,3 For these

two countries, the results from these studies were used to

measure TB incidence directly.

4.3 Estimating TB incidence from empirical

measurements of disease prevalence

Incidence can be estimated using measurements from

national surveys of the prevalence of TB disease combined

with estimates of the duration of disease. Incidence is esti-

mated as the prevalence of TB divided by the average dura-

tion of disease.

In practice, the duration of disease cannot be directly

measured. For example, measurements of the duration of

symptoms in prevalent TB cases that are detected during a

prevalence survey are systematically biased towards lower

values, since active case-nding truncates the natural his-

tory of undiagnosed disease. Measurements of the duration

of disease in notied cases ignore the duration of disease

among non-notied and untreated cases.

Literature reviews commissioned by the WHO Global

Task Force on TB Impact Measurement have provided esti-

mates of the duration of disease in untreated TB cases from

the pre-chemotherapy era (before the 1950s). e best esti-

mate of the mean duration of disease (for smear-positive

cases and smear-negative cases combined) in HIV-negative

individuals is about three years. However, the proportion

of incident cases that remain untreated is unknown. ere

are few data on the duration of disease in HIV-positive indi-

viduals.

When measurements from two prevalence surveys were

available, trends in TB prevalence were derived by tting a

log-linear model to available measurements. When three or

more prevalence measurements were available, the preva-

lence trajectory was built using cubic spline interpolation.

If only one prevalence survey measurement was available,

time-trends were assessed using in-depth analysis of sur-

veillance data, as described above.

In this report, the prevalence to incidence method was

used for two countries: Ethiopia and the Lao People’s Dem-

ocratic Republic.

4.4 Disaggregation of TB incidence

In this report, TB incidence is disaggregated by HIV-infec-

tion status (see section 4.5) at country level. e estima-

tion of smear-positive TB incidence was discontinued in

E(l – E)

s = – l

1 R Development Core Team. R: a language and environment for sta-

tistical computing. Vienna, R Foundation for Statistical Computing,

2009 (www.R-project.org).

2 Tuberculosis in the UK: annual report on tuberculosis surveillance in the UK

2010. London, Health Protection Agency Centre for Infections, 2010

(also available at: www.hpa.org.uk/web/HPAweb&HPAwebStandard/

HPAweb_C/1287143581697; accessed July 2011).

3 van Hest NA et al. Completeness of notication of tuberculosis in

e Netherlands: how reliable is record-linkage and capture–recap-

ture analysis? Epidemiology and Infection, 2007, 135(6):1021–1029.

107GLOBAL TUBERCULOSIS REPORT 2013

2010, for reasons explained in detail in the global report

published in 2010.

Global and WHO regional estimates of sex-disaggregat-

ed incidence were also calculated, based on country-level

female:male ratios of total new (all case types) TB case

notications, under the assumption that they are a proxy

of female:male ratios of incidence. Model-based estimated

WHO regional ratios were applied to global incidence for

the nal sex disaggregation (Chapter 2).

TB incidence was also disaggregated by age, to produce

global estimates among children (aged <15 years) and

adults (aged ≥ 15 years). Details of methods are provided in

Chapter 2, Box 2.2.

4.5 Estimates of HIV prevalence among

incident TB cases, 1990–2012

TB incidence was disaggregated by HIV and CD4 status

using the Spectrum software.1 WHO estimates of TB inci-

dence were used as inputs to the Spectrum HIV model. e

model was tted to WHO estimates of TB incidence, and

then used to produce estimates of TB incidence among

people living with HIV disaggregated by CD4 category.2 A

regression method was used to estimate the relative risk

(RR) for TB incidence according to the CD4 categories used

by Spectrum for national HIV projections. Spectrum data

were based on the national projections prepared for the

UNAIDS Report on the global AIDS epidemic 2012. e model

can also be used to estimate TB mortality among HIV-pos-

itive people, the resource requirements associated with

recently updated guidance on ART3 and the impact of ART

expansion.

A exible and relatively simple way of modelling TB inci-

dence (or any time-dependent function) is to represent it as

k time-dependent m’th order cubic-spline functions:

I(x) = Σi=1 to k βi Bmi(x)

where βi is the i’th spline coecient and Bmi(x) represents

the evaluation of the i-th basis function at time(year) x. e

TABLE A1.4

Parameter estimates used to produce estimates of TB incidence, prevalence and mortality

/1&'.2#4#/'6'4 &+564+$76+10 &+564+$76+102#4#/'6'45b

Incidence, high-income countries Betaa

where ě was set at 1. times the notißcation rate noted N and V is

deßned by

HIV prevalence among incident TB Betaa

Where –

Z is the eZpected Xalue and V is IiXen by

&WTCVKQPQHFKUGCUGPQPPQVKßGF 7PKHQTO NW[GCTU

HIV-negative cases of TB

&WTCVKQPQHFKUGCUGPQPPQVKßGF 7PKHQTO NW[GCTU

HIV-positive cases of TB

&WTCVKQPQHFKUGCUGPQVKßGF 7PKHQTO NW[GCTU

HIV-negative cases of TB

&WTCVKQPQHFKUGCUGPQVKßGF 7PKHQTO NW[GCTU

HIV-positive cases of TB

a 6JGRTQDCDKNKV[FGPUKV[HWPEVKQPQHVJG$GVCFKUVTKDWVKQPKU

b u and l denote upper and lower bounds.

α = –

Z .–

Z (1– –

Z )

V– 1

α = ě .ě (1– ě )

V– 1

β = (1– ě )

.ě (1– ě )

V– 1

β = (1– –

Z ) .–

Z (1– –

Z )

V– 1

4 (Z; _, β) = Z _ –1 (1– x) ` –1

0t _ –1 (1– t) ` –1 dt

V = 0.3

4N2

V = u – l

1 http://www.futuresinstitute.org/spectrum.aspx

2 Stover J, McKinnon R, Winfrey B. Spectrum: a model platform for

linking maternal and child survival interventions with AIDS, fam-

ily planning and demographic projections. International Journal of

Epidemiology 2010; 39 Suppl 1:i7–10.

3 http://www.who.int/hiv/pub/guidelines/arv2013/en/index.html

 GLOBAL TUBERCULOSIS REPORT 2013

order of each basis function is m and cubic splines are used,

i.e. m=3. e equation simply states that any time-depen-

dent function, such as incidence, can be represented as a

linear combination of cubic-spline basis functions. e val-

ues of the cubic-spline coecients β were determined by

an optimization routine that minimizes the least squares

error between incidence data (Iobs) and the estimated inci-

dence curve I(x):

Σx=1990:2012 |I(x) - Iobs(x)|2 + λ β T S β

Here |I - Iobs|2 is the sum of squared errors in estimat-

ed incidence and S is a dierence penalty matrix applied

directly to the parameters β to control the level of varia-

tion between adjacent coecients of the cubic-spline, and

thus control (through a choice of λ) the smoothness of the

time-dependent case incidence curve. Another important

purpose of the use of the smoothness penalty matrix S is to

regularize (by creating smoothness dependencies between

adjacent parameters) the ill-conditioned inverse problem

(more unknown parameters than the data can resolve) that

would tend to over t the data when left ill-conditioned.

Cubic5plines and conßdence intervals

e cubic-spline method was then used to t indicators

(incidence, case notications, etc.) to a set of bootstrapped

data, obtained by sampling from the normal error distribu-

tion resulting from tting the ‘point estimate’. is boot-

strap method produces a sample of projected cubic-spline

curves that are practically equivalent to a set that would

be obtained from tting the model to the same number of

repeated measurements (or assessments) of the given indi-

cator. Condence intervals based on the bootstrapped data

are typically narrow in the years where the model has data

to utilize, and ‘spread out’ after that, according to a Gauss-

ian process with an increasing variance.

Projecting TB incidence among people living with HIV

by CD4 category

e disaggregation of TB incidence by CD4 category among

people living with HIV was based on the idea that an

increase in the relative risk for TB incidence is a function of

CD4 decline. Williams et al captured this idea in a model for

the relationship between the RR for TB and CD4 decline.1

ey suggested a 42% (+/- 17%) increase in RR for TB for

each unit of 100μL CD4 decline.

e Spectrum-TB model’s disaggregation method is

based on the Williams et al. model. e model rst esti-

mates incidence among people living with HIV, and then

calculates the ‘risk of TB’ F=I- / P-, where I- is TB incidence

among people living with HIV and P- is the number of peo-

ple living with HIV who are susceptible to TB.

An assumption is made that the risk of TB infection

among people living with HIV with CD4 count > 500 μL is

proportional to F (it was assumed that it was higher by a

factor of 2.52). For each 100 μL CD4 decline in the remain-

ing categories (350–499, 250–349, 200–249, 100–199,

50–99 CD4 cells/μL, and CD4 count less than 50 cells μL),

the risk of infection is represented as:

F(c<500) = F(c>500)∙p(1)∙p(2)dc,

where p(1) is a parameter that is used to recognize that

people living with HIV who have high CD4 counts could

be at higher risk of TB infection relative to those who are

HIV-negative, and p(2) controls the exponential increase in

RR that occurs with CD4 decline. dc is the number of 100μL

CD4 decline associated with the midpoint of each CD4 cate-

gory relative to 500: dc= (3.0, 4.4, 8.6, 12.9, 19.2, 28.6, 37.3)

for the six CD4 categories.

A reduction in RR is applied for those who have been on

ART for more than one year.

Parameter assumptions

To match total TB incidence and estimates of the num-

ber of HIV-positive TB cases from HIV testing data where

available, it was assumed that p(1)=2.5 and p(2) was tted

accordingly.

In the RR-approach, the ‘biological meaning’ that should

be attached to the parameters and a more straightforward

interpretation of these parameters as regression coe-

cients need to be balanced. Both parameters can be tted

or both can be xed. Varying at least p(2) captures the vari-

ation among countries that is expected due to variation

in the baseline (HIV-negative) CD4 count, and it strikes a

balance between the biological and regression mechanisms.

e RR model approach to estimation of TB incidence

was used for people on ART. Although an estimate of TB

incidence among people on ART could be obtained from

surveillance data reported to WHO (such that it is arguably

not necessary to use the RR model), limitations of the ART

data (in particular that some countries appear to report

cumulative totals of people on ART) meant that the RR

approach needed to be used.

Hazard ratios (HR) of 0.35 were assumed for all CD4 at

ART initiation categories. Suthar et al have reported HRs

of 0.16, 0.35 and 0.43 for those on ART with CD4 count

< 200, 200–350 and > 350,3 and these values could in prin-

ciple be used. However, Spectrum tracks only CD4 at initi-

ation, thus limiting the use of CD4-specic HRs for people

on ART.

It was further assumed that the HR of 0.35 applies only

to patients on ART for more than six months. Spectrum’s

ART-mortality estimates, derived mostly from ART cohorts

in Sub-Saharan Africa, suggest that mortality remains very

1 Williams B. e impact of ART for HIV on TB. http://www.who.int/

hiv/topics/artforprevention/williams.pdf (accessed July 2013).

2 Sonnenberg P, et al. How Soon after Infection with HIV Does the

Risk of Tuberculosis Start to Increase? A Retrospective Cohort

Study in South African Gold Miners. Journal of Infectious Diseas-

es.2005 Jan 15;191(2):150–8.

3 Suthar AB, Lawn SD, del Amo J, Getahun H, Dye C, et al. (2012)

Antiretroviral erapy for Prevention of Tuberculosis in Adults

with HIV: A Systematic Review and Meta-Analysis. PLoS Med 9(7):

e1001270. doi:10.1371/journal.pmed.1001270

109GLOBAL TUBERCULOSIS REPORT 2013

high in the rst six months of ART. Since TB is a leading

contributor to mortality among HIV-positive people, it was

judged that the HR for patients on ART for 0‒6 months is

likely to remain high; therefore, a reduction factor due to

ART was not applied for this subset of patients.

Likelihood function

A simple least squares approach was used to t the model to

total TB incidence, and to all available estimates of TB inci-

dence among people living with HIV. ese estimates of TB

incidence among people living with HIV were obtained by

three sampling methods: population surveys of the preva-

lence of HIV among TB cases (least biased, but scarce due

to logistical constraints), sentinel HIV data (biases include

more testing of people with advanced HIV-related disease)

and routine HIV testing of reported TB patients (variable

coverage). To increase the inuence of survey data, replicas

of the survey data were included in the likelihood function.

In other words, for years for which data from HIV testing

were available, identical copies of the HIV-test data were

added to the likelihood function. e estimate of total TB

incidence was based on much more data, evenly spread out

in the estimation period 1990–2015.

Model testing showed that using two replicates of the

HIV survey data (i.e. duplicating the survey data) and

two replicates of the routine testing data with coverage

greater than 90% was the best approach to disaggregating

TB incidence: the t passed close to the survey or high-

coverage routine testing data points that were available.

For each of a) HIV sentinel and b) routine testing with cov-

erage between 50–90%, data were not used.

A prototype Bayesian importance sampling (IMIS)

algorithm was developed to handle complex data weigh-

ing possibilities, but it was based on subjective priors and

likelihood functions and is more time-consuming to run

than simple least squares. For the purposes of producing

estimates for all countries automatically, the least squares

method was used. In future, least squares and IMIS tting

could be made available to the end user.

For countries with no data, a range for p(2) was esti-

mated from countries with survey or testing data, which

suggest that p(2) = 1.96 [1.8–2.1]. e RR-model was then

tted to total TB incidence only. ere is no satisfactory

way to verify results for TB incidence among people living

with HIV when no HIV-testing data are available. However,

comparison of the global estimate for TB incidence among

people living with HIV produced by Spectrum and esti-

mates previously published by WHO (based on a dierent

method using HIV prevalence instead of CD4 distributions

and using HIV-test data in a dierent way) suggests that

the RR-model works reasonably well.

Provider-initiated testing and counselling with at least

50% HIV testing coverage is the most widely available

source of information on the prevalence of HIV in TB

patients. However, this source of data is aected by biases,

particularly when coverage is closer to 50% than to 100%.

In all countries with repeat data from testing, the relation-

ship between the prevalence of HIV in TB patients and the

coverage of HIV testing was examined graphically. In some

countries, the prevalence of HIV in TB patients was found

to decrease with increasing HIV testing coverage while in

others it increased with increasing HIV testing coverage;

in most countries, the prevalence of HIV followed highly

inconsistent patterns (with repeat changes in direction) as

HIV testing coverage increased. erefore, it was not pos-

sible to adjust for the eect of incomplete coverage of HIV

testing on estimates of the prevalence of HIV among TB

patients. e assumption was thus made that TB patients

with an HIV test result were statistically representative

of all TB cases. As coverage of HIV testing continues to

increase globally, biases will decrease.

For the 1003 country-year data points corresponding to

countries for which no surveillance data were available, the

prevalence of HIV was estimated indirectly according to

the following equation:

In this equation, t is HIV prevalence among incident TB

cases, h is HIV prevalence among the general population

(from the latest time-series provided by UNAIDS) and ρ is

the incidence rate ratio (IRR) (dened as the incidence rate

of TB in HIV-positive people divided by the incidence rate

of TB in HIV-negative people). We then let logit(t) be log(t/

(1-t)) and logit(h) be log(h/(1-h)). Using data from countries

where HIV prevalence has been estimated by UNAIDS as an

independent variable, a linear model of logit-transformed

t was tted using logit-transformed h according to the fol-

lowing equation, written in matrix notation:

TXβ

where ˆ

T is a vector of predicted logit(t), X is an n x 2 matrix

in which the rst column holds 1s, and the second column

holds logit(h). e vector β holds estimated model parame-

ters. Models were tested with lags set for logit(h) ranging

from no lag to a lag of eight years. e best t was obtained

with a lag of one year.

Models were run using Monte Carlo simulations in

which h was drawn randomly from a Beta distribution with

shape parameters computed as described in Section 4.1,

(low and high uncertainty bounds are provided by UNAIDS

– also see Table A1.5). e model was run 50000 times

TABLE A1.5

Sources of data on HIV prevalence among

incident TB cases

&+4'%6/'#574'/'061(6*'24'8#.'0%'1(*+8+06$2#6+'065 07/$'41(%17064;;'#45

National surveysa124

HIV sentinel surveillance 24

Provider-initiated testing and counselling with at

least 50% coverage of testing 1297

Total, at least one data source available 1322

a the reported survey number is over-stated as a number of country reports confused

survey and routine testing with near 100% coverage

l + h(l – l)

t =

110 GLOBAL TUBERCULOSIS REPORT 2013

using country-specic distributions for H and T (noted in

capital letters to denote vectors or matrices) based on their

uncertainty intervals. e uncertainty bounds for β were

chosen as the 2.5th and 97.5th centiles.

5. Estimates of TB prevalence, 1990–2012

e best way to measure the prevalence of TB is through

national population-based surveys of TB disease.1,2 Data

from such surveys are available for an increasing number

of countries (Chapter 2). It should be noted, however, that

measurements of prevalence are typically conned to the

adult population. Furthermore, prevalence surveys exclude

extrapulmonary cases and do not allow the diagnosis of

cases of culture-negative pulmonary TB.

When there is no direct measurement from a national

survey of the prevalence of TB disease, prevalence is the

most uncertain of the three TB indicators used to measure

disease burden. is is because prevalence is the product of

two uncertain quantities: (i)incidence and (ii) disease dura-

tion. e duration of disease is very dicult to quantify

because it cannot be measured during surveys of the prev-

alence of TB disease (surveys truncate the natural history

of disease). Duration can be assessed in self-presenting

patients, but there is no practical way to measure the dura-

tion of disease in patients who are not notied to NTPs.

Indirect estimates of prevalence were calculated accord-

ing to the following equation:

P = -Ii,jdi,j, iD{1,2}, jD{1,2}

where the index variable i denotes HIV+ and HIV–, the

index variable j denotes notied and non-notied cases, d

denotes the duration of disease in notied cases and I is

total incidence. In the absence of measurements, we did not

allow duration in notied cases to vary among countries.

Given their underlying uncertainty, prevalence estimates

should be used with great caution in the absence of direct

measurements from a prevalence survey. Unless measure-

ments were available from national programmes (for exam-

ple, Turkey), assumptions of the duration of disease were

used as shown in the last four rows of Table A1.3.

6. Estimates of the number of cases

of and deaths from MDR-TB

 2TQRQTVKQPQHPQVKßGFECUGUQH6$VJCVJCXG

MDR-TB, 2012

Global and regional estimates of the proportion of new and

retreatment cases of TB that had MDR-TB in 2012 were cal-

culated using country-level information. If countries had

reported data on the proportion of new and retreatment

cases of TB that have MDR-TB from routine surveillance

or a survey of drug resistance the latest available informa-

tion was used. For countries that have not reported such

data, estimates of the proportion of new and retreatment

cases of TB that have MDR-TB were produced using mod-

elling (including multiple imputation) that was based on

data from countries for which data do exist. Estimates for

countries without data were based on countries that were

considered to be similar in terms of TB epidemiology (for

country groups see Appendix 1). e observed and imputed

estimates of the proportion of new and retreatment cases

of TB that have MDR-TB were then pooled to give a global

estimate, with countries weighted according to their share

of global notications of new and retreatment cases.

6.2 MDR-TB mortality, 2012

e VR mortality data reported to WHO by Member States

does not dierentiate between MDR-TB and non-MDR-TB

as a cause of death (there is no specic ICD-9 or ICD-10

codes for MDR-TB, although countries such as South Africa

have allocated two specic codes U51 and U52 to classify

deaths from MDR-TB and XDR-TB respectively).3 ere-

fore, a systematic review and meta-analysis of the pub-

lished literature was undertaken to estimate the relative

risk of dying from MDR-TB compared with non MDR-TB.

e global estimate of MDR-TB deaths (Box 2.3) was then

based on the following formula:

m = M.p.r

Where:

m = global MDR-TB mortality,

M = global TB mortality,

p = overall proportion of MDR-TB among prevalent TB

cases, approximated by the weighted average of the

proportion of new and retreated cases that have MDR-

TB,

r = the relative risk of dying from MDR-TB versus non-

MDR-TB.

6.3 Numbers of incident cases of MDR-TB, 2012

e global estimate of MDR-TB incidence was calculated as

the addition of three groups of MDR-TB incident cases:

1. incident MDR-TB among new pulmonary and extra-pul-

monary incident TB cases, using the proportion of

MDR-TB among new cases from drug resistance surveil-

lance (DRS);

2. incident MDR-TB among relapses, using the proportion

of MDR-TB among new cases from DRS and the esti-

mated relative risk of MDR among relapse versus new

cases; and

3. incident MDR-TB among retreated cases that are not

relapses, which was assumed to follow a uniform distri-

bution with min=0, max=upper limit of the global pro-

portion of MDR-TB among retreated cases estimated

from DRS.

A second method to estimate global MDR-TB incidence was

also explored, in which the global estimate of mortality due

1 Glaziou P et al. Tuberculosis prevalence surveys: rationale and

cost. International Journal of Tuberculosis and Lung Disease, 2008,

12(9):1003–1008.

2 TB prevalence surveys: a handbook. Geneva, World Health Organiza-

tion, 2011 (WHO/HTM/TB/2010.17).

3 Mortality and causes of death in South Africa, 2010: Findings from

death notification. http://www.statssa.gov.za/publications/

p03093/p030932010.pdf

111GLOBAL TUBERCULOSIS REPORT 2013

to MDR-TB was divided by the estimated case fatality ratio

(CFR) among cases of MDR-TB. e CFR was calculated as

a weighted average of the case fatality ratio among patients

that are treated and those that are not, according to the fol-

lowing formula:

4 = pt * 4t + (1-pt)*4un

Where:

pt = proportion treated, approximated by the proportion

of enrolled MDR-TB patients on treatment out of

those estimated to exist among notied TB patients

with pulmonary TB;

4t = case fatality rate among patients treated for MDR-TB,

using treatment outcome data for MDR-TB patient

cohorts;

4un = case fatality rate among people with MDR-TB who are

not treated, which was assumed to follow a uniform

distribution with min=0.4, max=0.6.

Outputs from both methods gave similar best estimates

of MDR-TB incidence with largely overlapping condence

intervals.

6.4 Resistance to second-line drugs among

patients with MDR-TB

Data from 75 countries were used to produce global esti-

mates of the following proportions: (i) patients with MDR-

TB who had XDR-TB; (ii) patients with MDR-TB who had

uoroquinolone resistance; (iii) patients with MDR-TB who

had resistance to second-line injectable drugs and uoro-

quinolones but not XDR-TB. e latest available national

and subnational data from each country were analysed

using logistic regression models with robust standard

errors to account for the clustering eect at the level of the

country or territory. e analysis was limited to countries

in which more than 66% of MDR-TB cases received sec-

ond-line DST.

7. Projections of incidence, prevalence

and mortality up to 2015

Projections of TB incidence, prevalence and mortality

ratesup to 2015enable assessment of whether global tar-

gets set for 2015 are likely to be achieved at global, region-

al and country levels. Projections for the years 2013–2015

weremade using exponential smoothingmodels tted to

data from 2006–2012.

8. Estimation of uncertainty

ere are many potential sources of uncertainty associated

with estimates of TB incidence, prevalence and mortality,

as well as estimates of the burden of HIV-associated TB

and MDR-TB. ese include uncertainties in input data, in

parameter values, in extrapolations used to impute missing

data, and in the models used.

We used xed population values from the UNPD. We did

not account for any uncertainty in these values.

Notication data are of uneven quality. Cases may be

underreported (for example, missing quarterly reports

from remote administrative areas are not uncommon), mis-

classied (in particular, misclassication of recurrent cases

in the category of new cases is common), or overreported

as a result of duplicated entries in TB information systems.

e latter two issues can only be addressed eciently in

countries with case-based nationwide TB databases that

include patient identiers. Sudden changes in notications

over time are often the result of errors or inconsistencies in

reporting, but may sometimes reect abrupt changes in TB

epidemiology (for example, resulting from a rapid inux of

migrants from countries with a high burden of TB, or from

rapid improvement in case-nding eorts).

Missing national aggregates of new and recurrent cas-

es were imputed by interpolation. Notication trajectories

were smoothed using a penalized cubic splines function

with parameters based on the data. Attempts to obtain cor-

rections for historical data are made every year, but only

rarely do countries provide appropriate data corrections.

Mortality estimates incorporated the following sourc-

es of uncertainty: sampling uncertainty in the underlying

measurements of TB mortality rates from data sources,

uncertainty in estimates of incidence rates and rates of HIV

prevalence among both incident and notied TB cases, and

parameter uncertainty in the Bayesian model. Time series

of TB mortality were generated for each country through

Monte Carlo simulations.

Unless otherwise specied, uncertainty bounds and

ranges were dened as the 2.5th and 97.5th centiles of out-

come distributions. roughout this report, ranges with

upper and lower bounds dened by these centiles are pro-

vided for all estimates established with the use of simula-

tions. When uncertainty was established with the use of

observed or other empirical data, 95% condence intervals

are reported.

e model used the following sequence: (1) Overall TB

incidence estimation after review and cleaning of case

notication data; (2) cleaning and adjustment of raw mor-

tality data from VR systems and mortality surveys, fol-

lowed by imputation of missing values in countries with

VR or survey data – in some countries, step 1 was updat-

ed to account for mortality data; (3) cleaning of measure-

ments of HIV prevalence among TB patients followed by

estimating HIV-positive TB incidence using the Spectrum

programme and HIV-positive TB mortality; (4) estimation

of HIV prevalence among incident cases of TB through

modelling in countries with no measurements; (5) estima-

tion of HIV-negative TB mortality in countries with no VR

data followed with an update of step 1 in some countries;

(6) review of prevalence measurements, adjustments for

childhood TB and bacteriologically unconrmed TB, and

estimation of prevalence followed with an update of step 1

in some countries; (7) estimation of incidence and mortali-

ty disaggregated by age and sex and disaggregated by drug

resistance status.

e general approach to uncertainty analyses was to

draw values from specied distributions for every param-

112 GLOBAL TUBERCULOSIS REPORT 2013

eter (except for notications and population values) in

Monte Carlo simulations, with the number of simulation

runs set so that they were sucient to ensure stability

in the outcome distributions. For each country, the same

random generator seed was used for every year, and errors

were assumed to be time-dependent within countries

(thus generating autocorrelation in time series). Regional

parameters were used in some instances (for example, for

CFRs). Summaries of quantities of interest were obtained

by extracting the mean, 2.5th and 97.5th centiles of pos-

terior distributions. Wherever possible, uncertainty was

propagated analytically by approximating the moments of

functions of random variables using Taylor expansions –

such as when taking the product or the ratio of two random

variables – rather than through Monte Carlo simulations,

in order to shorten computing time.

Appendix 1. Epidemiological regions used

for analyses

Africa – countries with high HIV prevalence: Botswa-

na, Burundi, Cameroon, the Central African Republic, the

Congo, Côte d’Ivoire, the Democratic Republic of the Con-

go, Ethiopia, Gabon, Kenya, Lesotho, Malawi, Mozambique,

Namibia, Nigeria, Rwanda, South Africa, South Sudan,

Swaziland, Uganda, the United Republic of Tanzania, Zam-

bia, Zimbabwe.

Africa – countries with low HIV prevalence: Alge-

ria, Angola, Benin, Burkina Faso, Cape Verde, Chad, the

Comoros, Djibouti, Eritrea, the Gambia, Ghana, Guinea,

Guinea-Bissau, Liberia, Madagascar, Mali, Mauritania,

Mauritius, the Niger, Sao Tome and Principe, Senegal, Sey-

chelles, Sierra Leone, Somalia, Sudan, Togo.

Central Europe: Albania, Bosnia and Herzegovina, Mon-

tenegro, Serbia, the former Yugoslav Republic of Macedo-

nia, Turkey.

Eastern Europe: Armenia, Azerbaijan, Belarus, Bulgaria,

Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, the

Republic of Moldova, Romania, the Russian Federation,

Tajikistan, Turkmenistan, Ukraine, Uzbekistan.

High-income countries: Andorra, Aruba, Australia,

Austria, the Bahamas, Bahrain, Barbados, Belgium, Bermu-

da, Brunei Darussalam, Canada, the Cayman Islands, Chi-

na, Hong Kong SAR, China Macao SAR, Croatia, Cyprus,

the Czech Republic, Denmark, Equatorial Guinea, Esto-

nia, Finland, France, French Polynesia, Germany, Greece,

Greenland, Guam, Hungary, Iceland, Ireland, Israel, Italy,

Japan, Kuwait, Luxembourg, Malta, Monaco, the Nether-

lands, the Netherlands Antilles, New Caledonia, New Zea-

land, Northern Mariana Islands, Norway, Oman, Poland,

Portugal, Puerto Rico, Qatar, the Republic of Korea, Saint

Kitts and Nevis, San Marino, Saudi Arabia, Singapore, Slo-

vakia, Slovenia, Spain, Sweden, Switzerland, Trinidad and

Tobago, the Turks and Caicos Islands, US Virgin Islands,

United Arab Emirates, the United Kingdom, the United

States.

Eastern Mediterranean: Afghanistan, Egypt, Iran (Islamic

Republic of), Iraq, Jordan, Lebanon, Libya, Morocco, Paki-

stan, Syrian Arab Republic, Tunisia, West Bank and the

Gaza Strip, Yemen.

Latin America: Anguilla, Antigua and Barbuda, Argen-

tina, Belize, Bolivia (Plurinational State of), Bonaire,

Saint Eustatius and Saba, Brazil, British Virgin Islands,

Chile, Colombia, Costa Rica, Cuba, Curaçao, Dominica, the

Dominican Republic, Ecuador, El Salvador, Grenada, Gua-

temala, Guyana, Haiti, Honduras, Jamaica, Mexico, Mont-

serrat, Nicaragua, Panama, Paraguay, Peru, Saint Kitts

and Nevis, Saint Lucia, Saint Vincent and the Grenadines,

Sint Maarten (Dutch part), Suriname, Uruguay, Venezuela

(Bolivarian Republic of).

South East Asia: Bangladesh, Bhutan, Democratic Peo-

ple’s Republic of Korea, India, Indonesia, Maldives, Myan-

mar, Nepal, Sri Lanka, ailand, Timor-Leste.

West Pacic: American Samoa, Cambodia, China, Cook

Islands, Fiji, Kiribati, Lao People’s Democratic Republic,

Malaysia, Marshall Islands, Micronesia (Federated State

of), Mongolia, Nauru, Niue, Palau, Papua New Guinea,

the Philippines, Samoa, Solomon Islands, Tokelau, Tonga,

Tuvalu, Vanuatu, Viet Nam, Wallis and Futuna Islands.

#00':

Country proßles

115 Data for all years can be downloaded from www.who.int/tb/data GLOBAL TUBERCULOSIS REPORT 2013

Data are as reported to WHO. Estimates of TB and MDR-TB burden are produced by WHO in consultation with

countries.

a Ranges represent uncertainty intervals.

HIGH TB BURDEN

Estimates of TB burdena 2012

07/$'4(thousands)4#6' (per 100 000 population)

/QTVCNKV[GZENWFGU*+86$ ¿ ¿

/QTVCNKV[*+86$QPN[ ¿ ¿ 

2TGXCNGPEGKPENWFGU*+86$ ¿ ¿

+PEKFGPEGKPENWFGU*+86$ ¿ ¿

Incidence (HIV+TB only) 0.31 (0.19–0.46) 1 (0.63–1.5)

Case detection, all forms (%) 52 (44–63)

6$ECUGPQVKßECVKQPU    

0'9%#5'5   4'64'#6/'06%#5'5  

5OGCTRQUKVKXG   4GNCRUG  

Smear-negative 4 740 (17) Treatment after failure 160 (13)

Smear-unknown / not done 2 665 (9) Treatment after default 37 (3)

Extrapulmonary 6 906 (24) Other

Other 702 (2)

Total new 28 332 Total retreatment 1 246

Other (history unknown)

6QVCNPGYCPFTGNCRUG   6QVCNECUGUPQVKßGF 

New cases

  5/'#40')#6+8'70-0190

 5/'#4215+6+8' 016&10' ':64#27./10#4;

/(TCVKQ   

#IG   

Laboratories 2012

Smear (per 100 000 population) 2.0

Culture (per 5 million population) 0.3

Drug susceptibility testing (per 5 million population) 0

+UUGEQPFNKPGFTWIUWUEGRVKDKNKV[VGUVKPICXCKNCDNG! ;GUQWVUKFGEQWPVT[

6TGCVOGPVUWEEGUUTCVG    

New smear-positive and/or culture-positive 91

0GYUOGCTPGICVKXGGZVTCRWNOQPCT[ 

4GVTGCVOGPV 

Is rifampicin used throughout treatment for new patients? No

TB/HIV 2012 07/$'4 (%)

TB patients with known HIV status 7 275 (25)

*+8RQUKVKXG6$RCVKGPVU  

*+8RQUKVKXG6$RCVKGPVUQPEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26  

*+8RQUKVKXG6$RCVKGPVUQPCPVKTGVTQXKTCNVJGTCR[#46  

*+8RQUKVKXGRGQRNGUETGGPGFHQT6$  

HIV-positive people provided with IPT 25

Estimates of MDR-TB burden 2012a 0'9 4'64'#6/'06

QH6$ECUGUYKVJ/&46$ ¿ ¿

/&46$ECUGUCOQPIPQVKßGF

pulmonary TB cases 750 (21–2 600) 400 (93–700)

Reported cases of MDR-TB 20120'9 4'64'#6/'06 616#.

%CUGUVGUVGFHQT/&46$   

.CDQTCVQT[EQPßTOGF/&46$ECUGU   

2CVKGPVUUVCTVGFQP/&46$VTGCVOGPV   

Financing TB control 2013

0CVKQPCN6$RTQITCOOGDWFIGV75OKNNKQPU 

% Funded domestically 3%

% Funded internationally 65%

% Unfunded 32%

AFGHANISTAN Population 2012 30 million

Mortality (excludes HIV+TB) (rate

per 100 000 population per year)

1990 1995 2000 2005 2010

100

120

Prevalence

(rate per 100 000 population)

1990 1995 2000 2005 2010

250

500

750

1000

Incidence (rate per 100 000

population per year)

1990 1995 2000 2005 2010

Incidence Incidence (HIV+TB) Notifications

100

200

300

Treatment success rate (%)

1995 1997 1999 2001 2003 2005 2007 2009 2011

100

New smear-positive (and/or culture-positive) Retreatment

New smear-negative/extrapulmonary

Number of patients

HIV-positive TB patients on CPT on ART

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Total budget (US$ millions)

Funded domestically Funded internationally Unfunded

2009 2010 2011 2012 2013

116 GLOBAL TUBERCULOSIS REPORT 2013 Data for all years can be downloaded from www.who.int/tb/data

&CVCCTGCUTGRQTVGFVQ9*1'UVKOCVGUQH6$CPF/&46$DWTFGPCTGRTQFWEGFD[9*1KPEQPUWNVCVKQPYKVJ

countries.

a 4CPIGUTGRTGUGPVWPEGTVCKPV[KPVGTXCNU'UVKOCVGUQH6$FKUGCUGDWTFGPJCXGPQVDGGPCRRTQXGFD[

the national TB programme in Bangladesh and a joint reassessment will be undertaken following the

completion of the prevalence survey planned for 2014.

b Comprehensive data on domestic and international funding in 2013 could not be reported. Funding from

75#+&HQT1EVQDGT¿5GRVGODGTYCU75OKNNKQP

BANGLADESH Population 2012 155 million

HIGH TB BURDEN | HIGH MDR-TB BURDEN

Estimates of TB burdena 2012

 07/$'46*175#0&5 4#6'(per 100 000 population)

/QTVCNKV[GZENWFGU*+86$ ¿ ¿

/QTVCNKV[*+86$QPN[ ¿ ¿

2TGXCNGPEGKPENWFGU*+86$ ¿ ¿

+PEKFGPEGKPENWFGU*+86$ ¿ ¿

Incidence (HIV+TB only) 0.24 (0.2–0.29) 0.16 (0.13–0.19)

Case detection, all forms (%) 49 (41–59)

6$ECUGPQVKßECVKQPU    

0'9%#5'5   4'64'#6/'06%#5'5  

5OGCTRQUKVKXG   4GNCRUG  

5OGCTPGICVKXG   6TGCVOGPVCHVGTHCKNWTG  

Smear-unknown / not done 0 (0) Treatment after default 257 (3)

'ZVTCRWNOQPCT[   1VJGT  

Other 0 (0)

Total new 161 790 Total retreatment 8 001

1VJGTJKUVQT[WPMPQYP     

6QVCNPGYCPFTGNCRUG   6QVCNECUGUPQVKßGF 

New cases

  5/'#40')#6+8'70-0190

 5/'#4215+6+8' 016&10' ':64#27./10#4;

/(TCVKQ   

#IG   

Laboratories 2012

Smear (per 100 000 population) 0.7

%WNVWTGRGTOKNNKQPRQRWNCVKQP 

&TWIUWUEGRVKDKNKV[VGUVKPIRGTOKNNKQPRQRWNCVKQP 

+UUGEQPFNKPGFTWIUWUEGRVKDKNKV[VGUVKPICXCKNCDNG! ;GUQWVUKFGEQWPVT[

6TGCVOGPVUWEEGUUTCVG    

New smear-positive and/or culture-positive 92

0GYUOGCTPGICVKXGGZVTCRWNOQPCT[ 

4GVTGCVOGPV 

+UTKHCORKEKPWUGFVJTQWIJQWVVTGCVOGPVHQTPGYRCVKGPVU! ;GU

TB/HIV 2012 07/$'4 (%)

6$RCVKGPVUYKVJMPQYP*+8UVCVWU  

HIV-positive TB patients 63 (3)

*+8RQUKVKXG6$RCVKGPVUQPEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26  

*+8RQUKVKXG6$RCVKGPVUQPCPVKTGVTQXKTCNVJGTCR[#46  

HIV-positive people screened for TB 429

HIV-positive people provided with IPT 0

Estimates of MDR-TB burden 2012a 0'9 4'64'#6/'06

QH6$ECUGUYKVJ/&46$ ¿ ¿

/&46$ECUGUCOQPIPQVKßGF

pulmonary TB cases 1 900 (920–3 300) 2 300 (1 900–2 700)

Reported cases of MDR-TB 20120'9 4'64'#6/'06 616#.

%CUGUVGUVGFHQT/&46$   

.CDQTCVQT[EQPßTOGF/&46$ECUGU   

2CVKGPVUUVCTVGFQP/&46$VTGCVOGPV   

Financing TB controlb 2013

0CVKQPCN6$RTQITCOOGDWFIGV75OKNNKQPU 

Mortality (excludes HIV+TB) (rate

per 100 000 population per year)

1990 1995 2000 2005 2010

100

150

Prevalence

(rate per 100 000 population)

1990 1995 2000 2005 2010

250

500

750

1000

Incidence (rate per 100 000

population per year)

1990 1995 2000 2005 2010

Incidence Incidence (HIV+TB) Notifications

100

200

300

400

Treatment success rate (%)

New smear-positive (and/or culture-positive) Retreatment

New smear-negative/extrapulmonary

100

1995 1997 1999 2001 2003 2005 2007 2009 2011

Number of patients

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

HIV-positive TB patients on CPT on ART

Total budget (US$ millions)

Funded domestically Funded internationally Unfunded

2009 2010 2011 2012

117 Data for all years can be downloaded from www.who.int/tb/data GLOBAL TUBERCULOSIS REPORT 2013

Data are as reported to WHO. Estimates of TB and MDR-TB burden are produced by WHO in consultation with

countries.

a Ranges represent uncertainty intervals.

BRAZIL Population 2012 199 million

HIGH TB BURDEN | HIGH HIV BURDEN

Estimates of TB burdena 2012

07/$'4(thousands)4#6' (per 100 000 population)

Mortality (excludes HIV+TB) 4.9 (4.6–5.2) 2.5 (2.3–2.6)

Mortality (HIV+TB only) 2.5 (2.2–3) 1.3 (1.1–1.5)

Prevalence (includes HIV+TB) 120 (51–210) 59 (25–107)

+PEKFGPEGKPENWFGU*+86$ ¿ ¿

+PEKFGPEG*+86$QPN[ ¿ ¿

%CUGFGVGEVKQPCNNHQTOU ¿ 

6$ECUGPQVKßECVKQPU    

0'9%#5'5   4'64'#6/'06%#5'5  

5OGCTRQUKVKXG   4GNCRUG  

5OGCTPGICVKXG   6TGCVOGPVCHVGTHCKNWTG  

5OGCTWPMPQYPPQVFQPG   6TGCVOGPVCHVGTFGHCWNV 

Extrapulmonary 10 297 (14) Other 4 133 (36)

1VJGT     

Total new 71 230 Total retreatment 11 500

Other (history unknown) 25

6QVCNPGYCPFTGNCRUG   6QVCNECUGUPQVKßGF 

New cases

  5/'#40')#6+8'70-0190

 5/'#4215+6+8' 016&10' ':64#27./10#4;

/(TCVKQ   

#IG   

Laboratories 2012

Smear (per 100 000 population) 2.0

Culture (per 5 million population) 5.5

Drug susceptibility testing (per 5 million population) 0.9

+UUGEQPFNKPGFTWIUWUEGRVKDKNKV[VGUVKPICXCKNCDNG! ;GUKPEQWPVT[

6TGCVOGPVUWEEGUUTCVG    

New smear-positive and/or culture-positive 76

New smear-negative/extrapulmonary 70

4GVTGCVOGPV 

+UTKHCORKEKPWUGFVJTQWIJQWVVTGCVOGPVHQTPGYRCVKGPVU! ;GU

TB/HIV 2012 07/$'4 (%)

TB patients with known HIV status 45 733 (55)

HIV-positive TB patients 9 049 (20)

*+8RQUKVKXG6$RCVKGPVUQPEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26  

*+8RQUKVKXG6$RCVKGPVUQPCPVKTGVTQXKTCNVJGTCR[#46  

HIV-positive people screened for TB

HIV-positive people provided with IPT

Estimates of MDR-TB burden 2012a 0'9 4'64'#6/'06

QH6$ECUGUYKVJ/&46$ ¿ ¿

/&46$ECUGUCOQPIPQVKßGF

RWNOQPCT[6$ECUGU ¿ ¿

Reported cases of MDR-TB 20120'9 4'64'#6/'06 616#.

%CUGUVGUVGFHQT/&46$   

.CDQTCVQT[EQPßTOGF/&46$ECUGU   

2CVKGPVUUVCTVGFQP/&46$VTGCVOGPV   

Financing TB control 2013

0CVKQPCN6$RTQITCOOGDWFIGV75OKNNKQPU 

(WPFGFFQOGUVKECNN[ 

% Funded internationally 2%

% Unfunded 14%

Mortality (excludes HIV+TB) (rate

per 100 000 population per year)

1990 1995 2000 2005 2010

Prevalence

(rate per 100 000 population)

1990 1995 2000 2005 2010

100

200

300

Incidence (rate per 100 000

population per year)

1990 1995 2000 2005 2010

Incidence Incidence (HIV+TB) Notifications

100

150

Treatment success rate (%)

New smear-positive (and/or culture-positive) Retreatment

New smear-negative/extrapulmonary

1995 1997 1999 2001 2003 2005 2007 2009 2011

100

Number of patients

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

HIV-positive TB patients on CPT on ART

2000

4000

6000

8000

10 000

Total budget (US$ millions)

Funded domestically Funded internationally Unfunded

2009 2010 2011 2012 2013

100

 GLOBAL TUBERCULOSIS REPORT 2013 Data for all years can be downloaded from www.who.int/tb/data

Data are as reported to WHO. Estimates of TB and MDR-TB burden are produced by WHO in consultation with

countries.

a Ranges represent uncertainty intervals.

CAMBODIA Population 2012 15 million

HIGH TB BURDEN | HIGH HIV BURDEN

Estimates of TB burdena 2012

07/$'4(thousands)4#6'(per 100 000 population)

Mortality (excludes HIV+TB) 9.3 (4.3–16) 63 (29–110)

/QTVCNKV[*+86$QPN[ ¿ ¿

2TGXCNGPEGKPENWFGU*+86$ ¿ ¿

Incidence (includes HIV+TB) 61 (52–70) 411 (353–474)

+PEKFGPEG*+86$QPN[ ¿ ¿

Case detection, all forms (%) 66 (57–77)

6$ECUGPQVKßECVKQPU    

0'9%#5'5   4'64'#6/'06%#5'5  

5OGCTRQUKVKXG   4GNCRUG  

5OGCTPGICVKXG   6TGCVOGPVCHVGTHCKNWTG  

Smear-unknown / not done 0 (0) Treatment after default 22 (4)

Extrapulmonary 15 290 (40) Other

Other 0 (0)

Total new 38 637 Total retreatment 519

Other (history unknown) 1 102

6QVCNPGYCPFTGNCRUG   6QVCNECUGUPQVKßGF 

New cases

  5/'#40')#6+8'70-0190

 5/'#4215+6+8' 016&10' ':64#27./10#4;

/(TCVKQ   

#IG   

Laboratories 2012

Smear (per 100 000 population) 1.4

Culture (per 5 million population) 1.0

Drug susceptibility testing (per 5 million population) 0.3

Is second-line drug susceptibility testing available? No

6TGCVOGPVUWEEGUUTCVG    

New smear-positive and/or culture-positive 93

New smear-negative/extrapulmonary 94

4GVTGCVOGPV 

+UTKHCORKEKPWUGFVJTQWIJQWVVTGCVOGPVHQTPGYRCVKGPVU! ;GU

TB/HIV 2012 07/$'4 (%)

6$RCVKGPVUYKVJMPQYP*+8UVCVWU  

HIV-positive TB patients 1 433 (4)

*+8RQUKVKXG6$RCVKGPVUQPEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26  

*+8RQUKVKXG6$RCVKGPVUQPCPVKTGVTQXKTCNVJGTCR[#46  

HIV-positive people screened for TB

HIV-positive people provided with IPT 1 145

Estimates of MDR-TB burden 2012a 0'9 4'64'#6/'06

QH6$ECUGUYKVJ/&46$ ¿ ¿

/&46$ECUGUCOQPIPQVKßGF

pulmonary TB cases 330 (160–590) 56 (21–110)

Reported cases of MDR-TB 20120'9 4'64'#6/'06 616#.

%CUGUVGUVGFHQT/&46$   

.CDQTCVQT[EQPßTOGF/&46$ECUGU   

2CVKGPVUUVCTVGFQP/&46$VTGCVOGPV   

Financing TB control 2013

0CVKQPCN6$RTQITCOOGDWFIGV75OKNNKQPU 

% Funded domestically 5%

% Funded internationally 34%

% Unfunded 62%

Mortality (excludes HIV+TB) (rate

per 100 000 population per year)

1990 1995 2000 2005 2010

100

200

300

400

Prevalence

(rate per 100 000 population)

1990 1995 2000 2005 2010

500

1000

1500

2000

2500

Incidence (rate per 100 000

population per year)

1990 1995 2000 2005 2010

Incidence Incidence (HIV+TB) Notifications

250

500

750

1000

Treatment success rate (%)

New smear-positive (and/or culture-positive) Retreatment

New smear-negative/extrapulmonary

1995 1997 1999 2001 2003 2005 2007 2009 2011

100

Number of patients

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

HIV-positive TB patients on CPT on ART

2000

4000

6000

Total budget (US$ millions)

Funded domestically Funded internationally Unfunded

2009 2010 2011 2012 2013

119 Data for all years can be downloaded from www.who.int/tb/data GLOBAL TUBERCULOSIS REPORT 2013

Data are as reported to WHO. Estimates of TB and MDR-TB burden are produced by WHO in consultation with

countries.

a Ranges represent uncertainty intervals.

CHINA Population 2012 1 377 million

HIGH TB BURDEN | HIGH HIV BURDEN | HIGH MDR-TB BURDEN

Estimates of TB burdena 2012

07/$'4(thousands)4#6' (per 100 000 population)

Mortality (excludes HIV+TB) 44 (43–46) 3.2 (3.1–3.3)

/QTVCNKV[*+86$QPN[ ¿ ¿

2TGXCNGPEGKPENWFGU*+86$ ¿ ¿

+PEKFGPEGKPENWFGU*+86$ ¿ ¿

+PEKFGPEG*+86$QPN[ ¿ ¿

%CUGFGVGEVKQPCNNHQTOU ¿ 

6$ECUGPQVKßECVKQPU    

0'9%#5'5   4'64'#6/'06%#5'5  

5OGCTRQUKVKXG   4GNCRUG  

5OGCTPGICVKXG   6TGCVOGPVCHVGTHCKNWTG  

5OGCTWPMPQYPPQVFQPG   6TGCVOGPVCHVGTFGHCWNV 

'ZVTCRWNOQPCT[   1VJGT  

Other 0 (0)

Total new 858 861 Total retreatment 41 817

Other (history unknown) 0

6QVCNPGYCPFTGNCRUG   6QVCNECUGUPQVKßGF 

New cases

  5/'#40')#6+8'70-0190

 5/'#4215+6+8' 016&10' ':64#27./10#4;

/(TCVKQ   

#IG   

Laboratories 2012

Smear (per 100 000 population) 0.2

Culture (per 5 million population) 3.7

Drug susceptibility testing (per 5 million population) 0.7

+UUGEQPFNKPGFTWIUWUEGRVKDKNKV[VGUVKPICXCKNCDNG! ;GUKPEQWPVT[

6TGCVOGPVUWEEGUUTCVG    

New smear-positive and/or culture-positive 95

New smear-negative/extrapulmonary 95

4GVTGCVOGPV 

+UTKHCORKEKPWUGFVJTQWIJQWVVTGCVOGPVHQTPGYRCVKGPVU! ;GU

TB/HIV 2012 07/$'4 (%)

TB patients with known HIV statusb  

*+8RQUKVKXG6$RCVKGPVU  

*+8RQUKVKXG6$RCVKGPVUQPEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26  

*+8RQUKVKXG6$RCVKGPVUQPCPVKTGVTQXKTCNVJGTCR[#46  

HIV-positive people screened for TB 294 795

HIV-positive people provided with IPT

Estimates of MDR-TB burden 2012a 0'9 4'64'#6/'06

QH6$ECUGUYKVJ/&46$ ¿ ¿

/&46$ECUGUCOQPIPQVKßGF

RWNOQPCT[6$ECUGU ¿ ¿

Reported cases of MDR-TB 20120'9 4'64'#6/'06 616#.

%CUGUVGUVGFHQT/&46$   

.CDQTCVQT[EQPßTOGF/&46$ECUGU   

2CVKGPVUUVCTVGFQP/&46$VTGCVOGPV   

Financing TB control 2013

0CVKQPCN6$RTQITCOOGDWFIGV75OKNNKQPU 

% Funded domestically 74%

% Funded internationally 11%

% Unfunded 15%

Mortality (excludes HIV+TB) (rate

per 100 000 population per year)

1990 1995 2000 2005 2010

Prevalence

(rate per 100 000 population)

1990 1995 2000 2005 2010

100

200

300

Incidence (rate per 100 000

population per year)

1990 1995 2000 2005 2010

Incidence Incidence (HIV+TB) Notifications

100

150

200

Treatment success rate (%)

New smear-positive (and/or culture-positive) Retreatment

New smear-negative/extrapulmonary

1995 1997 1999 2001 2003 2005 2007 2009 2011

100

Number of patients

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

HIV-positive TB patients on CPT on ART

2000

4000

6000

Total budget (US$ millions)

Funded domestically Funded internationally Unfunded

2009 2010 2011 2012 2013

100

200

300

400

120 GLOBAL TUBERCULOSIS REPORT 2013 Data for all years can be downloaded from www.who.int/tb/data

Data are as reported to WHO. Estimates of TB and MDR-TB burden are produced by WHO in consultation with

countries.

a Ranges represent uncertainty intervals.

DEMOCRATIC REPUBLIC OF THE CONGO Population 2012 66 million

HIGH TB BURDEN | HIGH HIV BURDEN | HIGH MDR-TB BURDEN

Estimates of TB burdena 2012

07/$'4(thousands)4#6'(per 100 000 population)

Mortality (excludes HIV+TB) 36 (16–64) 54 (24–97)

/QTVCNKV[*+86$QPN[ ¿ ¿

2TGXCNGPEGKPENWFGU*+86$ ¿ ¿

+PEKFGPEGKPENWFGU*+86$ ¿ ¿

Incidence (HIV+TB only) 16 (14–19) 25 (22–29)

Case detection, all forms (%) 51 (44–59)

6$ECUGPQVKßECVKQPU    

0'9%#5'5   4'64'#6/'06%#5'5  

5OGCTRQUKVKXG   4GNCRUG  

5OGCTPGICVKXG   6TGCVOGPVCHVGTHCKNWTG  

5OGCTWPMPQYPPQVFQPG   6TGCVOGPVCHVGTFGHCWNV  

Extrapulmonary 20 669 (20) Other 2 321 (31)

Other

Total new 105 007 Total retreatment 7 492

Other (history unknown)

6QVCNPGYCPFTGNCRUG   6QVCNECUGUPQVKßGF 

New cases

  5/'#40')#6+8'70-0190

 5/'#4215+6+8' 016&10' ':64#27./10#4;

/(TCVKQ   

#IG   

Laboratories 2012

Smear (per 100 000 population) 2.3

Culture (per 5 million population) 0.3

Drug susceptibility testing (per 5 million population) 0.2

+UUGEQPFNKPGFTWIUWUEGRVKDKNKV[VGUVKPICXCKNCDNG! ;GUKPCPFQWVUKFGEQWPVT[

6TGCVOGPVUWEEGUUTCVG    

0GYUOGCTRQUKVKXGCPFQTEWNVWTGRQUKVKXG 

0GYUOGCTPGICVKXGGZVTCRWNOQPCT[ 

4GVTGCVOGPV 

+UTKHCORKEKPWUGFVJTQWIJQWVVTGCVOGPVHQTPGYRCVKGPVU! ;GU

TB/HIV 2012 07/$'4 (%)

TB patients with known HIV status 35 097 (31)

*+8RQUKVKXG6$RCVKGPVU  

*+8RQUKVKXG6$RCVKGPVUQPEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26  

*+8RQUKVKXG6$RCVKGPVUQPCPVKTGVTQXKTCNVJGTCR[#46  

HIV-positive people screened for TB

HIV-positive people provided with IPT

Estimates of MDR-TB burden 2012a 0'9 4'64'#6/'06

QH6$ECUGUYKVJ/&46$ ¿ ¿

/&46$ECUGUCOQPIPQVKßGF

RWNOQPCT[6$ECUGU ¿ ¿

Reported cases of MDR-TB 20120'9 4'64'#6/'06 616#.

%CUGUVGUVGFHQT/&46$   

.CDQTCVQT[EQPßTOGF/&46$ECUGU   

2CVKGPVUUVCTVGFQP/&46$VTGCVOGPV   

Financing TB control 2013

0CVKQPCN6$RTQITCOOGDWFIGV75OKNNKQPU 

% Funded domestically 1%

% Funded internationally 25%

% Unfunded 74%

Mortality (excludes HIV+TB) (rate

per 100 000 population per year)

1990 1995 2000 2005 2010

100

150

Prevalence

(rate per 100 000 population)

1990 1995 2000 2005 2010

500

1000

1500

Incidence (rate per 100 000

population per year)

1990 1995 2000 2005 2010

Incidence Incidence (HIV+TB) Notifications

100

200

300

400

Treatment success rate (%)

New smear-positive (and/or culture-positive) Retreatment

New smear-negative/extrapulmonary

1995 1997 1999 2001 2003 2005 2007 2009 2011

100

Number of patients

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

HIV-positive TB patients on CPT on ART

2000

4000

6000

8000

Total budget (US$ millions)

Funded domestically Funded internationally Unfunded

2009 2010 2011 2012 2013

121 Data for all years can be downloaded from www.who.int/tb/data GLOBAL TUBERCULOSIS REPORT 2013

Data are as reported to WHO. Estimates of TB and MDR-TB burden are produced by WHO in consultation with

countries.

a Ranges represent uncertainty intervals.

ETHIOPIA Population 2012 92 million

HIGH TB BURDEN | HIGH HIV BURDEN | HIGH MDR-TB BURDEN

Estimates of TB burdena 2012

07/$'4(thousands)4#6' (per 100 000 population)

/QTVCNKV[GZENWFGU*+86$ ¿ ¿

/QTVCNKV[*+86$QPN[ ¿ ¿

2TGXCNGPEGKPENWFGU*+86$ ¿ ¿

+PEKFGPEGKPENWFGU*+86$ ¿ ¿

Incidence (HIV+TB only) 23 (17–30) 25 (19–33)

%CUGFGVGEVKQPCNNHQTOU ¿ 

6$ECUGPQVKßECVKQPU    

0'9%#5'5   4'64'#6/'06%#5'5  

5OGCTRQUKVKXG   4GNCRUG  

5OGCTPGICVKXG   6TGCVOGPVCHVGTHCKNWTG  

5OGCTWPMPQYPPQVFQPG   6TGCVOGPVCHVGTFGHCWNV  

'ZVTCRWNOQPCT[   1VJGT  

Other 0 (0)

Total new 143 503 Total retreatment 4 089

Other (history unknown) 0

6QVCNPGYCPFTGNCRUG   6QVCNECUGUPQVKßGF 

New cases

  5/'#40')#6+8'70-0190

 5/'#4215+6+8' 016&10' ':64#27./10#4;

/(TCVKQ   

#IG   

Laboratories 2012

5OGCTRGTRQRWNCVKQP 

Culture (per 5 million population) 0.3

&TWIUWUEGRVKDKNKV[VGUVKPIRGTOKNNKQPRQRWNCVKQP 

Is second-line drug susceptibility testing available? No

6TGCVOGPVUWEEGUUTCVG    

New smear-positive and/or culture-positive 90

0GYUOGCTPGICVKXGGZVTCRWNOQPCT[ 

4GVTGCVOGPV 

+UTKHCORKEKPWUGFVJTQWIJQWVVTGCVOGPVHQTPGYRCVKGPVU! ;GU

TB/HIV 2012 07/$'4 (%)

TB patients with known HIV status 96 245 (65)

*+8RQUKVKXG6$RCVKGPVU  

*+8RQUKVKXG6$RCVKGPVUQPEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26  

*+8RQUKVKXG6$RCVKGPVUQPCPVKTGVTQXKTCNVJGTCR[#46  

*+8RQUKVKXGRGQRNGUETGGPGFHQT6$  

HIV-positive people provided with IPT 30 395

Estimates of MDR-TB burden 2012a 0'9 4'64'#6/'06

QH6$ECUGUYKVJ/&46$ ¿ ¿

/&46$ECUGUCOQPIPQVKßGF

RWNOQPCT[6$ECUGU ¿ ¿

Reported cases of MDR-TB 20120'9 4'64'#6/'06 616#.

%CUGUVGUVGFHQT/&46$   

.CDQTCVQT[EQPßTOGF/&46$ECUGU   

2CVKGPVUUVCTVGFQP/&46$VTGCVOGPV   

Financing TB control 2013

0CVKQPCN6$RTQITCOOGDWFIGV75OKNNKQPU 

% Funded domestically 17%

% Funded internationally 32%

% Unfunded 51%

Mortality (excludes HIV+TB) (rate

per 100 000 population per year)

1990 1995 2000 2005 2010

Prevalence

(rate per 100 000 population)

1990 1995 2000 2005 2010

200

400

600

800

Incidence (rate per 100 000

population per year)

1990 1995 2000 2005 2010

Incidence Incidence (HIV+TB) Notifications

250

500

750

Treatment success rate (%)

New smear-positive (and/or culture-positive) Retreatment

New smear-negative/extrapulmonary

1995 1997 1999 2001 2003 2005 2007 2009 2011

100

Number of patients

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

HIV-positive TB patients on CPT on ART

4000

8000

12 000

Total budget (US$ millions)

Funded domestically Funded internationally Unfunded

2009 2010 2011 2012 2013

120

180

122 GLOBAL TUBERCULOSIS REPORT 2013 Data for all years can be downloaded from www.who.int/tb/data

&CVCCTGCUTGRQTVGFVQ9*1'UVKOCVGUQH6$CPF/&46$DWTFGPCTGRTQFWEGFD[9*1KPEQPUWNVCVKQPYKVJ

countries.

a 4CPIGUTGRTGUGPVWPEGTVCKPV[KPVGTXCNU'UVKOCVGUHQT+PFKCJCXGPQV[GVDGGPQHßEKCNN[CRRTQXGFD[VJG

/KPKUVT[QH*GCNVJ(COKN[9GNHCTG)QXGTPOGPVQH+PFKCCPFUJQWNFVJGTGHQTGDGEQPUKFGTGFRTQXKUKQPCN

INDIA Population 2012 1 237 million

HIGH TB BURDEN | HIGH HIV BURDEN | HIGH MDR-TB BURDEN

Estimates of TB burdena 2012

07/$'4(thousands)4#6'(per 100 000 population)

Mortality (excludes HIV+TB) 270 (170–390) 22 (14–32)

/QTVCNKV[*+86$QPN[ ¿ ¿

2TGXCNGPEGKPENWFGU*+86$ ¿ ¿

Incidence (includes HIV+TB) 2 200 (2 000–2 400) 176 (159–193)

Incidence (HIV+TB only) 130 (120–140) 10 (9.4–12)

Case detection, all forms (%) 59 (54–66)

6$ECUGPQVKßECVKQPU    

0'9%#5'5   4'64'#6/'06%#5'5  

5OGCTRQUKVKXG   4GNCRUG  

Smear-negative 317 616 (27) Treatment after failure 16 400 (6)

5OGCTWPMPQYPPQVFQPG   6TGCVOGPVCHVGTFGHCWNV  

Extrapulmonary 234 029 (20) Other 96 567 (34)

1VJGT     

Total new 1 183 373 Total retreatment 284 212

Other (history unknown)

6QVCNPGYCPFTGNCRUG   6QVCNECUGUPQVKßGF 

New cases

  5/'#40')#6+8'70-0190

 5/'#4215+6+8' 016&10' ':64#27./10#4;

/(TCVKQ   

#IG   

Laboratories 2012

Smear (per 100 000 population) 1.1

Culture (per 5 million population) 0.3

Drug susceptibility testing (per 5 million population) 0.2

+UUGEQPFNKPGFTWIUWUEGRVKDKNKV[VGUVKPICXCKNCDNG! ;GUKPEQWPVT[

6TGCVOGPVUWEEGUUTCVG    

0GYUOGCTRQUKVKXGCPFQTEWNVWTGRQUKVKXG 

New smear-negative/extrapulmonary 90

4GVTGCVOGPV 

+UTKHCORKEKPWUGFVJTQWIJQWVVTGCVOGPVHQTPGYRCVKGPVU! ;GU

TB/HIV 2012 07/$'4 (%)

6$RCVKGPVUYKVJMPQYP*+8UVCVWU  

HIV-positive TB patients 44 063 (5)

*+8RQUKVKXG6$RCVKGPVUQPEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26  

*+8RQUKVKXG6$RCVKGPVUQPCPVKTGVTQXKTCNVJGTCR[#46 

*+8RQUKVKXGRGQRNGUETGGPGFHQT6$  

HIV-positive people provided with IPT

Estimates of MDR-TB burden 2012a 0'9 4'64'#6/'06

QH6$ECUGUYKVJ/&46$ ¿ ¿

/&46$ECUGUCOQPIPQVKßGF

RWNOQPCT[6$ECUGU ¿ ¿

Reported cases of MDR-TB 20120'9 4'64'#6/'06 616#.

%CUGUVGUVGFHQT/&46$   

.CDQTCVQT[EQPßTOGF/&46$ECUGU   

2CVKGPVUUVCTVGFQP/&46$VTGCVOGPV   

Financing TB control 2013

0CVKQPCN6$RTQITCOOGDWFIGV75OKNNKQPU 

% Funded domestically 37%

% Funded internationally 57%

% Unfunded 6%

Mortality (excludes HIV+TB) (rate

per 100 000 population per year)

1990 1995 2000 2005 2010

Prevalence

(rate per 100 000 population)

1990 1995 2000 2005 2010

200

400

600

Incidence (rate per 100 000

population per year)

1990 1995 2000 2005 2010

Incidence Incidence (HIV+TB) Notifications

100

200

300

Treatment success rate (%)

New smear-positive (and/or culture-positive) Retreatment

New smear-negative/extrapulmonary

1995 1997 1999 2001 2003 2005 2007 2009 2011

100

Number of patients

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

HIV-positive TB patients on CPT on ART

10 000

20 000

30 000

40 000

50 000

Total budget (US$ millions)

Funded domestically Funded internationally Unfunded

2009 2010 2011 2012 2013

100

150

200

250

123 Data for all years can be downloaded from www.who.int/tb/data GLOBAL TUBERCULOSIS REPORT 2013

Data are as reported to WHO. Estimates of TB and MDR-TB burden are produced by WHO in consultation with

countries.

a Ranges represent uncertainty intervals.

INDONESIA Population 2012 247 million

HIGH TB BURDEN | HIGH HIV BURDEN | HIGH MDR-TB BURDEN

Estimates of TB burdena 2012

07/$'4(thousands)4#6'(per 100 000 population)

/QTVCNKV[GZENWFGU*+86$ ¿ ¿

/QTVCNKV[*+86$QPN[ ¿ ¿

Prevalence (includes HIV+TB) 730 (350–1 200) 297 (144–506)

+PEKFGPEGKPENWFGU*+86$ ¿ ¿

Incidence (HIV+TB only) 7.5 (5.6–9.7) 3.1 (2.3–3.9)

%CUGFGVGEVKQPCNNHQTOU ¿ 

6$ECUGPQVKßECVKQPU    

0'9%#5'5   4'64'#6/'06%#5'5  

5OGCTRQUKVKXG   4GNCRUG  

5OGCTPGICVKXG   6TGCVOGPVCHVGTHCKNWTG  

Smear-unknown / not done Treatment after default 954 (11)

Extrapulmonary 15 697 (5) Other 1 179 (14)

Other

Total new 322 882 Total retreatment 8 542

Other (history unknown)

6QVCNPGYCPFTGNCRUG   6QVCNECUGUPQVKßGF 

New cases

  5/'#40')#6+8'70-0190

 5/'#4215+6+8' 016&10' ':64#27./10#4;

/(TCVKQ   

#IG   

Laboratories 2012

Smear (per 100 000 population) 2.3

Culture (per 5 million population) 0.9

Drug susceptibility testing (per 5 million population) 0.1

+UUGEQPFNKPGFTWIUWUEGRVKDKNKV[VGUVKPICXCKNCDNG! ;GUKPEQWPVT[

6TGCVOGPVUWEEGUUTCVG    

New smear-positive and/or culture-positive 90

0GYUOGCTPGICVKXGGZVTCRWNOQPCT[ 

4GVTGCVOGPV 

+UTKHCORKEKPWUGFVJTQWIJQWVVTGCVOGPVHQTPGYRCVKGPVU! ;GU

TB/HIV 2012 07/$'4 (%)

6$RCVKGPVUYKVJMPQYP*+8UVCVWU  

*+8RQUKVKXG6$RCVKGPVU  

*+8RQUKVKXG6$RCVKGPVUQPEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26  

*+8RQUKVKXG6$RCVKGPVUQPCPVKTGVTQXKTCNVJGTCR[#46  

HIV-positive people screened for TB 22 677

HIV-positive people provided with IPT

Estimates of MDR-TB burden 2012a 0'9 4'64'#6/'06

QH6$ECUGUYKVJ/&46$ ¿ ¿

/&46$ECUGUCOQPIPQVKßGF

RWNOQPCT[6$ECUGU ¿ ¿

Reported cases of MDR-TB 20120'9 4'64'#6/'06 616#.

%CUGUVGUVGFHQT/&46$   

.CDQTCVQT[EQPßTOGF/&46$ECUGU   

2CVKGPVUUVCTVGFQP/&46$VTGCVOGPV   

Financing TB control 2013

0CVKQPCN6$RTQITCOOGDWFIGV75OKNNKQPU 

% Funded domestically 14%

% Funded internationally 35%

% Unfunded 51%

Mortality (excludes HIV+TB) (rate

per 100 000 population per year)

1990 1995 2000 2005 2010

100

150

Prevalence

(rate per 100 000 population)

1990 1995 2000 2005 2010

250

500

750

1000

Incidence (rate per 100 000

population per year)

1990 1995 2000 2005 2010

Incidence Incidence (HIV+TB) Notifications

100

200

300

Treatment success rate (%)

New smear-positive (and/or culture-positive) Retreatment

New smear-negative/extrapulmonary

1995 1997 1999 2001 2003 2005 2007 2009 2011

100

Number of patients

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

HIV-positive TB patients on CPT on ART

1000

2000

3000

Total budget (US$ millions)

Funded domestically Funded internationally Unfunded

2009 2010 2011 2012 2013

100

125

124 GLOBAL TUBERCULOSIS REPORT 2013 Data for all years can be downloaded from www.who.int/tb/data

Data are as reported to WHO. Estimates of TB and MDR-TB burden are produced by WHO in consultation with

countries.

a Ranges represent uncertainty intervals.

KENYA Population 2012 43 million

HIGH TB BURDEN | HIGH HIV BURDEN

Estimates of TB burdena 2012

07/$'4(thousands)4#6'(per 100 000 population)

Mortality (excludes HIV+TB) 9.5 (5.4–15) 22 (13–34)

/QTVCNKV[*+86$QPN[ ¿ ¿

Prevalence (includes HIV+TB) 130 (71–210) 299 (163–475)

+PEKFGPEGKPENWFGU*+86$ ¿ ¿

Incidence (HIV+TB only) 45 (44–47) 105 (101–109)

%CUGFGVGEVKQPCNNHQTOU ¿ 

6$ECUGPQVKßECVKQPU    

0'9%#5'5   4'64'#6/'06%#5'5  

5OGCTRQUKVKXG   4GNCRUG  

5OGCTPGICVKXG   6TGCVOGPVCHVGTHCKNWTG  

5OGCTWPMPQYPPQVFQPG   6TGCVOGPVCHVGTFGHCWNV  

'ZVTCRWNOQPCT[   1VJGT  

Other 0 (0)

Total new 89 568 Total retreatment 9 581

Other (history unknown) 0

6QVCNPGYCPFTGNCRUG   6QVCNECUGUPQVKßGF 

New cases

  5/'#40')#6+8'70-0190

 5/'#4215+6+8' 016&10' ':64#27./10#4;

/(TCVKQ   

#IG   

Laboratories 2012

Smear (per 100 000 population) 4.2

Culture (per 5 million population) 0.2

Drug susceptibility testing (per 5 million population) 0.2

+UUGEQPFNKPGFTWIUWUEGRVKDKNKV[VGUVKPICXCKNCDNG! ;GUKPCPFQWVUKFGEQWPVT[

6TGCVOGPVUWEEGUUTCVG    

0GYUOGCTRQUKVKXGCPFQTEWNVWTGRQUKVKXG 

0GYUOGCTPGICVKXGGZVTCRWNOQPCT[ 

4GVTGCVOGPV 

+UTKHCORKEKPWUGFVJTQWIJQWVVTGCVOGPVHQTPGYRCVKGPVU! ;GU

TB/HIV 2012 07/$'4 (%)

6$RCVKGPVUYKVJMPQYP*+8UVCVWU  

*+8RQUKVKXG6$RCVKGPVU  

*+8RQUKVKXG6$RCVKGPVUQPEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26  

*+8RQUKVKXG6$RCVKGPVUQPCPVKTGVTQXKTCNVJGTCR[#46 

HIV-positive people screened for TB

HIV-positive people provided with IPT

Estimates of MDR-TB burden 2012a 0'9 4'64'#6/'06

QH6$ECUGUYKVJ/&46$ ¿ ¿

/&46$ECUGUCOQPIPQVKßGF

RWNOQPCT[6$ECUGU ¿ ¿

Reported cases of MDR-TB 20120'9 4'64'#6/'06 616#.

%CUGUVGUVGFHQT/&46$   

.CDQTCVQT[EQPßTOGF/&46$ECUGU   

2CVKGPVUUVCTVGFQP/&46$VTGCVOGPV   

Financing TB control 2013

0CVKQPCN6$RTQITCOOGDWFIGV75OKNNKQPU 

% Funded domestically 24%

% Funded internationally 15%

% Unfunded 61%

Mortality (excludes HIV+TB) (rate

per 100 000 population per year)

1990 1995 2000 2005 2010

Prevalence

(rate per 100 000 population)

1990 1995 2000 2005 2010

200

400

600

Incidence (rate per 100 000

population per year)

1990 1995 2000 2005 2010

Incidence Incidence (HIV+TB) Notifications

100

200

300

400

Treatment success rate (%)

New smear-positive (and/or culture-positive) Retreatment

New smear-negative/extrapulmonary

1995 1997 1999 2001 2003 2005 2007 2009 2011

100

Number of patients

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

HIV-positive TB patients on CPT on ART

20 000

40 000

60 000

Total budget (US$ millions)

Funded domestically Funded internationally Unfunded

2009 2010 2011 2012 2013

125 Data for all years can be downloaded from www.who.int/tb/data GLOBAL TUBERCULOSIS REPORT 2013

Data are as reported to WHO. Estimates of TB and MDR-TB burden are produced by WHO in consultation with

countries.

a Ranges represent uncertainty intervals.

MOZAMBIQUE Population 2012 25 million

HIGH TB BURDEN | HIGH HIV BURDEN

Estimates of TB burdena 2012

07/$'4(thousands)4#6'(per 100 000 population)

/QTVCNKV[GZENWFGU*+86$ ¿ ¿

/QTVCNKV[*+86$QPN[ ¿ ¿

2TGXCNGPEGKPENWFGU*+86$ ¿ ¿

+PEKFGPEGKPENWFGU*+86$ ¿ ¿

+PEKFGPEG*+86$QPN[ ¿ ¿

Case detection, all forms (%) 34 (25–50)

6$ECUGPQVKßECVKQPU    

0'9%#5'5   4'64'#6/'06%#5'5  

5OGCTRQUKVKXG   4GNCRUG  

Smear-negative 19 797 (43) Treatment after failure 243 (5)

5OGCTWPMPQYPPQVFQPG   6TGCVOGPVCHVGTFGHCWNV  

Extrapulmonary 5 542 (12) Other 2 595 (57)

Other 0 (0)

Total new 46 290 Total retreatment 4 537

Other (history unknown) 0

6QVCNPGYCPFTGNCRUG   6QVCNECUGUPQVKßGF 

New cases

  5/'#40')#6+8'70-0190

 5/'#4215+6+8' 016&10' ':64#27./10#4;

/(TCVKQ   

#IG   

Laboratories 2012

Smear (per 100 000 population) 1.2

Culture (per 5 million population) 0.6

Drug susceptibility testing (per 5 million population) 0.4

+UUGEQPFNKPGFTWIUWUEGRVKDKNKV[VGUVKPICXCKNCDNG! ;GUQWVUKFGEQWPVT[

6TGCVOGPVUWEEGUUTCVG    

New smear-positive and/or culture-positive

New smear-negative/extrapulmonary

4GVTGCVOGPV 

+UTKHCORKEKPWUGFVJTQWIJQWVVTGCVOGPVHQTPGYRCVKGPVU! ;GU

TB/HIV 2012 07/$'4 (%)

TB patients with known HIV status 47 960 (94)

*+8RQUKVKXG6$RCVKGPVU  

*+8RQUKVKXG6$RCVKGPVUQPEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26  

*+8RQUKVKXG6$RCVKGPVUQPCPVKTGVTQXKTCNVJGTCR[#46 

HIV-positive people screened for TB

HIV-positive people provided with IPT 17 317

Estimates of MDR-TB burden 2012a 0'9 4'64'#6/'06

QH6$ECUGUYKVJ/&46$ ¿ ¿

/&46$ECUGUCOQPIPQVKßGF

pulmonary TB cases 1 400 (900–2 000) 540 (0–1 100)

Reported cases of MDR-TB 20120'9 4'64'#6/'06 616#.

%CUGUVGUVGFHQT/&46$   

.CDQTCVQT[EQPßTOGF/&46$ECUGU   

2CVKGPVUUVCTVGFQP/&46$VTGCVOGPV   

Financing TB control 2013

0CVKQPCN6$RTQITCOOGDWFIGV75OKNNKQPU 

% Funded domestically 19%

% Funded internationally 51%

% Unfunded 30%

Mortality (excludes HIV+TB) (rate

per 100 000 population per year)

1990 1995 2000 2005 2010

100

200

300

400

Prevalence

(rate per 100 000 population)

1990 1995 2000 2005 2010

1000

2000

3000

Incidence (rate per 100 000

population per year)

1990 1995 2000 2005 2010

Incidence Incidence (HIV+TB) Notifications

250

500

750

1000

1250

Treatment success rate (%)

New smear-positive (and/or culture-positive) Retreatment

New smear-negative/extrapulmonary

1995 1997 1999 2001 2003 2005 2007 2009 2011

100

Number of patients

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

HIV-positive TB patients on CPT on ART

10 000

20 000

30 000

Total budget (US$ millions)

Funded domestically Funded internationally Unfunded

2009 2010 2011 2012 2013

126 GLOBAL TUBERCULOSIS REPORT 2013 Data for all years can be downloaded from www.who.int/tb/data

Data are as reported to WHO. Estimates of TB and MDR-TB burden are produced by WHO in consultation with

countries.

a Ranges represent uncertainty intervals.

MYANMAR Population 2012 53 million

HIGH TB BURDEN | HIGH HIV BURDEN | HIGH MDR-TB BURDEN

Estimates of TB burdena 2012

07/$'4(thousands)4#6'(per 100 000 population)

/QTVCNKV[GZENWFGU*+86$ ¿ ¿

/QTVCNKV[*+86$QPN[ ¿ ¿

2TGXCNGPEGKPENWFGU*+86$ ¿ ¿

Incidence (includes HIV+TB) 200 (170–230) 377 (322–435)

Incidence (HIV+TB only) 19 (16–21) 35 (30–41)

%CUGFGVGEVKQPCNNHQTOU ¿ 

6$ECUGPQVKßECVKQPU    

0'9%#5'5   4'64'#6/'06%#5'5  

5OGCTRQUKVKXG   4GNCRUG  

Smear-negative 73 042 (53) Treatment after failure 1 671 (14)

Smear-unknown / not done 0 (0) Treatment after default 521 (5)

'ZVTCRWNOQPCT[   1VJGT  

Other 0 (0)

Total new 136 612 Total retreatment 11 537

Other (history unknown) 0

6QVCNPGYCPFTGNCRUG   6QVCNECUGUPQVKßGF 

New cases

  5/'#40')#6+8'70-0190

 5/'#4215+6+8' 016&10' ':64#27./10#4;

/(TCVKQ   

#IG   

Laboratories 2012

Smear (per 100 000 population) 0.9

Culture (per 5 million population) 0.2

Drug susceptibility testing (per 5 million population) 0.2

+UUGEQPFNKPGFTWIUWUEGRVKDKNKV[VGUVKPICXCKNCDNG! ;GUKPCPFQWVUKFGEQWPVT[

6TGCVOGPVUWEEGUUTCVG    

0GYUOGCTRQUKVKXGCPFQTEWNVWTGRQUKVKXG 

New smear-negative/extrapulmonary 90

4GVTGCVOGPV 

+UTKHCORKEKPWUGFVJTQWIJQWVVTGCVOGPVHQTPGYRCVKGPVU! ;GU

TB/HIV 2012 07/$'4 (%)

TB patients with known HIV status 19 219 (13)

HIV-positive TB patients 5 161 (27)

*+8RQUKVKXG6$RCVKGPVUQPEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26  

*+8RQUKVKXG6$RCVKGPVUQPCPVKTGVTQXKTCNVJGTCR[#46  

HIV-positive people screened for TB

HIV-positive people provided with IPT

Estimates of MDR-TB burden 2012a 0'9 4'64'#6/'06

QH6$ECUGUYKVJ/&46$ ¿ ¿

/&46$ECUGUCOQPIPQVKßGF

pulmonary TB cases 4 900 (3 600–6 500) 1 200 (790–1 600)

Reported cases of MDR-TB 20120'9 4'64'#6/'06 616#.

%CUGUVGUVGFHQT/&46$   

.CDQTCVQT[EQPßTOGF/&46$ECUGU   

2CVKGPVUUVCTVGFQP/&46$VTGCVOGPV   

Financing TB control 2013

0CVKQPCN6$RTQITCOOGDWFIGV75OKNNKQPU 

% Funded domestically 2%

% Funded internationally 39%

% Unfunded 60%

Mortality (excludes HIV+TB) (rate

per 100 000 population per year)

1990 1995 2000 2005 2010

100

200

300

Prevalence

(rate per 100 000 population)

1990 1995 2000 2005 2010

500

1000

1500

2000

Incidence (rate per 100 000

population per year)

1990 1995 2000 2005 2010

Incidence Incidence (HIV+TB) Notifications

200

400

600

Treatment success rate (%)

New smear-positive (and/or culture-positive) Retreatment

New smear-negative/extrapulmonary

1995 1997 1999 2001 2003 2005 2007 2009 2011

100

Number of patients

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

HIV-positive TB patients on CPT on ART

2000

4000

6000

Total budget (US$ millions)

Funded domestically Funded internationally Unfunded

2009 2010 2011 2012 2013

127 Data for all years can be downloaded from www.who.int/tb/data GLOBAL TUBERCULOSIS REPORT 2013

Data are as reported to WHO. Estimates of TB and MDR-TB burden are produced by WHO in consultation with

countries.

a Ranges represent uncertainty intervals.

NIGERIA Population 2012 169 million

HIGH TB BURDEN | HIGH HIV BURDEN | HIGH MDR-TB BURDEN

Estimates of TB burdena 2012

07/$'4(thousands)4#6'(per 100 000 population)

/QTVCNKV[GZENWFGU*+86$ ¿ ¿

Mortality (HIV+TB only) 19 (11–25) 11 (6.7–15)

Prevalence (includes HIV+TB) 270 (43–710) 161 (25–420)

+PEKFGPEGKPENWFGU*+86$ ¿ ¿

+PEKFGPEG*+86$QPN[ ¿ ¿

Case detection, all forms (%) 51 (29–110)

6$ECUGPQVKßECVKQPU    

0'9%#5'5   4'64'#6/'06%#5'5  

5OGCTRQUKVKXG   4GNCRUG  

5OGCTPGICVKXG   6TGCVOGPVCHVGTHCKNWTG  

Smear-unknown / not done Treatment after default 1 174 (16)

Extrapulmonary 4 432 (5) Other 3 249 (43)

Other

Total new 90 305 Total retreatment 7 548

Other (history unknown)

6QVCNPGYCPFTGNCRUG   6QVCNECUGUPQVKßGF 

New cases

  5/'#40')#6+8'70-0190

 5/'#4215+6+8' 016&10' ':64#27./10#4;

/(TCVKQ   

#IG   

Laboratories 2012

5OGCTRGTRQRWNCVKQP 

Culture (per 5 million population) 0.1

&TWIUWUEGRVKDKNKV[VGUVKPIRGTOKNNKQPRQRWNCVKQP 

+UUGEQPFNKPGFTWIUWUEGRVKDKNKV[VGUVKPICXCKNCDNG! ;GUQWVUKFGEQWPVT[

6TGCVOGPVUWEEGUUTCVG    

0GYUOGCTRQUKVKXGCPFQTEWNVWTGRQUKVKXG 

0GYUOGCTPGICVKXGGZVTCRWNOQPCT[ 

4GVTGCVOGPV 

+UTKHCORKEKPWUGFVJTQWIJQWVVTGCVOGPVHQTPGYRCVKGPVU! ;GU

TB/HIV 2012 07/$'4 (%)

6$RCVKGPVUYKVJMPQYP*+8UVCVWU  

HIV-positive TB patients 19 342 (23)

*+8RQUKVKXG6$RCVKGPVUQPEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26  

*+8RQUKVKXG6$RCVKGPVUQPCPVKTGVTQXKTCNVJGTCR[#46 

HIV-positive people screened for TB 140 460

HIV-positive people provided with IPT 2 257

Estimates of MDR-TB burden 2012a 0'9 4'64'#6/'06

QH6$ECUGUYKVJ/&46$ ¿ ¿

/&46$ECUGUCOQPIPQVKßGF

RWNOQPCT[6$ECUGU ¿ ¿

Reported cases of MDR-TB 20120'9 4'64'#6/'06 616#.

%CUGUVGUVGFHQT/&46$   

.CDQTCVQT[EQPßTOGF/&46$ECUGU   

2CVKGPVUUVCTVGFQP/&46$VTGCVOGPV   

Financing TB control 2013

0CVKQPCN6$RTQITCOOGDWFIGV75OKNNKQPU 

(WPFGFFQOGUVKECNN[ 

% Funded internationally 24%

7PHWPFGF 

Mortality (excludes HIV+TB) (rate

per 100 000 population per year)

1990 1995 2000 2005 2010

100

150

200

Prevalence

(rate per 100 000 population)

1990 1995 2000 2005 2010

500

1000

1500

Incidence (rate per 100 000

population per year)

1990 1995 2000 2005 2010

Incidence Incidence (HIV+TB) Notifications

100

200

300

400

500

600

Treatment success rate (%)

New smear-positive (and/or culture-positive) Retreatment

New smear-negative/extrapulmonary

1995 1997 1999 2001 2003 2005 2007 2009 2011

100

Number of patients

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

HIV-positive TB patients on CPT on ART

5000

10 000

15 000

20 000

Total budget (US$ millions)

Funded domestically Funded internationally Unfunded

2009 2010 2011 2012 2013

120

180

 GLOBAL TUBERCULOSIS REPORT 2013 Data for all years can be downloaded from www.who.int/tb/data

Data are as reported to WHO. Estimates of TB and MDR-TB burden are produced by WHO in consultation with

countries.

a Ranges represent uncertainty intervals.

PAKISTAN Population 2012 179 million

HIGH TB BURDEN | HIGH MDR-TB BURDEN

Estimates of TB burdena 2012

07/$'4(thousands)4#6'(per 100 000 population)

Mortality (excludes HIV+TB) 62 (27–110) 34 (15–61)

/QTVCNKV[*+86$QPN[ ¿ ¿

2TGXCNGPEGKPENWFGU*+86$ ¿ ¿

Incidence (includes HIV+TB) 410 (340–490) 231 (190–276)

+PEKFGPEG*+86$QPN[ ¿ ¿

%CUGFGVGEVKQPCNNHQTOU ¿ 

6$ECUGPQVKßECVKQPU    

0'9%#5'5   4'64'#6/'06%#5'5  

5OGCTRQUKVKXG   4GNCRUG  

5OGCTPGICVKXG   6TGCVOGPVCHVGTHCKNWTG  

Smear-unknown / not done 0 (0) Treatment after default 1 241 (11)

Extrapulmonary 41 410 (16) Other 3 534 (30)

Other 0 (0)

Total new 261 380 Total retreatment 11 717

Other (history unknown) 0

6QVCNPGYCPFTGNCRUG   6QVCNECUGUPQVKßGF 

New cases

  5/'#40')#6+8'70-0190

 5/'#4215+6+8' 016&10' ':64#27./10#4;

/(TCVKQ   

#IG   

Laboratories 2012

5OGCTRGTRQRWNCVKQP 

Culture (per 5 million population) 0.2

Drug susceptibility testing (per 5 million population) 0.1

+UUGEQPFNKPGFTWIUWUEGRVKDKNKV[VGUVKPICXCKNCDNG! ;GUKPEQWPVT[

6TGCVOGPVUWEEGUUTCVG    

New smear-positive and/or culture-positive 92

New smear-negative/extrapulmonary 93

4GVTGCVOGPV 

+UTKHCORKEKPWUGFVJTQWIJQWVVTGCVOGPVHQTPGYRCVKGPVU! ;GU

TB/HIV 2012 07/$'4 (%)

TB patients with known HIV status 10 419 (4)

*+8RQUKVKXG6$RCVKGPVU  

*+8RQUKVKXG6$RCVKGPVUQPEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26  

*+8RQUKVKXG6$RCVKGPVUQPCPVKTGVTQXKTCNVJGTCR[#46  

HIV-positive people screened for TB

HIV-positive people provided with IPT

Estimates of MDR-TB burden 2012a 0'9 4'64'#6/'06

QH6$ECUGUYKVJ/&46$ ¿ ¿

/&46$ECUGUCOQPIPQVKßGF

RWNOQPCT[6$ECUGU ¿ ¿

Reported cases of MDR-TB 20120'9 4'64'#6/'06 616#.

%CUGUVGUVGFHQT/&46$   

.CDQTCVQT[EQPßTOGF/&46$ECUGU   

2CVKGPVUUVCTVGFQP/&46$VTGCVOGPV   

Financing TB control 2013

0CVKQPCN6$RTQITCOOGDWFIGV75OKNNKQPU 

% Funded domestically 5%

(WPFGFKPVGTPCVKQPCNN[ 

% Unfunded 9%

Mortality (excludes HIV+TB) (rate

per 100 000 population per year)

1990 1995 2000 2005 2010

100

150

200

Prevalence

(rate per 100 000 population)

1990 1995 2000 2005 2010

500

1000

1500

Incidence (rate per 100 000

population per year)

1990 1995 2000 2005 2010

Incidence Incidence (HIV+TB) Notifications

100

200

300

400

Treatment success rate (%)

New smear-positive (and/or culture-positive) Retreatment

New smear-negative/extrapulmonary

1995 1997 1999 2001 2003 2005 2007 2009 2011

100

Number of patients

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

HIV-positive TB patients on CPT on ART

Total budget (US$ millions)

Funded domestically Funded internationally Unfunded

2009 2010 2011 2012 2013

129 Data for all years can be downloaded from www.who.int/tb/data GLOBAL TUBERCULOSIS REPORT 2013

Data are as reported to WHO. Estimates of TB and MDR-TB burden are produced by WHO in consultation with

countries.

a Ranges represent uncertainty intervals.

PHILIPPINES Population 2012 97 million

HIGH TB BURDEN | HIGH MDR-TB BURDEN

Estimates of TB burdena 2012

07/$'4(thousands)4#6'(per 100 000 population)

Mortality (excludes HIV+TB) 23 (22–25) 24 (22–26)

Mortality (HIV+TB only) 0.11 (0.09–0.13) 0.11 (0.09–0.14)

Prevalence (includes HIV+TB) 450 (390–500) 461 (405–520)

Incidence (includes HIV+TB) 260 (210–310) 265 (219–316)

+PEKFGPEG*+86$QPN[ ¿ ¿

%CUGFGVGEVKQPCNNHQTOU ¿ 

6$ECUGPQVKßECVKQPU    

0'9%#5'5   4'64'#6/'06%#5'5  

5OGCTRQUKVKXG   4GNCRUG  

Smear-negative 115 263 (54) Treatment after failure 591 (3)

Smear-unknown / not done 0 (0) Treatment after default 1 243 (5)

Extrapulmonary 3 270 (2) Other 17 575 (75)

Other 0 (0)

Total new 212 119 Total retreatment 23 489

Other (history unknown) 0

6QVCNPGYCPFTGNCRUG   6QVCNECUGUPQVKßGF 

New cases

  5/'#40')#6+8'70-0190

 5/'#4215+6+8' 016&10' ':64#27./10#4;

/(TCVKQ   

#IG   

Laboratories 2012

Smear (per 100 000 population) 2.7

Culture (per 5 million population) 0.7

Drug susceptibility testing (per 5 million population) 0.2

+UUGEQPFNKPGFTWIUWUEGRVKDKNKV[VGUVKPICXCKNCDNG! ;GUKPEQWPVT[

6TGCVOGPVUWEEGUUTCVG    

New smear-positive and/or culture-positive 90

0GYUOGCTPGICVKXGGZVTCRWNOQPCT[ 

4GVTGCVOGPV 

+UTKHCORKEKPWUGFVJTQWIJQWVVTGCVOGPVHQTPGYRCVKGPVU! ;GU

TB/HIV 2012 07/$'4 (%)

6$RCVKGPVUYKVJMPQYP*+8UVCVWU  

*+8RQUKVKXG6$RCVKGPVU  

*+8RQUKVKXG6$RCVKGPVUQPEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26  

*+8RQUKVKXG6$RCVKGPVUQPCPVKTGVTQXKTCNVJGTCR[#46  

HIV-positive people screened for TB

HIV-positive people provided with IPT

Estimates of MDR-TB burden 2012a 0'9 4'64'#6/'06

QH6$ECUGUYKVJ/&46$ ¿ ¿

/&46$ECUGUCOQPIPQVKßGF

RWNOQPCT[6$ECUGU ¿ ¿

Reported cases of MDR-TB 20120'9 4'64'#6/'06 616#.

%CUGUVGUVGFHQT/&46$   

.CDQTCVQT[EQPßTOGF/&46$ECUGU   

2CVKGPVUUVCTVGFQP/&46$VTGCVOGPV   

Financing TB control 2013

0CVKQPCN6$RTQITCOOGDWFIGV75OKNNKQPU 

% Funded domestically 16%

% Funded internationally 15%

% Unfunded 69%

Mortality (excludes HIV+TB) (rate

per 100 000 population per year)

1990 1995 2000 2005 2010

Prevalence

(rate per 100 000 population)

1990 1995 2000 2005 2010

500

1000

1500

Incidence (rate per 100 000

population per year)

1990 1995 2000 2005 2010

Incidence Incidence (HIV+TB) Notifications

200

400

600

Treatment success rate (%)

New smear-positive (and/or culture-positive) Retreatment

New smear-negative/extrapulmonary

1995 1997 1999 2001 2003 2005 2007 2009 2011

100

Number of patients

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

HIV-positive TB patients on CPT on ART

Total budget (US$ millions)

Funded domestically Funded internationally Unfunded

2009 2010 2011 2012 2013

120

160

130 GLOBAL TUBERCULOSIS REPORT 2013 Data for all years can be downloaded from www.who.int/tb/data

&CVCCTGCUTGRQTVGFVQ9*1'UVKOCVGUQH6$CPF/&46$DWTFGPCTGRTQFWEGFD[9*1KPEQPUWNVCVKQPYKVJ

countries.

a 4CPIGUTGRTGUGPVWPEGTVCKPV[KPVGTXCNU

b The reported number of TB patients with known HIV status is for new TB patients in the civilian sector only.

It was not possible to calculate the percentage of all TB patients with known HIV status.

RUSSIAN FEDERATION Population 2012 143 million

HIGH TB BURDEN | HIGH HIV BURDEN | HIGH MDR-TB BURDEN

Estimates of TB burdena 2012

07/$'4(thousands)4#6'(per 100 000 population)

/QTVCNKV[GZENWFGU*+86$ ¿ ¿

/QTVCNKV[*+86$QPN[ ¿ ¿

Prevalence (includes HIV+TB) 170 (73–320) 121 (51–221)

Incidence (includes HIV+TB) 130 (110–150) 91 (77–106)

Incidence (HIV+TB only) 9.3 (7.9–11) 6.5 (5.5–7.5)

%CUGFGVGEVKQPCNNHQTOU ¿ 

6$ECUGPQVKßECVKQPU    

0'9%#5'5   4'64'#6/'06%#5'5  

5OGCTRQUKVKXG   4GNCRUG  

Smear-negative 59 019 (61) Treatment after failure 9 109 (17)

Smear-unknown / not done 1 039 (1) Treatment after default 2 593 (5)

Extrapulmonary 10 017 (10) Other 32 466 (62)

Other 0 (0)

Total new 97 542 Total retreatment 52 379

Other (history unknown) 0

6QVCNPGYCPFTGNCRUG   6QVCNECUGUPQVKßGF 

New cases

  5/'#40')#6+8'70-0190

 5/'#4215+6+8' 016&10' ':64#27./10#4;

/(TCVKQ   

#IG   

Laboratories 2012

Smear (per 100 000 population) 0.7

Culture (per 5 million population) 4.1

&TWIUWUEGRVKDKNKV[VGUVKPIRGTOKNNKQPRQRWNCVKQP 

+UUGEQPFNKPGFTWIUWUEGRVKDKNKV[VGUVKPICXCKNCDNG! ;GUKPEQWPVT[

6TGCVOGPVUWEEGUUTCVG    

New smear-positive and/or culture-positive 54

New smear-negative/extrapulmonary 73

4GVTGCVOGPV 

+UTKHCORKEKPWUGFVJTQWIJQWVVTGCVOGPVHQTPGYRCVKGPVU! ;GU

TB/HIV 2012 07/$'4 (%)

TB patients with known HIV statusb 75 995

*+8RQUKVKXG6$RCVKGPVU  

*+8RQUKVKXG6$RCVKGPVUQPEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26  

*+8RQUKVKXG6$RCVKGPVUQPCPVKTGVTQXKTCNVJGTCR[#46  

HIV-positive people screened for TB

HIV-positive people provided with IPT

Estimates of MDR-TB burden 2012a 0'9 4'64'#6/'06

QH6$ECUGUYKVJ/&46$ ¿ ¿

/&46$ECUGUCOQPIPQVKßGF

RWNOQPCT[6$ECUGU ¿ ¿

Reported cases of MDR-TB 20120'9 4'64'#6/'06 616#.

%CUGUVGUVGFHQT/&46$   

.CDQTCVQT[EQPßTOGF/&46$ECUGU   

2CVKGPVUUVCTVGFQP/&46$VTGCVOGPV   

Financing TB control 2013

0CVKQPCN6$RTQITCOOGDWFIGV75OKNNKQPU 

% Funded domestically 100%

(WPFGFKPVGTPCVKQPCNN[ 

% Unfunded 0%

Mortality (excludes HIV+TB) (rate

per 100 000 population per year)

1990 1995 2000 2005 2010

Prevalence

(rate per 100 000 population)

1990 1995 2000 2005 2010

100

200

300

400

Incidence (rate per 100 000

population per year)

1990 1995 2000 2005 2010

Incidence Incidence (HIV+TB) Notifications

100

150

200

Treatment success rate (%)

New smear-positive (and/or culture-positive) Retreatment

New smear-negative/extrapulmonary

1995 1997 1999 2001 2003 2005 2007 2009 2011

100

Number of patients

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

HIV-positive TB patients on CPT on ART

2000

4000

6000

8000

Total budget (US$ millions)

Funded domestically Funded internationally Unfunded

2009 2010 2011 2012 2013

600

1200

1800

131 Data for all years can be downloaded from www.who.int/tb/data GLOBAL TUBERCULOSIS REPORT 2013

Data are as reported to WHO. Estimates of TB and MDR-TB burden are produced by WHO in consultation with

countries.

a Ranges represent uncertainty intervals.

SOUTH AFRICA Population 2012 52 million

HIGH TB BURDEN | HIGH HIV BURDEN | HIGH MDR-TB BURDEN

Estimates of TB burdena 2012

07/$'4(thousands)4#6'(per 100 000 population)

/QTVCNKV[GZENWFGU*+86$ ¿ ¿

/QTVCNKV[*+86$QPN[ ¿ ¿

2TGXCNGPEGKPENWFGU*+86$ ¿ ¿

+PEKFGPEGKPENWFGU*+86$ ¿ ¿

Incidence (HIV+TB only) 330 (270–390) 631 (521–752)

Case detection, all forms (%) 62 (52–75)

6$ECUGPQVKßECVKQPU    

0'9%#5'5   4'64'#6/'06%#5'5  

5OGCTRQUKVKXG   4GNCRUG  

Smear-negative 63 210 (21) Treatment after failure 3 123 (6)

5OGCTWPMPQYPPQVFQPG   6TGCVOGPVCHVGTFGHCWNV  

Extrapulmonary 42 467 (14) Other 15 007 (29)

Other 0 (0)

Total new 296 996 Total retreatment 52 586

Other (history unknown) 0

6QVCNPGYCPFTGNCRUG   6QVCNECUGUPQVKßGF 

New cases

  5/'#40')#6+8'70-0190

 5/'#4215+6+8' 016&10' ':64#27./10#4;

/(TCVKQ   

#IG   

Laboratories 2012

Smear (per 100 000 population) 0.4

Culture (per 5 million population) 1.4

Drug susceptibility testing (per 5 million population) 1.4

+UUGEQPFNKPGFTWIUWUEGRVKDKNKV[VGUVKPICXCKNCDNG! ;GUKPEQWPVT[

6TGCVOGPVUWEEGUUTCVG    

New smear-positive and/or culture-positive 79

New smear-negative/extrapulmonary 76

4GVTGCVOGPV 

+UTKHCORKEKPWUGFVJTQWIJQWVVTGCVOGPVHQTPGYRCVKGPVU! ;GU

TB/HIV 2012 07/$'4 (%)

6$RCVKGPVUYKVJMPQYP*+8UVCVWU  

HIV-positive TB patients 190 093 (65)

*+8RQUKVKXG6$RCVKGPVUQPEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26  

*+8RQUKVKXG6$RCVKGPVUQPCPVKTGVTQXKTCNVJGTCR[#46  

*+8RQUKVKXGRGQRNGUETGGPGFHQT6$  

HIV-positive people provided with IPT 369 747

Estimates of MDR-TB burden 2012a 0'9 4'64'#6/'06

QH6$ECUGUYKVJ/&46$ ¿ ¿

/&46$ECUGUCOQPIPQVKßGF

RWNOQPCT[6$ECUGU ¿ ¿

Reported cases of MDR-TB 20120'9 4'64'#6/'06 616#.

%CUGUVGUVGFHQT/&46$   

.CDQTCVQT[EQPßTOGF/&46$ECUGU   

2CVKGPVUUVCTVGFQP/&46$VTGCVOGPV   

Financing TB control 2013

0CVKQPCN6$RTQITCOOGDWFIGV75OKNNKQPU 

% Funded domestically 97%

% Funded internationally 3%

% Unfunded 0%

Mortality (excludes HIV+TB) (rate

per 100 000 population per year)

1990 1995 2000 2005 2010

100

150

200

Prevalence

(rate per 100 000 population)

1990 1995 2000 2005 2010

500

1000

1500

2000

Incidence (rate per 100 000

population per year)

1990 1995 2000 2005 2010

Incidence Incidence (HIV+TB) Notifications

250

500

750

1000

1250

Treatment success rate (%)

New smear-positive (and/or culture-positive) Retreatment

New smear-negative/extrapulmonary

1995 1997 1999 2001 2003 2005 2007 2009 2011

100

Number of patients

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

HIV-positive TB patients on CPT on ART

50 000

100 000

150 000

200 000

250 000

Total budget (US$ millions)

Funded domestically Funded internationally Unfunded

2009 2010 2011 2012 2013

100

200

300

400

500

132 GLOBAL TUBERCULOSIS REPORT 2013 Data for all years can be downloaded from www.who.int/tb/data

&CVCCTGCUTGRQTVGFVQ9*1'UVKOCVGUQH6$CPF/&46$DWTFGPCTGRTQFWEGFD[9*1KPEQPUWNVCVKQPYKVJ

countries.

a 4CPIGUTGRTGUGPVWPEGTVCKPV[KPVGTXCNU

b Based on data reported for 2013 in the 2012 round of data collection. In 2013, Thailand was not able to

report funding for the sub-national level.

THAILAND Population 2012 67 million

HIGH TB BURDEN | HIGH HIV BURDEN

Estimates of TB burdena 2012

07/$'4(thousands)4#6'(per 100 000 population)

/QTVCNKV[GZENWFGU*+86$ ¿ ¿

/QTVCNKV[*+86$QPN[ ¿ ¿

2TGXCNGPEGKPENWFGU*+86$ ¿ ¿

+PEKFGPEGKPENWFGU*+86$ ¿ ¿

+PEKFGPEG*+86$QPN[ ¿ ¿

Case detection, all forms (%) 76 (64–92)

6$ECUGPQVKßECVKQPU    

0'9%#5'5   4'64'#6/'06%#5'5  

5OGCTRQUKVKXG   4GNCRUG  

Smear-negative 17 537 (31) Treatment after failure 327 (12)

Smear-unknown / not done Treatment after default 577 (21)

'ZVTCRWNOQPCT[   1VJGT  

Other

Total new 57 387 Total retreatment 2 791

Other (history unknown) 1 030

6QVCNPGYCPFTGNCRUG   6QVCNECUGUPQVKßGF 

New cases

  5/'#40')#6+8'70-0190

 5/'#4215+6+8' 016&10' ':64#27./10#4;

/(TCVKQ   

#IG   

Laboratories 2012

Smear (per 100 000 population) 1.6

Culture (per 5 million population) 4.9

Drug susceptibility testing (per 5 million population) 1.3

+UUGEQPFNKPGFTWIUWUEGRVKDKNKV[VGUVKPICXCKNCDNG! ;GUKPEQWPVT[

6TGCVOGPVUWEEGUUTCVG    

0GYUOGCTRQUKVKXGCPFQTEWNVWTGRQUKVKXG 

0GYUOGCTPGICVKXGGZVTCRWNOQPCT[ 

4GVTGCVOGPV 

+UTKHCORKEKPWUGFVJTQWIJQWVVTGCVOGPVHQTPGYRCVKGPVU! ;GU

TB/HIV 2012 07/$'4 (%)

TB patients with known HIV status 44 035 (72)

*+8RQUKVKXG6$RCVKGPVU  

*+8RQUKVKXG6$RCVKGPVUQPEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26  

*+8RQUKVKXG6$RCVKGPVUQPCPVKTGVTQXKTCNVJGTCR[#46  

HIV-positive people screened for TB

HIV-positive people provided with IPT

Estimates of MDR-TB burden 2012a 0'9 4'64'#6/'06

QH6$ECUGUYKVJ/&46$ ¿ ¿

/&46$ECUGUCOQPIPQVKßGF

RWNOQPCT[6$ECUGU ¿ ¿

Reported cases of MDR-TB 20120'9 4'64'#6/'06 616#.

%CUGUVGUVGFHQT/&46$   

.CDQTCVQT[EQPßTOGF/&46$ECUGU   

2CVKGPVUUVCTVGFQP/&46$VTGCVOGPV   

Financing TB control 2013

0CVKQPCN6$RTQITCOOGDWFIGV75OKNNKQPU b

% Funded domestically 92%

% Funded internationally 2%

% Unfunded 6%

Mortality (excludes HIV+TB) (rate

per 100 000 population per year)

1990 1995 2000 2005 2010

Prevalence

(rate per 100 000 population)

1990 1995 2000 2005 2010

100

200

300

400

500

Incidence (rate per 100 000

population per year)

1990 1995 2000 2005 2010

Incidence Incidence (HIV+TB) Notifications

100

150

200

250

Treatment success rate (%)

New smear-positive (and/or culture-positive) Retreatment

New smear-negative/extrapulmonary

1995 1997 1999 2001 2003 2005 2007 2009 2011

100

Number of patients

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

HIV-positive TB patients on CPT on ART

2000

4000

6000

8000

10 000

Total budget (US$ millions)

Funded domestically Funded internationally Unfunded

2009 2010 2011 2012 2013

133 Data for all years can be downloaded from www.who.int/tb/data GLOBAL TUBERCULOSIS REPORT 2013

Data are as reported to WHO. Estimates of TB and MDR-TB burden are produced by WHO in consultation with

countries.

a Ranges represent uncertainty intervals.

UGANDA Population 2012 36 million

HIGH TB BURDEN | HIGH HIV BURDEN

Estimates of TB burdena 2012

07/$'4(thousands)4#6'(per 100 000 population)

/QTVCNKV[GZENWFGU*+86$ ¿ ¿

/QTVCNKV[*+86$QPN[ ¿ ¿

Prevalence (includes HIV+TB) 64 (24–120) 175 (67–334)

Incidence (includes HIV+TB) 65 (53–79) 179 (145–216)

+PEKFGPEG*+86$QPN[ ¿ ¿

%CUGFGVGEVKQPCNNHQTOU ¿ 

6$ECUGPQVKßECVKQPU    

0'9%#5'5   4'64'#6/'06%#5'5  

5OGCTRQUKVKXG   4GNCRUG  

5OGCTPGICVKXG   6TGCVOGPVCHVGTHCKNWTG  

5OGCTWPMPQYPPQVFQPG   6TGCVOGPVCHVGTFGHCWNV  

Extrapulmonary 5 143 (12) Other 1 114 (29)

Other 0 (0)

Total new 43 329 Total retreatment 3 882

Other (history unknown) 0

6QVCNPGYCPFTGNCRUG   6QVCNECUGUPQVKßGF 

New cases

  5/'#40')#6+8'70-0190

 5/'#4215+6+8' 016&10' ':64#27./10#4;

/(TCVKQ   

#IG   

Laboratories 2012

Smear (per 100 000 population) 3.2

Culture (per 5 million population) 0.6

Drug susceptibility testing (per 5 million population) 0.6

+UUGEQPFNKPGFTWIUWUEGRVKDKNKV[VGUVKPICXCKNCDNG! ;GUKPEQWPVT[

6TGCVOGPVUWEEGUUTCVG    

New smear-positive and/or culture-positive 77

New smear-negative/extrapulmonary 66

4GVTGCVOGPV 

+UTKHCORKEKPWUGFVJTQWIJQWVVTGCVOGPVHQTPGYRCVKGPVU! ;GU

TB/HIV 2012 07/$'4 (%)

6$RCVKGPVUYKVJMPQYP*+8UVCVWU  

HIV-positive TB patients 20 376 (50)

*+8RQUKVKXG6$RCVKGPVUQPEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26  

*+8RQUKVKXG6$RCVKGPVUQPCPVKTGVTQXKTCNVJGTCR[#46  

HIV-positive people screened for TB

HIV-positive people provided with IPT

Estimates of MDR-TB burden 2012a 0'9 4'64'#6/'06

QH6$ECUGUYKVJ/&46$ ¿ ¿

/&46$ECUGUCOQPIPQVKßGF

RWNOQPCT[6$ECUGU ¿ ¿

Reported cases of MDR-TB 20120'9 4'64'#6/'06 616#.

%CUGUVGUVGFHQT/&46$   

.CDQTCVQT[EQPßTOGF/&46$ECUGU   

2CVKGPVUUVCTVGFQP/&46$VTGCVOGPV   

Financing TB control 2013

0CVKQPCN6$RTQITCOOGDWFIGV75OKNNKQPU 

% Funded domestically 7%

% Funded internationally 62%

% Unfunded 31%

Mortality (excludes HIV+TB) (rate

per 100 000 population per year)

1990 1995 2000 2005 2010

100

200

300

Prevalence

(rate per 100 000 population)

1990 1995 2000 2005 2010

500

1000

1500

2000

2500

Incidence (rate per 100 000

population per year)

1990 1995 2000 2005 2010

Incidence Incidence (HIV+TB) Notifications

250

500

750

1000

1250

Treatment success rate (%)

New smear-positive (and/or culture-positive) Retreatment

New smear-negative/extrapulmonary

1995 1997 1999 2001 2003 2005 2007 2009 2011

100

Number of patients

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

HIV-positive TB patients on CPT on ART

5000

10 000

15 000

20 000

25 000

Total budget (US$ millions)

Funded domestically Funded internationally Unfunded

2009 2010 2011 2012 2013

134 GLOBAL TUBERCULOSIS REPORT 2013 Data for all years can be downloaded from www.who.int/tb/data

Data are as reported to WHO. Estimates of TB and MDR-TB burden are produced by WHO in consultation with

countries.

a Ranges represent uncertainty intervals.

UNITED REPUBLIC OF TANZANIA Population 2012 48 million

HIGH TB BURDEN | HIGH HIV BURDEN

Estimates of TB burdena 2012

07/$'4(thousands)4#6'(per 100 000 population)

/QTVCNKV[GZENWFGU*+86$ ¿ ¿

/QTVCNKV[*+86$QPN[ ¿ ¿

2TGXCNGPEGKPENWFGU*+86$ ¿ ¿

+PEKFGPEGKPENWFGU*+86$ ¿ ¿

+PEKFGPEG*+86$QPN[ ¿ ¿

%CUGFGVGEVKQPCNNHQTOU ¿ 

6$ECUGPQVKßECVKQPU    

0'9%#5'5   4'64'#6/'06%#5'5  

5OGCTRQUKVKXG   4GNCRUG  

Smear-negative 21 393 (35) Treatment after failure 154 (6)

Smear-unknown / not done 0 (0) Treatment after default 201 (7)

Extrapulmonary 14 595 (24) Other 1 359 (49)

Other 0 (0)

Total new 61 126 Total retreatment 2 766

Other (history unknown) 0

6QVCNPGYCPFTGNCRUG   6QVCNECUGUPQVKßGF 

New cases

  5/'#40')#6+8'70-0190

 5/'#4215+6+8' 016&10' ':64#27./10#4;

/(TCVKQ   

#IG   

Laboratories 2012

Smear (per 100 000 population) 2.0

Culture (per 5 million population) 0.4

Drug susceptibility testing (per 5 million population) 0.1

+UUGEQPFNKPGFTWIUWUEGRVKDKNKV[VGUVKPICXCKNCDNG! ;GUKPEQWPVT[

6TGCVOGPVUWEEGUUTCVG    

0GYUOGCTRQUKVKXGCPFQTEWNVWTGRQUKVKXG 

0GYUOGCTPGICVKXGGZVTCRWNOQPCT[ 

4GVTGCVOGPV 

+UTKHCORKEKPWUGFVJTQWIJQWVVTGCVOGPVHQTPGYRCVKGPVU! ;GU

TB/HIV 2012 07/$'4 (%)

6$RCVKGPVUYKVJMPQYP*+8UVCVWU  

HIV-positive TB patients 20 269 (39)

*+8RQUKVKXG6$RCVKGPVUQPEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26  

*+8RQUKVKXG6$RCVKGPVUQPCPVKTGVTQXKTCNVJGTCR[#46 

HIV-positive people screened for TB 357 400

HIV-positive people provided with IPT

Estimates of MDR-TB burden 2012a 0'9 4'64'#6/'06

QH6$ECUGUYKVJ/&46$ ¿ ¿

/&46$ECUGUCOQPIPQVKßGF

pulmonary TB cases 500 (140–1 300) 0 (0–160)

Reported cases of MDR-TB 20120'9 4'64'#6/'06 616#.

%CUGUVGUVGFHQT/&46$   

.CDQTCVQT[EQPßTOGF/&46$ECUGU   

2CVKGPVUUVCTVGFQP/&46$VTGCVOGPV   

Financing TB control 2013

0CVKQPCN6$RTQITCOOGDWFIGV75OKNNKQPU 

% Funded domestically 14%

% Funded internationally 19%

% Unfunded 67%

Mortality (excludes HIV+TB) (rate

per 100 000 population per year)

1990 1995 2000 2005 2010

Prevalence

(rate per 100 000 population)

1990 1995 2000 2005 2010

200

400

600

800

Incidence (rate per 100 000

population per year)

1990 1995 2000 2005 2010

Incidence Incidence (HIV+TB) Notifications

100

200

300

Treatment success rate (%)

New smear-positive (and/or culture-positive) Retreatment

New smear-negative/extrapulmonary

100

1995 1997 1999 2001 2003 2005 2007 2009 2011

Number of patients

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

HIV-positive TB patients on CPT on ART

5000

10 000

15 000

20 000

25 000

Total budget (US$ millions)

Funded domestically Funded internationally Unfunded

2009 2010 2011 2012 2013

135 Data for all years can be downloaded from www.who.int/tb/data GLOBAL TUBERCULOSIS REPORT 2013

Data are as reported to WHO. Estimates of TB and MDR-TB burden are produced by WHO in consultation with

countries.

a Ranges represent uncertainty intervals.

VIET NAM Population 2012 91 million

HIGH TB BURDEN | HIGH HIV BURDEN | HIGH MDR-TB BURDEN

Estimates of TB burdena 2012

07/$'4(thousands)4#6'(per 100 000 population)

/QTVCNKV[GZENWFGU*+86$ ¿ ¿

/QTVCNKV[*+86$QPN[ ¿ ¿

2TGXCNGPEGKPENWFGU*+86$ ¿ ¿

Incidence (includes HIV+TB) 130 (99–170) 147 (109–192)

Incidence (HIV+TB only) 9.3 (6.9–12) 10 (7.6–13)

Case detection, all forms (%) 76 (59–100)

6$ECUGPQVKßECVKQPU    

0'9%#5'5   4'64'#6/'06%#5'5  

5OGCTRQUKVKXG   4GNCRUG  

Smear-negative 21 706 (23) Treatment after failure 567 (6)

Smear-unknown / not done Treatment after default 494 (5)

'ZVTCRWNOQPCT[   1VJGT  

Other 3 210 (3)

Total new 94 853 Total retreatment 9 053

Other (history unknown)

6QVCNPGYCPFTGNCRUG   6QVCNECUGUPQVKßGF 

New cases

  5/'#40')#6+8'70-0190

 5/'#4215+6+8' 016&10' ':64#27./10#4;

/(TCVKQ   

#IG   

Laboratories 2012

Smear (per 100 000 population) 0.9

Culture (per 5 million population) 1.4

Drug susceptibility testing (per 5 million population) 0.1

+UUGEQPFNKPGFTWIUWUEGRVKDKNKV[VGUVKPICXCKNCDNG! ;GUKPEQWPVT[

6TGCVOGPVUWEEGUUTCVG    

New smear-positive and/or culture-positive 93

New smear-negative/extrapulmonary 93

4GVTGCVOGPV 

Is rifampicin used throughout treatment for new patients? No

TB/HIV 2012 07/$'4 (%)

6$RCVKGPVUYKVJMPQYP*+8UVCVWU  

HIV-positive TB patients 4 775 (7)

*+8RQUKVKXG6$RCVKGPVUQPEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26  

*+8RQUKVKXG6$RCVKGPVUQPCPVKTGVTQXKTCNVJGTCR[#46  

HIV-positive people screened for TB

HIV-positive people provided with IPT 5 663

Estimates of MDR-TB burden 2012a 0'9 4'64'#6/'06

QH6$ECUGUYKVJ/&46$ ¿ ¿

/&46$ECUGUCOQPIPQVKßGF

RWNOQPCT[6$ECUGU ¿ ¿

Reported cases of MDR-TB 20120'9 4'64'#6/'06 616#.

%CUGUVGUVGFHQT/&46$   

.CDQTCVQT[EQPßTOGF/&46$ECUGU   

2CVKGPVUUVCTVGFQP/&46$VTGCVOGPV   

Financing TB control 2013

0CVKQPCN6$RTQITCOOGDWFIGV75OKNNKQPU 

(WPFGFFQOGUVKECNN[ 

% Funded internationally 20%

% Unfunded 72%

Mortality (excludes HIV+TB) (rate

per 100 000 population per year)

1990 1995 2000 2005 2010

Prevalence

(rate per 100 000 population)

1990 1995 2000 2005 2010

250

500

750

1000

Incidence (rate per 100 000

population per year)

1990 1995 2000 2005 2010

Incidence Incidence (HIV+TB) Notifications

100

200

300

400

Treatment success rate (%)

New smear-positive (and/or culture-positive) Retreatment

New smear-negative/extrapulmonary

100

1995 1997 1999 2001 2003 2005 2007 2009 2011

Number of patients

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

HIV-positive TB patients on CPT on ART

2000

4000

6000

Total budget (US$ millions)

Funded domestically Funded internationally Unfunded

2009 2010 2011 2012 2013

136 GLOBAL TUBERCULOSIS REPORT 2013 Data for all years can be downloaded from www.who.int/tb/data

Data are as reported to WHO. Estimates of TB and MDR-TB burden are produced by WHO in consultation with

countries.

a Ranges represent uncertainty intervals.

ZIMBABWE Population 2012 14 million

HIGH TB BURDEN | HIGH HIV BURDEN

Estimates of TB burdena 2012

07/$'4(thousands)4#6'(per 100 000 population)

Mortality (excludes HIV+TB) 4.6 (0.16–16) 33 (1.2–117)

/QTVCNKV[*+86$QPN[ ¿ ¿

Prevalence (includes HIV+TB) 59 (13–140) 433 (92–1 034)

Incidence (includes HIV+TB) 77 (60–97) 562 (434–706)

+PEKFGPEG*+86$QPN[ ¿ ¿

Case detection, all forms (%) 46 (37–60)

6$ECUGPQVKßECVKQPU    

0'9%#5'5   4'64'#6/'06%#5'5  

5OGCTRQUKVKXG   4GNCRUG  

Smear-negative 14 354 (42) Treatment after failure 200 (5)

Smear-unknown / not done 2 962 (9) Treatment after default 176 (4)

'ZVTCRWNOQPCT[   1VJGT  

Other 0 (0)

Total new 34 391 Total retreatment 4 329

Other (history unknown) 0

6QVCNPGYCPFTGNCRUG   6QVCNECUGUPQVKßGF 

New cases

  5/'#40')#6+8'70-0190

 5/'#4215+6+8' 016&10' ':64#27./10#4;

/(TCVKQ   

#IG   

Laboratories 2012

Smear (per 100 000 population) 1.3

Culture (per 5 million population) 0.7

Drug susceptibility testing (per 5 million population) 0.7

Is second-line drug susceptibility testing available? No

6TGCVOGPVUWEEGUUTCVG    

0GYUOGCTRQUKVKXGCPFQTEWNVWTGRQUKVKXG 

0GYUOGCTPGICVKXGGZVTCRWNOQPCT[ 

4GVTGCVOGPV 

+UTKHCORKEKPWUGFVJTQWIJQWVVTGCVOGPVHQTPGYRCVKGPVU! ;GU

TB/HIV 2012 07/$'4 (%)

6$RCVKGPVUYKVJMPQYP*+8UVCVWU  

HIV-positive TB patients 23 957 (70)

*+8RQUKVKXG6$RCVKGPVUQPEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26  

*+8RQUKVKXG6$RCVKGPVUQPCPVKTGVTQXKTCNVJGTCR[#46  

HIV-positive people screened for TB

HIV-positive people provided with IPT

Estimates of MDR-TB burden 2012a 0'9 4'64'#6/'06

QH6$ECUGUYKVJ/&46$ ¿ ¿

/&46$ECUGUCOQPIPQVKßGF

pulmonary TB cases 570 (300–960) 360 (76–970)

Reported cases of MDR-TB 20120'9 4'64'#6/'06 616#.

%CUGUVGUVGFHQT/&46$   

.CDQTCVQT[EQPßTOGF/&46$ECUGU   

2CVKGPVUUVCTVGFQP/&46$VTGCVOGPV   

Financing TB control 2013

0CVKQPCN6$RTQITCOOGDWFIGV75OKNNKQPU 

% Funded domestically 4%

% Funded internationally 39%

% Unfunded 56%

Mortality (excludes HIV+TB) (rate

per 100 000 population per year)

1990 1995 2000 2005 2010

100

150

Prevalence

(rate per 100 000 population)

1990 1995 2000 2005 2010

500

1000

1500

Incidence (rate per 100 000

population per year)

1990 1995 2000 2005 2010

Incidence Incidence (HIV+TB) Notifications

250

500

750

1000

Treatment success rate (%)

New smear-positive (and/or culture-positive) Retreatment

New smear-negative/extrapulmonary

1995 1997 1999 2001 2003 2005 2007 2009 2011

100

Number of patients

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

HIV-positive TB patients on CPT on ART

10 000

20 000

30 000

40 000

Total budget (US$ millions)

Funded domestically Funded internationally Unfunded

2009 2010 2011 2012 2013

#00':

Regional proßles

139 Data for all years can be downloaded from www.who.int/tb/data GLOBAL TUBERCULOSIS REPORT 2013

WHO AFRICAN REGION Population 2012 893 million

WHO MEMBER STATES 46

Estimates of TB burdena 2012

 07/$'4thousands 4#6'per 100 000 population)

/QTVCNKV[GZENWFGU*+86$ ¿ ¿

/QTVCNKV[*+86$QPN[ ¿ ¿

Prevalence (includes HIV+TB) 2 700 (2 100–3 300) 303 (239–373)

Incidence (includes HIV+TB) 2 300 (2 100–2 500) 255 (235–275)

+PEKFGPEG*+86$QPN[ ¿ ¿

Case detection, all forms (%) 59 (55–64)

6$ECUGPQVKßECVKQPU    

0'9%#5'5   4'64'#6/'06%#5'5  

5OGCTRQUKVKXG   4GNCRUG  

Smear-negative 345 947 (27) Treatment after failure 9 174 (7.2)

5OGCTWPMPQYPPQVFQPG   6TGCVOGPVCHVGTFGHCWNV  

'ZVTCRWNOQPCT[   1VJGT  

1VJGT     

Total new 1 282 355 Total retreatment 128 267

Other (history unknown) 2 017

6QVCNPGYCPFTGNCRUG   6QVCNECUGUPQVKßGF 

New cases

  5/'#40')#6+8'70-0190

 5/'#4215+6+8' 016&10' ':64#27./10#4;

/(TCVKQ   

#IG   

Laboratories 2012 07/$'41(/'/$'456#6'5b

5OGCTRGTRQRWNCVKQPÜ QWVQH

%WNVWTGRGTOKNNKQPRQRWNCVKQPÜ QWVQH

&TWIUWUEGRVKDKNKV[VGUVKPIRGTOKNNKQPRQRWNCVKQPÜ QWVQH

6TGCVOGPVUWEEGUUTCVG 

0GYUOGCTRQUKVKXGCPFQTEWNVWTGRQUKVKXG 

New smear-negative/extrapulmonary 76

4GVTGCVOGPV 

/&46$EQJQTV 

TB/HIV 2012 07/$'4 (%)c

TB patients with known HIV status 1 040 292 (74)

*+8RQUKVKXG6$RCVKGPVU  

*+8RQUKVKXG6$RCVKGPVUQPEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26  

*+8RQUKVKXG6$RCVKGPVUQPCPVKTGVTQXKTCNVJGTCR[#46  

HIV-positive people screened for TB 2 391 601

HIV-positive people provided with IPT 473 214

Estimates of MDR-TB burden 2012a 0'9 4'64'#6/'06

QH6$ECUGUYKVJ/&46$ ¿ ¿

/&46$ECUGUCOQPIPQVKßGF

pulmonary TB cases 24 000 (2 100–46 000) 14 000 (5 600–22 000)

Reported cases of MDR-TB 20120'9 4'64'#6/'06 616#.

%CUGUVGUVGFHQT/&46$   

.CDQTCVQT[EQPßTOGF/&46$ECUGU   

2CVKGPVUUVCTVGFQP/&46$VTGCVOGPV   

(KPCPEKPI6$EQPVTQNNQYCPFOKFFNGKPEQOGEQWPVTKGUd 2013

0CVKQPCN6$RTQITCOOGDWFIGV75OKNNKQPU 

% Funded domestically 44

% Funded internationally 21

% Unfunded 36

&CVCCTGCUTGRQTVGFVQ9*1'UVKOCVGUQH6$CPF/&46$DWTFGPCTGRTQFWEGFD[9*1KPEQPUWNVCVKQPYKVJ

countries.

a 4CPIGUTGRTGUGPVWPEGTVCKPV[KPVGTXCNU

b Data are not collected from all Member States.

c Calculations exclude countries with missing numerators or denominators.

d Financing indicators exclude funding for general healthcare services provided outside NTPs.

Mortality (excludes HIV+TB) (rate

per 100 000 population per year)

1990 1995 2000 2005 2010

Prevalence

(rate per 100 000 population)

1990 1995 2000 2005 2010

250

500

750

Incidence (rate per 100 000

population per year)

1990 1995 2000 2005 2010

Incidence Incidence (HIV+TB) Notifications

100

200

300

400

Treatment success rate (%)

New smear-positive (and/or culture-positive) Retreatment

New smear-negative/extrapulmonary

1995 1997 1999 2001 2003 2005 2007 2009 2011

100

Number of patients

HIV-positive TB patients on CPT on ART

2004 2005 2006 2007 2008 2009 2010 2011 2012

100

200

300

400

500

Total budget (US$ millions)

Funded domestically Funded internationally Unfunded

2009 2010 2011 2012 2013

500

1000

1500

140 GLOBAL TUBERCULOSIS REPORT 2013 Data for all years can be downloaded from www.who.int/tb/data

WHO REGION OF THE AMERICAS Population 2012 961 million

WHO MEMBER STATES 35

OTHER COUNTRIES AND TERRITORIES 11

Estimates of TB burdena 2012

 07/$'4thousands 4#6'per 100 000 population)

Mortality (excludes HIV+TB) 19 (16–21) 1.9 (1.7–2.2)

/QTVCNKV[*+86$QPN[ ¿ ¿

Prevalence (includes HIV+TB) 390 (300–490) 40 (31–51)

+PEKFGPEGKPENWFGU*+86$ ¿ ¿

+PEKFGPEG*+86$QPN[ ¿ ¿

%CUGFGVGEVKQPCNNHQTOU ¿ 

6$ECUGPQVKßECVKQPU    

0'9%#5'5   4'64'#6/'06%#5'5  

5OGCTRQUKVKXG   4GNCRUG  

Smear-negative 35 606 (17) Treatment after failure 1 195 (5.0)

5OGCTWPMPQYPPQVFQPG   6TGCVOGPVCHVGTFGHCWNV  

'ZVTCRWNOQPCT[   1VJGT  

1VJGT     

Total new 208 845 Total retreatment 23 811

Other (history unknown) 39

6QVCNPGYCPFTGNCRUG   6QVCNECUGUPQVKßGF 

New cases

  5/'#40')#6+8'70-0190

 5/'#4215+6+8' 016&10' ':64#27./10#4;

/(TCVKQ   

#IG   

Laboratories 2012 07/$'41(/'/$'456#6'5b

5OGCTRGTRQRWNCVKQPÜ QWVQH

%WNVWTGRGTOKNNKQPRQRWNCVKQPÜ QWVQH

&TWIUWUEGRVKDKNKV[VGUVKPIRGTOKNNKQPRQRWNCVKQPÜ QWVQH

6TGCVOGPVUWEEGUUTCVG 

0GYUOGCTRQUKVKXGCPFQTEWNVWTGRQUKVKXG 

New smear-negative/extrapulmonary 71

4GVTGCVOGPV 

/&46$EQJQTV 

TB/HIV 2012 07/$'4 (%)c

TB patients with known HIV status 129 174 (56)

HIV-positive TB patients 20 355 (16)

*+8RQUKVKXG6$RCVKGPVUQPEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26  

*+8RQUKVKXG6$RCVKGPVUQPCPVKTGVTQXKTCNVJGTCR[#46 

*+8RQUKVKXGRGQRNGUETGGPGFHQT6$  

*+8RQUKVKXGRGQRNGRTQXKFGFYKVJ+26  

Estimates of MDR-TB burden 2012a 0'9 4'64'#6/'06

QH6$ECUGUYKVJ/&46$ ¿ ¿

/&46$ECUGUCOQPIPQVKßGF

RWNOQPCT[6$ECUGU ¿ ¿

Reported cases of MDR-TB 20120'9 4'64'#6/'06 616#.

%CUGUVGUVGFHQT/&46$   

.CDQTCVQT[EQPßTOGF/&46$ECUGU   

2CVKGPVUUVCTVGFQP/&46$VTGCVOGPV   

(KPCPEKPI6$EQPVTQNNQYCPFOKFFNGKPEQOGEQWPVTKGUd 2013

0CVKQPCN6$RTQITCOOGDWFIGV75OKNNKQPU 

% Funded domestically 69

% Funded internationally 12

% Unfunded 19

Mortality (excludes HIV+TB) (rate

per 100 000 population per year)

1990 1995 2000 2005 2010

Prevalence

(rate per 100 000 population)

1990 1995 2000 2005 2010

100

150

Incidence (rate per 100 000

population per year)

1990 1995 2000 2005 2010

Incidence Incidence (HIV+TB) Notifications

Treatment success rate (%)

New smear-positive (and/or culture-positive) Retreatment

New smear-negative/extrapulmonary

1995 1997 1999 2001 2003 2005 2007 2009 2011

100

Number of patients

HIV-positive TB patients on CPT on ART

2004 2005 2006 2007 2008 2009 2010 2011 2012

Total budget (US$ millions)

Funded domestically Funded internationally Unfunded

2009 2010 2011 2012 2013

100

150

200

&CVCCTGCUTGRQTVGFVQ9*1'UVKOCVGUQH6$CPF/&46$DWTFGPCTGRTQFWEGFD[9*1KPEQPUWNVCVKQPYKVJ

countries.

a 4CPIGUTGRTGUGPVWPEGTVCKPV[KPVGTXCNU

b Data are not collected from all Member States.

c Calculations exclude countries with missing numerators or denominators.

d Financing indicators exclude funding for general healthcare services provided outside NTPs.

141 Data for all years can be downloaded from www.who.int/tb/data GLOBAL TUBERCULOSIS REPORT 2013

WHO EASTERN MEDITERRANEAN REGION Population 2012 617 million

WHO MEMBER STATES 22

OTHER COUNTRIES AND TERRITORIES 1

Estimates of TB burdena 2012

 07/$'4thousands 4#6'per 100 000 population)

Mortality (excludes HIV+TB) 100 (63–150) 16 (10–24)

/QTVCNKV[*+86$QPN[ ¿ ¿

2TGXCNGPEGKPENWFGU*+86$ ¿ ¿

Incidence (includes HIV+TB) 670 (590–750) 109 (96–122)

+PEKFGPEG*+86$QPN[ ¿ ¿

Case detection, all forms (%) 63 (56–71)

6$ECUGPQVKßECVKQPU    

0'9%#5'5   4'64'#6/'06%#5'5  

5OGCTRQUKVKXG   4GNCRUG  

Smear-negative 135 346 (33) Treatment after failure 2 007 (9.5)

5OGCTWPMPQYPPQVFQPG   6TGCVOGPVCHVGTFGHCWNV  

Extrapulmonary 90 943 (22) Other 5 200 (24)

1VJGT     

Total new 409 477 Total retreatment 21 228

1VJGTJKUVQT[WPMPQYP     

6QVCNPGYCPFTGNCRUG   6QVCNECUGUPQVKßGF 

New cases

  5/'#40')#6+8'70-0190

 5/'#4215+6+8' 016&10' ':64#27./10#4;

/(TCVKQ   

#IG   

Laboratories 2012 07/$'41(/'/$'456#6'5b

5OGCTRGTRQRWNCVKQPÜ QWVQH

%WNVWTGRGTOKNNKQPRQRWNCVKQPÜ QWVQH

&TWIUWUEGRVKDKNKV[VGUVKPIRGTOKNNKQPRQRWNCVKQPÜ QWVQH

6TGCVOGPVUWEEGUUTCVG 

0GYUOGCTRQUKVKXGCPFQTEWNVWTGRQUKVKXG 

0GYUOGCTPGICVKXGGZVTCRWNOQPCT[ 

4GVTGCVOGPV 

/&46$EQJQTV 

TB/HIV 2012 07/$'4 (%)c

6$RCVKGPVUYKVJMPQYP*+8UVCVWU  

HIV-positive TB patients 2 020 (3.5)

*+8RQUKVKXG6$RCVKGPVUQPEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26  

*+8RQUKVKXG6$RCVKGPVUQPCPVKTGVTQXKTCNVJGTCR[#46  

HIV-positive people screened for TB 15 012

HIV-positive people provided with IPT 243

Estimates of MDR-TB burden 2012a 0'9 4'64'#6/'06

QH6$ECUGUYKVJ/&46$ ¿ ¿

/&46$ECUGUCOQPIPQVKßGF

pulmonary TB cases 11 000 (320–36 000) 6 900 (2 400–11 000)

Reported cases of MDR-TB 20120'9 4'64'#6/'06 616#.

%CUGUVGUVGFHQT/&46$   

.CDQTCVQT[EQPßTOGF/&46$ECUGU   

2CVKGPVUUVCTVGFQP/&46$VTGCVOGPV   

(KPCPEKPI6$EQPVTQNNQYCPFOKFFNGKPEQOGEQWPVTKGUd 2013

0CVKQPCN6$RTQITCOOGDWFIGV75OKNNKQPU 

% Funded domestically 32

% Funded internationally 53

% Unfunded 16

Mortality (excludes HIV+TB) (rate

per 100 000 population per year)

1990 1995 2000 2005 2010

Prevalence

(rate per 100 000 population)

1990 1995 2000 2005 2010

100

200

300

400

500

Incidence (rate per 100 000

population per year)

1990 1995 2000 2005 2010

Incidence Incidence (HIV+TB) Notifications

100

150

200

Treatment success rate (%)

New smear-positive (and/or culture-positive) Retreatment

New smear-negative/extrapulmonary

1995 1997 1999 2001 2003 2005 2007 2009 2011

100

Number of patients

HIV-positive TB patients on CPT on ART

2004 2005 2006 2007 2008 2009 2010 2011 2012

0.5

1.0

1.5

2.0

Total budget (US$ millions)

Funded domestically Funded internationally Unfunded

2009 2010 2011 2012 2013

100

150

200

&CVCCTGCUTGRQTVGFVQ9*1'UVKOCVGUQH6$CPF/&46$DWTFGPCTGRTQFWEGFD[9*1KPEQPUWNVCVKQPYKVJ

countries.

a 4CPIGUTGRTGUGPVWPEGTVCKPV[KPVGTXCNU

b Data are not collected from all Member States.

c Calculations exclude countries with missing numerators or denominators.

d Financing indicators exclude funding for general healthcare services provided outside NTPs.

142 GLOBAL TUBERCULOSIS REPORT 2013 Data for all years can be downloaded from www.who.int/tb/data

WHO EUROPEAN REGION Population 2012 905 million

WHO MEMBER STATES 53

OTHER COUNTRIES AND TERRITORIES 1

Estimates of TB burdena 2012

 07/$'4thousands 4#6'per 100 000 population)

Mortality (excludes HIV+TB) 36 (35–36) 3.9 (3.9–4)

/QTVCNKV[*+86$QPN[ ¿ ¿

2TGXCNGPEGKPENWFGU*+86$ ¿ ¿

+PEKFGPEGKPENWFGU*+86$ ¿ ¿

Incidence (HIV+TB only) 19 (17–21) 2.1 (1.9–2.3)

Case detection, all forms (%) 74 (70–79)

6$ECUGPQVKßECVKQPU    

0'9%#5'5   4'64'#6/'06%#5'5  

5OGCTRQUKVKXG   4GNCRUG  

5OGCTPGICVKXG   6TGCVOGPVCHVGTHCKNWTG  

5OGCTWPMPQYPPQVFQPG   6TGCVOGPVCHVGTFGHCWNV 

Extrapulmonary 39 029 (16) Other 51 237 (55)

1VJGT     

Total new 242 266 Total retreatment 92 847

Other (history unknown) 2 054

6QVCNPGYCPFTGNCRUG   6QVCNECUGUPQVKßGF 

New cases

  5/'#40')#6+8'70-0190

 5/'#4215+6+8' 016&10' ':64#27./10#4;

/(TCVKQ   

#IG   

Laboratories 2012 07/$'41(/'/$'456#6'5b

5OGCTRGTRQRWNCVKQPÜ QWVQH

%WNVWTGRGTOKNNKQPRQRWNCVKQPÜ QWVQH

&TWIUWUEGRVKDKNKV[VGUVKPIRGTOKNNKQPRQRWNCVKQPÜ QWVQH

6TGCVOGPVUWEEGUUTCVG 

New smear-positive and/or culture-positive 65

New smear-negative/extrapulmonary 79

4GVTGCVOGPV 

/&46$EQJQTV 

TB/HIV 2012 07/$'4 (%)c

TB patients with known HIV status 203 705 (60)

HIV-positive TB patients 12 900 (6.3)

*+8RQUKVKXG6$RCVKGPVUQPEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26  

*+8RQUKVKXG6$RCVKGPVUQPCPVKTGVTQXKTCNVJGTCR[#46  

HIV-positive people screened for TB 23 567

*+8RQUKVKXGRGQRNGRTQXKFGFYKVJ+26  

Estimates of MDR-TB burden 2012a 0'9 4'64'#6/'06

QH6$ECUGUYKVJ/&46$ ¿ ¿

/&46$ECUGUCOQPIPQVKßGF

RWNOQPCT[6$ECUGU ¿ ¿

Reported cases of MDR-TB 20120'9 4'64'#6/'06 616#.

%CUGUVGUVGFHQT/&46$   

.CDQTCVQT[EQPßTOGF/&46$ECUGU   

2CVKGPVUUVCTVGFQP/&46$VTGCVOGPV   

(KPCPEKPI6$EQPVTQNNQYCPFOKFFNGKPEQOGEQWPVTKGUd 2013

0CVKQPCN6$RTQITCOOGDWFIGV75OKNNKQPU 

% Funded domestically 92

% Funded internationally 3.7

% Unfunded 4.3

Mortality (excludes HIV+TB) (rate

per 100 000 population per year)

1990 1995 2000 2005 2010

Prevalence

(rate per 100 000 population)

1990 1995 2000 2005 2010

100

150

200

Incidence (rate per 100 000

population per year)

1990 1995 2000 2005 2010

Incidence Incidence (HIV+TB) Notifications

100

Treatment success rate (%)

New smear-positive (and/or culture-positive) Retreatment

New smear-negative/extrapulmonary

1995 1997 1999 2001 2003 2005 2007 2009 2011

100

Number of patients

HIV-positive TB patients on CPT on ART

2004 2005 2006 2007 2008 2009 2010 2011 2012

Total budget (US$ millions)

Funded domestically Funded internationally Unfunded

2009 2010 2011 2012 2013

500

1000

1500

2000

2500

&CVCCTGCUTGRQTVGFVQ9*1'UVKOCVGUQH6$CPF/&46$DWTFGPCTGRTQFWEGFD[9*1KPEQPUWNVCVKQPYKVJ

countries.

a 4CPIGUTGRTGUGPVWPEGTVCKPV[KPVGTXCNU

b Data are not collected from all Member States.

c Calculations exclude countries with missing numerators or denominators.

d Financing indicators exclude funding for general healthcare services provided outside NTPs.

143 Data for all years can be downloaded from www.who.int/tb/data GLOBAL TUBERCULOSIS REPORT 2013

WHO SOUTH-EAST ASIA REGION Population 2012 1 833 million

WHO MEMBER STATES 11

Estimates of TB burdena 2012

 07/$'4thousands 4#6'per 100 000 population)

/QTVCNKV[GZENWFGU*+86$ ¿ ¿

/QTVCNKV[*+86$QPN[ ¿ ¿

2TGXCNGPEGKPENWFGU*+86$ ¿ ¿

+PEKFGPEGKPENWFGU*+86$ ¿ ¿

+PEKFGPEG*+86$QPN[ ¿ ¿

%CUGFGVGEVKQPCNNHQTOU ¿ 

6$ECUGPQVKßECVKQPU    

0'9%#5'5   4'64'#6/'06%#5'5  

5OGCTRQUKVKXG   4GNCRUG  

5OGCTPGICVKXG   6TGCVOGPVCHVGTHCKNWTG 

Smear-unknown / not done 0 (0) Treatment after default 69 100 (21)

'ZVTCRWNOQPCT[   1VJGT  

1VJGT     

Total new 1 993 614 Total retreatment 332 580

Other (history unknown) 5 261

6QVCNPGYCPFTGNCRUG   6QVCNECUGUPQVKßGF 

New cases

  5/'#40')#6+8'70-0190

 5/'#4215+6+8' 016&10' ':64#27./10#4;

/(TCVKQ   

#IG   

Laboratories 2012 07/$'41(/'/$'456#6'5b

5OGCTRGTRQRWNCVKQPÜ QWVQH

%WNVWTGRGTOKNNKQPRQRWNCVKQPÜ QWVQH

&TWIUWUEGRVKDKNKV[VGUVKPIRGTOKNNKQPRQRWNCVKQPÜ QWVQH

6TGCVOGPVUWEEGUUTCVG 

0GYUOGCTRQUKVKXGCPFQTEWNVWTGRQUKVKXG 

0GYUOGCTPGICVKXGGZVTCRWNOQPCT[ 

4GVTGCVOGPV 

/&46$EQJQTV 

TB/HIV 2012 07/$'4 (%)c

TB patients with known HIV status 904 223 (39)

HIV-positive TB patients 56 093 (6.2)

*+8RQUKVKXG6$RCVKGPVUQPEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26  

*+8RQUKVKXG6$RCVKGPVUQPCPVKTGVTQXKTCNVJGTCR[#46 

*+8RQUKVKXGRGQRNGUETGGPGFHQT6$  

*+8RQUKVKXGRGQRNGRTQXKFGFYKVJ+26  

Estimates of MDR-TB burden 2012a 0'9 4'64'#6/'06

QH6$ECUGUYKVJ/&46$ ¿ ¿

/&46$ECUGUCOQPIPQVKßGF

pulmonary TB cases 36 000 (26 000–46 000) 54 000 (37 000–70 000)

Reported cases of MDR-TB 20120'9 4'64'#6/'06 616#.

%CUGUVGUVGFHQT/&46$   

.CDQTCVQT[EQPßTOGF/&46$ECUGU   

2CVKGPVUUVCTVGFQP/&46$VTGCVOGPV   

(KPCPEKPI6$EQPVTQNNQYCPFOKFFNGKPEQOGEQWPVTKGUd 2013

0CVKQPCN6$RTQITCOOGDWFIGV75OKNNKQPU 

% Funded domestically 30

% Funded internationally 41

% Unfunded 29

Mortality (excludes HIV+TB) (rate

per 100 000 population per year)

1990 1995 2000 2005 2010

Prevalence

(rate per 100 000 population)

1990 1995 2000 2005 2010

200

400

600

Incidence (rate per 100 000

population per year)

1990 1995 2000 2005 2010

Incidence Incidence (HIV+TB) Notifications

100

200

300

Treatment success rate (%)

New smear-positive (and/or culture-positive) Retreatment

New smear-negative/extrapulmonary

1995 1997 1999 2001 2003 2005 2007 2009 2011

100

Number of patients

HIV-positive TB patients on CPT on ART

2004 2005 2006 2007 2008 2009 2010 2011 2012

Total budget (US$ millions)

Funded domestically Funded internationally Unfunded

2009 2010 2011 2012 2013

200

400

600

&CVCCTGCUTGRQTVGFVQ9*1'UVKOCVGUQH6$CPF/&46$DWTFGPCTGRTQFWEGFD[9*1KPEQPUWNVCVKQPYKVJ

countries.

a 4CPIGUTGRTGUGPVWPEGTVCKPV[KPVGTXCNU

b Data are not collected from all Member States.

c Calculations exclude countries with missing numerators or denominators.

d Financing indicators exclude funding for general healthcare services provided outside NTPs.

144 GLOBAL TUBERCULOSIS REPORT 2013 Data for all years can be downloaded from www.who.int/tb/data

WHO WESTERN PACIFIC REGION Population 2012 1 846 million

WHO MEMBER STATES 27

OTHER COUNTRIES AND TERRITORIES 9

Estimates of TB burdena 2012

 07/$'4thousands 4#6'per 100 000 population)

/QTVCNKV[GZENWFGU*+86$ ¿ ¿

Mortality (HIV+TB only) 5 (4–5) 0.26 (0.23–0.29)

2TGXCNGPEGKPENWFGU*+86$ ¿ ¿

+PEKFGPEGKPENWFGU*+86$ ¿ ¿

Incidence (HIV+TB only) 24 (21–27) 1.3 (1.1–1.5)

%CUGFGVGEVKQPCNNHQTOU ¿ 

6$ECUGPQVKßECVKQPU    

0'9%#5'5   4'64'#6/'06%#5'5  

5OGCTRQUKVKXG   4GNCRUG  

Smear-negative 691 714 (55) Treatment after failure 3 714 (4.6)

5OGCTWPMPQYPPQVFQPG   6TGCVOGPVCHVGTFGHCWNV 

'ZVTCRWNOQPCT[   1VJGT  

1VJGT     

Total new 1 264 217 Total retreatment 80 017

Other (history unknown) 1 232

6QVCNPGYCPFTGNCRUG   6QVCNECUGUPQVKßGF 

New cases

  5/'#40')#6+8'70-0190

 5/'#4215+6+8' 016&10' ':64#27./10#4;

/(TCVKQ   

#IG   

Laboratories 2012 07/$'41(/'/$'456#6'5b

5OGCTRGTRQRWNCVKQPÜ QWVQH

%WNVWTGRGTOKNNKQPRQRWNCVKQPÜ QWVQH

&TWIUWUEGRVKDKNKV[VGUVKPIRGTOKNNKQPRQRWNCVKQPÜ QWVQH

6TGCVOGPVUWEEGUUTCVG 

New smear-positive and/or culture-positive 94

New smear-negative/extrapulmonary 93

4GVTGCVOGPV 

/&46$EQJQTV 

TB/HIV 2012 07/$'4 (%)c

TB patients with known HIV status 451 302 (34)

HIV-positive TB patients 14 119 (3.1)

*+8RQUKVKXG6$RCVKGPVUQPEQVTKOQZC\QNGRTGXGPVKXGVJGTCR[%26  

*+8RQUKVKXG6$RCVKGPVUQPCPVKTGVTQXKTCNVJGTCR[#46  

*+8RQUKVKXGRGQRNGUETGGPGFHQT6$  

*+8RQUKVKXGRGQRNGRTQXKFGFYKVJ+26  

Estimates of MDR-TB burden 2012a 0'9 4'64'#6/'06

QH6$ECUGUYKVJ/&46$ ¿ ¿

/&46$ECUGUCOQPIPQVKßGF

RWNOQPCT[6$ECUGU ¿ ¿

Reported cases of MDR-TB 20120'9 4'64'#6/'06 616#.

%CUGUVGUVGFHQT/&46$   

.CDQTCVQT[EQPßTOGF/&46$ECUGU   

2CVKGPVUUVCTVGFQP/&46$VTGCVOGPV   

(KPCPEKPI6$EQPVTQNNQYCPFOKFFNGKPEQOGEQWPVTKGUd 2013

0CVKQPCN6$RTQITCOOGDWFIGV75OKNNKQPU 

% Funded domestically 50

% Funded internationally 15

% Unfunded 36

Mortality (excludes HIV+TB) (rate

per 100 000 population per year)

1990 1995 2000 2005 2010

Prevalence

(rate per 100 000 population)

1990 1995 2000 2005 2010

100

200

300

400

Incidence (rate per 100 000

population per year)

1990 1995 2000 2005 2010

Incidence Incidence (HIV+TB) Notifications

100

150

200

Treatment success rate (%)

New smear-positive (and/or culture-positive) Retreatment

New smear-negative/extrapulmonary

1995 1997 1999 2001 2003 2005 2007 2009 2011

100

Number of patients

HIV-positive TB patients on CPT on ART

2004 2005 2006 2007 2008 2009 2010 2011 2012

Total budget (US$ millions)

Funded domestically Funded internationally Unfunded

2009 2010 2011 2012 2013

200

400

600

800

&CVCCTGCUTGRQTVGFVQ9*1'UVKOCVGUQH6$CPF/&46$DWTFGPCTGRTQFWEGFD[9*1KPEQPUWNVCVKQPYKVJ

countries.

a 4CPIGUTGRTGUGPVWPEGTVCKPV[KPVGTXCNU

b Data are not collected from all Member States.

c Calculations exclude countries with missing numerators or denominators.

d Financing indicators exclude funding for general healthcare services provided outside NTPs.

#00':

Key indicators for the

world, WHO regions

and individual countries

Summary by WHO region 147

#HTKECP4GIKQP 

4GIKQPQHVJG#OGTKECU 

'CUVGTP/GFKVGTTCPGCP4GIKQP 

'WTQRGCP4GIKQP 

5QWVJ'CUV#UKC4GIKQP 

9GUVGTP2CEKßE4GIKQP 

57//#4;$;9*14')+10

Table A4.1 Estimates of the burden of disease caused by TB, 1990–2012 149

6CDNG# +PEKFGPEGPQVKßECVKQPCPFECUGFGVGEVKQPTCVGUCNNHQTOU¿ 

6CDNG# %CUGPQVKßECVKQPU¿ 

Table A4.4 Treatment outcomes, new smear-positive cases, 1995–2011 152

Table A4.5 Treatment outcomes, retreatment cases, 1995–2011 152

6CDNG# *+8VGUVKPICPFRTQXKUKQPQH%26#46CPF+26¿ 

6CDNG# 6GUVKPIHQT/&46$CPFPWODGTQHEQPßTOGFECUGUQH/&46$¿ 

6CDNG# 0GYUOGCTRQUKVKXGECUGPQVKßECVKQPD[CIGCPFUGZ¿ 

 GLOBAL TUBERCULOSIS REPORT 2013 Data for all years can be downloaded from www.who.int/tb/data

Estimates of mortality, prevalence and incidence

Estimated values are shown as best estimates followed by lower and upper bounds. e lower and upper bounds are dened

as the 2.5th and 97.5th centiles of outcome distributions produced in simulations. See ANNEX 1 for further details.

Estimated numbers are shown rounded to two signicant gures. Estimated rates are shown rounded to three signicant

gures unless the value is under 100, in which case rates are shown rounded to two signicant gures.

Estimates for all years are recalculated as new information becomes available and techniques are rened, so

they may dier from those published in previous reports in this series. e main updates implemented in this

report are explained in Box 2.1 of Chapter 2. Estimates published in previous global TB control reports should no

longer be used.

Data source

Data shown in this annex are taken from the WHO global TB database on 1 October 2013. Data shown in the main part of

the report were taken from the database in Ju