Tuberculosis Controlapps.searo.who.int/pds_docs/B4189.pdf · · 2009-03-23ISTC International standard for tuberculosis care IVMS International Centre for Veterinary and Medical

Tuberculosisin the South-East Asia Region

Annual Report: 2009

SEA-TB-315Distribution: General

© World Health Organization 2009

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Tuberculosis in the South-East Asia Region – Annual Reportiii

Contents

Abbreviations ..........................................................................................v

Preface ..................................................................................................ix

1. Introduction .................................................................................. 1

2. Epidemiology of TB in the Region ................................................. 3

2.1 TB disease incidence, prevalence and mortality .................. 4

2.2 TB infection ........................................................................ 6

2.3 TB disease incidence, prevalence and mortality ................... 6

2.4 Impact of HIV on TB in the Region ..................................... 7

2.5 Drug-resistant TB ............................................................... 8

3. Achievements ............................................................................. 10

3.1 DOTS coverage .................................................................. 10

3.2 Case notifications ............................................................... 11

3.3 Treatment outcomes .......................................................... 16

3.4 Case detection and treatment success rates ........................ 18

4. Key Milestones achieved in 2008 ................................................ 20

4.1 DOTS ................................................................................ 20

4.2 Strengthening national laboratory networks ........................ 20

4.3 Addressing TB/HIV, MDR-TB, and other challenges ............. 21

4.4 Public and private partnerships .......................................... 22

4.5 Surveillance, monitoring and evaluation ............................. 22

4.6 Resources ......................................................................... 23

4.7 Operational Research ........................................................ 24

Tuberculosis in the South-East Asia Region – Annual Reportiv

5. WHO support in the Region ....................................................... 25

5.1 Technical assistance .......................................................... 25

5.2 Strengthening national laboratory networks ........................ 26

5.3 Capacity building, information exchange ........................... 26

5.4 Resource mobilization ........................................................ 27

5.5 Ensuring regular supplies of drugs and improving procurement and supply management .....................................27

5.6 Operational research ........................................................ 28

5.7 Coordination, collaboration and partnerships ..................... 28

5.8 Advocacy, communication and social mobilization ............ 29

5.9 Monitoring and evaluation ................................................. 29

Country Profiles ................................................................................... 31

Bangladesh ................................................................................. 33

Bhutan ........................................................................................ 38

DPR Korea .................................................................................. 42

India .......................................................................................... 46

Indonesia .................................................................................... 52

Maldives ..................................................................................... 57

Myanmar .................................................................................... 61

Nepal ......................................................................................... 66

Sri Lanka ..................................................................................... 71

Thailand ..................................................................................... 75

Timor-Leste ................................................................................. 80

Definitions ........................................................................................... 84

Tuberculosis in the South-East Asia Region – Annual Reportv

AbbreviationsACSM Advocacy, Communication and Social Mobilization

ADB Asian Development Bank

AFB Acid-fast bacilli

AIDS Acquired immunodeficiency syndrome

ART Antiretroviral treatment

ARTI Annual risk for tuberculosis infection

AusAID Australian agency for international development

BRAC Bangladesh Rural Advancement Committee

CHC Community Health Centre

CIDA Canadian International Development Agency

CPT Cotrimoxazole Preventive Therapy

DFID United Kingdom Department for International Development

DOT Directly observed treatment

DOTS Directly observed treatment short course

DPR Korea Democratic People’s Republic of Korea

DRS Drug-resistance survey/surveillance

DST Drug-susceptibility testing

DTC District TB Coordinator

EC European Commission

EP Extra-pulmonary

EQA External quality assessment

ERD External Resource Division

FDC Fixed Dose Combination

FHI Family Health International

Fidelis Fund for Innovative DOTS Expansion through Local Initiatives to Stop TB

Tuberculosis in the South-East Asia Region – Annual Reportvi

FIND Foundation for Innovative New Diagnostics

GDF Global TB Drug Facility

GF Global Fund to fight AIDS, Tuberculosis and Malaria

GLC Green Light Committee

HIV Human immunodeficiency virus

HNPNP Health, Nutrition and Population Sector Programme

HRD Human resources development

ICDDR,B International Centre for Diarrhoeal Disease Research, Bangladesh

ICTC Integrated Counselling and Testing Centre

IDU Intravenous drug use/r

IEC Information, Education, Communication

IMA Indian Medical Association

IMPACT Indian Medical Professional Associations Coalition against TB

INGO International nongovernmental organization

IPT Isoniazid Preventive Treatment

ISAC Intensified Support and Action Countries

ISTC International standard for tuberculosis care

IVMS International Centre for Veterinary and Medical Sciences, Australia

JATA Japan anti-TB association

JICA Japan International cooperation agency

KNCV Royal Dutch Tuberculosis Association

MDG Millennium Development Goal

MDR-TB Multidrug-resistant tuberculosis

MIFA Managing Information for Action

MO Medical officer

MoF Ministry of Finance

MoU Memorandum of Understanding

NAP National AIDS Programme

Tuberculosis in the South-East Asia Region – Annual Reportvii

NGO Nongovernmental organization

NRL National Reference Laboratory

NSP New smear-positive (TB cases)

NTI National Tuberculosis Institute, Bangalore, India

NPO National professional officer

NTP National Tuberculosis Programme

OGAC Office of Global AIDS Control

OSE On-site evaluation

PAL Practical approach to lung health

PLHIV People living with HIV

PPM Public-private, public-public or private-private mix

PPP Public-private partnership

PSI Population Services International

QA Quality Assurance

RBRC Random blinded re-checking

RHC Rural Health Centre

RNTCP Revised National Tuberculosis Control Programme (India)

SAARC South-Asian Association for Regional Cooperation

SEA Region WHO South-East Asia Region

SNRL Supra-national reference laboratory

SOP Standard Operating Procedures

STD Sexually transmitted disease

SSA Special Services Agreement

TBCTA TB Coalition for Technical Assistance

TB Tuberculosis

TB/HIV Tuberculosis and human immunodeficiency virus

TBTEAM TB technical assistance mechanism

TDR UNICEF-UNDP-World Bank-WHO Special Programme for Research and Training in Tropical Diseases

TRC TB Research Centre, Chennai, India

Tuberculosis in the South-East Asia Region – Annual Reportviii

TSG Technical Strategic Group

UNICEF United Nations Children’s Fund

UNICERF UN Common Emergency Relief Fund

UNITAID International facility for the purchase of drugs against HIV/AIDS, Malaria and Tuberculosis

UNDP United Nations Development Programme

Union International Union Against Tuberculosis and Lung Disease

USAID United States Agency for International Development

US$ United States dollar

VCTC Voluntary counselling and testing centre

WHO World Health Organization

XDR-TB Extensively drug-resistant tuberculosis

3DF Three disease fund

Tuberculosis in the South-East Asia Region – Annual Reportix

Preface

Good progress continues to be made towards reaching the targets set for TB control in Member States of the South-East Asia Region. The indicators set under the Millennium Development Goals to measure progress in TB control are the case detection and treatment success rates among the new smear-positive TB cases and the rate of fall in the incidence, prevalence and mortality due to the

disease. The overall rates for the first two indicators in the Region now stand at 69% and 87%, respectively. In terms of the impact indicators, the Region is witnessing a small but steady decline in TB incidence, prevalence, and mortality rates.

Countries of the Region are also increasingly addressing the dual challenge of drug-resistant and HIV-associated TB. Interventions to diagnose and treat multidrug resistant TB (MDR-TB) are in place in 7 out of the 11 Member States of the Region. In response to the overlapping epidemics of TB and HIV, national HIV/AIDS and TB programmes within Ministries of Health have developed and established national policies and strategies and are expanding interventions to detect and care for people with HIV and active TB.

Recognizing that national programmes and public health systems alone will not reach all those who require diagnosis and treatment for TB, over 250 medical colleges and large public and private hospitals, several thousand private practitioners and nongovernmental organizations, and over 100 corporate institutions have been involved in working with national TB control programmes. India and Indonesia have formally established widely inclusive partnerships to support TB control efforts at the national level. Many national TB programmes have established links with professional societies as a means of disseminating the principles and practices of the international standards for TB care to all care providers. A number of community-based TB care projects are also in place in countries of the Region. All 11 Member States continue to benefit from funding

Tuberculosis in the South-East Asia Region – Annual Reportx

support through many development partners, international initiatives such as the Global Fund, the Global Drug Facility, UNITAID and others, including the 3-Disease Fund in Myanmar.

However, sustaining this progress by pursuing quality DOTS and implementing the five other equally important components of the Stop TB strategy is becoming increasingly challenging.

While many national TB programmes in the Region are being acknowledged globally for establishing broad partnerships with private and public sector health-care providers, there is still a long way to go in effectively expanding the reach of services through these partnerships. A lot of work remains to be done in mobilizing people and communities so that they use available services in a timely manner. Health systems and service delivery need to be improved through a strengthened and inclusive primary health care approach. At the same time, we must recognize that the health systems alone cannot succeed in isolation, and we must therefore address social, cultural and economic factors that impact the continuing epidemic of tuberculosis in this Region.

These annual reports document the progress, present the challenges, constraints and plans for the effective implementation of interventions to combat TB in the Region. WHO will continue to provide technical support to catalyse and accelerate the implementation of TB control services in Member States through a range of activities as detailed in this report. There is much in this report that is very encouraging and I am confident that our collective efforts will lead us to achieve the goals set for reducing tuberculosis by 2015.

Dr Samlee PlianbangchangRegional Director

Tuberculosis in the South-East Asia Region – Annual Report1

Tuberculosis continues to remain one of the most serious health and developmental problems in the WHO South-East Asia Region. The Region still accounts for the highest numbers of TB patients globally, carrying over 30% of the world’s TB burden. In the 11 Member countries of the Region, an estimated three million people contact TB, and 500 000 die of the disease every year.

The Region is also home to the second-highest number of people living with HIV/AIDS, following Africa. However, the HIV epidemic in South-East Asia is at different stages both across the Region and within countries. India, Indonesia, Myanmar and Thailand are among the 41 countries globally that carry a high burden of both HIV and TB.

Countries are responding to these challenges and expanding the implementation of the new Stop TB Strategy. Over two million TB patients are being registered for treatment by national programmes every year, of whom over 85% are successfully treated, averting at least 300 000 deaths from TB every year. As a result, the Region is already demonstrating a slow but steady decline in TB incidence rates. TB/HIV interventions to address the needs of those dually affected with TB and HIV are widely available in Thailand and are being expanded in India and Myanmar. Indonesia, with a concentrated HIV epidemic, has established interventions in Papua and Java Bali, two HIV high-prevalence areas in the country. Countries are also slowly expanding diagnostic and treatment facilities for MDR-TB.

This progress in TB control needs to be sustained and built upon to enable individual countries to achieve the targets set under the Millennium

1

Introduction


Development Goals. While it costs less than US$ 20 to treat a patient diagnosed for the first time with drug susceptible TB, the cost of treating a patient with MDR-TB is a hundred fold. Reaching and curing each newly diagnosed case of TB through the application of DOTS by both public and the large and ever-growing private sector therefore has to remain the foremost priority.

In addition, national programmes are now aiming to achieve universal case detection, further shorten diagnostic and treatment delays in order to cut transmission and prevent complications and deaths. At the same time, major efforts are being made to address TB-HIV through effective interventions together with HIV programmes; ensuring quality assured laboratory networks for microscopy, culture and drug susceptibility testing; rapidly scaling up capacity to treat existing multi-drug resistant cases and focusing on “difficult areas” such as TB control among high risk populations and in cross-border areas.

Sustaining these efforts will require continued commitment and adequate resources for national TB control programmes for several more years. This is because an irreversible decline in TB incidence can only be achieved after several years of reduced transmission in the community.


2

Epidemiology of TB in the Region

The South-East Asia Region, with an estimated 4.88 million prevalent cases and an annual incidence of 3.17 million TB cases, carries one-third of the global burden of TB (Figure 1). Five of the 11 Member countries in the Region are among the 22 high-burden countries, with India accounting for over 20% of the world’s cases. Most cases occur in the age group of 15-54 years, with males being disproportionately affected. The male/female ratio among newly detected cases is 2:1. Though deaths due to TB have declined after introduction of DOTS in the Region, the disease still claims more than 500 000 lives each year.

Figure 1: Estimated incidence of all forms of TB, by WHO Region, 2008.

Americas

Europe

Eastern Mediterrenean

Western Pacific

Africa

South-East Asia

4%5%

6%

21%

30%

34%

Source: Global Tuberculosis Control Surveillance, Planning, Financing, WHO, Geneva, 2009


2.1 TB disease incidence, prevalence and mortality The control of tuberculosis in the Region is affected by variations in the quality and coverage of various TB control interventions, population demographics, urbanization, changes in socio-economic standards, HIV and, more recently, emerging drug resistance. Table 1 shows the estimated TB incidence, prevalence and mortality rates for countries in the Region.

Table 1: Estimates of TB disease incidence, prevalence and mortality in the South-East Asia Region, 2008

Country Population* (in 1000’s)

Estimated Annual Incidence

rate/100 000 population

Estimated Prevalence

rate per 100 000 pop.

– all forms of TB

Estimated death rate

per 100 000 pop. – all

forms of TBAll cases

SS+ cases

Bangladesh 158,665 223 100 387 45

Bhutan 658 246 110 363 44

DPR Korea 23 790 344 155 441 65

India 1 169 016 168 75 283 28

Indonesia 231 627 228 102 244 39

Maldives 306 47 21 48 4

Myanmar 48 798 171 75 162 13

Nepal 28 196 173 77 240 23

Sri Lanka 19 299 60 27 79 8

Thailand 63 884 142 62 192 21

Timor-Leste 1155 322 145 378 47

SEAR 1 745 394 181 81 280 31

* UN Population Division, World Population Reports, 2007, New York (Rev.)

Figure 2 shows the estimated TB prevalence rates in the 11 Member countries of the Region comparing the rates between 1990, 2004 and 2007. These are indicative of a decrease in all countries of the Region.


Figure 2: Estimated prevalence rates for all forms of TB, SEA Region 1990, 2004, 2007

Source: Global Tuberculosis Control, WHO Reports 2001-2008

0

100

200

300

400

500

600

700

800

900

1,000

BAN BHU DPRK IND INO MAV MMR NEP SRL THA TLS

1990 2004 2007

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Figure 3 shows the estimated TB mortality rates for all forms of tuberculosis per 100 000 population, comparing the rates between 1990, 2004 and 2007. With respect to 1990, a significant decrease is observed in 2007 in all countries of the Region.

Figure 3: Estimated mortality rates for all forms of TB per 100 000 populationSEA Region: 1990, 2004, 2007

Source: Global Tuberculosis Control, WHO Reports, 2001-2008

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BAN BHU DPRK IND INO MAV MMR NEP SRL THA TLS

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Figure 4 shows the overall trends in the estimated TB prevalence, incidence and mortality rates per 100 000 population in the Region as a whole, between 1990 and 2007. The estimated prevalence and mortality rates decreased slowly between 2004 and 2007.

Figure 4: Trends in estimated prevalence, incidence and mortality: SEA Region, 1990-2007

Source: Global Tuberculosis Control: WHO Reports, 2001-2008

0

100

200

300

400

500

600

1990 2000 2001 2002 2003 2004 2005 2006 2007

Estimated prevalence all forms Estimated incidence all forms

Estimated incidence new smear+ Estimated TB mortality

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2.2 TB infection Annual Risk of TB Infection (ARTI) studies undertaken in countries have revealed widely disparate results. Studies in four zones in India carried out during 2000-2003 showed ARTI rates ranging from 1.0 % in the south zone to 1.9% in the north zone; repeat ARTI surveys are being undertaken, but the results are not yet available. In Indonesia, an ARTI study carried out in 2006 in West Sumatra yielded an incidence rate of 1.3%. A limited ARTI survey undertaken in 2008 in DPR Korea is indicative that the incidence rates for the country as estimated by WHO may need to be revised upwards by a factor of two. Nepal undertook an ARTI survey in three ecological zones and in the Kathmandu valley during 2006-2007, revealing a rate of 0.86%, substantially lower than the previous rate of 2.1%. Similar surveys are planned in Bhutan and Sri Lanka in 2009.

2.3 TB disease incidence, prevalence and mortalityWhile these surveys are indeed contributing to more accurate estimations of the burden of disease in countries, there are still uncertainties about the current


estimates for TB disease incidence, prevalence and mortality rates in individual countries in the Region. The use of routine notification data as a measure of disease incidence is certainly the way to go in the future. This however requires strengthening all aspects of the TB surveillance system, focusing on quality of data entry, compilation and reporting, and giving attention to precise analysis and interpretation of the data. As part of this effort, the WHO Regional Office for South-East Asia (SEARO) organized a series of trainings on managing information for action (MIFA) in four Member countries during 2007-2008.

Meanwhile there is clearly a need to continue to support well-designed population-based surveys in the Region, particularly in the higher TB burden countries, until such time as routine case notifications can begin to be used to correctly reflect actual trends.

2.4 Impact of HIV on TB in the Region The expanding HIV epidemic in the Region is a growing concern. Of the 31.6 million people estimated to be living with HIV in the world at the end of 2007, more than 3.6 million are estimated to be in the South-East Asia Region. India alone is estimated to have 2.4 million people living with HIV (Figure 5).

Figure 5: HIV Prevalence in the SEA Region: 2007

Five countries accountfor the majority of HIVburden in the Region

India2 400 000

Myanmar240 000

Thailand610 000

Nepal70 000

Indonesia270 000

Source: Report on the Global AIDS Epidemic: UNAIDS, 2008


Three countries in the Region (Thailand, Myanmar and a number of districts in nine states in India) have rates of HIV > 1% in the general population and the highest HIV/TB co-infection rates in the Region. Four countries have concentrated epidemics: Bangladesh, Nepal, Indonesia and some states of India. While Myanmar and Thailand have a more homogenous and high HIV prevalence, only some states in India and three provinces in Indonesia report high HIV rates.

HIV does not appear to have fundamentally altered the epidemiology of TB in the Region to the extent observed in sub-Saharan Africa. Available data suggest that the incidence of TB has been minimally affected by the HIV epidemic. The impact on TB mortality however, has been much more substantial. In India, Myanmar and Thailand, high TB case-fatality rates have been reported in areas with high HIV rates in the general population.

2.5 Drug-resistant TB Seven countries have reported data on drug resistance since 2002, namely, Bangladesh, India, Indonesia, Myanmar, Nepal, Sri Lanka, and Thailand. India reported data from three districts and one state, while Indonesia reported data from one district only. Orissa in India, Sri Lanka, and Thailand reported less than 2.0% MDR-TB among new cases. Districts surveyed in the states of Kerala, West Bengal and Gujarat in India as well as Mimika district of Papua province in Indonesia, and Nepal reported between 2.0-3.0% MDR-TB among new cases. Myanmar reported a higher level of 3.9% (2.6%-5.7%) MDR among new cases. While a few tertiary-care facilities have reported levels of multi-drug resistance as high as 60% among previously treated cases, these are not representative of the situation in the community.

Resistance to first-line anti-TB drugs is equally a concern for national TB control programmes in countries of the Region. The population weighted mean of MDR-TB based on all the countries that have reported in the South-East Asian Region is 2.8% (1.9%-3.6%) among new cases and 18.8% (13.3%-24.3%) among previously treated cases. However, given the large numbers of TB cases in the Region, these figures translate into nearly 150 000 cases as a whole, with over 80% of these cases residing in Bangladesh, India, Indonesia, Myanmar and Thailand. While Myanmar and Thailand report relatively lower rates of MDR-TB among new cases, the two countries report 15.5% and 35.5 % MDR-TB rates respectively, among previously treated cases, which is a serous concern.


Extensively drug resistant tuberculosis (XDR-TB), has been isolated in samples from India, Indonesia, Bangladesh, and Thailand. Given the widespread availability and use of second-line drugs, and as laboratory capacity to conduct second-line drugs susceptibility testing increases, additional occurrences of XDR-TB are likely to be identified.

The other concern is that unless well managed MDR-TB programmes are rapidly established under national programmes, MDR-TB cases will continue to be treated by the private sector through not necessarily well supervised or well designed second-line regimens, or through over-the-counter purchase of these drugs, given their widespread and easy availability, risking further increase in drug resistance.


3

Achievements

3.1 DOTS coverageDOTS coverage is defined as the population living in administrative areas where DOTS services are available. This indicator serves as a proxy for people with access to DOTS. Population access to DOTS steadily increased to 100 % in the whole region by the end of 2007 (Figure 6).

Figure 6: Population covered by DOTS services, SEA Region 1997-2008

Source: Tuberculosis control in the South-East Asia Region, Annual Reports 1998-2008, WHO/SEARO

0

10

20

30

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60

70

80

90

100

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Perc

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cove

red


3.2 Case notificationsTable 2 shows the cases notified in 2007 by type of TB, in each Member country. The 11 Member countries of the Region together notified 2 202 149 cases of tuberculosis (all forms) which represents a case notification rate of 126 per 100 000 population. Of those, 972 441 (44 %) were new smear-positive pulmonary cases. Five countries in the Region, Bangladesh, India, Indonesia, Myanmar and Thailand which belong to the global list of 22 countries with the highest burdens of TB, notified a total of 2 086 971 cases, or 95% of all cases notified in the Region.

Table 2: Estimated incidence and cases notified in the Member countries, SEA Region, 2007

Country

Estimated incidence TB cases notified

New smear-positive cases

All forms of TB

New smear-positive cases

New smear-

negative cases

New extra-pulmonary

casesRelapse Other re-

treatment

Total notifica-

tions

Bangladesh 158 797 353 103 104 296 23 152 16 106 3 788 – 147 342

Bhutan 726 1620 328 253 373 45 9 1 008

DPR Korea 36 857 81 944 23 575 25 789 7 579 1 859 9 375 68 177

India 872 514 1 961 825 592 587 398 862 206 840 96 856 179 686 1 475 629

Indonesia 236 029 528 063 160 617 102 613 8 048 3 915 467 275 660

Maldives 64 143 59 37 30 1 2 129

Myanmar 36 620 83 403 42 588 41 826 40 002 4 665 4 466 133 547

Nepal 21 827 48 766 14 353 9 350 6 986 2 249 499 33 439

Sri Lanka 5 253 11 676 4 528 1 985 1 984 221 217 9 155

Thailand 39 347 90 878 28 487 17 156 7 485 1 665 – 54 793

Timor-Leste 1 673 3 718 1 021 1 772 433 29 15 3 270

SEA Region 1 409 708 3 165 139 972 441 662 795 295 866 115 293 194 736 2 202 149

Percentage change 2007 vs. 2006 + 3.6 + 8.7 + 13.0 + 5.5 - 6.7 +4.7

Figure 7 shows the trends in notifications of new smear-positive (NSP) and all forms of TB cases in the Region. The NSP notifications increased gradually until 1999, with a sharper increase thereafter until 2006. There appears to be a leveling off since, suggesting that much more effort is now needed to further increase case detection.


Notifications of all forms of TB showed a rather unstable profile till 2000, followed by a steady increase from 2003 onwards. This is probably attributable to the increasing involvement of medical colleges and private practitioners, through whom increasing numbers of smear negative and extra-pulmonary cases are notified.

Figure 7: All Forms of TB and NSP cases notified, SEA Region, 1993-2007


Case Notifications: New ss+ and all forms of TBSEA Region, 1993-2007

0

250,000

500,000

750,000

1,000,000

1,250,000

1,500,000

1,750,000

2,000,000

2,250,000

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

All cases NSP cases

YEARS

Nu

mb

ers

of

case

snotified

Figure 8 a, b and c, show three distinct patterns in trends of case notifications: Bangladesh, India, Indonesia, Myanmar and Thailand characterized by an increasing trend over time; Bhutan, DPRK, Maldives, Nepal and Sri Lanka characterized by more or less stable rates over time, with Sri Lanka and the Maldives presenting low rates, and DPRK, Bhutan and Nepal presenting much higher rates; and a third pattern represented by Timor-Leste, which shows a sharply declining trend till 2006, followed by a slight increase in 2007.


Figure 8a: Annual NSP notification rates of selected countries, SEA Region, 1995-2007: Increasing trend

0

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60

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80

90

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1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Bangladesh

Myanmar

Indonesia

Thailand

India

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Figure 8b: Annual NSP notification rates, selected countries, SEA Region, 1995-2007: Stable trend

0

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1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Sri Lanka

Maldives

Nepal

Bhutan

DPRK

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Figure 8c: Annual NSP notification rates, Timor-Leste, 2002-2007


Source: Global Tuberculosis control: WHO Reports 1998-2008

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130

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

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Figure 9: Proportion of S+ retreatment cases, out of all S+ cases, all SEA Member countries, 2005-2007

2005 2006 2007

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Figure 9 shows the proportions of re-treatment cases among all smear-positive cases in all countries of the Region. However, the true percentages could be slightly higher, given under-reporting by some countries.

Of the smear-positive cases, the re-treatment cases represent 13-14%. At country level, India and DPR Korea present high proportions, up to 19 % in India. Five countries present less than 5%; while in four countries the proportion varies between 5% and 8 %. The trend over time does not show marked differences, with the exception of the Maldives and Thailand. The variability in the Maldives could be attributed to the small numbers whereas in Thailand this could be due to variations in reporting.

Age-and sex-specific rates among new smear-positive (NSP) casesThe male:female ratio among new smear-positive patients registered in the Region in 2007 was 2:1. This ratio varies by country, as shown in Figure 10. The highest ratio was seen in Sri Lanka (2.8) and the lowest in Timor-Leste (1.2)

The age-and sex-specific NSP notification rates for 2007 are shown in Figure 11. The rate in adult males shows a steady increase starting at 63/100 000 pop.

Figure 10: Ratio of male vs female NSP cases, SEAR Member countries, 2007

Source: Annual reports, National TB Control Programmes, SEAR Member countries, 2008

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

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eto

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ratio

among

NSP

case

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SEAR

Tim

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Thailan

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anka

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Mya

nmar

Mald

ives

Indo

nesia

Indi

a

DPR

Kore

a

Bhutan

Bangla

desh


Figure 11: Age and sex specific NSP notification rates SEA Region, 2007

Source: Annual reports, National TB Control Programmes, SEAR Member countries, December 2008

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0-14 15-24 25-34 35-44 45-54 55-64 65+

Age grous (yrs)

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male female

reaching a peak at 170/100 000 pop in the 55-64 years age groups, followed by a decline in the 65+ age group. The NSP rate in females shows a plateau between the ages of 15 to 64 years, followed by a decline in the 65+ years age group. The NSP rate in the 65+ old females decreased 40% vs. the previous age strata (55-54 years), while the decrease in the males of age 65+ years vs. 55-64 years was only 22%.

3.3 Treatment outcomesTable 3 shows the treatment success rates among new smear-positive cases enrolled for treatment in countries of the Region during 2006. The treatment success rate is 87% in the Region as a whole and above 85% in eight of the 11 Member countries. The case fatality rate among new smear-positive cases was 4%, the default rate 5%, and the failure rate 2% for the 938 637 cases registered in 2006 (Table 3).


The success rate (72%) among re-treatment cases was substantially lower. Similarly, while the case fatality rate among new smear-positive cases was around 4%, it was much higher among the re-treatment cases (7%). The default rate (14%) was also substantially higher among retreatment cases, especially in India, Sri Lanka and Timor-Leste as was the failure rate (5%) which was 2.5 times higher among retreatment cases than among NSP cases.

Table 3: Treatment outcomes among cases notified; SEA Region: 2006

Countries

New smear-positive cases* Re-treatment Cases*

Notified Success rate

Case fatality

rate

Failure rate

Default rate Notified Success

rate

Case fatality

rate

Failure rate

Default rate

Bangladesh 101 967 92 3 1 2 4 211 77 5 2 4

Bhutan 312 89 5 1 1 61 75 2 7 0

DPR Korea 18 435 86 3 4 4 8 820 77 4 13 4

India 553 851 86 5 2 6 259 130 72 7 4 15

Indonesia 175 320 91 2 1 5 4 227 77 5 2 11

Maldives 53 91 0 2 4 5 80 20 0 0

Myanmar 40 241 84 6 3 5 8 666 71 12 7 8

Nepal 14 028 88 5 1 3 2 920 94 6 4 3

Sri Lanka 4 442 87 5 1 7 435 71 6 3 17

Thailand 29 081 77 8 2 6 2 843 62 13 4 11

Timor-Leste 907 79 5 0 12 44 80 5 0 16

SEAR 938 637 87 4 2 5 291 362 72 7 4 14

*The group of “Transferred out” and “Not evaluated” have not been included in the table since both figures were very small. This implies that the sum of the outcomes of success, died, failed and default will not always add up to exactly 100%.

Figure 12 shows the treatment outcomes disaggregated by sex in India. It is clear that females have more favourable treatment outcomes than males. In the cohort of patients registered in 2006, the treatment success rates (88%) among female NSP patients was higher than among male patients (85%) , while the default (5%) and death (4%) rates among female NSP patients were lower than among males (default 7%; deaths 5%) .


3.4 Case detection and treatment success ratesWith further improvements in both case-detection and case holdings in almost all countries in the Region compared to previous years (see country profiles), the Region as a whole is showing steady progress towards reaching both 70% case detection and 85% treatment success targets, as shown in Figure 13.

Figure 12: Treatment outcomes among female and male NSP patients, India (cohort of patient registration, 2006)

Source: RNTCP India Annual Report December 2008

RNTCP: Treatment outcome of malenew Sm+ve TB patients

registered in 2006 (n=383,129)

Cured83%

Treat. Com.2%

Died5%

Failure2%

Defaulted7%

Transferred1%

RNTCP: Treatment outcomes of femalenew S+ve TB cases registered

in 2006 (n=170,002)

Cured86%

Treat. Com.2%

Died4%

Failure2%

Transferred1%

Defaulted5%

Figure 13: Case detection and treatment success rates SEA Region, 1997 to 2007

Source: Annual Reports on TB control, National TB Programmes, SEAR Member Countries, December 2008

50

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0 10 20 30 40 50 60 70 80 90 100

Case detection rate (%)

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Trea

tmen

tsu

cces

sra

te(%

)

Targetzone


By the end of 2007, five of the 11 Member countries in the Region had achieved or maintained the global target for case detection, and nine the global target for treatment success, resulting in four countries being in the target zone as shown in Figure 14.

Figure 14: Case detection and treatment success rates, SEA Region, 2008

Source: Annual Reports on TB Control, National TB Programmes, SEAR Member countries, December 2008

BANBHU

DPRKIND

INO MAV

MMRNEP

SRL

THATLS

SEAR

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0 10 20 30 40 50 60 70 80 90 100 110 120 130

Case detection rate (2007 cohort of NSP TB cases)

Trea

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te(2

00

6co

hort

of

NSP

case

s)

The case detection rates for Bangladesh, India, Indonesia and Nepal when calculated based on the UN population figures for these countries reflects them as not having achieved the case detection target of 70%. However, the case detection rates were 70% or above in these countries when the most recent national population census figures were applied.


4.1 DOTSThe entire population in the Region now lives within access to DOTS facilities;

The overall case detection rate reported in 2007 was 68.5%, close to the global target of 70%, and the overall treatment success rate for the cohort of new smear-positive cases initiated on treatment in 2006 was 87%. By the end of 2008, five* countries—Bhutan, DPR Korea, Maldives, Myanmar and Sri Lanka—had achieved or maintained both global targets for case detection and treatment success under DOTS, based on UN population figures for the Member countries.

4.2 Strengthening national laboratory networksExternal quality assurance for smear microscopy is being strengthened in all Member countries through training of laboratory staff. Seven countries—Bangladesh, India, Indonesia, Myanmar, Nepal, Sri Lanka, and Thailand—have at least one national-level laboratory with facilities for mycobacterial culture and drug susceptibility testing for the detection of MDR-TB cases. Bangladesh, Nepal and Sri Lanka are in the process of having their national reference laboratories accredited for quality assurance of culture and drug susceptibility testing, while additional reference laboratories are being accredited in India, Indonesia, Myanmar and Thailand.

* Based on national population figures, more countries join that list: Bangladesh, India, Indonesia and Nepal.

4

Key Milestones achieved in 2008


4.3 Addressing TB/HIV, MDR-TB, and other challenges

Recognizing that TB-HIV co-infection must be addressed effectively, national HIV/AIDS and TB programmes in seven countries in the Region have developed national policies and strategies for TB-HIV. National level TB/HIV coordinating bodies have been established. The regional strategic framework for TB/HIV is also being revised and updated. TB/HIV activities are widely available in Thailand and are being expanded in India and Myanmar. India is implementing an intensified package of TB/HIV interventions in the nine states with a high HIV prevalence. There has been a more than 5 fold increase in referrals from HIV counselling and testing centres to the TB services and more than 3 fold increase in referrals from the TB to HIV services over the last 3 years. Indonesia, with a concentrated HIV epidemic, has established interventions in Papua and Java Bali, which are the country’s HIV high-prevalence areas. Cross-referrals between the TB and HIV programmes have been strengthened, and the TB recording and reporting systems in these countries revised to include information on TB/HIV co-infection.

Bangladesh, India, Nepal, and Timor-Leste have established MDR-TB case management under their national programmes. Nepal has recently expanded to all five regions in the country, while India is gradually expanding services to additional states. Indonesia and Myanmar are expected to begin enrolling MDR-TB patients in early 2009. Two countries, Bhutan and Sri Lanka, have submitted applications to the Green Light Committee and plan to commence MDR-TB case management in 2009.

National guidelines for the management of childhood TB were finalized in Bangladesh, Indonesia and Myanmar. Myanmar and Nepal received their first grants for anti-TB paediatric formulations through the Global Drug Facility (GDF), supported through UNITAID, while paediatric grants were approved for DPR Korea and Sri Lanka.

India is introducing infection control measures in health facilities while Indonesia, Myanmar and Thailand will undertake assessments and prepare infection control plans in 2009.

Countries have also included measures to address vulnerable populations at higher risk and cross-border issues in their national plans for TB control and Global Fund applications.


4.4 Public and private partnershipsTB technical working groups and/or specific task forces and sub-working groups have been established both at the regional and at national levels in Bangladesh, DPR Korea, India, Indonesia, Myanmar, and Nepal.

A major strategy towards improving case detection and treatment success rates has been the inclusion of public health care providers operating outside the Ministry of Health, such as the railways, military and prison health services, as well as private providers in all Member countries where patients seek services through the private health sector. The International Standards of TB Care were endorsed by professional bodies-- medical associations in India, Indonesia, Myanmar, and Nepal. Inter-sectoral collaboration and public-private partnerships for delivery of services were further scaled up in eight Member countries—Bangladesh, India, Indonesia, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste. Over 350 medical colleges, 22 000 private practitioners, 1 500 large public and private hospitals, 150 corporate institutions, 2,500 nongovernmental organizations and 550 prisons are now working with national TB control programmes. Some recent initiatives in countries were formal inclusion of pre-service training on the principles and practices of TB control and establishing of referral mechanisms through providing lists of DOTS centres to teaching institutes, inclusion of private laboratories in diagnostic network and QA systems, and launching of “IMPACT” a coalition of professional associations for TB control, in India. In 2008, India also formally established a widely inclusive national partnership, becoming the second country in the Region to establish such a partnership, in addition to Indonesia. Indonesia intensified training of private and public hospital and laboratory staff and introduced coordination meetings between community health facilities and hospitals to improve transfer mechanisms between lung clinics and puskesmas. In Myanmar, services have been resumed throughout the network of PSI Sun Quality Clinics and the NTP plans further expansion of public/private mix services through the Myanmar Medical Association. There are also very encouraging examples of community-based approaches in several countries, but these need to be systematically documented and the experiences used to more widely replicate successful models at the national level.

4.5 Surveillance, monitoring and evaluationImpact assessments in the form of prevalence or ARTI surveys are on-going in Bangladesh, India, Indonesia, and Myanmar. ARTI surveys are expected to commence in Bhutan, India and Sri Lanka in 2009. The estimates for TB


prevalence and incidence were revised for Timor-Leste based on a review of more recent data and trends in cases notified and for DPR Korea based on an ARTI survey completed in 2007. Annual reports were received from all countries and are being used to finalize the Regional and WHO Global reports for 2009.

In five countries in the Region, drug resistance surveys were conducted or will continue through 2008-2009, to assess the extent of anti-TB drug resistance among TB patients. The overall rates of multi-drug resistant TB (MDR-TB) in the Region is 2.8% among new smear-positive patients and 18.8% among previously treated patients.

Surveillance for HIV prevalence among TB patients is undertaken routinely in Thailand and in nine states in India. In Myanmar, Nepal, Sri Lanka and in the remaining states and union territories in India, data from sentinel surveys are used to follow trends in HIV prevalence among TB patients.

These surveys are contributing to more accurate estimations of the burden of disease. At the same time, countries are beginning to focus on mechanisms that will ensure that routine case notifications begin to reflect the disease magnitude and trends. Data management software was upgraded in Myanmar and Nepal and further improvements made in the Windows-based EPI centre software in India. Training on data management and analysis for central and international level programme staff were conducted in Bangladesh, India, Myanmar and Thailand.

The practice of quarterly and annual internal reviews and larger joint reviews every two/three years, inviting international experts for joint monitoring and evaluation together with national programmes and partners was continued. These have helped to objectively review the performance of the respective national TB programmes, and lead to substantial improvements in programme performance.

4.6 Resources Domestic funding for TB control continues to account for over half of the funding for national TB control programmes. By the end of 2008, a total of 23 proposals were approved by the Global Fund in support of TB control programmes in the Region. In addition, nine Member countries benefit from funds from other development partners and donor governments with the exception of Bhutan and Maldives where the only external funds are through WHO country budgets.


All 11 Member countries continue to access quality-assured affordable anti-TB drugs on a regular basis through grants or direct procurement services of the Global Drug Facility.

4.7 Operational ResearchNational TB programmes and partners are engaged in carrying forward several operational research projects. Examples are public-private mix (PPM) models in India and Indonesia; field testing of new diagnostics and shorter treatment regimens in India; approaches to community-based TB care in Bangladesh, India, Indonesia, Thailand and Timor-Leste.

In addition, some support continues to be received through the small grants scheme under TDR. National workshops on operations research priority setting and dissemination are held regularly in India.


5.1 Technical assistance All 11 countries in the Region continue to receive technical assistance through the WHO Regional office and country offices, and international technical partners, namely, CDC, International Centre for Veterinary and Medical Sciences (IVMS), Royal Foundation for Tuberculosis in the Netherlands (KNCV), Institute of Tropical Medicine (ITM, Belgium), the Union and a few independent consultants recruited through WHO and the three WHO Collaborating Centres, namely, the National TB Institute, (NTI) and TB Research Centre, (TRC) in India, and the SAARC TB and HIV/AIDS Centre in Nepal. Technical partners in countries in the Region also provided technical assistance during the year.

Technical support missions were undertaken to all 11 Member countries during the year to provide assistance to national programmes in various areas, including laboratory assessments and laboratory capacity building, to establish MDR-TB and TB-HIV interventions, improve drug procurement and supply management, data management, and undertake impact assessments. Countries have also been assisted in developing these measures to address vulnerable populations at higher risk and cross-border areas and including them in their national plans for TB control and GF applications.

Combined missions by staff from the HIV/AIDS, TB and Malaria units at WHO/SEARO were instituted from January 2008 to review and plan next steps relating to WHO support to the national programmes and these were undertaken to Bangladesh, Bhutan, and Nepal during 2008.

5

WHO support in the Region


The increase in funding for TB control in countries has generated a manifold increase in the demand for technical assistance. In this context, a global mechanism, the TB Technical Assistance Mechanism (TBTEAM) aimed at better coordination of technical assistance to countries has been developed by WHO/HQ, through joint efforts with all six WHO Regions and technical partners over the past year. A roster of experts who could potentially provide technical assistance to countries in various areas has been developed and all proposed technical assistance missions to countries mapped, with the aim of deploying suitable consultants to meet the technical assistance requirements of countries. This will also serve to facilitate seeking additional funding from the Global Fund or financial partners for the necessary technical assistance.

5.2 Strengthening national laboratory networksTechnical assistance, coordinated through WHO, is being provided through the supra-national reference laboratories (SNRLs) based at the Institute of Medical and Veterinary Science (Australia), Institute of Tropical Medicine (Belgium), Central Reference Laboratory, Gauting (Germany), and the Tuberculosis Research Centre (India), to help establish culture and drug susceptibility testing (DST) facilities in countries in a phased manner, in line with national plans. Additional technical assistance requirements to support these plans have been identified. Nine countries have formally established linkages with SNRLs; Bhutan and Sri Lanka are in the process of being linked to the network of the SNRLs.

Laboratory staff from several Member countries were trained in the management of TB laboratories, quality assurance, mycobacterial culture techniques, and drug susceptibility testing at an inter-country workshop held at the SNRL at Bangkok, supported by the Union in 2008.

5.3 Capacity building, information exchangeTraining, exchange of information, and in-country technical support for policy formulation, guideline development and monitoring have been the key areas of work for WHO/SEARO and country office staff during the past year. Considerable attention and support was provided in the areas of strengthening laboratories and scaling up the management of TB-HIV and of MDR-TB. The regional and country offices have supported facilitation of national level training as well as training held at the three WHO collaborating centres, particularly the SAARC TB and HIV Centre. Modules on leadership and strategic management developed at SEARO were distributed to all countries. Several national programmes have


made use of these for training central and intermediate level staff. The WHO collaborative centres, the National TB Institute, Bangalore and the SAARC TB-HIV Center, Kathmandu, are also using these modules in their training and fellowship programmes.

A regional workshop on planning and budgeting for TB control programmes was organized in Indonesia in April 2008 for 10 out of the 11 Member countries in the Region. A regional workshop on health systems strengthening and TB control was held in Sri Lanka in August 2008 and the annual Programme Managers’ meeting in the Maldives, in December 2008. Study tours and exchange visits, between countries to learn from best practices, were also supported.

5.4 Resource mobilizationEight Member countries were benefiting from funds mobilized from the Global Fund as of the end of 2008. Countries applying during the Round 8 GF call for applications were assisted in preparing proposals, and preparatory work to help countries applying during Round 9 has begun. Several Member countries were also assisted in mobilizing resources from other development partners and donor governments.

Five workshops on GF grant negotiation and implementation, proposal writing, monitoring and evaluation, procurement and supply management and resubmission were organized together with the Global Fund staff during 2008.

A meeting of donors was held in Myanmar in December 2008 to help resolve the acute crisis in funding for first-line drugs in Myanmar beyond 2009, when the grants through GDF will come to an end.

Additional funds for technical assistance to countries is being sourced through OGAC, funded through USAID. Some funding also continued through Stop TB at WHO/HQ, for organizing the recently-held regional workshops on planning and budgeting, TB and health systems strengthening and to support some staff working on TB in the Region.

5.5 Ensuring regular supplies of drugs and improving procurement and supply management

All 11 countries were assisted in continuing to access quality-assured affordable anti-TB drugs on a regular basis either through grants or the direct procurement


services of the Global Drug Facility. Nepal, Timor-Leste, and Myanmar were assisted to receive support through UNITAID for paediatric and second-line drugs.

Assistance is being provided to countries resulting in streamlining timely procurements of quality first-and second-line anti-TB drugs. However, issues remain in terms of steady government funding and timely disbursements of procurement.

Training and workshops have also been organized, supported by the GDF focal point at SEARO on procurement and supply management, introduction of new drug formulations and diagnostics in Bangladesh, Bhutan, Myanmar, Sri Lanka and Timor-Leste. National meetings on GDF services and WHO pre-qualification programme were held in Thailand and on GDF services in Bhutan.

5.6 Operational research Several operational research projects are on-going in countries. Some small special surveys to help in modeling the impact of HIV and the emergence of MDR-TB are being discussed with research institutes. WHO coordinated the field testing of newer diagnostics in India and is working with the Foundation for Innovative New Diagnostics (FIND) to explore the possibility of field testing these in other countries in the Region.

5.7 Coordination, collaboration and partnershipsWHO, at all three levels, continued to interact with several donor and development partners to mobilize greater commitment for TB control in the Region. The Region is represented on the Stop TB Coordinating Board and the Board of the Global Fund. The 18th meeting of the Board of the Global Fund was held in New Delhi in November 2008.

The first meeting on TB control in the Korean Peninsula to increase collaboration between the national programmes in the Republic of Korea and DPR Korea, was organized in China in early 2008. WHO/SEARO and Myanmar contributed to the donors’ meeting to discuss sustainable funding for first-line drugs in Myanmar in December 2008.


Staff from the Regional office and country offices participated and contributed to workshops and meetings held by partner agencies: WHO Global “3I’s” meeting on tuberculosis infection control (April 2008) ; Global Core Group on TB/HIV,(April 2008); Second meeting of the XDR-TB Taskforce (April 2008); WHO/TBCAP Meeting on Human Resource Development (May 2008); Consultative workshop on training materials for airborne infection control in collaboration with CDC and other partners (June 2008); the First International Union Conference of South-East Asia Region and 63rd National Conference on TB and Chest Diseases (September 2008); 36th UNION Conference on TB and Lung Disease and meetings of the DOTS Expansion Working Group, sub-groups and core groups (October 2008); and the 2nd SAARC Conference on Tuberculosis, HIV/AIDS and Respiratory Diseases (December 2008).

5.8 Advocacy, communication and social mobilization

Bangladesh, Indonesia and India are being supported to develop advocacy and communication campaigns, while many community-based initiatives have been established through the active involvement of NGOs in Bangladesh, India, Indonesia, Myanmar, and Thailand. These need to be properly documented, analyzed for cost-effectiveness, and best practices emanating from these utilized for wider replication.

5.9 Monitoring and evaluationImpact assessments in the form of prevalence or ARTI surveys are being supported in Bangladesh, India, Indonesia, and Myanmar. Bhutan and Sri Lanka were supported for developing protocols and training staff for ARTI surveys to commence in 2009. The estimates for TB prevalence and incidence were revised for Timor-Leste based on a review of more recent survey data and trends in cases notified, and for DPR Korea, based on an ARTI survey completed in 2007. Nepal and Myanmar were assisted in improving data management software. Countries were also assisted in further improving supervision and monitoring of programme performance.

An innovative and unique initiative that the TB unit at SEARO has worked on during the past two years has been the development of simple tools and a training package for both provincial/state and district level programme staff on analyzing, interpreting and then using the analyses of routine programme


data to formulate simple operational level interventions to address gaps in implementation, instead of simply sending data to the central level and waiting for feedback (often received too late to make any timely interventions). Training on “Managing Information for Action (MIFA)” has been conducted in Bangladesh, India, Myanmar and Thailand and the feedback has been very encouraging. The unit plans to advance this through developing generic materials for use in other countries and other programmes as requested by other technical units in SEARO.


Country Profiles


With a population of 150 million, Bangladesh ranks sixth among countries with the highest TB burdens. The estimated prevalence and incidence rates of all forms of tuberculosis were respectively 387 and 223 per 100 000 population, in 2007. TB control activities were further expanded by increasing the number of peripheral laboratories, sputum collection or smearing centres so that access to TB diagnostic services improved. The case-detection rate increased to 73% in 2007*. The reported treatment success rate has increased to 92% for the cohort of patients registered in 2006. The National TB Guidelines were updated bringing national policies in line with more recent international recommendations. A nationwide disease prevalence survey is being conducted to establish more accurate estimates of the prevalence of tuberculosis and to assess the trend of the epidemic in the country.

Community-based DOTS through village doctors and BRAC’s network of shasthya shebikas (community health volunteers) is the most common mechanism for supervising drug intake. Collaboration with garments’ manufacturers—with three million employees and one of the largest industrial sectors—was formalized and plans developed for providing TB services in these companies.

Data from national drug resistance surveys indicate low levels of MDR-TB. A population-based survey is planned in 2009 to evaluate the magnitude of drug resistance. Isolated surveys have indicated that MDR-TB rates among newly diagnosed cases range between 0.4% and 3% and among previously treated

* based on the national population census figure for 2007, which is 143 million.

Bangladesh


cases, between 3% and 15.4%. A limited survey of drug susceptibility among patients failing category II regimens showed that 88% had MDR-TB. The National Tuberculosis Reference Laboratory was accredited for culture and DST by the Supranational Reference Laboratory in Bangkok in 2007. One regional reference laboratory has been set up in Rajshahi division and two additional regional reference laboratories are planned to be established during 2009-2010.

The first hundred MDR-TB patients were enrolled in a GLC-approved DOTS-Plus pilot project at the National Institute of Diseases of Chest and Hospital, Dhaka, while Damien Foundation extended its support for MDR-TB case management to cover an additional 30 million population.

HIV prevalence in the adult population (15-49 years) and the proportion of HIV positive individuals among TB cases has been estimated to be low at 0.02% and 0.1% respectively. A recent survey revealed an HIV prevalence of 7% among injecting drug users. This has raised concerns regarding the potential for transmission of HIV to other population groups. National TB/HIV guidelines have been developed. While a national TB/HIV committee is now functional, collaboration between the two programmes needs to be strengthened. A limited number of NGOs provide HIV counseling, prevention and care for TB-HIV co-infected individuals.

TB services are part of an essential services package under the sector-wide health, nutrition and population sector programme (HNPSP) which is implemented through the primary health care system of the country. Bangladesh is an outstanding example of implementing TB control in partnership with NGOs. Several private and corporate sectors are involved in TB control and in rendering services in line with international standards for TB care. Thirty seven public hospitals including medical college hospitals and military hospitals have been involved so far. Services have also been established in the prison system. The data management software has been upgraded. NTP and NGO staff is being trained in data analysis and use for programme management and development. An HRD plan has been developed and a focal point for HR designated at the central level.

The TB programme benefits from Global Fund support through Rounds 3 and 5. This support is channelled through two principal recipients: the External Resource Division (ERD) of the Ministry of Finance (MoF) and BRAC. WHO provided strong technical and operational support to the programme. In addition, USAID has been providing financial assistance to NTP directly while


several other donors are funding TB activities through NGOs. Some support for TB control is also made available through the HNPSP.

Major AchievementsEnhanced quality of laboratory services;

Establishment of a national MDR-TB coordination committee, clinical management, social support committee and laboratory working groups;

Improved coordination and collaboration between NGO partners and between the government and NGOs;

“Managing Information for Action” (MIFA) courses held for central and district level staff;

Scaling up of public-private partnership (PPP) and involvement of civil society and community;

Improved drug management through implementation of SOPs; and

Improvements in data management software.

Major challenges and constraintsSustaining the quality of DOTS;

Maintaining implementation in the face of high turnover of government and NGO staff;

Scaling up the management of MDR-TB;

Building linkages with the National AIDS and STI programme for TB/ HIV;

Further scaling up and strengthening PPP;

Addressing drug management issues that have led to emergency procurements; and

Lack of sufficient supportive supervision

Enhancing evidence-based programme management

Planned activitiesFinalizing the national TB/HIV operational guidelines;

Phase-wise expansion of TB/HIV collaborative activities;


National HIV prevalence survey among TB patients in 2009;

HR development for wider implementation of TB/HIV, MDR-TB and PPM DOTS interventions;

Upgrading regional reference laboratories for culture and drug susceptibility testing;

Undertaking national drug resistance survey in 2009;

Gradual expansion of PPM activities;

Strengthening the procurement and supply management system;

Strengthening supervision and monitoring;

Scaling up of comprehensive Advocacy, communication and social mobilization (ACSM) activities;

Curricula development/implementation for under graduate/post graduate medical, paramedical and nursing students on DOTS, TB/HIV, MDR-TB.

Conducting an assessment of the impact of the IEC campaigns on the population and service recipients; and

Continued operational research for programme development.

Case notifications by type of patients, 2007 TB notification rate (per 100 000 population)

Newextrapulmonary

11% Relapse3%

Other3%

New smear-positive70%

New smear-negative16%

Other retreatment0%

Treatmentafter failure

0%

Treatment afterdefault

0%0

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40

50

60

70

80

90

100

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

New and relapse New smear-positive

TB epidemiological profile, BangladeshTB Unit of the WHO Regional Office for South-East Asia


Notified new smear-positive cases per age groups and sex, 2007

Treatment outcomes of new smear-positive cases, 2006 cohort

Notified new smear-positive cases per age groups and sex (rate per 100 000 population), 2007

Treatment outcomes of new smear-positive cases

0

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Cured90%

Completed1% Died

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Failed1%

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Transferred out2%

non-evaluated1%

Other8%

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1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Success rateUnfavorable outcomes (died+failed+defaulted+transferred out+non-evaluated)

Estimates and notification rates for 2007 UN population-based

Population 158 665 000

Incidence all forms of TB 353 103

Incidence rate all forms of TB (per 100K pop/yr) 223

Incidence NSP cases 158 797

Incidence rate NSP cases (per 100K pop/yr) 100

Prevalence rate of all forms of TB (per 100K pop) 387

TB death rate (of all forms of TB/100K pop/yr) 45

Notification rate of all forms of TB (per 100K pop/2007) 93

Notification rate of NSP cases (per 100K pop/2007) 66

NSP Case detection rate (%)* 66

Treatment success rate (%) of NSP cases for 2006 cohort 92

* The case detection rate among new smear positive cases is 73% when calculated using the most recent national population figure which is 143 million.


With a population of over 658 000, Bhutan has an annual incidence of 91 cases of all forms of TB /100 000 population. The case detection rate has been steadily increasing each year and was over 100% in 2007 based on the current WHO estimates of incidence for the country.* The treatment success rate achieved for the cohort of the patients registered in 2006 was 89%. The TB control programme is fully integrated into the general health services.

There is no representative data on levels of drug resistance. However, it is estimated that 0.6% of newly diagnosed smear positive TB cases have MDR-TB. Currently, there are very limited laboratory facilities for culture and drug susceptibility testing (DST) in the country. Culture and DST facilities will be upgraded at the National Referral Hospital at Thimphu and additional laboratory staff trained in undertaking quality-assured culture and DST. It is proposed that DST will be done for all Category II failures through assistance from the designated SNRL, until the national laboratory is set up, when DST may be extended to all smear-positive cases initiated on treatment. The national programme has applied to the Green Light Committee in 2008 for second-line drugs and management of MDR-TB.

A national body responsible for coordinating TB-HIV activities was formed in 2007 and a national plan for collaborative TB-HIV activities has been developed.

* Based on 2006 data

Bhutan


A comprehensive HRD plan is in place and a focal point for HR has been designated at the central level. Drug management needs further strengthening. Collaboration between NTP and non-NTP service delivery partners including military and large employment sectors has been established. Two military hospitals are involved in TB services.

The TB programme benefits from Global Fund support through Rounds 4 and 6.

Major achievementsARTI survey being carried out to better estimate incidence of the disease;

Quality control of smear microscopy expanded to sub-national level;

National plan for TB-HIV collaborative activities developed; cross referral of TB and HIV patients established; and

IEC programmes on tuberculosis undertaken to further improve community awareness.

Major challenges and constraintsLimited management capacity at the central level;

Need to strengthen TB surveillance including data management;

Inadequate access to diagnostic and treatment facilities among people living in the border and remote areas and

Migration of people with TB freely across the open border with India

Planned activitiesDeveloping a manual for training of trainers on TB control;

Improving data management, monitoring and supervision of programme implementation;

Developing national policy and guidelines for MDR-TB management;

Developing culture and DST capacity at the central reference laboratory;

Conducting a national drug resistance survey in 2009; and

Addressing TB control among cross-border and vulnerable populations.



TB epidemiological profile, BhutanTB Unit of the WHO Regional Office for South-East Asia





Other

5%

Relapse4%

New extrapulmonary37%

New smear-positive

33%

New smear-negative

25%

Otherretreatment

0%

Treatment afterfailure

1%


0%

0

50

100

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200

250

300

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007


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11%

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Cured

79%

Defaulted1%

Failed1%

Died5%

non-evaluated5%

Completed

9%

60

80

100

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Unfavorable outcomes (died+failed+defaulted+transferred out+non-evaluated)Success rate



Population 658 000

Incidence all forms of TB 601


Incidence NSP cases 270






NSP Case detection rate (%) 66



With a population of approximately 24 million, Democratic People’s Republic of Korea (DPR Korea) has an annual incidence of 344 cases of all forms of TB /100 000 population. An active case finding campaign and integration of previously non-DOTS sectors such as health facilities under ministries of military, security and railways has led to further increase in case notification. The case detection rate among new smear-positive cases was 64% in 2007* and the treatment success rate for the cohort of patients registered in 2006 was 86%. A multi-year strategic plan has been developed for 2008-2015, in line with the global plan to stop TB and the regional plan for TB control, 2008-2015.

Patients with possible drug resistance are currently not being diagnosed and second-line regimens are not available through the programme. There is no reliable data on the extent of MDR-TB in the country. However, re-treatment cases comprise 18% of all notified cases.

A preliminary survey of drug resistance among patients failing Category II regimens is being carried out with the assistance of the supranational reference laboratory in Hong Kong, aimed at identifying the resistance pattern in the country towards developing an MDR-TB regimen tailored to the country setting. The central TB Institute in Pyongyang is being developed to function as the National Reference Laboratory.

* Following a revision of the estimates for the country based on a national ARTI survey completed in 2007.

DPR Korea


HIV has not been reported in the country. There is a plan to establish HIV prevention activities.

The government provides for over half of the programmes’ funding requirements in terms of staffing, infrastructure, some drugs and surveillance. WHO continues to provide support to the programme, in terms of technical assistance, training health staff, strengthening laboratory services, upgrading infrastructure, and monitoring and evaluation. Regular supplies of anti-TB drugs have been ensured through the GDF grant mechanism from 2003 and the grant was extended exceptionally for an extra year until 2009. Limited support was also provided through the Eugene Bell foundation and Christian Friends of Korea. A proposal submitted to the Global Fund has been approved during Round 8. A comprehensive HRD plan for the Ministry of Health as a whole and a GAVI-HSS proposal for strengthening health services have been developed.

Major achievementsDOTS firmly in place with service delivery extending to the most peripheral level;

TB estimates revised on the basis of ARTI survey;

Health facilities in other sectors involved;

In-country logistics for drugs and consumables established;

Additional staff trained and routine supervision activities resumed;

Involvement of household doctors in DOTS institutionalized;

Standardized laboratory kits introduced;

Patient-wise kits being introduced; and

Securing Global Fund support.

Major challenges and constraintsSustaining funding to implement basic DOTS: shortages of laboratory reagents and first-line drugs;

Low level of documentation of DOT by household doctors;

Insufficient supervision of DOTS implementation;


Inadequate laboratory capacity for undertaking laboratory QA; culture and DST;

Diagnosis of TB in children not widely in practice; and

Lack of information on pattern of MDR-TB in the country and no ground work for GLC application.

Planned activitiesStrengthening of coordination with other sectors;

DOTS training for household doctors;

Undertaking systematic supervision;

Undertaking the first MDR-TB survey;

Procuring additional equipment for culture and DST for the NRL; and

Training paediatricians and TB staff on paediatric TB case management.


TB epidemiological profile, DPR KoreaTB Unit of the WHO Regional Office for South-East Asia

Other

16%

New extrapulmonary

11%Relapse

3%

New smear-

positive

35%

New smear-

negative

37%

Other

retreatment

8%

Treatment after

failure

4%

Treatment after

default

2%

0

50

100

150

200

250

300

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007









Prevalence rate of all forms of TB (per 100K pop) 104 953










0

500

1000

1500

2000

2500

3000

3500

4000

0-14 15-24 25-34 35-44 45-54 55-64 65+

Male Female

Nu

mb

erof

case

s

0

50

100

150

200

250

0-14 15-24 25-34 35-44 45-54 55-64 65+

Male Female

Nu

mb

erof

case

sp

er1

00

00

0p

op

ula

tion

Other

14%

Defaulted4%

Transferred out3%

Failed4%

Died3%

non-evaluated

0%

Completed

4%

Cured

82%

0

20

40

60

80

100

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006



India

India is the largest country in the Region with a population of almost 1.2 billion living in 30 states and 5 union territories. The country continues to be burdened with high morbidity and mortality due to tuberculosis, contributing one-fifth of the global TB cases and 331 268 deaths due to TB in 2006.

Since its inception, the programme has initiated over 9 million patients on treatment. The programme has consistently achieved the global target of 85% treatment success rate among new sputum-positive (NSP) cases. The case detection rate among new smear-positive cases was 68%* in 2007 and the treatment success was 86% for the cohort of patients registered for treatment in 2006.

Eleven intermediate reference laboratories are being accredited for culture and drug susceptibility and five state laboratories are now performing culture and DST. An MDR/XDR-TB response plan has been developed at the national level, and following a consultative meeting in September 2007, a “Consensus Statement on the Management of MDR-TB cases outside of RNTCP” was widely disseminated in order to rationalize the treatment and use of second-line drugs outside RNTCP. Treatment services for MDR-TB patients were introduced in two states in March 2007, and preparatory activities for MDR-TB management are on-going in seven additional states.

Following the revision of the estimated HIV prevalence in India to 2.5 million, it is estimated that 1.2% of TB patients in the country are HIV infected.



However, more recent data at country level (unpublished) shows that about 4%-5% of TB patients are HIV-positive. Implementation of the revised “National framework of joint TB/HIV collaborative activities” began in early 2008 and interventions now cover the entire country. An “intensified TB/HIV package” is being rolled out in nine states and in a few additional districts classified as high HIV prevalence settings, covering a population of over 320 million.

During 2007 in the states that had fully integrated reporting on TB/HIV activities (covering a population of over 300 million), 46 048 HIV infected TB suspects were referred from the Integrated Counseling and Testing Centres (ICTCs) to RNTCP services. Of these, 7 596 were diagnosed as HIV infected TB cases. In addition, 78 058 HIV negative TB suspects were referred by the ICTCs to RNTCP services, of whom 15671 were diagnosed as having TB disease. Pilot field studies on the operationalization of decentralized delivery of CPT to HIV infected TB patients has been completed and the initial results of routine referral of TB patients for HIV counseling and testing are now available.

A consultative meeting was held in early 2008 to revise and update guidelines to operationalize RNTCP activities with NGOs and private sectors. The International Standards for TB care (ISTC) has been adopted by the Indian Medical Association (IMA) and has been included in the training module for private practitioners. The IMA, supported through funds received under Global Fund Round 6, is implementing public-private mix (PPM-TB) activities across six states of the country. The Indian Medical Professional Associations Coalition Against TB (IMPACT) comprising the Indian Medical Association, National College of Chest Physicians, India Chest Society, Association of Physicians of India, Federation of Family Physicians of India and the Indian Academy of Paediatrics has endorsed the ISTC. The RNTCP has successfully involved several medical colleges, NGOs, private practitioners and the corporate sector.

Health services are administered in a decentralized manner at the level of the states and union territories through diverse public and private sector facilities. Policies for TB control activities are formulated at the central level in consultation with other stake-holders, with the Central TB Division in the Ministry of Health and Family Welfare having overall responsibility for the Revised National TB Control Programme (RNTCP). The RNTCP plan and budgets are aligned with the national health plan. The National Rural Health Mission provides an opportunity for strengthening TB service delivery at the grass root level. A national HRD plan for TB is in place and a focal point for HRD has been designated at the central level. The EPI centre software has been successfully transitioned to a Windows based system. RNTCP has planned to pilot the Practical Approach


to Lung Health in Kerala in 2009. The next joint review of RNTCP is planned for April 2009.

The government of India supports over half of the budget for RNTCP. The RNTCP additionally benefits from funding through DFID, the Global Fund, USAID and the World Bank.

Major achievementsDecentralized diagnosis through a network of around 12,400 quality assured sputum microscopy laboratories;

Treatment services decentralized through a network of over 0.3 million DOT centres/providers using patient-wise boxes both for adults and paediatric patients;

Successful involvement of 265 medical colleges, over 2,600 NGOs, 19,000 private practitioners and over 150 corporate sector health units;

Updated RNTCP guidelines and schemes for involvement of NGOs and private providers in RNTCP activities published;

Joint national framework for TB-HIV collaborative activities being rolled out nation-wide;

More than five fold increase in referrals from VCTC to RNTCP and more than three fold increase in referrals from RNTCP to VCTC over the last 3 years;

Endorsement of the revised diagnostic algorithm and case definitions for smear-positive TB;

Five intermediate reference laboratories (IRLs) for M.tb culture and drug susceptibility testing now accredited; another seven currently undergoing accreditation;

Treatment for MDR-TB patients introduced in the states of Gujarat and Maharashtra; preparatory activities for the introduction of MDR-TB management on-going in nine additional states;

Indian Medical Professional Associations Coalition against TB (IMPACT) launched on World TB Day 2007;

GF supported Indian Medical Association Project for enhancing the involvement of private practitioners in RNTCP started in six states; and

TB disease prevalence studies initiated at six “sentinel sites”.


Major challenges and constraintsAchieving universal access while maintaining and further improving the quality of services across the country;

Introducing newer interventions for TB control [e.g. Practical Approach to Lung Health (PAL), newer diagnostics etc.,];

Keeping staff motivated to perform optimally;

Promoting rational use of first- and second-line anti-TB drugs outside the programme to prevent MDR and XDR TB;

Scaling up culture, DST and treatment services for MDR-TB;

Scaling up of PPM activities to link all providers to the national programme;

Fully implementing the 2008 National Framework for TB-HIV collaboration in the whole country;

Developing and implementing airborne infection control measures in health facilities; and

Effectively promoting operational research to address local challenges.

Planned activitiesMaintaining and further improving both quality and reach of services to move towards achieving universal access;

Piloting the Practical Approach to Lung Health initiative in Kerala;

Widening the network of quality assured culture and drug susceptibility testing (DST) services to have at least 27 accredited laboratories in place by 2010, and strengthen capacity of the four national reference laboratories to undertake second-line DST;

Widening the delivery of services for MDR-TB cases to at least a total of 27 DOTS-Plus sites by 2010;

Introducing the revised RNTCP schemes for the involvement of NGOs and private practitioners, and monitoring its implementation across the country;

Completing the implementation of the 2008 National Framework for TB-HIV collaboration across the whole country;


Developing guidelines for “airborne infection control in health care facilities” and pilot the guidelines;

Conducting the Joint Government of India / WHO Monitoring Mission of RNTCP in early 2009;

Introducing the revised definition of TB suspect (two weeks history of cough etc), revised diagnostic algorithm (two initial smear examinations for diagnosis) and revised case definition of smear-positive pulmonary TB (one positive smear result) in 2009; and

Completing the evaluation studies of liquid culture and molecular test systems for the diagnosis of drug resistant TB in collaboration with FIND.


TB epidemiological profile, IndiaTB Unit of the WHO Regional Office for South-East Asia



Other

19%

New14%

extrapulmonaryRelapse

7%

New smear-

positive

40%

New smear-

negative

27%

Otherretreatment

6%


1%

Treatment after

default

5%

0

20

40

60

80

100

120

140

160

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007


0100002000030000400005000060000700008000090000

100000

0-14 15-24 25-34 35-44 45-54 55-64 65+

Male Female

Nu

mb

erof

case

s

0

20

40

60

80100

120

140

160

180

0-14 15-24 25-34 35-44 45-54 55-64 65+

Male Female

Nu

mb

erof

case

sp

er1

00

00

0p

op

ula

tion


Estimates and notification rates for 2008 UN population based

Population 1 169 016 000

Incidence all forms of TB 1 961 825













Other

14%

Defaulted6%

Transferred out1%

Failed2%

Died5%

non-evaluated0%

Completed

2%

Cured

84%

0

20

40

60

80

100

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Unfavorable outcomes (died+failed+defaulted+transferred out+non-evaluated)

Success rate


With a population of 231 million, Indonesia carries the third highest TB burden globally. After achieving a case detection rate of 73% in 2006, Indonesia slipped out of the target zone in 2007, reporting a case detection of 68%*. This is in part attributed to the temporary cessation of Global Fund support for nine months. However, the overall notification rate dipped only by two points to 119/100 000, demonstrating that sustainable mechanisms are in place. The treatment success rate for the cohort of patients registered in 2006 was 91 %. The country has adopted the new Stop TB Strategy and finalized the second national strategic plan (2006-10) for TB control, including all the components of the new strategy. Tuberculin surveys and mortality studies are on-going.

Around 2% of newly diagnosed TB cases are estimated to have developed multi-drug resistance. A drug resistance survey is currently ongoing in Central Java and is planned for East Java. Efforts to develop and strengthen the national laboratory network are underway, with the assistance of the SNRL at Adelaide, Australia. Intermediate reference laboratories are being established in an additional seven provinces. National programmatic guidelines, treatment guidelines, training materials and modules for staff for MDR-TB management have been developed. A GLC approved project is in place and it is expected that MDR-TB cases will be enrolled by early 2009.

Indonesia has an overall low prevalence of HIV, but has concentrated epidemics among high-risk population groups in most provinces. TB-HIV

* The case detection rate among new smear positive cases is 71% when calculated using the most recent national population figure which is 225 642 000.

Indonesia


collaborative activities have been initiated in a few high HIV prevalence areas of the country.

The TB programme has scaled up public-private partnerships and hospital-community DOTS linkages; 560 public and medical college hospitals have been involved by the TB control programme. In addition, 408 prisons and 119 military hospitals have also been involved. Teaching of the principles and practices of DOTS has been integrated into the medical school curriculum. The ISTC has been endorsed by the professional associations and widely disseminated. ACSM activities are being scaled up in different provinces of the country.

A comprehensive HRD plan is in place and a focal point for HR has been designated at the central level. Drug management remains suboptimal and needs strengthening. The NTP’s plan and budget are aligned with the national health sector development plan. However, there are challenges due to the decentralization of health services down to the level of each district in the country, and because of cuts in overall government budgets.

The Indonesian programme receives support from several sources including the Global Fund, Tuberculosis Coalition for Technical Assistance (USAID), and DFID. Technical assistance is being provided by WHO, KNCV Tuberculosis Foundation, Management Sciences for Health, FHI, JICA and IMVS, Adelaide.

Major achievementsSecond Five-Year Strategic Plan (2006-2010) being effectively implemented;

Hospital involvement scaled up - including endorsement and roll out of ISTC;

Specific guidelines developed for hospital-DOTS linkage, TB-HIV, –TB in workplaces, ACSM, Paediatric TB etc);

First Drug-resistance survey (DRS) finalized in one provincel

EQA accreditation of four laboratories for culture and DST;

GLC application approved and DOTS-plus pilot sites in preparation;

TB-HIV collaborative activities initiated in some high burden areas; and

Use of FDCs expanded to all provinces.


Major challenges and constraintsProblems of access and geographic terrain in the eastern part of the country;

Low commitment from local governments in terms of financial contribution;

Temporary cessation of GF support in 2007 affected operational activities;

Suboptimal quality of DOTS implementation in hospitals, private clinics and practitioners;

Emergence of TB/HIV in high HIV prevalence provinces;

Inadequate human resources due to high turn over and zero recruitment policy; and

Repeated emergency procurements of drugs due to lack of sustained government funding.

Planned activitiesStrengthening provision of TB services in hospitals, including roll out of ISTC to professional societies and organizations;

Strengthening capacity of provincial laboratories for culture and DST, with proper accreditation;

Strengthening and expanding TB/HIV collaborative activities in high- risk provinces;

Establishing and then scaling up MDR TB management in future;

Conducting DRS surveys in other provinces, based on experience gained in the DRS survey done in Central Java;

Continuing capacity building in the priority areas for fully implementing the Stop TB Strategy through conducting trainings, work shops, exchange visits etc; and

Strengthening procurement and TB drug supply management, through capacity building and advocacy for sustained funding.



TB epidemiological profile, IndonesiaTB Unit of the WHO Regional Office for South-East Asia





Other2%

Newextrapulmonary

3%Relapse

1%

New smear-positive

59%

New smear-negative

37%

Otherretreatment

0%


0%


0%

0

20

40

60

80

100

120

140

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007


0

5000

10000

15000

20000

25000

0-14 15-24 25-34 35-44 45-54 55-64 65+

Male Female

Nu

mb

erof

case

s

0

50

100

150

200

250

0-14 15-24 25-34 35-44 45-54 55-64 65+

Male Female

Nu

mb

erof

case

sp

er1

00

00

0p

op

ula

tion

Other

9%

Defaulted

5%

Transferred out

2%

Failed

1%

Died

2%

non-evaluated

0%

Completed

8%

Cured

82%

0

20

40

60

80

100

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

















With a population of 306 000, Maldives has an estimated incidence of 47 per 100,000 population of all forms of TB. Maldives has sustained the global targets for TB control since 1996. The National TB control programme (NTP) at the Department of Public Health is the central body for registration, planning, monitoring, training and evaluation of the TB control activities, since its establishment in 1976. TB is a notifiable disease and DOTS remains the core element of the National TB programme. Close coordination and collaboration with other health establishments especially private health care institutions, in identifying and accurately reporting identified cases has been established. All anti-TB drugs are available only through the government-run national TB control programme.

The main objectives of the NTP are to improve and strengthen TB preventive and promotive activities, to cure as many patients as possible and provide better services to the community. In this regard, establishment of critical infrastructure and human resource development for intensified case finding, early case detection and strengthening the microscopy network are critical. At the same time, social mobilization for increased community involvement and utilization of available services and strengthening NTP management have also been identified as key areas.

MDR-TB and TB-HIV are not major problems in Maldives. Drug susceptibility testing (DST) as deemed clinically necessary, is undertaken through shipment of samples to the Tuberculosis Research Centre In India, which is the designated SNRL for the country. Patients diagnosed with MDR-TB are managed clinically at

Maldives


the tertiary care hospital (IGMH) in Malé, and treatment is based on individualized regimens. Second-line drugs for the management of these cases are procured by the MoH on a case-by-case basis. Screening of all HIV positives for active TB is in place in collaboration with the HIV programme since 2003.

The NTP is technically supported by WHO and benefits from an on-going grant from the Global Drug Facility for first-line drugs.

Major achievementsDevelopment of a health master plan for 2007-2017, which accords high priority and adequate funding for TB control;

Successful coordination with the ministries of Trade, Labour, Atolls Administration, Education and Home Affairs in implementing TB control services;

Collaboration with the HIV/AIDS programme;

Legislation ensuring that anti-TB drugs are available only from NTP;

Long-standing stigma attached to TB addressed through Information Education and Communication (IEC); and

Awareness programmes undertaken to encourage early self-referral and decrease the proportion of nationals seeking care abroad.

Major challenges and constraintsSustainability of the laboratory EQA system;

Difficulties in ensuring adequate supervision and monitoring by the programme;

Large migrant workforce from high TB-burden countries.

Planned activitiesEstablishing culture and drug sensitivity testing at national reference laboratory in Malé;

Conducting active surveillance for TB/HIV co-infection;

Intensified case finding in crowded urban areas and factories;

Reviewing and revising the national TB treatment guidelines to include management of MDR-and XDR-TB, and HIV/TB co-infection; and

Conducting a limited TB prevalence study in selected atolls/islands.



TB epidemiological profile, MaldivesTB Unit of the WHO Regional Office for South-East Asia





Other2%

New extrapulmonary

23%

Relapse1%

New smear-

positive

45%

New smear-

negative

29%

Otherretreatment

2%

Treatmentafter failure

0%


0%

0

10

20

30

40

50

60

70

80

90

100

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007


0

2

4

6

8

10

12

14

16

0-14 15-24 25-34 35-44 45-54 55-64 65+

Male Female

Nu

mb

erof

case

s

0102030405060708090

100

0-14 15-24 25-34 35-44 45-54 55-64 65+

Male Female

Nu

mb

erof

case

sp

er1

00

00

0p

op

ula

tion

Other

9%

Defaulted4%

Transferred out4%

Failed2%

Died0%

non-evaluated0%

Completed

0%

Cured

90%


60

80

100

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006




Population 306 000

Incidence all forms of TB 143


Incidence NSP cases 64









With an estimated population of 55.4 million, Myanmar is among the 22 countries with the highest burdens of TB. TB control is a priority in the country’s National Health Plan. DOTS was introduced in 1997 and was expanded to the entire country by 2003. Myanmar achieved the TB control targets in 2006. The case detection rate has steadily increased, reaching 116% in 2007. The treatment success rate for the cohort of patients registered in 2006 was 85%.

Results from a TB prevalence survey, completed in both rural and urban areas in the Yangon Division in 2006 showed that the incidence of TB is 2.26 times higher than the current WHO estimates for the country and affects mainly the younger age groups, which is typical for a young and growing epidemic.

The national reference laboratory in Yangon performs cultures and first-line DST. Second-line DST is being undertaken at the SNRL in Bangkok. Two reference laboratories at Mandalay and Taunggyi are being upgraded. A nationwide drug resistance survey carried out in 2002-2003 had shown an MDR-TB prevalence of 4% among newly diagnosed and 15.5% among previously treated cases. The Ministry of Health has established a national committee on drug-resistant TB including hospital specialists, NTP, WHO and INGOs, to oversee the national response. A GLC approved project is in place and patient enrolment is expected to commence in 2009.

The national prevalence of HIV infection is estimated at 0.67%, and the prevalence of HIV among TB patients is estimated to be 10.9%, based on data from on-going annual sentinel HIV surveillance. TB/HIV collaborative

Myanmar


activities are being implemented jointly by the NTP and national AIDS programmes in Yangon and Mandalay, but need support for further expansion. Resource constraints have adversely affected on plans for expansion of TB/HIV collaborative interventions.

A new Five-Year Strategic Plan 2011-2015, has been drafted with all partners. A comprehensive HRD plan is in place and a focal point for HR has been designated at the central level. The NTP’s plan and budget are aligned with the national health sector development plan. The programme has established a national PPM DOTS sub-group and involved general practitioners through the PSI Sun Quality clinics and private practitioners through the Myanmar Medical Association. The ISTC has been endorsed by specialists and the professional associations in the country. Data management software has been established and central, state and divisional staff trained in data management and use. MDR-TB case management will commence in early 2009. A pilot project to provide IPT to PLHIV will become functional in 2009.

The NTP is being supported by increased funding from the government, supplemented significantly by funding from external sources such as GDF, the Union/Yadana project, WHO, the Japan International Cooperation Agency (JICA) and the Japan Anti-TB Association (JATA). After the Global Fund unilaterally withdrew support to Myanmar, in 2006 a new 3 Diseases Fund to fight AIDS, TB and Malaria in Myanmar was established as a multi-donor trust fund by DFID, EC, AusAID, Norway, the Netherlands and Sweden. WHO Myanmar is the executing agency as an intermediary partner for activities proposed to the 3DF.

Major achievementsThe community awareness programme has accelerated the TB case finding and case holding;

Standard operating procedures (SOPs) for external quality control system for TB laboratories, SOPs for drug and supply management and national guidelines on management of TB in children were developed;

Prevention and control activities for TB/HIV co-infection and management as planned in the Five-year national strategic plan, implemented;


Three Diseases Fund approved USD 1.8 million for TB control in 2008;

Intensified activities to improve case finding (sputum collection points, mobile team activities, contact tracing) and case holding (cohort review meeting) were introduced;

TB control services resumed in Nargis-affected area with emergency funding through UNCERF;

Upgrading of culture and drug sensitivity testing facility in Upper Myanmar TB laboratory;

Public-public mix DOTS and public-private DOTS activities successfully established;

A limited TB prevalence survey, national drug resistant survey and TB/ HIV sentinel surveillance carried out; and

A Managing Information for Action (MIFA) course held.

Major challenges and constraintsMobilizing resources particularly for first-line anti-TB drugs after GDF grant expires in 2009;

Strengthening the general health system for better TB service delivery;

Improving case finding and treatment outcomes in selected townships (border and remote) with high treatment interruption rates and low community involvement in TB control;

Further mobilizing the necessary financial resources; and

Strengthening partnerships for long-term sustainability.

Planned activitiesFurther decentralizing DOTS services to Rural Health Centres (RHC) level and sputum microscopy facilities to reach 1/ 100 000 population;

Reviewing and revising the national guidelines;

Developing a national Advocacy, Communication and Social Mobilization (ACSM) strategy;

Further improving contact tracing measures for better case finding;


Improving implementation in low performance townships;

Evaluating and scaling up prevention and control activities for TB/HIV co-infection;

Initiating MDR-TB case management at Yangon and Mandalay;

Scaling up on public-private mix and strengthening the public-public mix activities;

Evaluating the programme impact on TB situation through a national TB prevalence survey; and

Establishing an external quality control system for all the laboratories including those in the private sector.


TB epidemiological profile, MyanmarTB Unit of the WHO Regional Office for South-East Asia



Other

7%

New extrapulmonary

30%Relapse

3%

New smear-positive

32%

New smear-negative

31%

Other

retreatment

2%


1%

Treatment after

default

1%

0

50

100

150

200

250

300

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007


0

1000

2000

3000

4000

5000

6000

7000

8000

0-14 15-24 25-34 35-44 45-54 55-64 65+

Male Female

Nu

mb

erof

case

s

0

50

100

150

200

250

0-14 15-24 25-34 35-44 45-54 55-64 65+

Male Female

Nu

mb

erof

case

sp

er1

00

00

0p

op

ula

tion


Estimates and notification rates for 2008 UN population based















Other

16%Defaulted

5%

Transferred out

2%

Failed3%

Died6%

non-evaluated

0%

Completed

7%

Cured

77%

0

20

40

60

80

100

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006



With a population of over 28 million, Nepal estimates an incidence of 173 cases of all forms of tuberculosis per 100 000 population, while the incidence of new smear-positive is estimated at 77/100 000. Tuberculosis is identified as a priority programme within the Ministry of Health and Population.

Since 2001 there has been a slow decline in the number of cases notified. Similarly, there is a slight shift to the older age group. This data suggests that there is a decline of TB burden in Nepal in recent years. The case detection rate for new smear-positive cases was 66%* in 2007 with a treatment success rate of 89% for the cohort of patients registered in 2006.

Culture and DST facilities are being provided through a unique public-private partnership with an NGO-run laboratory – GENETUP which is actively supported by the SNRL at Gauting, Germany. A national reference laboratory was established at the National TB Centre in 2007. Four drug resistance surveys have been carried out since 2005. MDR-TB rates of 2.9% (1.8%-3.2%) among new cases and 11.7% (7.1%-18.3%) among re-treatment cases were reported at the end of the fourth survey. Nepal was one of the first countries globally to introduce MDR-TB case management since 2005 by diagnosing and treating Category II failures and other culture demonstrated MDR-TB cases under a GLC approved DOTS-Plus project. The management of MDR-TB has been expanded to all five regions in the country. Currently there are 10 treatment and 32 sub-


Nepal


treatment centres offering MDR-TB treatment services through primary health care services or NTP partners.

Sentinel surveys of HIV among TB patients conducted in 2006-07 show a prevalence of 2.4%. The country has established a National Working Group on TB-HIV and a National TB/HIV Coordination Committee. A national strategy for TB-HIV was officially endorsed by both national TB and HIV programme managers in mid-2008. Joint planning, evaluation and logistics management, information sharing, advocacy and operational research have been planned by the two programmes.

A comprehensive HRD plan is in place and a focal point for HR has been designated at the central level. The NTP’s plan and budget are aligned with the national health sector development plan. The programme has successfully involved private practitioners in Kathmandu and Lalithpur, several NGOs, public hospitals, all 13 medical hospitals both in the public and private sectors and two major prisons in the country. The military hospitals have also been involved. Drug forecasting and management need to be improved. The data management system of the NTP has been improved through introduction of Windows based EPI Centre software. The Practical approach to Lung Health (PAL) was introduced in two districts in 2007 and the NTP plans to expand PAL to other districts.

The NTP is heavily dependent on donor funding. The programme has received support through GF Rounds 4 and 7.

Major achievementsSuccessful implementation and nationwide coverage of DOTS-plus programme for management of MDR-TB;

Full coverage of DOTS at all institutions including primary health care centres in the country;

Successful resource mobilization through the GF (Rounds 4 and 7) and LHL, Norway;

Establishment of PAL in two pilot districts in the country;

Endorsement and wide dissemination of the ISTC;

Establishment of a national reference laboratory;

Completion of field testing of laboratory SOPs (part of WHO Global initiative); and

Introduction of paediatric fixed-dose combination drugs.


Major challenges and constraintsManaging ambulatory care for MDR-TB cases and meeting the need for socio-economic support;

Establishing interventions for TB/HIV;

Managing cross-border migration of patients across the open border with India;

Difficulties in expanding DOTS in urban areas; and

Lack of human resources (central level programme management staff, regional level laboratory staff for QA).

Planned activitiesChanging the treatment regimen from the eight month to the standard six month regimen using fixed dose combination (FDC) drugs;

Developing PPM, TB HIV, and ISTC guidelines by mid 2009;

Initiating TB/HIV collaborative activities;

Introducing electronic database and cohort analysis for MDR-TB patients; and

Assessment of infection control and preparation of a national plan for infection control.



TB epidemiological profile, NepalTB Unit of the WHO Regional Office for South-East Asia





Other

8%

New

extrapulmonary

21%Relapse

7%

New smear-positive

42%

New smear-negative

28%

Otherretreatment

0%


1%


1%

0

20

40

60

80

100

120

140

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007


0

500

1000

1500

2000

2500

0-14 15-24 25-34 35-44 45-54 55-64 65+

Male Female

Nu

mb

erof

case

s

0

50

100

150

200

250

300

0-14 15-24 25-34 35-44 45-54 55-64 65+

Male Female

Nu

mb

erof

case

sp

er1

00

00

0p

op

ula

tion

Other

12%

Defaulted3%

Transferred out3%

Failed1%

Died5%

non-evaluated0%

Completed

2%

Cured

86%

0

20

40

60

80

100

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006






Incidence all forms TB 48 766

Incidence rate all forms TB (per 100K pop/yr) 173



Prevalence rate of all cases (per 100K pop) 240


Notification rate of all forms of TB (per 100K pop/2007)

117

Notification rate of NSP cases (per 100K pop/2007)

51




The country has a population of 19 million and is among the low TB prevalence countries in the Region. It is estimated that prevalence of TB is 79 per 100 000 population. The incidence rate of new smear-positive cases is estimated to be 27/100 000 population. The country has achieved the global targets for case detection and treatment success rate. The case detection rate for 2007 was 85.6% and treatment success for the 2006 cohort of new smear-positive cases was 87%.

Preliminary data from a new survey in Sri Lanka shows an MDR-TB rate of 1.4% among newly diagnosed cases. Culture and DST is performed for all patients who fail Category I regimens, at the time of initiation of treatment for all patients commencing Category II regimens, contacts of MDR-TB cases, all patients commencing re-treatment regimens, HIV infected TB cases, migrants and prisoners. MDR-TB is diagnosed at the central reference laboratory, and patients are treated initially at the referral hospital after which they are referred for treatment at hospitals in their respective districts. Second-line anti-TB drugs for treatment of MDR-TB cases are procured by the government from the open market. Periodic stock-outs have been reported. The success rate among MDR-TB cases is not yet known. National guidelines for the treatment of MDR-TB have not yet been developed. The country has submitted an application to the Green Light Committee and will initiate an MDR-TB case management project supported by the Global Fund.

TB patients have been included under the annual surveillance for HIV since 1993. Only one HIV positive case has been detected from among the TB

Sri Lanka


patients tested. However, since 80% of HIV cases reported in the country are in the age group of 20-44 years, this is a concern especially since the annual notifications for HIV have been increasing since 1987. A national policy for provision of CPT and ART to HIV positive TB patients is in place.

The NTP’s plan and budget are aligned with the national health sector development plan. The public-private approach for TB control has been initiated on a limited scale maintaining ISTC. Forty two public hospitals including medical college hospitals and five military hospitals have been involved by NTP. There is a plan for initiation of Practical Approach to Lung Health (PAL).

The government provides the majority of funding for the TB programme, with additional resources from the Global Fund.

Major achievementsReaching the global targets in 2005;

Reduction in default rate;

Introduction of fixed dose combinations (FDCs) and paediatric formulations of FDCs;

Decentralization of diagnostic centres;

Initiation of PPM activities; and

Improvements in the infrastructure.

Major challenges and constraintsHigh turnover of trained staff;

Introducing TB control in prisons;

Managing cases in tea estates (limited access to services, overcrowding etc.);

TB control in conflict-affected areas (no supervision, inadequate staff etc.);

Lack of opportunities for development for the key staff; and

Stigmatization of TB.


Planned activitiesTraining of different categories of health staff including private sector and community DOT providers by using the modules developed for each category;

Assessment of the laboratory capacity and planning scale up of Culture and DST facilities;

Improving procurement and supply management by training of key staff;

Establishing interventions to address HIV-related TB (TB/HIV) and drug resistant TB;

Strengthening advocacy, communications and social mobilization approaches;

Improving surveillance, monitoring and evaluation-

Maintenance and updating of the software package;•

Regular supervisory visits from the central unit to districts and • from the district to peripheral facilities and organization of review meetings;

Conducting a joint review of the national TB control programme • with partners; and

Initiating PAL as a pilot project in 2009.


TB epidemiological profile, Sri LankaTB Unit of the WHO Regional Office for South-East Asia

Other5%

Newextrapulmonary

22%

Relapse2%

New smear-

positive

51%

New smear-negative

22%

Otherretreatment

0%


1%


2%

0

10

20

30

40

50

60

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007










Incidence rate of all forms of TB cases (per 100K pop/yr) 60









0100200300400500600700800900

0-14 15-24 25-34 35-44 45-54 55-64 65+

Male Female

Nu

mb

erof

case

s

0

10

20

30

40

50

60

70

80

0-14 15-24 25-34 35-44 45-54 55-64 65+

Male Female

Nu

mb

erof

case

sp

er1

00

00

0p

op

ula

tion

Other

13%

Defaulted7%

Transferred out

0%

Failed1%

Died5%

non-evaluated

0%

Completed4%

Cured83%

0

20

40

60

80

100

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006



With a population of approximately 64 million Thailand ranks 18th in the list of 22 high TB burden countries. The prevalence of TB was estimated at 192 per 100 000 population for all forms in 2007, with an incidence rate of 62 new smear-positive cases per 100 000 population. The country has achieved full DOTS coverage, maintaining the global target for case detection since 2003. A case detection rate of 72 % was achieved in 2007.The treatment success rate for the cases reported for 2006 was 77%. The low treatment success rate is attributed to high default and mortality rates and incomplete reporting particularly from the city of Bangkok.

Based on a national drug resistance survey in 2006, MDR-TB rates were reported to be 1.65 % among newly diagnosed cases and 34.5 % among previously treated cases. Thailand has an extensive and well developed laboratory network. However, due to the decentralized nature of laboratory services and the presence of several private sector laboratories also undertaking TB diagnosis, maintaining quality assurance is one of the major challenges faced by the NTP. Most patients with drug-resistant tuberculosis are diagnosed and managed by university, regional/provincial and some private hospitals, which procure second-line anti-TB drugs using local resources. National guidelines for MDR-TB, in line with international recommendations, have been developed and adopted by the national experts. Culture and DST is recommended for all patients who fail Category I and II regimens, contacts of MDR-TB cases, all patients commencing re-treatment regimens, HIV infected TB cases, migrants and prisoners. The capacity for first-line DST is being expanded through the

Thailand


establishment of culture facilities at selected regional laboratories. The national reference laboratory has capacity for second-line DST, and has recently been formally designated as the second SNRL in the South-East Asia Region.

Substantial progress has been made in implementing TB/HIV collaborative activities throughout the country. A national working group for TB/HIV has been established and the NTP provides guidance for collaborative TB/HIV activities. Diagnostic HIV testing of TB patients has been incorporated into national guidelines and is being increasingly implemented throughout the country. Routine HIV screening is recommended nationally for all registered TB patients. In 2007, the HIV counseling and testing rate among TB patients was 68 %, and 20 % among all those tested were found to be HIV-infected. Care and treatment for HIV-infected persons is highly subsidized and widely available. Cotrimoxazole preventive therapy and anti-retroviral treatment was provided to 67 % and 32 % respectively, of HIV-positive TB patients. Improved identification of HIV-infected TB patients, together with effective linkage to care and treatment will be required to significantly reduce TB mortality rates.

An HRD plan has been developed and a focal point for HR designated at the central level. TB services are fully integrated within primary health care. Thailand has made remarkable progress in involving NGOs and the private sector. Recently a Memorandum of Understanding was signed with the National Health Security Office, Ministry of Labour and Médecins Sans Frontières (MSF) for implementation of TB in workplaces, prisons and among migrants. The programme has involved private hospital associations, NGOs (World Vision, American Refugee Committee, and Thailand Business Coalition of AIDS to control TB) to provide TB care according to ISTC.

The country’s TB programme is supported by GF and other bilateral partners and additional funding has been allocated by the National Health Security Office.

Major achievementsThe National Health Security Office has provided additional funds to support TB activities at the provincial and local levels;

TB/HIV collaborative activities have been scaled up countrywide;

TB services among marginalized populations such as migrants and cross-bordered population have been maintained by collaborating with NGOs through GFATM support;


Establishing TB services in 138 prisons;

Greater commitment from the Ministry of Public Health: designation of a “Mr/Ms TB” at all hospitals and provisional health offices;

Managing Information for Action (MIFA) course introduced; and

Global Fund support through Rounds 6 and 8.

Major challenges and constraintsImproving quality of DOTS in decentralized situation and in big cities;

Further strengthening TB/HIV integrated activities;

Better managing systematic and regular supervision of programme activities;

Ensuring systematic MDR-TB care and recording and reporting on these cases;

Involving private hospitals in TB control;

Obtaining adequate commitment for implementing TB control activities in Bangkok; and

Addressing Human resource constraints at the central and Regional levels.

Planned Activities Capacity building of health care volunteers in decentralized settings and in big cities to ensure treatment adherence;

Strengthening of regular supervision, monitoring and evaluation of the programme;

Piloting MDR-TB treatment under the programme; procurement of second-line drugs through GLC;

Increasing the involvement of private hospitals and ensuring practices are in line with the national guidelines;

Advocating with the Bangkok Metropolitan Administration for greater commitment for TB Control; and

Updating the database of health staff in place and developing a strategic plan according to the need.



TB epidemiological profile, ThailandTB Unit of the WHO Regional Office for South-East Asia





Other

3%

New

extrapulmonary

14%

Relapse3%

New smear-positive

52%

New smear-negative

31%

Otherretreatment

0%


0%


0%

0

10

20

30

40

50

60

70

80

90

100

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007


0500

100015002000250030003500400045005000

0-14 15-24 25-34 35-44 45-54 55-64 65+

Male Female

Nu

mb

erof

case

s

020406080

100120140160180

0-14 15-24 25-34 35-44 45-54 55-64 65+

Male Female

Nu

mb

erof

case

sp

er1

00

00

0p

op

ula

tion

Other

23%

Defaulted

6%

Transferred out

3%

Failed

2%

Died

8%

non-evaluated

4%

Completed

6%

Cured

71%

0

20

40

60

80

100

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006










TB death rate (of all forms of TB)/100K pop/yr 21






The estimated population for Timor-Leste is 1 155 187. The NTP is functioning in all 13 districts and 65 sub-districts of the country, with the district TB coordinators (DTCs) working within the district health management teams in all districts and with the 65 community health centres (CHCs) at sub-district level. The estimated prevalence of all forms of TB and incidence of smear-positive TB is 378 and 145 per 100 000 population respectively. The revised estimates for TB in the country are based on recent prevalence studies carried out in East Nusa Tenggara province and on a house-to-house active survey of pulmonary TB carried out in the sub-district of Bazartette in 2006-2007. A case detection rate* of 61% was achieved in 2007, while the treatment success rate for the patients registered for the cohort 2006 was 79%.

It is estimated that MDR-TB rates are 1.6% among newly diagnosed and 14.5% among previously treated TB cases. A Green Light Committee approved MDR-TB case management project is in place. The National TB Control Programme has established a treatment center in the NGO facility of Klibur Domin in the district of Liquica. Two MDR-TB patients are currently enrolled for management at this centre. GDF is providing the necessary second-line, anti-TB drugs supported through UNITAID. The Institute of Medical and Veterinary Sciences, Adelaide, Australia, is providing assistance for sputum culture and sensitivity testing for diagnosis and follow up, and also provides technical assistance for TB laboratory services.

* Based on the national population figure for 2007, the case detection rate among new smear positive cases was 68%.

Timor-Leste


HIV remains relatively uncommon in Timor-Leste. However, the country reported 56 cases of HIV infection among whom two were confirmed to have active TB. Surveillance is conducted through routine notifications. Initial collaboration between the National TB Control Programme and the National AIDS Programme has been established.

The TB programme is supported by Global Fund Round 7 and other bilateral partners. Presently, three of the 18 microscopy centres are based in NGO facilities. Four NGO facilities are providing ambulatory care and one is providing in-patient MDR-TB management. There are five other NGOs which support the NTP in identification of TB suspects and referral to DOTS facilities for diagnosis and treatment. Civil society participation is expected to improve and expand with the infusion of Global Fund resources.

Major achievementsGlobal Fund Round 7 proposal approved;

NTP manual and reporting forms revised;

Country-specific TB estimates revised;

MoU signed with supranational laboratory in Australia for culture and DST;

MDR-TB case management launched in July 2008;

TB/HIV collaboration established at national level;

Expansion of TB control services to three prisons;

Public-private mix (PPM) guidelines drafted;

Drugs management training conducted;

Laboratory technicians’ training completed in June 2008;

Expatriate doctors working in Community Health Centres (CHCs), and hospitals trained by NTP.

Major challenges and constraintsInadequate capacity at national, district and sub-national levels;

Inadequate access to NTP services in many areas of the country;

Low community awareness about TB and NTP services;

High default rates particularly in Dili district;


Low case detection rate and inadequate implementation of DOT;

Over-diagnosis of TB in the national hospital, referral hospital and some CHC, as not all doctors follow NTP guidelines; and

Weak drug and data management.

Planned activitiesRevising the national laboratory manual;

Developing training modules for District TB Coordinators (DTCs) and Regional Supervisors;

Training and refresher training of DTCs and Regional Supervisors;

Recruiting additional TB staff at national and CHC level;

Study tour for DTCs and regional supervisors to learn from best practices elsewhere in the Region;

Involving NGOs to extend services to uncovered areas;

Increasing the involvement of the community; and

Improving Monitoring and Evaluation-

Six-mon• thly regional meetings and quarterly meeting with DTCs;

Resuming r• egular supervision to districts and CHCs.


TB epidemiological profile, Timor-LesteTB Unit of the WHO Regional Office for South-East Asia

Other1%

New

extrapulmonary

13%

Relapse1%

New smear-

positive

31%

New smear-

negative

55%

Otherretreatment

0%


0%


0%

0

50

100

150

200

250

300

350

400

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007






Incidence rate all forms of TB cases (per 100K pop/yr) 322














0

20

40

60

80

100

120

140

0-14 15-24 25-34 35-44 45-54 55-64 65+

Nu

mb

erof

case

s

Male Female

050

100150200250300350400450

0-14 15-24 25-34 35-44 45-54 55-64 65+

Male Female

Nu

mb

erof

case

sp

er1

00

00

0p

op

ula

tion

Other

21%

Defaulted

12%

Transferred out

3%

Failed

0%

Died

5%

non-evaluated

0%

Completed

10%

Cured

70%

0

20

40

60

80

100

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006



1 WHO, IUATLD, KNCV. Revised international definitions in tuberculosis control. Int J Tuberc Lung Dis 2001; 5: 213-215.

1. Definitions of tuberculosis casesA case of tuberculosis. A patient in whom tuberculosis has been bacteriologically confirmed, or diagnosed by a clinician. Any person given treatment for tuberculosis should be recorded.

All types: The sum of new smear-positive pulmonary, relapse, new smear-negative pulmonary and extrapulmonary cases.

New smear-positive pulmonary tuberculosis: A patient who has never received treatment for tuberculosis or has taken anti-tuberculosis drugs for less than 30 days and who has one of the following:

Two or more initial sputum smear examinations positive for acid fast bacilli (AFB); or

One sputum examination positive for AFB plus radiographic abnormalities consistent with active pulmonary tuberculosis as determined by a clinician; or

One sputum specimen positive for AFB and at least one sputum that is culture positive for AFB.

New smear-negative pulmonary tuberculosis: A case of pulmonary tuberculosis that does not meet the above definition for smear-positive tuberculosis:

Definitions1


Extrapulmonary tuberculosis: Tuberculosis of organs other than the lungs: e.g. pleura, lymph nodes, abdomen, genito-urinary tract, skin, joints, bones, meninges, etc. Diagnosis should be based on one culture-positive specimen, or histological or strong clinical evidence consistent with active extrapulmonary tuberculosis, followed by a decision by a clinician to treat with a full course of anti-tuberculosis chemotherapy. (A patient diagnosed with both pulmonary and extrapulmonary tuberculosis should be classified as a case of pulmonary tuberculosis.)

Retreatment cases: Patient previously treated for tuberculosis, undergoing treatment for a new episode of bacteriologically-positive (sputum smear or culture) tuberculosis.

Relapse: A patient previously treated for tuberculosis and declared cured or treatment completed, who is later diagnosed with bacteriologically-positive (culture smear) tuberculosis.

2. Definitions of Treatment OutcomeCured: Initially smear-positive patient who was smear-negative in the last month of treatment, and on at least one previous occasion.

Completed treatment: A patient who has completed treatment but who does not meet the criteria to be classified as a cure or a failure.

Treatment success: The sum of patients who are cured and those who have completed treatment.

Died: A patient who dies for any reason during the course of treatment.

Failure: Smear-positive patient who remained smear-positive at five months or later during treatment.

Defaulted: A patient who has interrupted treatment for two consecutive months or more.

Transferred out: A patient who has been transferred to another recording and reporting unit and for whom the treatment outcome is not known.

Not evaluated: Patient who did not have the treatment outcome evaluated.

Note: In countries where culture is current practice, patients can be classified as cured or failure on the basis of culture results.


3. Indicators to assess treatment outcomeCure rate: Proportion of cured cases out of all cases registered in a certain period.

Treatment success rates: The sum of the proportion of patients who were cured and patients who completed treatment out of all cases registered in a certain period. The global target is a 85% cure rate and a greater treatment success rate.

The cure rate and treatment success rate are expressed as a percentage of registered cases. The number of new cases registered for treatment in 2006 (reported in 2007) is compared to the number of cases notified as smear-positive in 2005 (reported in 2006).

Documents

Tuberculosis Controlapps.searo.who.int/pds_docs/B4189.pdf · · 2009-03-23ISTC International standard for tuberculosis care IVMS International Centre for Veterinary and Medical