annual tb report 2016
In alignment with the WHO End-TB Strategy, a new Regional Strategic Plan
(2016–2020) has now been developed for TB control in the South-East Asia Region
with the vision to have a Region free of TB with zero death, disease and suffering due
to TB. All Member States can adopt this vision in their national strategies and plans.
The goal for TB control is to End the TB epidemic in the Region by 2035, by adopting and
adapting the vision, milestones and targets as outlined in the WHA67.1 resolution.
The WHO Regional Office, in coordination with all country offices and international
and national partners, continues to support all Member States in their efforts to
achieve universal health coverage and to end the TB epidemic.
World Health House
Indraprastha Estate,
Mahatma Gandhi Marg,
New Delhi-110002, India
www.searo.who.int/topics/tuberculosis
9 789290 225041
Annual Report 2016
ISBN 978-92-9022-504-1
Tuberculosis Control in the South-East Asia Region
The South-East Asia Region of WHO is home to 26% of the world's population;
however, the Region accounts for 41% of the global burden of tuberculosis (TB) in
terms of disease incidence. In 2014, there were an estimated 5.4 million prevalence
and 4 million incidence of TB, and about 460 000 people died due to TB in the Region.
India and Indonesia have among the largest numbers of cases (23% and 10% of the
global total, respectively). An estimated 340 000 children in the South-East Asia
Region developed TB in 2014. The Region has a total of 99 000 estimated MDR-TB
cases among notified pulmonary TB cases, accounting for approximately 30% of the
world's MDR-TB cases in 2014. Six of the 30 high MDR-TB-burden countries are in the
South-East Asia Region: Bangladesh, Democratic People's Republic of Korea, India,
Indonesia, Myanmar and Thailand. An estimated 210 000 cases (5.2%) of the 4 million
TB-incident cases are HIV-positive. This corresponds to 11 per 100 000 and 5% of all
estimated TB-incident cases. An estimated 62 000 cases died of HIV-associated TB in
2014.
Tuberculosis
control
in the South-East Asia Region
Annual report 2016
Tuberculosis control
in the South-East Asia Region
Annual report 2016
WHO Library Cataloguing-in-Publicaion data
World Health Organizaion, Regional Oice for South-East Asia.
Tuberculosis control in the South-East Asia Region: annual report 2016.
1. Tuberculosis – prevenion and control – staisics and numerical data
2. Tuberculosis, Mulidrug-Resistant 3. HIV 4. Health Resources
5. Data Collecion.
ISBN 978-92-9022-504-1
(NLM classiicaion: WF 200)
© World Health Organizaion 2016
All rights reserved.
Requests for publicaions, or for permission to reproduce or translate WHO publicaions – whether for sale or for noncommercial distribuion – can be obtained from Publishing and Sales, World
Health Organizaion, Regional Oice for South- East Asia, Indraprastha Estate, Mahatma Gandhi
Marg, New Delhi 110 002, India (fax: +91 11 23370197; e-mail: publicaions@who.int).
The designaions employed and the presentaion of the material in this publicaion do not imply
the expression of any opinion whatsoever on the part of the World Health Organizaion concerning the legal status of any country, territory, city or area or of its authoriies, or concerning the
delimitaion of its froniers or boundaries. Doted lines on maps represent approximate border
lines for which there may not yet be full agreement.
The menion of speciic companies or of certain manufacturers’ products does not imply that
they are endorsed or recommended by the World Health Organizaion in preference to others of
a similar nature that are not menioned. Errors and omissions excepted, the names of proprietary
products are disinguished by iniial capital leters.
All reasonable precauions have been taken by the World Health Organizaion to verify the informaion contained in this publicaion. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretaion
and use of the material lies with the reader. In no event shall the World Health Organizaion be
liable for damages arising from its use.
Maps disclaimer
The boundaries and names shown and the designaions used on the maps contained in this document do not imply the expression of any opinion whatsoever on the part of the World Health
Organizaion concerning the legal status of any country, territory, city or area or of its authoriies,
or concerning the delimitaion of its froniers or boundaries. Doted and dashed lines on maps
represent approximate border lines for which there may not yet be full agreement.
Printed in India
iii
Contents
Abbreviaions .......................................................................................................... v
Foreword .................................................................................................................ix
1.
Global and Regional burden of Tuberculosis .................................................. 1
TB burden ........................................................................................................................... 2
Drug-resistant TB ................................................................................................................ 4
Co-epidemics of TB and HIV ............................................................................................... 5
TB inancing ......................................................................................................................... 6
2.
Global and Regional progress in Tuberculosis care and management............ 8
TB care and control ............................................................................................................ 9
Drug-resistant TB .............................................................................................................. 10
Co-epidemic of TB and HIV................................................................................................ 11
New diagnosics rollout .................................................................................................... 13
New drugs rollout.............................................................................................................. 13
Research and development .............................................................................................. 13
3.
Regional challenges ...................................................................................... 15
Over reliance on donor funding ........................................................................................ 16
4.
The End-TB Strategy ..................................................................................... 20
5.
Regional Strategic Plan – Overview .............................................................. 25
Vision and goal ................................................................................................................. 26
Objecives.......................................................................................................................... 26
Regional targets and milestones ....................................................................................... 26
Strategic direcions and intervenions .............................................................................. 28
6.
WHO support in the Region .......................................................................... 32
Transiioning to the End TB Strategy ................................................................................. 33
Diagnosic capacity-building ............................................................................................. 34
Expansion of DR-TB services ............................................................................................. 35
Strengthening TB/HIV collaboraion ................................................................................. 37
Capacity-building and informaion exchange .................................................................... 37
Drug supply and management .......................................................................................... 38
Tuberculosis control in the South-East Asia Region
Annual Report 2016
iv
Rouine surveillance .......................................................................................................... 38
Operaional research ......................................................................................................... 39
Resource mobilizaion ....................................................................................................... 40
7.
Major SEA Regional partnerships ................................................................. 41
Axshya project supported by The Global Fund ................................................................. 42
EXPAND-TB project ........................................................................................................... 43
Global TB Drug Facility (GDF) ............................................................................................ 45
Paediatric TB project ......................................................................................................... 47
TB REACH project .............................................................................................................. 47
UNITAID support in SEAR countries .................................................................................. 49
United States Agency for Internaional Development (USAID) in SEAR countries ............ 51
8.
Country proiles ............................................................................................ 57
Bangladesh ........................................................................................................................ 59
Bhutan ............................................................................................................................... 77
Democraic People’s Republic of Korea ............................................................................. 90
India ............................................................................................................................. 103
Indonesia ......................................................................................................................... 118
Maldives .......................................................................................................................... 134
Myanmar ......................................................................................................................... 146
Nepal ............................................................................................................................. 157
Sri Lanka .......................................................................................................................... 170
Thailand........................................................................................................................... 182
Timor-Leste ..................................................................................................................... 194
Tuberculosis control in the South-East Asia Region
Annual Report 2016
v
Abbreviaions
ACSM
advocacy, communicaion and social mobilizaion
AFB
acid-fast bacilli
AIDS
acquired immunodeiciency syndrome
ART
aniretroviral therapy
ARV
aniretrovirals
CBO
community-based organizaions
CCM
country coordinaion mechanism
CDC
Centers for Disease Control, Atlanta, USA
CHW
community health worker
CSMBS
Civil Servant Medical Beneit Scheme (Thailand)
CN
concept note(s)
CPT
co-trimoxazole prevenive therapy
CV
community volunteer
DOT
directly observed therapy
DOTS
the internaionally recommended strategy for TB control and the
foundaion of the Stop TB Strategy introduced in 2006
DRS
drug resistance surveillance
DR-TB
drug-resistant tuberculosis
DST
drug suscepibility tesing
EQA
external quality assurance
FDC
ixed-dose combinaion
FHI
Family Health Internaional
FLD
First-line ani-TB drugs
GDF
Global (TB) Drug Facility
GDI
Global Drug-resistant TB Iniiaive
GF
Global Fund Global Fund to Fight AIDS, Tuberculosis and Malaria
GLC
Green Light Commitee
Tuberculosis control in the South-East Asia Region
Annual Report 2016
vi
rGLC
regional Green Light Commitee
GLI
Global Laboratory Iniiaive
HBC
high-burden (TB) country
HRD
human resource development
HRH
human resources for health
HSS
health system strengthening
IC
infecion control
IPT
isoniazid prevenive therapy
IQC
internal quality control
ISTC
Internaional Standards for TB Care
IC
infecion control
JICA
Japan Internaional Cooperaion Agency
KNCH
Royal Dutch Foundaion
LED
light-emiing diode microscopes
LTBI
latent TB infecion
MCH
maternal and child health
MDG
Millennium Development Goals
MDR-TB
TB mulidrug-resistant tuberculosis
M&E
monitoring and evaluaion NFM New Funding Model
MSH
Management Sciences for Health
NGO
nongovernmental organizaion
NRL
naional reference laboratory
NSP
naional strategic plan
NSP
new smear posiive
NTP
naional TB control programme
OTC
over-the-counter (sale of medicines)
PAL
pracical approach to lung health
PHC
primary health care
PLHIV
persons living with HIV/AIDS
Tuberculosis control in the South-East Asia Region
Annual Report 2016
vii
PMDT
programmaic management of drug-resistant tuberculosis
PMTCT
prevenion of mother to child transmission
PPM
public-private mix
PTB
pulmonary TB
PWID
people who inject drugs
PR
principal recipient (under Global Fund grants)
QA
quality assurance
RNTCP
Revised Naional TB Control Programme (of India)
RR-TB
rifampicin-resistant TB
SCC
short coerce chemotherapy
SDG
Sustainable Development Goals
SEA
South-East Asia
SEAR
South-East Asia Region (of WHO)
SLD
Second-line ani-TB drugs
SOPs
standard operaing procedures
SR
subrecipient (under Global Fund grants)
SSF
single stream funding (GF)
SSS
Social Security Scheme (Thailand)
TA
technical assistance
TB
Tuberculosis
The Union
Internaional Union against Tuberculosis and Lung Disease
TWG-TB
Technical Working Group on TB
USAID
United States Agency for Internaional Development
UCS
Universal Coverage Scheme (Thailand)
VR
vital registraion
WHA
World Health Assembly
WHO
World Health Organizaion
XDR-RB
extensively drug-resistant TB
Tuberculosis control in the South-East Asia Region
Annual Report 2016
viii
Tuberculosis control in the South-East Asia Region
Annual Report 2016
ix
Foreword
The start of 2016 heralds the beginning of a new era in
global health and development. The United Naions has
adopted the Sustainable Development Goals (SDGs),
providing a new development framework for 2016−2030,
replacing the 2000−2015 Millennium Development Goal
(MDG) framework. Under Goal 3 of the SDGs speciically
pertaining to health, target 3.3 states - By 2030, end the
epidemics of AIDS, tuberculosis, malaria and neglected
tropical diseases and combat hepaiis, waterborne
diseases and other communicable diseases. The year 2016 also marks the
beginning of implementaion of the WHO End TB strategy based on the principles
and targets enshrined in the World Health Assembly resoluion WHA67.1. The
three pillars of the End TB strategy include integrated, paient-centred care
and prevenion; bold policies and supporive systems; and intensiied research
and innovaion. Thus there is a reinvigorated emphasis on ending the global TB
epidemic, and 2016 will be the year to lay the foundaion for TB control globally as
well as in the South-East Asia (SEA) Region.
Thus, we need to acknowledge the massive challenge before us. Tuberculosis
remains a major global health problem. Worldwide, 9.6 million people are
esimated to have fallen ill with TB in 2014 of which 1.5 million people died
comprising of 890 000 men, 480 000 women and 140 000 children. The WHO SEA
Region accounts for 41% of the global burden in terms of TB incidence. In 2014,
there were an esimated 5.4 million prevalence and 4 million incidence of TB and
about 460 000 people died due to TB in SEAR. An esimated 340 000 children
in the Region developed TB in 2014. TB noiicaions in the Region were about
2.6 million in 2014 whereas in 2013, they were 2.3 million. This was mostly due
to a 29% increase in noiicaions in India, which followed the introducion of a
policy of mandatory noiicaion in May 2012, creaion of a naional web-based
reporing system in June 2012 and intensiied eforts to engage the private health
sector. TB treatment success rate in the Region coninues to be more than 88%
since 2009. The Region also faces the challenge of treaing an esimated 99 000
mulidrug-resistant (MDR) cases among the noiied pulmonary cases and about
210 000 cases coinfected with HIV.
Tuberculosis control in the South-East Asia Region
Annual Report 2016
x
The Regional Strategic Plan towards Ending TB in the SEAR 2016–2020 describes
the future direcions and focus of the work towards TB eliminaion aiming to
support Member States in the reducion in tuberculosis mortality and incidence in
line with the global targets as set in World Health Assembly resoluion WHA67.1,
guiding the countries in addressing the persising and emerging epidemiological
and demographic challenges and advancing universal health coverage and
robust health systems. The plan builds on and expands the exising updated
Regional Strategic Plan for TB Care and Control 2012–2015 and focuses on the
implementaion of the End TB Strategy in the coming 5 years within the overall
scope of the 20-year strategy covering the period 2015 to 2035.
Ending the TB epidemic is not mere biomedical but a developmental
challenge. The global, regional, naional and local level response to ending the
TB epidemic must therefore be a part of an inclusive response designed to meet
the overall development goals. The progress towards ending the TB epidemic will
depend as much on achieving overall health improvement as it will on opimizing
current strategies, developing new tools and technologies to diagnose, treat and
prevent TB, and reaching them to all who need them.
I urge all Member States to work at all levels along with partners for renewed
commitment towards ending the TB epidemic. Addiional resources would need
to be mobilized. Ending the TB epidemic will require an expansion of the scope
and reach of intervenions for TB prevenion, care and control: the insituion of
systems and policies to promote an enabling environment, shared responsibiliies
with universal coverage; and an aggressive pursuit of research and innovaion to
promote development and use of new tools for TB care and prevenion.
Dr Poonam Khetrapal Singh
Regional Director
Tuberculosis control in the South-East Asia Region
Annual Report 2016
1
1
Global and Regional burden
of Tuberculosis
Source: World Health Organizaion. Global tuberculosis report 2015. Geneva: WHO, 2015
Tuberculosis control in the South-East Asia Region
Annual Report 2016
2
Tuberculosis (TB) is contagious and airborne. It ranks alongside HIV/AIDS as a
leading cause of death worldwide.
TB burden
Globally, 9.6 million people fell ill with TB in 2014, including 1.2 million people
living with HIV. In the same year 1.5 million people died from TB, including 0.4
million among people who were HIV-posiive. TB is one of the top ive killers of
women among adult women aged 20–59 years. 480 000 women died from TB in
2014, including 140 000 deaths among women who were HIV-posiive. 890 000
men died from TB and 5.4 million fell ill with the disease. An esimated 1 million
children became ill with TB and 140 000 children died of TB in 2014.
The SEA Region of WHO is home to 26% of the world’s populaion; however
the Region accounts for 41% of the global burden in terms of TB incidence. In
2014, there were an esimated 5.4 million prevalence and 4 million incidence
of TB, and about 460 000 people died due to TB in SEAR. India and Indonesia
have among the largest numbers of cases (23% and 10% of the global total
respecively). An esimated 340 000 children in the Region developed TB in 2014.
Table 1.1: Esimates of TB burden in SEAR countries in terms of incidence,
prevalence and mortality, 2014
Death rate for all
forms of TB, excluding
HIV (uncertainty
intervals)
Incidence rate of all
forms of TB
(uncertainty intervals)
Prevalence rate
of all forms of TB
(uncertainty intervals)
Bangladesh
227 (200–256)
404 (211 – 659)
51 (37–68)
Bhutan
164 (148–181)
190 (75–359)
9.5 (5.1–15)
Democraic
People’s Republic
of Korea
442 (412–473)
552 (150 1 210)
20 (7.9–37)
India
167 (156–179)
195 (131–271)
17 (12–27)
Indonesia
399 (274–546)
647 (513–797)
41 (26–59)
Maldives
41 (36–47)
56 (25–98)
2.3 (1.9–2.8)
Myanmar
369 (334–406)
457 (352–575)
53 (38–70)
Nepal
Country
158 (139–178)
215 (102–369)
17 (12–24)
Sri Lanka
66 (57–73)
99 (51–164)
6.1 (4.8–7.6)
Thailand
171 (90–276)
236 (161–326)
11 (5.7–18)
Timor-Leste
498 (411–594)
802 (426–1 340)
94 (66–126)
SEAR
211 (192–232)
286 (233–343)
24 (19–30)
Source: World Health Organizaion. Global tuberculosis report 2015. Geneva: WHO, 2015.
Tuberculosis control in the South-East Asia Region
Annual Report 2016
3
The trends of TB burden in SEA Region in terms of esimated disease
incidence, prevalence and mortality are shown in Graph 1.1, Graph 1.2 and Graph
1.3 respecively
Graph 1.1: Esimated TB incidence rates (green) and esimated incidence rates of HIV-posiive
TB (red) in SEAR. Shaded areas represent uncertainty bands
200
100
0
1990
1995
2000
2005
2010
2015
Source: World Health Organizaion. Global tuberculosis report 2015. Geneva: WHO, 2015.
Graph 1.2: Esimated TB prevalence in SEAR (1990–2015). Shaded areas represent uncertainty
bands. The horizontal dashed lines represent the Stop TB Partnership target of a 50% reducion
in the prevalence rate by 2015 compared with 1990
600
400
200
0
1990
1995
2000
2005
2010
2015
Source: World Health Organizaion. Global tuberculosis report 2015. Geneva: WHO, 2015.
Tuberculosis control in the South-East Asia Region
Annual Report 2016
4
Graph 1.3: Esimated TB mortality rates in SEAR (1990–2015). Esimated TB mortality excludes
TB deaths among HIV-posiive people. Shaded areas represent uncertainty bands. The
horizontal dashed lines represent the Stop TB Partnership target of a 50% reducion in the
mortality rate by 2015 compared with 1990
60
40
20
0
1990
1995
2000
2005
2010
2015
Source: World Health Organizaion. Global tuberculosis report 2015. Geneva: WHO, 2015.
Drug-resistant TB
An esimated 480 000 people developed mulidrug-resistant TB (MDR-TB) and an
esimated 190 000 deaths from MDR-TB occurred globally in 2014. If all TB cases
noiied in 2014 had been tested for drug resistance, an esimated 300 000 would
have been found to have MDR-TB.
The SEA region has relaively low levels (2.2, range: 1.9–2.6%) of mulidrugresistant (MDR) among newly detected cases. The esimated levels of MDR-TB
among retreatment cases is 16% (range 14–18%). However, given the large
number of TB cases in the SEA Region, this translates to a total of 99 000
esimated MDR-TB cases among noiied pulmonary TB cases accouning for
approximately 30% of the world’s MDR-TB cases among noiied pulmonary TB
cases in 2014. Six of the 30 high MDR-TB-burden countries are in the SEA Region:
Bangladesh, Democraic People’s Republic of Korea, India, Indonesia, Myanmar
and Thailand.
Tuberculosis control in the South-East Asia Region
Annual Report 2016
5
Table 1.2: Esimates of proporion of MDR-TB among new and retreatment cases
in SEAR countries, 2014
Country
New cases
%
Retreatment cases
Number
%
Number
Bangladesh
1.4 (0.7–2.5)
2 100 (1 000–3 700)
29 (24–34)
2 700 (2 200–3 200)
Bhutan
2.2 (1.9–2.6)
12 (10–14)
35 (21–52)
25 (15–37)
Democraic
People’s
Republic of
Korea
1.9 (0.8–3.9)
1 400 (610–3 000) 15 (8.8–24)
2 400 (1 400–3 800)
India
2.2 (1.9–2.6)
Indonesia
1.9 (1.4–2.5)
5 600 (4 200–7 400) 12 (8.1–17)
Maldives
2.2 (1.9–2.6)
2 (2–2)
16 (14–18)
0 (0–0)
Myanmar
5 (3.1–6.8)
5 600 (3 500–7 700)
27 (15–39)
3 400 (1 900–4 900)
Nepal
2.2 (1.3–3.8)
540 (320–930)
15 (10–23)
620 (410–920)
Sri Lanka
0.18 (0–0.99)
11 (0–62)
0.58 (0.07–
2.1)
3 (0–10)
Thailand
2 (1.4–2.8)
1 100 (780–1 600)
19 (14–25)
1 100 (800–1 500)
2.2 (1.9–2.6)
67 (58–80)
16 (14–18)
32 (28–35)
Timor-Leste
Total
24 000 (21 000–29 000)
2.2 (1.9–2.6) 40 432 (33 800– 53 488)
15 (11–19) 47 000 (35 000–59 000)
1 100 (770–1 600)
16 (14–18) 58 380 (42 523–75 002)
Source: World Health Organizaion. Global tuberculosis report 2015. Geneva: WHO, 2015.
Co-epidemics of TB and HIV
In 2014, an esimated 1.2 million (12%) of the 9.6 million people who developed
TB worldwide were HIV posiive. In SEAR, an esimated 210 000 cases (5.2%) of
the 4 million incident cases were HIV posiive. This corresponds to 11 per 100 000
and 5% of all esimated TB incident cases.
Globally, the number of people dying from HIV-associated TB peaked at
570 000 in 2004 and had fallen to 390 000 in 2014 (32% decrease). In SEAR, an
esimated 62 000 cases died of HIV-associated TB in 2014.
Tuberculosis control in the South-East Asia Region
Annual Report 2016
6
Table 1.3: Esimated HIV prevalence among adult populaions and the number of people living
with HIV infecion in SEAR countries, 2013
Country
Esimated number
of people newly
infected with HIV
Esimated adult
(15–49 years) HIV
prevalence (%)
Esimated number of
people living with HIV
Bangladesh
1 300
(2016–2020) has now been developed for TB control in the South-East Asia Region
with the vision to have a Region free of TB with zero death, disease and suffering due
to TB. All Member States can adopt this vision in their national strategies and plans.
The goal for TB control is to End the TB epidemic in the Region by 2035, by adopting and
adapting the vision, milestones and targets as outlined in the WHA67.1 resolution.
The WHO Regional Office, in coordination with all country offices and international
and national partners, continues to support all Member States in their efforts to
achieve universal health coverage and to end the TB epidemic.
World Health House
Indraprastha Estate,
Mahatma Gandhi Marg,
New Delhi-110002, India
www.searo.who.int/topics/tuberculosis
9 789290 225041
Annual Report 2016
ISBN 978-92-9022-504-1
Tuberculosis Control in the South-East Asia Region
The South-East Asia Region of WHO is home to 26% of the world's population;
however, the Region accounts for 41% of the global burden of tuberculosis (TB) in
terms of disease incidence. In 2014, there were an estimated 5.4 million prevalence
and 4 million incidence of TB, and about 460 000 people died due to TB in the Region.
India and Indonesia have among the largest numbers of cases (23% and 10% of the
global total, respectively). An estimated 340 000 children in the South-East Asia
Region developed TB in 2014. The Region has a total of 99 000 estimated MDR-TB
cases among notified pulmonary TB cases, accounting for approximately 30% of the
world's MDR-TB cases in 2014. Six of the 30 high MDR-TB-burden countries are in the
South-East Asia Region: Bangladesh, Democratic People's Republic of Korea, India,
Indonesia, Myanmar and Thailand. An estimated 210 000 cases (5.2%) of the 4 million
TB-incident cases are HIV-positive. This corresponds to 11 per 100 000 and 5% of all
estimated TB-incident cases. An estimated 62 000 cases died of HIV-associated TB in
2014.
Tuberculosis
control
in the South-East Asia Region
Annual report 2016
Tuberculosis control
in the South-East Asia Region
Annual report 2016
WHO Library Cataloguing-in-Publicaion data
World Health Organizaion, Regional Oice for South-East Asia.
Tuberculosis control in the South-East Asia Region: annual report 2016.
1. Tuberculosis – prevenion and control – staisics and numerical data
2. Tuberculosis, Mulidrug-Resistant 3. HIV 4. Health Resources
5. Data Collecion.
ISBN 978-92-9022-504-1
(NLM classiicaion: WF 200)
© World Health Organizaion 2016
All rights reserved.
Requests for publicaions, or for permission to reproduce or translate WHO publicaions – whether for sale or for noncommercial distribuion – can be obtained from Publishing and Sales, World
Health Organizaion, Regional Oice for South- East Asia, Indraprastha Estate, Mahatma Gandhi
Marg, New Delhi 110 002, India (fax: +91 11 23370197; e-mail: publicaions@who.int).
The designaions employed and the presentaion of the material in this publicaion do not imply
the expression of any opinion whatsoever on the part of the World Health Organizaion concerning the legal status of any country, territory, city or area or of its authoriies, or concerning the
delimitaion of its froniers or boundaries. Doted lines on maps represent approximate border
lines for which there may not yet be full agreement.
The menion of speciic companies or of certain manufacturers’ products does not imply that
they are endorsed or recommended by the World Health Organizaion in preference to others of
a similar nature that are not menioned. Errors and omissions excepted, the names of proprietary
products are disinguished by iniial capital leters.
All reasonable precauions have been taken by the World Health Organizaion to verify the informaion contained in this publicaion. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretaion
and use of the material lies with the reader. In no event shall the World Health Organizaion be
liable for damages arising from its use.
Maps disclaimer
The boundaries and names shown and the designaions used on the maps contained in this document do not imply the expression of any opinion whatsoever on the part of the World Health
Organizaion concerning the legal status of any country, territory, city or area or of its authoriies,
or concerning the delimitaion of its froniers or boundaries. Doted and dashed lines on maps
represent approximate border lines for which there may not yet be full agreement.
Printed in India
iii
Contents
Abbreviaions .......................................................................................................... v
Foreword .................................................................................................................ix
1.
Global and Regional burden of Tuberculosis .................................................. 1
TB burden ........................................................................................................................... 2
Drug-resistant TB ................................................................................................................ 4
Co-epidemics of TB and HIV ............................................................................................... 5
TB inancing ......................................................................................................................... 6
2.
Global and Regional progress in Tuberculosis care and management............ 8
TB care and control ............................................................................................................ 9
Drug-resistant TB .............................................................................................................. 10
Co-epidemic of TB and HIV................................................................................................ 11
New diagnosics rollout .................................................................................................... 13
New drugs rollout.............................................................................................................. 13
Research and development .............................................................................................. 13
3.
Regional challenges ...................................................................................... 15
Over reliance on donor funding ........................................................................................ 16
4.
The End-TB Strategy ..................................................................................... 20
5.
Regional Strategic Plan – Overview .............................................................. 25
Vision and goal ................................................................................................................. 26
Objecives.......................................................................................................................... 26
Regional targets and milestones ....................................................................................... 26
Strategic direcions and intervenions .............................................................................. 28
6.
WHO support in the Region .......................................................................... 32
Transiioning to the End TB Strategy ................................................................................. 33
Diagnosic capacity-building ............................................................................................. 34
Expansion of DR-TB services ............................................................................................. 35
Strengthening TB/HIV collaboraion ................................................................................. 37
Capacity-building and informaion exchange .................................................................... 37
Drug supply and management .......................................................................................... 38
Tuberculosis control in the South-East Asia Region
Annual Report 2016
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Rouine surveillance .......................................................................................................... 38
Operaional research ......................................................................................................... 39
Resource mobilizaion ....................................................................................................... 40
7.
Major SEA Regional partnerships ................................................................. 41
Axshya project supported by The Global Fund ................................................................. 42
EXPAND-TB project ........................................................................................................... 43
Global TB Drug Facility (GDF) ............................................................................................ 45
Paediatric TB project ......................................................................................................... 47
TB REACH project .............................................................................................................. 47
UNITAID support in SEAR countries .................................................................................. 49
United States Agency for Internaional Development (USAID) in SEAR countries ............ 51
8.
Country proiles ............................................................................................ 57
Bangladesh ........................................................................................................................ 59
Bhutan ............................................................................................................................... 77
Democraic People’s Republic of Korea ............................................................................. 90
India ............................................................................................................................. 103
Indonesia ......................................................................................................................... 118
Maldives .......................................................................................................................... 134
Myanmar ......................................................................................................................... 146
Nepal ............................................................................................................................. 157
Sri Lanka .......................................................................................................................... 170
Thailand........................................................................................................................... 182
Timor-Leste ..................................................................................................................... 194
Tuberculosis control in the South-East Asia Region
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Abbreviaions
ACSM
advocacy, communicaion and social mobilizaion
AFB
acid-fast bacilli
AIDS
acquired immunodeiciency syndrome
ART
aniretroviral therapy
ARV
aniretrovirals
CBO
community-based organizaions
CCM
country coordinaion mechanism
CDC
Centers for Disease Control, Atlanta, USA
CHW
community health worker
CSMBS
Civil Servant Medical Beneit Scheme (Thailand)
CN
concept note(s)
CPT
co-trimoxazole prevenive therapy
CV
community volunteer
DOT
directly observed therapy
DOTS
the internaionally recommended strategy for TB control and the
foundaion of the Stop TB Strategy introduced in 2006
DRS
drug resistance surveillance
DR-TB
drug-resistant tuberculosis
DST
drug suscepibility tesing
EQA
external quality assurance
FDC
ixed-dose combinaion
FHI
Family Health Internaional
FLD
First-line ani-TB drugs
GDF
Global (TB) Drug Facility
GDI
Global Drug-resistant TB Iniiaive
GF
Global Fund Global Fund to Fight AIDS, Tuberculosis and Malaria
GLC
Green Light Commitee
Tuberculosis control in the South-East Asia Region
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rGLC
regional Green Light Commitee
GLI
Global Laboratory Iniiaive
HBC
high-burden (TB) country
HRD
human resource development
HRH
human resources for health
HSS
health system strengthening
IC
infecion control
IPT
isoniazid prevenive therapy
IQC
internal quality control
ISTC
Internaional Standards for TB Care
IC
infecion control
JICA
Japan Internaional Cooperaion Agency
KNCH
Royal Dutch Foundaion
LED
light-emiing diode microscopes
LTBI
latent TB infecion
MCH
maternal and child health
MDG
Millennium Development Goals
MDR-TB
TB mulidrug-resistant tuberculosis
M&E
monitoring and evaluaion NFM New Funding Model
MSH
Management Sciences for Health
NGO
nongovernmental organizaion
NRL
naional reference laboratory
NSP
naional strategic plan
NSP
new smear posiive
NTP
naional TB control programme
OTC
over-the-counter (sale of medicines)
PAL
pracical approach to lung health
PHC
primary health care
PLHIV
persons living with HIV/AIDS
Tuberculosis control in the South-East Asia Region
Annual Report 2016
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PMDT
programmaic management of drug-resistant tuberculosis
PMTCT
prevenion of mother to child transmission
PPM
public-private mix
PTB
pulmonary TB
PWID
people who inject drugs
PR
principal recipient (under Global Fund grants)
QA
quality assurance
RNTCP
Revised Naional TB Control Programme (of India)
RR-TB
rifampicin-resistant TB
SCC
short coerce chemotherapy
SDG
Sustainable Development Goals
SEA
South-East Asia
SEAR
South-East Asia Region (of WHO)
SLD
Second-line ani-TB drugs
SOPs
standard operaing procedures
SR
subrecipient (under Global Fund grants)
SSF
single stream funding (GF)
SSS
Social Security Scheme (Thailand)
TA
technical assistance
TB
Tuberculosis
The Union
Internaional Union against Tuberculosis and Lung Disease
TWG-TB
Technical Working Group on TB
USAID
United States Agency for Internaional Development
UCS
Universal Coverage Scheme (Thailand)
VR
vital registraion
WHA
World Health Assembly
WHO
World Health Organizaion
XDR-RB
extensively drug-resistant TB
Tuberculosis control in the South-East Asia Region
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Tuberculosis control in the South-East Asia Region
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ix
Foreword
The start of 2016 heralds the beginning of a new era in
global health and development. The United Naions has
adopted the Sustainable Development Goals (SDGs),
providing a new development framework for 2016−2030,
replacing the 2000−2015 Millennium Development Goal
(MDG) framework. Under Goal 3 of the SDGs speciically
pertaining to health, target 3.3 states - By 2030, end the
epidemics of AIDS, tuberculosis, malaria and neglected
tropical diseases and combat hepaiis, waterborne
diseases and other communicable diseases. The year 2016 also marks the
beginning of implementaion of the WHO End TB strategy based on the principles
and targets enshrined in the World Health Assembly resoluion WHA67.1. The
three pillars of the End TB strategy include integrated, paient-centred care
and prevenion; bold policies and supporive systems; and intensiied research
and innovaion. Thus there is a reinvigorated emphasis on ending the global TB
epidemic, and 2016 will be the year to lay the foundaion for TB control globally as
well as in the South-East Asia (SEA) Region.
Thus, we need to acknowledge the massive challenge before us. Tuberculosis
remains a major global health problem. Worldwide, 9.6 million people are
esimated to have fallen ill with TB in 2014 of which 1.5 million people died
comprising of 890 000 men, 480 000 women and 140 000 children. The WHO SEA
Region accounts for 41% of the global burden in terms of TB incidence. In 2014,
there were an esimated 5.4 million prevalence and 4 million incidence of TB and
about 460 000 people died due to TB in SEAR. An esimated 340 000 children
in the Region developed TB in 2014. TB noiicaions in the Region were about
2.6 million in 2014 whereas in 2013, they were 2.3 million. This was mostly due
to a 29% increase in noiicaions in India, which followed the introducion of a
policy of mandatory noiicaion in May 2012, creaion of a naional web-based
reporing system in June 2012 and intensiied eforts to engage the private health
sector. TB treatment success rate in the Region coninues to be more than 88%
since 2009. The Region also faces the challenge of treaing an esimated 99 000
mulidrug-resistant (MDR) cases among the noiied pulmonary cases and about
210 000 cases coinfected with HIV.
Tuberculosis control in the South-East Asia Region
Annual Report 2016
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The Regional Strategic Plan towards Ending TB in the SEAR 2016–2020 describes
the future direcions and focus of the work towards TB eliminaion aiming to
support Member States in the reducion in tuberculosis mortality and incidence in
line with the global targets as set in World Health Assembly resoluion WHA67.1,
guiding the countries in addressing the persising and emerging epidemiological
and demographic challenges and advancing universal health coverage and
robust health systems. The plan builds on and expands the exising updated
Regional Strategic Plan for TB Care and Control 2012–2015 and focuses on the
implementaion of the End TB Strategy in the coming 5 years within the overall
scope of the 20-year strategy covering the period 2015 to 2035.
Ending the TB epidemic is not mere biomedical but a developmental
challenge. The global, regional, naional and local level response to ending the
TB epidemic must therefore be a part of an inclusive response designed to meet
the overall development goals. The progress towards ending the TB epidemic will
depend as much on achieving overall health improvement as it will on opimizing
current strategies, developing new tools and technologies to diagnose, treat and
prevent TB, and reaching them to all who need them.
I urge all Member States to work at all levels along with partners for renewed
commitment towards ending the TB epidemic. Addiional resources would need
to be mobilized. Ending the TB epidemic will require an expansion of the scope
and reach of intervenions for TB prevenion, care and control: the insituion of
systems and policies to promote an enabling environment, shared responsibiliies
with universal coverage; and an aggressive pursuit of research and innovaion to
promote development and use of new tools for TB care and prevenion.
Dr Poonam Khetrapal Singh
Regional Director
Tuberculosis control in the South-East Asia Region
Annual Report 2016
1
1
Global and Regional burden
of Tuberculosis
Source: World Health Organizaion. Global tuberculosis report 2015. Geneva: WHO, 2015
Tuberculosis control in the South-East Asia Region
Annual Report 2016
2
Tuberculosis (TB) is contagious and airborne. It ranks alongside HIV/AIDS as a
leading cause of death worldwide.
TB burden
Globally, 9.6 million people fell ill with TB in 2014, including 1.2 million people
living with HIV. In the same year 1.5 million people died from TB, including 0.4
million among people who were HIV-posiive. TB is one of the top ive killers of
women among adult women aged 20–59 years. 480 000 women died from TB in
2014, including 140 000 deaths among women who were HIV-posiive. 890 000
men died from TB and 5.4 million fell ill with the disease. An esimated 1 million
children became ill with TB and 140 000 children died of TB in 2014.
The SEA Region of WHO is home to 26% of the world’s populaion; however
the Region accounts for 41% of the global burden in terms of TB incidence. In
2014, there were an esimated 5.4 million prevalence and 4 million incidence
of TB, and about 460 000 people died due to TB in SEAR. India and Indonesia
have among the largest numbers of cases (23% and 10% of the global total
respecively). An esimated 340 000 children in the Region developed TB in 2014.
Table 1.1: Esimates of TB burden in SEAR countries in terms of incidence,
prevalence and mortality, 2014
Death rate for all
forms of TB, excluding
HIV (uncertainty
intervals)
Incidence rate of all
forms of TB
(uncertainty intervals)
Prevalence rate
of all forms of TB
(uncertainty intervals)
Bangladesh
227 (200–256)
404 (211 – 659)
51 (37–68)
Bhutan
164 (148–181)
190 (75–359)
9.5 (5.1–15)
Democraic
People’s Republic
of Korea
442 (412–473)
552 (150 1 210)
20 (7.9–37)
India
167 (156–179)
195 (131–271)
17 (12–27)
Indonesia
399 (274–546)
647 (513–797)
41 (26–59)
Maldives
41 (36–47)
56 (25–98)
2.3 (1.9–2.8)
Myanmar
369 (334–406)
457 (352–575)
53 (38–70)
Nepal
Country
158 (139–178)
215 (102–369)
17 (12–24)
Sri Lanka
66 (57–73)
99 (51–164)
6.1 (4.8–7.6)
Thailand
171 (90–276)
236 (161–326)
11 (5.7–18)
Timor-Leste
498 (411–594)
802 (426–1 340)
94 (66–126)
SEAR
211 (192–232)
286 (233–343)
24 (19–30)
Source: World Health Organizaion. Global tuberculosis report 2015. Geneva: WHO, 2015.
Tuberculosis control in the South-East Asia Region
Annual Report 2016
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The trends of TB burden in SEA Region in terms of esimated disease
incidence, prevalence and mortality are shown in Graph 1.1, Graph 1.2 and Graph
1.3 respecively
Graph 1.1: Esimated TB incidence rates (green) and esimated incidence rates of HIV-posiive
TB (red) in SEAR. Shaded areas represent uncertainty bands
200
100
0
1990
1995
2000
2005
2010
2015
Source: World Health Organizaion. Global tuberculosis report 2015. Geneva: WHO, 2015.
Graph 1.2: Esimated TB prevalence in SEAR (1990–2015). Shaded areas represent uncertainty
bands. The horizontal dashed lines represent the Stop TB Partnership target of a 50% reducion
in the prevalence rate by 2015 compared with 1990
600
400
200
0
1990
1995
2000
2005
2010
2015
Source: World Health Organizaion. Global tuberculosis report 2015. Geneva: WHO, 2015.
Tuberculosis control in the South-East Asia Region
Annual Report 2016
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Graph 1.3: Esimated TB mortality rates in SEAR (1990–2015). Esimated TB mortality excludes
TB deaths among HIV-posiive people. Shaded areas represent uncertainty bands. The
horizontal dashed lines represent the Stop TB Partnership target of a 50% reducion in the
mortality rate by 2015 compared with 1990
60
40
20
0
1990
1995
2000
2005
2010
2015
Source: World Health Organizaion. Global tuberculosis report 2015. Geneva: WHO, 2015.
Drug-resistant TB
An esimated 480 000 people developed mulidrug-resistant TB (MDR-TB) and an
esimated 190 000 deaths from MDR-TB occurred globally in 2014. If all TB cases
noiied in 2014 had been tested for drug resistance, an esimated 300 000 would
have been found to have MDR-TB.
The SEA region has relaively low levels (2.2, range: 1.9–2.6%) of mulidrugresistant (MDR) among newly detected cases. The esimated levels of MDR-TB
among retreatment cases is 16% (range 14–18%). However, given the large
number of TB cases in the SEA Region, this translates to a total of 99 000
esimated MDR-TB cases among noiied pulmonary TB cases accouning for
approximately 30% of the world’s MDR-TB cases among noiied pulmonary TB
cases in 2014. Six of the 30 high MDR-TB-burden countries are in the SEA Region:
Bangladesh, Democraic People’s Republic of Korea, India, Indonesia, Myanmar
and Thailand.
Tuberculosis control in the South-East Asia Region
Annual Report 2016
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Table 1.2: Esimates of proporion of MDR-TB among new and retreatment cases
in SEAR countries, 2014
Country
New cases
%
Retreatment cases
Number
%
Number
Bangladesh
1.4 (0.7–2.5)
2 100 (1 000–3 700)
29 (24–34)
2 700 (2 200–3 200)
Bhutan
2.2 (1.9–2.6)
12 (10–14)
35 (21–52)
25 (15–37)
Democraic
People’s
Republic of
Korea
1.9 (0.8–3.9)
1 400 (610–3 000) 15 (8.8–24)
2 400 (1 400–3 800)
India
2.2 (1.9–2.6)
Indonesia
1.9 (1.4–2.5)
5 600 (4 200–7 400) 12 (8.1–17)
Maldives
2.2 (1.9–2.6)
2 (2–2)
16 (14–18)
0 (0–0)
Myanmar
5 (3.1–6.8)
5 600 (3 500–7 700)
27 (15–39)
3 400 (1 900–4 900)
Nepal
2.2 (1.3–3.8)
540 (320–930)
15 (10–23)
620 (410–920)
Sri Lanka
0.18 (0–0.99)
11 (0–62)
0.58 (0.07–
2.1)
3 (0–10)
Thailand
2 (1.4–2.8)
1 100 (780–1 600)
19 (14–25)
1 100 (800–1 500)
2.2 (1.9–2.6)
67 (58–80)
16 (14–18)
32 (28–35)
Timor-Leste
Total
24 000 (21 000–29 000)
2.2 (1.9–2.6) 40 432 (33 800– 53 488)
15 (11–19) 47 000 (35 000–59 000)
1 100 (770–1 600)
16 (14–18) 58 380 (42 523–75 002)
Source: World Health Organizaion. Global tuberculosis report 2015. Geneva: WHO, 2015.
Co-epidemics of TB and HIV
In 2014, an esimated 1.2 million (12%) of the 9.6 million people who developed
TB worldwide were HIV posiive. In SEAR, an esimated 210 000 cases (5.2%) of
the 4 million incident cases were HIV posiive. This corresponds to 11 per 100 000
and 5% of all esimated TB incident cases.
Globally, the number of people dying from HIV-associated TB peaked at
570 000 in 2004 and had fallen to 390 000 in 2014 (32% decrease). In SEAR, an
esimated 62 000 cases died of HIV-associated TB in 2014.
Tuberculosis control in the South-East Asia Region
Annual Report 2016
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Table 1.3: Esimated HIV prevalence among adult populaions and the number of people living
with HIV infecion in SEAR countries, 2013
Country
Esimated number
of people newly
infected with HIV
Esimated adult
(15–49 years) HIV
prevalence (%)
Esimated number of
people living with HIV
Bangladesh
1 300