Guia Tuberculose WHO 2

z
Summary
T
he World Health Organization (WHO) has published
an annual report on global control of tuberculosis
(TB) every year since 1997. Te main purpose of the
report is to provide a comprehensive and up-to-date
assessment of the TB epidemic and progress made in TB
care and control at global, regional and country levels.
Progress towards global targets set for 2015 is given par-
ticular attention. Te target included in the Millennium
Development Goals (MDGs) is that TB incidence should
be falling by 2015. Te Stop TB Partnership has set two
additional targets, which are to halve rates of prevalence
and mortality by 2015 compared with their levels in
1990. Collectively, the WHOs Stop TB Strategy and the
Stop TB Partnerships Global Plan to Stop TB have set
out how the 2015 targets can be achieved.
Tis ffteenth annual report
1
contains more up-to-
date information than any previous report in the series,
following earlier data collection and the completion of
the production cycle within a calendar year.
Te estimates of the global burden of disease caused
by TB in 2009 are as follows: 9.4 million incident cases
(range, 8.9 million9.9 million), 14 million prevalent
cases (range, 12 million16 million), 1.3 million deaths
among HIV-negative people (range, 1.2 million1.5 mil-
lion) and 0.38 million deaths among HIV-positive people
(range, 0.32 million0.45 million). Most cases were in
the South-East Asia, African and Western Pacifc regions
(35%, 30% and 20%, respectively). An estimated 1113%
of incident cases were HIV-positive; the African Region
accounted for approximately 80% of these cases.
Tere were 5.8 million notifed cases of TB in 2009,
equivalent to a case detection rate (CDR, defned as the
proportion of incident cases that were notifed) of 63%
(range, 6067%), up from 61% in 2008. Of the 2.6 mil-
lion patients with sputum smear-positive pulmonary TB
in the 2008 cohort, 86% were successfully treated.
New and compelling data from 15 countries show that
eforts by national TB programmes (NTPs) to engage all
care providers in TB control (termed public-private mix,
or PPM) can be a particularly efective way to increase
the CDR. In areas where PPM was implemented, non-
NTP providers accounted for around one-ffth to one-
third of total notifcations in 2009.
In 2009, 26% of TB patients knew their HIV status
(up from 22% in 2008), including 53% of patients in
the African Region. A total of 300 000 HIV-positive TB
patients were enrolled on co-trimoxazole preventive
therapy, and almost 140 000 were enrolled on antiret-
roviral therapy (75% and 37% respectively of those who
tested HIV-positive). To prevent TB, almost 80 000 peo-
ple living with HIV were provided with isoniazid preven-
tive therapy. Tis is an increase from previous years, but
still represents less than 1% of the estimated number of
people living with HIV worldwide.
Among TB patients notifed in 2009, an estimated
250 000 (range, 230 000270 000) had multidrug-
resistant TB (MDR-TB). Of these, slightly more than
30 000 (12%) were diagnosed with MDR-TB and notifed.
Diagnosis and treatment of MDR-TB need to be rapidly
expanded.
Funding for TB control continues to increase and will
reach almost US$ 5 billion in 2011. Tere is considerable
variation in what countries spend on a per patient basis
(<US$ 100 to >US$ 1000), and the extent to which coun-
tries rely on domestic or external sources of funds. Com-
pared with the funding requirements estimated in the
Global Plan, the funding gap is approximately US$ 1 bil-
lion in 2011. Given the scale-up of interventions set out
in the plan, this could increase to US$ 3 billion by 2015
without intensifed eforts to mobilize more resources.
Incidence rates are falling globally and in fve of
WHOs six regions (the exception is the South-East Asia
Region, where the incidence rate is stable). If these trends
are sustained, the MDG target will be achieved. Mortal-
ity rates at global level fell by around 35% between 1990
and 2009, and the target of a 50% reduction by 2015
could be achieved if the current rate of decline is sus-
tained. At the regional level, the mortality target could
be achieved in fve of WHOs six regions; the exception
is the African Region (although rates of mortality are
falling). Prevalence is falling globally and in all six WHO
regions. Te target of halving the 1990 prevalence rate
by 2015 appears out of reach at global level, but could be
achieved in three of six regions: the Region of the Ameri-
cas, the Eastern Mediterranean Region and the Western
Pacifc Region.
Reductions in the burden of disease achieved to date
follow 15 years of intensive eforts to improve TB care
and control. Between 1995 and 2009, a total of 41 mil-
lion TB patients were successfully treated in DOTS pro-
grammes, and up to 6 million lives were saved including
2 million among women and children. Looking forwards,
the Stop TB Partnership launched an updated version of
the Global Plan to Stop TB in October 2010, for the years
20112015. In the fve years that remain until the tar-
get year of 2015, intensifed eforts are needed to plan,
fnance and implement the Stop TB Strategy, according
to the updated targets included in this plan. Tis could
save at least one million lives per year.
1
Two reports were published in 2009. Te lhTk0uuCTl0h and
MFTF0uS sections of this report explain why this was necessary.
z
lntrcductlcn
T
he World Health Organization (WHO) has published
an annual report on global control of tuberculosis
(TB) every year since 1997. Te main purpose of the
report is to provide a comprehensive and up-to-date
assessment of the TB epidemic and progress made in TB
care and control at global, regional and country levels.
Tis ffteenth annual report
1
contains more up-to-date
information than any previous report in the series, fol-
lowing earlier data collection and the completion of the
production cycle within a calendar year.
Te main part of the report is structured in eight
major sections, as follows:
N Methods. Tis section explains how the data used to
produce the report are collected, reviewed and ana-
lysed.
N Te global burden of disease caused by TB in
2009. Tis section presents estimates of incidence,
prevalence and mortality (absolute numbers and
rates) at global, regional and country levels in 2009.
N Global targets, the WHO Stop TB Strategy and
the Global Plan to Stop TB. Tis section defnes
the global targets for TB control that have been set
for 2015, as part of the Millennium Development
Goals (MDGs) and by the Stop TB Partnership. It then
describes the main components of the Stop TB Strat-
egy and the Stop TB Partnerships Global Plan to Stop
TB, which in combination have set out how the global
targets can be achieved.
N Progress in implementing the Stop TB Strat-
egy and the Global Plan to Stop TB. Tis section
includes analysis of case notifcations, treatment out-
comes, case detection rates (for all forms of TB), the
contribution of publicprivate mix (PPM) initiatives
to case notifcations, implementation of collabora-
tive TB/HIV activities and the management of drug-
resistant TB. It also features the topic of human
resource development and provides an update about
the work of the Global Laboratory Initiative, whose
goal is to strengthen laboratories worldwide.
N Financing for TB control. Recent trends in fund-
ing for TB control, including comparisons with the
funding requirements estimated in the Global Plan,
are presented and discussed. Recent successes in
strengthening planning and budgeting for TB control
using the WHO TB planning and budgeting tool are
showcased.
N Progress towards the 2015 targets. Tis section
analyses trends in rates of TB incidence, prevalence
and mortality from 1990 to 2009, and assesses wheth-
er the 2015 targets can be achieved at global, regional
and country levels.
N Improving measurement of the burden of disease
caused by TB. Tis section summarizes progress at
country level in strengthening surveillance (of cases
and deaths) and implementing surveys of the preva-
lence of TB disease, in the context of the policies and
recommendations of the WHO Global Task Force on
TB Impact Measurement.
N Conclusions. Tis fnal section draws together the
main fndings and recommendations in the report.
AhhFX 1 explains the methods that were used to produce
estimates of disease burden. AhhFX z contains summary
tables that provide global, regional and country-specifc
data for the main indicators of interest. C0uhTk
Pk0FlLFS for all countries are available online at www.
who.int/tb/data; their content is advertised in AhhFX .
0X 1
What's new in this repert?
Thls repcrt lncludes the same wealth cf lnfcrmatlcn as
prevlcus repcrts ln the serles, but fcur new features
are wcrth hlehllehtlne. Flrst, the data are mcre up-tc-
date than thcse lncluded ln prevlcus repcrts. uata up
tc and lncludlne zoo are presented fcr almcst all key
lndlcatcrs; nanclal data extend tc zo11. Seccnd, estl-
mates cf the case detectlcn rate are presented fcr all
fcrms cf T8 cnly (see 8cx 6). Thlrd, results frcm sev-
eral analyses undertaken fcr the rst tlme ln zo1o are
lncluded. Fxamples are: (l) fcr each cf the zz hleh-bur-
den ccuntrles (F8Cs), trends ln rates cf T8 lncldence
and mcrtallty slnce 1o ccmblned wlth prc|ectlcns cf
whether the tareet cf halvlne the 1o mcrtallty rate
by zo1 wlll be achleved; (ll) estlmates cf the llves
saved by T8 ccntrcl between 1 and zoo and prc-
|ectlcns cf the addltlcnal llves that cculd be saved up
tc zo1, lncludlne separate estlmates fcr wcmen and
chlldren; (lll) assessment cf prceress ln lmplementlne
and nanclne T8 care and ccntrcl aealnst the tareets
lncluded ln a |ust-released and updated verslcn cf the
Clcbal Plan tc Stcp T8; and (lv) a new and ccmpelllne
ccmpllatlcn cf data shcwlne the ccntrlbutlcn that PPM
can make tc case detectlcn. Fcurth, ccuntry prcles
are avallable fcr all ccuntrles (rather than the zz F8Cs
cnly) and can be dcwnlcaded cnllne at www.whc.lnt/
tb/data, always drawlne cn the latest data avallable ln
wF0's elcbal T8 database.
1
Two reports were published in 2009. Te frst report (March) includ-
ed key indicators up to and including 2007 (for example, estimates
of disease burden and case notifcations). Te second report (pub-
lished on the web in December) included key indicators up to and
including 2008. Two reports were produced in one year in anticipa-
tion of a diferent production cycle in which reports would always
contain data up to and including the previous calendar year.

1. Methcds
F
or the 2010 round of data collection, WHO updated
the forms that were used in 2009. Te main change
was that questions on surveillance of MDR-TB, which
had previously been asked through a separate data col-
lection efort, were integrated into the global TB data
collection form. As in 2009, two versions of the form
were developed (a long form and a short form). Te short
form was adapted for use in high-income countries (that
is, countries with a gross national income per capita of
US$ 12 196 in 2009, as defned by the World Bank) and/
or low-incidence countries (defned as countries with an
incidence rate of <20 cases per 100 000 population or
<10 cases in total). In consultation with WHO regional
ofces, a few countries that met the criteria for receiving
the short form were instead requested to complete the
long form. Tis included countries that had in previous
years provided the more detailed fnancial data request-
ed on the long form.
Both forms requested data on the following topics:
case notifcations and treatment outcomes, including
breakdowns by age, sex and HIV status; an overview of
services for the diagnosis and treatment of TB; laboratory
diagnostic services; drug management; monitoring and
evaluation; surveillance and surveys of drug-resistant
TB; management of drug-resistant TB; collaborative TB/
HIV activities; human resource development (HRD); TB
control in vulnerable populations and high-risk groups;
TB infection control; the Practical Approach to Lung
Health (PAL); PPM; advocacy, communication and social
mobilization (ACSM); the budgets of national TB control
programmes (NTPs) in 2010 and 2011; utilization of gen-
eral health services (hospitalization and outpatient visits)
during treatment; and NTP expenditures in 2009.
A web-based online system (www.stoptb.org/tme)
was used to report and validate data in all regions except
the European Region (80X z).
1
In 2010, data collection
was launched in mid-March, about four months earlier
than in any previous year, with a deadline of 16 May for
all regions except the Region of the Americas (31 May)
and the European Region (30 September). Following the
deadlines for reporting of data, all reports were carefully
reviewed using a system of built-in validation checks (also
available to country-based staf reporting data). Follow-
up queries were returned to respondents online. By 16
June (the deadline for responding to queries), 147 coun-
tries (excluding the European Region) had reported data
(for further details, see 80X z).
2
In the European Region,
21 out of 53 countries reported data by 16 June. Most of
the countries that had not reported data by 16 June were
high-income countries in western Europe. Taken togeth-
er, the 168 countries that reported data by the dead-
line of 16 June account for 99% of the worlds TB cases.
All data collected online in 2010 were added to a mas-
ter dataset that holds the TB-related data that have been
compiled by WHO since 1995. Data from the two online
systems used in the European Region
3
were also upload-
ed to the master dataset. All data in the global and Euro-
pean online systems as of the morning of 17 June 2010
were then used, together with historical data reported
in previous years, to produce the tables and fgures that
appear in the main part of the report. Country respond-
ents continue to have the option of updating or adding
data to the online system.
Te master dataset was updated for a second time on
31 August 2010, using all data in the global and Euro-
pean online systems at this time. Tis updated dataset
was used to create the detailed tables that are included
in AhhFX z, ensuring that data published for all coun-
tries were as up-to-date as possible at the time that the
report went to press.
Four additional points should be highlighted:
N NTPs sometimes provide WHO with updated infor-
mation for previous years, for incorporation in the
global TB database. As a result, the data presented in
this report may difer from those published in previ-
ous reports.
N Assessments of progress made in implementing PPM
initiatives and of global eforts to strengthen labora-
tory services and impact measurement draw on infor-
mation obtained from key informants as well as data
received via the online WHO TB data collection form.
N Financial data are presented in real terms, after
adjustment for infation. Tis allows fair comparison
of funding amounts across years, without distortions
caused by changes in prices.
N Te annual data collection form and database system
used by WHO are designed for collecting aggregated
national data. Tey are not recommended for collec-
tion of data within countries.
4
1
Te European Region has its own system for online reporting of
data, which is managed jointly by the European Centre for Disease
Control and Prevention (ECDC) and the WHO Regional Ofce for
Europe.
2
Te four countries for which data were not reported by 16 June were
Canada, Haiti, Brunei Darussalam and Japan. Data were reported
for all except Haiti by 31 August 2010 and as a result data for these
countries are included in AhhFX z.
3
One system for countries of the European Union, managed by the
ECDC; the other for all European countries, managed by the WHO
Regional Ofce for the European Region. Two data collection tools
are used. Data from the ECDC system are uploaded to the WHO
system.
4
WHO recommendations for recording and reporting within coun-
tries are described at: http://www.who.int/tb/dots/r_and_r_forms/
en/index.html
a WB0 RP0R1 2010 (-0#"-56#&3$6-04*4$0/530-
AhhFX 1 provides details about the methods used to
produce estimates of the disease burden caused by TB
(measured as incidence, prevalence and mortality).
In line with the methods explained in this annex, the
results provided in the main text of the report and in
AhhFX z are presented as best, low and high estimates.
0X 2
Ce||ecting g|eba| data en 1 - en|ine and with an ear|ier dead|ine in ze:e
When the term range is used after a best estimate in
the main text of the report, the lower and higher num-
bers correspond to the 2.5th and 97.5th centiles of the
outcome distributions produced by simulations. Tese
are distinct from 95% confdence intervals, which are
estimated directly from observed, empirical data.
ln luly zoo, wF0 launched a web-based system fcr ccllectlne elcbal T8 data (www.stcptb.cre/tme). Thls system
allcws representatlves cf hTPs as well as staff ln wF0 reelcnal and ccuntry cfces tc ccmplete the annual T8 data
ccllectlcn fcrm cnllne. The system has several advantaees, such as:
N The task cf repcrtlne data can be shared amcne varlcus cclleaeues.
N There ls nc need tc ccmplete the repcrt at cne tlme. users can lce cn and edlt parts cf the repcrt as cften as
necessary befcre the repcrtlne deadllnes.
N uata are checked as they are belne entered (real-tlme valldatlcn).
N users have access tc a repcrt that hlehllehts any lnccnslstencles amcne dlfferent sectlcns cf a repcrt and any
lnccnslstencles wlth data prcvlded ln prevlcus years.
N uata entry screens are tallcred fcr use by each ccuntry, and are avallable ln Fnellsh, French and Spanlsh.
N users have access tc summary tables shcwlne real-tlme prceress ln repcrtlne at reelcnal and ccuntry levels.
N users can ccrrect and update data at any tlme, lncludlne after the repcrtlne deadllnes fcr a speclc year have
passed.
ln zo1o, the maln chanee ln the elcbal system fcr ccllectlcn cf T8 data was tc request earller repcrtlne cf data. The
cnllne system was cpened fcr repcrtlne ln mld-March (lnstead cf lune/luly), wlth repcrtlne deadllnes ln May, wlth the
exceptlcn cf the Furcpean keelcn fcr whlch the deadllne was o September (thcueh early repcrtlne was enccuraeed).
1

Thls chanee was made tc allcw the cycle cf repcrt prcductlcn (frcm data ccllectlcn tc launch cf the repcrt) tc be ccm-
pleted ln a calendar year and ln turn the publlcatlcn cf mcre up-tc-date data at the tlme the repcrt ls launched.
8y the deadllne fcr respcndlne tc fcllcw-up querles cf 16 lune zo1o, 1u; ccuntrles (excludlne the Furcpean keelcn)
had repcrted data. Thls lncluded u (cf 6) ccuntrles ln the keelcn cf the Amerlcas, all ccuntrles ln the Afrlcan,
Fastern Medlterranean and Scuth-Fast Asla reelcns (u6, zz and 11 ccuntrles, respectlvely) and u (cf 6) ccuntrles
ln the western Paclc keelcn. ln the Furcpean keelcn, z1 cut cf ccuntrles had repcrted data by 16 lune. Mcst cf
the ccuntrles that had nct repcrted data by 16 lune were hleh-lnccme ccuntrles ln western Furcpe. Taken tceether,
the 168 ccuntrles that repcrted data by the deadllne cf 16 lune acccunt fcr % cf the wcrld's T8 cases.
The tables and eures publlshed ln the maln part cf the repcrt are based cn the data avallable cn 1; lune zo1o.
The data tables publlshed ln AhhFX z are based cn the data avallable cn 1 Aueust zo1o. updates recelved after 1
Aueust zo1o are avallable fcr dcwnlcadlne at www.whc.lnt/tb/data and wlll be used as part cf the dataset fcr wF0's
zo11 elcbal repcrt.
1
Ccllectlcn cf data ln the Furcpean keelcn ls manaeed separately by the wF0 keelcnal 0fce fcr Furcpe and the Furcpean Centre
fcr ulsease Ccntrcl and Preventlcn.

tinues to increase slightly from year to year, as slow
reductions in incidence rates per capita (see SFCTl0h 6)
continue to be outweighed by increases in population.
Estimates of the number of cases broken down by age
and sex have been prepared by an expert group
2
as part of
z. The elcbal burden cf T8
1AL :
stimated epidemie|egica| burden eI 1, zee. humbers ln thcusands except where lndlcated.
a
M0kTALlT
b
PkFvALFhCF lhCluFhCF
Flv PkFvALFhCF lh
lhCluFhT T8 CASFS (%)
P0PuLATl0h 8FST
c
L0w FlCF 8FST L0w FlCF 8FST L0w FlCF 8FST L0w FlCF
Afehanlstan z8 1o 11 ;.1 1 u u 16o u 6u - - -
8aneladesh
d
16z zz1 8 6o 11o 6o zo 1 1oo 6o oo uuo o.z o.1 o.
8razll 1 ;u u. z.z 8.u 1oo 6 18o 8; ;z 1oo 1z 11 1z
Cambcdla 1u 8o 1o ;.u 1u 1oo u; 1;o 6 6 ;6 6.u u. 8.
Chlna 1 u ;1 1o 1oo zzo 1 8oo ;uo ooo 1 oo 1 1oo 1 oo 1. o. z.z
uk Ccnec 66 ozo o 6 6; uo zoo 6o zo zoo oo 8.u 6.u 11
Fthlcpla 8z 8z u 8 ; u8o zzo ;o oo zuo 6o 1z 8.8 1
lndla 1 18 oo z8o 1;o uo ooo 1 oo ooo z ooo 1 6oo z uoo 6.u . .8
lndcnesla zz 6 6z 6 66o z;o 1 1oo uo o zo z.8 1.; u.
Kenya 8oz 6.z .o 1z 11o u 1o 1zo 1o uu uz u6
Mczamblque zz 8u 8.8 6. 1z 86 u 1o u ;6 11o 8 8 8
Myanmar
e
o ozo z 18 u oo 1o uo zoo 16o zuo 11 ;.; 1u
hleerla 1u ;z 11o 8 1uo 8o 8o 1 uoo u6o ;o o 1 1 1
Paklstan 18o 8o8 6o 6 6uo z;o 1 1oo uzo uo oo 1. 1.o z.z
Phlllpplnes 1 8 z z1 u u8o uo 1o z6o z1o 1o o. o. o.8
kusslan Federatlcn 1uo 8;u z 1; 8 1o 6 zo 1o 1zo 18o 8 ;
Scuth Afrlca o 11o z 1o uu o 16o 6o uo uoo o 6o u 6
Thalland 6; ;6u 1z ;.z 18 1o ; z1o ; 11o 1; 1z zz
ueanda z ;1o . . 1; 1 1;o 6 ;8 1zo 6 ;
uk Tanzanla u ; u.o 1. .z ;z z; 1o 8o ; 8 u; 61
vlet ham 88 o6 z 18 o zo 1o 1o 18o 1o zo u.z z. .8
Zlmbabwe 1z z 1o ;. 1u 6 u8 1o ;6 11o z 1 z
Bigh-burden ceuntries o z o8 : :ee e : zee :: eee 8 ee :o eee 6ee :ee 8 :ee :z :: :
AFk 8zu uo1 uo o u;o oo oo u 6oo z 8oo z ;oo ooo ;
AMk z o zo 16 zu o z8o uo z;o z6o zo 8. 8.1 8.
FMk 6 o ;u 1o 1 ooo 6o 1 oo 66o o ;o 1.6 1. z.1
Fuk 81 6z 1 ;u 6o uo ;zo uzo o uo . u. .;
SFAk 1 ;8 8; u8o 6o 6o u oo oo ; 1oo oo z oo ;oo .; u.1 ;.8
wPk 1 8oo 6uo zuo 18o 1o z oo 1 oo u zoo 1 oo 1 ;oo z 1oo 1.8 1.u z.
C|eba| 6 8z6 ze : ee : zee : ee :o eee :z eee :6 eee oee 8 ee ee :z :: :
- lndlcates nc data repcrted.
a
humbers fcr mcrtallty, prevalence and lncldence shcwn tc twc slenlcant eures. Tctals fcr F8Cs and elcbally ccmputed prlcr tc rcundlne uslne
Mcnte Carlc slmulatlcns.
b
Mcrtallty excludes deaths amcne Flv-pcsltlve T8 cases. ueaths amcne Flv-pcsltlve T8 cases are classled as Flv deaths acccrdlne tc lCu-1o.
c
8est, lcw and hleh lndlcate best estlmates fcllcwed by lcwer and upper bcunds. The lcwer and upper bcunds are dened as the z.th and ;.th
centlles cf cutccme dlstrlbutlcns prcduced ln slmulatlcns. See AhhFX 1 fcr further detalls.
d
8aneladesh ccmpleted a survey cf the prevalence cf T8 dlsease ln zoo. A reassessment cf the epldemlclcelcal burden cf T8, uslne data frcm the
survey ccmblned wlth an ln-depth analysls cf survelllance and prcerammatlc data, wlll be undertaken ln zo11.
e
Myanmar ccmpleted a survey cf the prevalence cf T8 dlsease ln zo1o. A reassessment cf the epldemlclcelcal burden cf T8 wlll be undertaken
fcllcwlne nallzatlcn and dlssemlnatlcn cf survey results.
1
Te range is the uncertainty interval that corresponds to the 2.5th and 97.5th centiles of the outcome distributions produced by simulations.
See also SFCTl0h 1 and AhhFX 1.
2
Tis expert group is convened by the WHO Global Task Force on TB Impact Measurement. See also SFCTl0h ; of this report.
z.: tncidence
l
n 2009, there were an estimated 9.4 million incident
cases (range, 8.9 million9.9 million)
1
of TB glo-
bally (equivalent to 137 cases per 100 000 population)
(TA8LF 1, FlCukF 1). Te absolute number of cases con-
6 WB0 RP0R1 2010 (-0#"-56#&3$6-04*4$0/530-
ftCUR :
stimated 1 incidence rates, by ceuntry, zee
024
2549
5099
100299
300
No estimate
Estimated new TB
cases (all forms) per
100 000 population
ftCUR z
stimated Btv preva|ence in new 1 cases, zee
04
519
2049
50
No estimate
HIV prevalence
in new TB cases,
all ages (%)
8)03&1035 CL0AL 1URCUL05t5 C0k1R0L j
an update to the Global Burden of Disease study.
1
Tese
indicate that women
2
account for an estimated 3.3 mil-
lion cases (range, 3.1 million3.5 million), equivalent to
35% of all cases.
Estimates of the numbers of TB cases among women
and children need to be improved through more report-
ing and more analysis of notifcation data disaggregated
by age and sex.
Most of the estimated number of cases in 2009
occurred in Asia (55%) and Africa (30%);
3
smaller pro-
portions of cases occurred in the Eastern Mediterranean
Region (7%), the European Region (4%) and the Region of
the Americas (3%). Te 22 HBCs that have received par-
ticular attention at the global level since 2000 account
for 81% of all estimated cases worldwide (TA8LF 1). Te
fve countries with the largest number of incident cases
in 2009 were India (1.62.4 million), China (1.11.5 mil-
lion), South Africa (0.400.59 million), Nigeria (0.37
0.55 million) and Indonesia (0.350.52 million). India
alone accounts for an estimated one ffth (21%) of all TB
cases worldwide, and China and India combined account
for 35%.
Of the 9.4 million incident cases in 2009, an estimated
1.01.2 million (1113%) were HIV-positive, with a best
estimate of 1.1 million (12%) (TA8LF 1, FlCukF z). Tese
numbers are slightly lower than those reported in pre-
vious years, refecting better estimates (based on more
direct measurements as documented in AhhFX 1) as well
as reductions in HIV prevalence in the general popula-
tion. Of these HIV-positive TB cases, approximately 80%
were in the African Region.
z.z Preva|ence
Tere were an estimated 14 million prevalent cases
(range, 12 million16 million) of TB in 2009 (TA8LF 1),
equivalent to 200 cases per 100 000 population. As
explained in AhhFX 1, prevalence is a robust indicator
of the burden of disease caused by TB when it is directly
measured in a nationwide survey. When survey data are
not available, it is difcult to estimate its absolute level
and trend. In those countries where surveys are done
and repeated at periodic intervals (see SFCTl0h ;), esti-
mates of the prevalence of TB and trends in rates of TB
prevalence will improve.
z. Merta|ity
In 2009, an estimated 1.3 million deaths (range, 1.2 mil-
lion1.5 million) occurred among HIV-negative cases
of TB (TA8LF 1), including 0.38 million deaths (range,
0.3 million0.5 million) among women. Tis is equiva-
lent to 20 deaths per 100 000 population. In addition,
there were an estimated 0.4 million deaths (range,
0.32 million0.45 million) among incident TB cases
that were HIV-positive (data not shown); these deaths
are classifed as HIV deaths in the 10th revision of the
International Classifcation of Diseases (ICD-10). Tus
in total, approximately 1.7 million people died of TB in
2009. Te number of TB deaths per 100 000 population
among HIV-negative people plus the estimated number
of TB deaths among HIV-positive people equates to a
best estimate of 26 deaths per 100 000 population.
z.o M0R-1 and X0R-1
Tere were an estimated 440 000 cases of multi-drug
resistant TB (MDR-TB) in 2008 (range, 390 000
510 000).
4
Te 27 countries (15 in the European Region)
that account for 86% of all such cases have been termed
the 27 high MDR-TB burden countries (see also SFCTl0h
u.6). Te four countries that had the largest number of
estimated cases of MDR-TB in absolute terms in 2008
were China (100 000; range, 79 000120 000), India
(99 000; range, 79 000120 000), the Russian Federa-
tion (38 000; range, 30 00045 000) and South Africa
(13 000; range 10 00016 000). By July 2010, 58 coun-
tries and territories had reported at least one case of
extensively drug-resistant TB (XDR-TB).
5
1
Tis study is an update to Lopez AD et al. Global burden of disease
and risk factors. New York, Oxford University Press and Te World
Bank, 2006.
2
Defned as females aged 15 years old.
3
Asia here means the WHO regions of South-East Asia and the West-
ern Pacifc. Africa means the WHO African Region.
4
Te latest estimates are for 2008, as published in March 2010 in:
Multidrug and extensively drug-resistant TB (M/XDR-TB): 2010 global
report on surveillance and response. Geneva, World Health Organiza-
tion, 2010 (WHO/HTM/TB/2010.3). Figures have not been updat-
ed for this report.
5
XDR-TB is defned as resistance to isoniazid and rifampicin (i.e.
MDR-TB) plus resistance to a fuoroquinolone and, at least, one
second-line injectable agent (amikacin, kanamycin and/or capreo-
mycin).
8
. Clcbal tareets, the Stcp T8 Strateey
and the Clcbal Plan tc Stcp T8
.: C|eba| targets Ier 1 centre|
C
lobal targets for reducing the burden of disease
caused by TB have been set for 2015 and 2050
(80X ). Currently, most attention is given to the tar-
gets set for 2015. Te target set within the context of
the MDGs is to halt and reverse the incidence of TB by
2015. Te additional targets set by the Stop TB Partner-
ship are to halve TB prevalence and death rates by 2015,
compared with their levels in 1990.
.z 1he 5tep 1 5trategy
Te Stop TB Strategy
1
is the approach recommended by
WHO to reduce the burden of TB in line with global tar-
gets set for 2015. Te strategy is summarized in 80X u.
Te six major components of the strategy are: (i) pursue
high-quality DOTS expansion and enhancement; (ii)
address TB/HIV, MDR-TB, and the needs of poor and
vulnerable populations; (iii) contribute to health-system
strengthening based on primary health care; (iv) engage
all care providers; (v) empower people with TB, and com-
munities through partnership; and (vi) enable and pro-
mote research.
0X 3
Cea|s, targets and indicaters Ier 1 centre|
BAL1B tk 1B MtLLkktUM 0vL0PMk1 C0AL5
51 f0R 2015
N C0AL 6: C0MA1 Btv{At05, MALARtA
Ak0 01BR 0t5A55
1arget 6.c: Falt and beeln tc reverse the lncldence cf
malarla and cther ma|cr dlseases
tndicater 6.: lncldence, prevalence and death rates
asscclated wlth T8
tndicater 6.:e: Prcpcrtlcn cf T8 cases detected and
cured under u0TS
510P 1 PAR1kR5BtP 1ARC15
51 f0R 2015 Ak0 2050
y 2015: keduce prevalence and death rates by o%,
ccmpared wlth thelr levels ln 1o.
y 2050: keduce the elcbal lncldence cf actlve T8
cases tc 1 case per 1 mllllcn pcpulatlcn per year.
Achievements in TB control in the years following
implementation of DOTS and the Stop TB Strategy, and
prospects for the further gains that could be made up to
2015, are highlighted in 80X .
. 1he C|eba| P|an te 5tep 1
Te Stop TB Partnerships Global Plan to Stop TB, 2006
2015,
2
was launched in January 2006. It set out the scale
at which the interventions included in the Stop TB Strat-
egy need to be implemented to achieve the 2015 targets.
In 2010, as the mid-point of the original 10-year plan
approached, the plan was updated. Tis updated ver-
sion of the plan, which covers the fve years from 2011
to 2015, includes an updated set of targets.
3
Te major
targets for 2015 in this updated plan have been defned
as follows:
N diagnosis, notifcation and treatment of approximate-
ly 7 million cases;
N a treatment success rate among sputum smear-
positive cases of 90%;
N HIV testing of 100% of TB patients;
N enrolment of 100% of HIV-positive TB patients on
co-trimoxazole preventive therapy (CPT) and antiret-
roviral therapy (ART);
N provision of isoniazid preventive therapy (IPT) to all
people living with HIV who are attending HIV care
services and are considered eligible for IPT;
N testing of 100% of previously treated TB patients for
MDR-TB, as well as testing of any new TB patients
considered at high risk of having MDR-TB (estimated
globally at around 20% of all new TB patients);
N enrolment of all patients with a confrmed diagnosis
of MDR-TB on treatment consistent with internation-
al guidelines;
N mobilization of US$ 7 billion per year to fnance
implementation of the Stop TB Strategy, plus around
US$ 1.3 billion per year for research and development
related to new drugs, new diagnostics and new vac-
cines.
1
Te Stop TB Strategy: building on and enhancing DOTS to meet the TB-
related Millennium Development Goals. Geneva, World Health Organ-
ization, 2006 (WHO/HTM/TB/2006.368).
2
Te Global Plan to Stop TB, 20062015: actions for life towards a world
free of tuberculosis. Geneva, World Health Organization, 2006
(WHO/HTM/STB/2006.35).
3
Te Global Plan to Stop TB, 20112015. Geneva, World Health Organ-
ization, 2010 (WHO/HTM/STB/2010.2).
8)03&1035 CL0AL 1URCUL05t5 C0k1R0L o
0X 4
1he 5tep 1 5trategy at a g|ance
1B 510P 1 51RA1C
vt5t0k A 1-Iree wer|d
C0AL Tc dramatlcally reduce the elcbal burden cf T8 by zo1 ln llne wlth the Mlllennlum uevelcpment
Ccals and the Stcp T8 Partnershlp tareets
08lFCTlvFS Achleve unlversal access tc hleh-quallty care fcr all pecple wlth T8
keduce the human sufferlne and scclceccncmlc burden asscclated wlth T8
Prctect vulnerable pcpulatlcns frcm T8, T8/Flv and drue-reslstant T8
Suppcrt develcpment cf new tccls and enable thelr tlmely and effectlve use
Prctect and prcmcte human rlehts ln T8 preventlcn, care and ccntrcl
TAkCFTS MuC 6, Tareet 6.c: Falt and beeln tc reverse the lncldence cf T8 by zo1
Tareets llnked tc the MuCs and endcrsed by the Stcp T8 Partnershlp:
- zo1: reduce prevalence cf and deaths due tc T8 by o% ccmpared wlth a basellne cf 1o
- zoo: ellmlnate T8 as a publlc health prcblem
C0MP0kk15
:. Pursue high-qua|ity 0015 expansien and enhancement
a. Secure pclltlcal ccmmltment, wlth adequate and sustalned nanclne
b. Fnsure early case detectlcn, and dlaencsls thrcueh quallty-assured bacterlclcey
c. Prcvlde standardlzed treatment wlth supervlslcn, and patlent suppcrt
d. Fnsure effectlve drue supply and manaeement
e. Mcnltcr and evaluate perfcrmance and lmpact
z. Address 1{Btv, M0R-1, and the needs eI peer and vu|nerab|e pepu|atiens
a. Scale-up ccllabcratlve T8/Flv actlvltles
b. Scale-up preventlcn and manaeement cf multldrue-reslstant T8 (Muk-T8)
c. Address the needs cf T8 ccntacts, and cf pccr and vulnerable pcpulatlcns
. Centribute te hea|th system strengthening based en primary hea|th care
a. Felp lmprcve health pcllcles, human rescurce develcpment, nanclne, supplles, servlce dellvery, and lnfcrmatlcn
b. Strenethen lnfectlcn ccntrcl ln health servlces, cther ccnereeate settlnes and hcusehclds
c. uperade labcratcry netwcrks, and lmplement the Practlcal Apprcach tc Lune Fealth (PAL)
d. Adapt successful apprcaches frcm cther elds and sectcrs, and fcster actlcn cn the scclal determlnants cf health
o. ngage a|| care previders
a. lnvclve all publlc, vcluntary, ccrpcrate and prlvate prcvlders thrcueh Publlc-Prlvate Mlx (PPM) apprcaches
b. Prcmcte use cf the lnternatlcnal Standards fcr Tuberculcsls Care (lSTC)
. mpewer peep|e with 1, and cemmunities threugh partnership
a. Pursue advccacy, ccmmunlcatlcn and scclal mcblllzatlcn
b. Fcster ccmmunlty partlclpatlcn ln T8 care, preventlcn and health prcmctlcn
c. Prcmcte use cf the Patlents' Charter fcr Tuberculcsls Care
6. nab|e and premete research
a. Ccnduct prceramme-based cperatlcnal research
b. Advccate fcr and partlclpate ln research tc develcp new dlaencstlcs, drues and vacclnes
ze
u. Prceress ln lmplementlne the Stcp T8
Strateey and the Clcbal Plan tc Stcp T8
0X 5
Achievements in 1 centre| during the peried :-zee and prespects Ier ze:e-ze:
The u0TS strateey was develcped as the lnternatlcnally
reccmmended apprcach tc T8 ccntrcl ln the mld-1os.
u0TS ls alsc the fcundatlcn cf the Stcp T8 Strateey,
launched by wF0 ln zoo6 tc eulde T8 ccntrcl effcrts
durlne the 1o years frcm zoo6 tc zo1. The start cf
wF0 effcrts tc systematlcally mcnltcr prceress ln T8
ccntrcl cn an annual basls ln 1 cclnclded wlth elcbal
prcmctlcn and expanslcn cf the u0TS strateey; data
ccmplled slnce then allcw assessment cf achlevements
ln T8 ccntrcl between 1 and zoo and prc|ectlcns
cf what further ealns cculd be made up tc zo1. Key
results are summarlzed belcw, wlth further detalls prc-
vlded ln SFCTl0h 6.
Patients treated and cured, :-zee. A tctal cf u
mllllcn patlents were treated ln u0TS prcerammes, cf
whcm u1 mllllcn were successfully treated.
1
ln zoo8, the
treatment success rate reached 86% wcrldwlde, and
8;% ln hleh-burden ccuntrles.
Merta|ity. Clcbally, T8 mcrtallty has fallen by mcre than
a thlrd slnce 1o. The keelcn cf the Amerlcas and the
western Paclc keelcn have already achleved the zo1
tareet cf halvlne the 1o mcrtallty rate. Mcrtallty rates
are falllne ln all wF0 reelcns.
tncidence. Clcbally, lncldence rates peaked ln zoou. Thls
means that the wcrld ls cn track tc achleve MuC Tareet
6.c, as are ve cf wF0's slx reelcns.
Lives saved :-zee. up tc 6 mllllcn llves were saved
thrcueh lmplementatlcn cf u0TS and the Stcp T8 Strat-
eey.
z,
Lives that ceu|d be saved Irem ze:e-ze:. A further mll-
llcn llves cculd be saved lf current effcrts ln T8 ccntrcl
are sustalned, lncludlne arcund z mllllcn wcmen and
chlldren. wlth expanslcn cf treatment fcr Muk-T8 and
lnterventlcns such as AkT fcr Flv-pcsltlve T8 patlents,
even mcre llves cculd be saved.
1
Assumlne the treatment success rate ln zoo8 ls malntalned
ln zoo.
z
Fxcludlne deaths averted amcne Flv-pcsltlve pecple (classl-
ed as deaths attrlbutable tc Flv rather than T8 ln lCu-1o).
Ccmpared wlth a ccunterfactual scenarlc dened as the

standard cf care and case nctlcatlcn rates malntalned at
1 levels.
T
his section examines the latest data on implementa-
tion of the Stop TB Strategy, and compares progress
with the targets included in the Global Plan to Stop TB,
20112015 where applicable. Te frst three topics cov-
ered are case notifcations, treatment success rates for
sputum smear-positive TB patients and case detection
rates for all forms of TB. Tese all illustrate progress in
implementing DOTS the foundation of the Stop TB
Strategy. Te fourth topic is the engagement of the full
range of care providers in TB control (component 4 of
the strategy) through PPM. Such engagement is essen-
tial to ensure high levels of case detection and treatment
success. Te next two sections cover collaborative TB/
HIV activities and the diagnosis and treatment of drug-
resistant TB, both of which fall under component 2 of
the Stop TB Strategy.
Boxes are used to feature four topics laboratory
strengthening, HRD, strengthened surveillance and
rational use of anti-TB medicines. All four topics are
closely related to health-system strengthening (compo-
nent 3 of the Stop TB Strategy) as well as DOTS and the
engagement of all care providers. ACSM, community TB
care and research (components 5 and 6 of the strategy)
are not discussed because there are limitations in the
available data. In future, additional eforts to compile
better data on these topics will be needed. Te data that
are currently available as well as data for all other topics
covered in the 2010 data collection form can be viewed
and downloaded on the WHO web site (www.who.int/tb/
data).
o.: Case netihcatiens
In 2009, 5.8 million cases of TB (new cases and relapse
cases) were notifed to NTPs, including 2.6 million new
cases of sputum smear-positive pulmonary TB, 2.0 mil-
lion new cases of sputum smear-negative pulmonary TB
(including cases for which smear status was unknown),
0.9 million new cases of extrapulmonary TB and 0.3 mil-
lion relapse cases (TA8LF z).
1
Among pulmonary cases, 57% of global notifcations
were sputum smear-positive. Among the 22 HBCs, the
percentage of notifed cases of pulmonary TB that were
sputum smear-positive was relatively low in Zimbabwe
(29%), the Russian Federation (31%), Pakistan (42%),
1
No distinction is made between DOTS and non-DOTS programmes. Tis is because by 2007, virtually all (more than 99%) notifed cases were
reported to WHO as treated in DOTS programmes. Since 2009, the WHO data collection form has made no distinction between notifcations
in DOTS and non-DOTS programmes.
8)03&1035 CL0AL 1URCUL05t5 C0k1R0L zz
Myanmar (45%), Kenya (46%) and Ethiopia (46%). A
comparatively high proportion of notifed cases were
sputum smear-positive in Bangladesh (81%), the Demo-
cratic Republic of the Congo (85%) and Viet Nam (73%).
o.z 1reatment eutcemes
Globally, the rate of treatment success for new sputum
smear-positive cases of pulmonary TB who were treated
in the 2008 cohort was 86% (TA8LF ). Tis is the sec-
ond successive year that the target of 85% (frst set in
1991) has been exceeded globally. Of the 22 HBCs, 13
reached the 85% target. Tis included Kenya and the
United Republic of Tanzania, demonstrating that coun-
tries in which there is a high prevalence of HIV among
TB patients are able to achieve this target. Among WHO
regions, three met or exceeded the 85% target: the East-
ern Mediterranean Region, the South-East Asia Region
and the Western Pacifc Region. Te treatment success
rate was 80% in the African Region, 77% in the Region
1AL z
Case netihcatiens, zee
hFw CASFS
PFkCFhT
PuLM0hAk
CASFS SMFAk-
P0SlTlvF
hFw Ahu
kFLAPSF
a
SMFAk-
P0SlTlvF
SMFAk-
hFCATlvF/
uhKh0wh
FXTkA-
PuLM0hAk kFLAPSF
kFTkFATMFhT
FXCL. kFLAPSF
FlST0k
uhKh0wh
Afehanlstan z6 1o 1z u; 6 1o8 ;o 1 o8z zo8 ; 6;
8aneladesh 16o 8; 1o uoz z ; z1 u o - - 81
8razll ; ouo z6; zz 1uu 1o z; uo 6 u;8 6u1 6u
Cambcdla zoz 1; 86 8 ;8 1z z uz ; o 68
Chlna 6 z; uu 1z u u 16 uz ; 1; ou6 o 1
uk Ccnec 11z zzz ; 11 1z u1 z1 ;o; u 8 u uuz - 8
Fthlcpla 1u8 6 uu 6 z o o zz8 z z 1 z8 - u6
lndla 1 1 1 6zu 61; 8u 11 z oz6 1o8 61 181 - 6z
lndcnesla zz ; 16 z1 1o8 616 11 z1 ;o 1 ;8 - 61
Kenya 1oz ; ; uoz uu 1u 1; u8 6u ; o68 - u6
Mczamblque u zz1 1 ; 1; o1 o1 1 zz z o8 o
Myanmar 1z8 u u1 ; o 1 1 o u 8 1 - u
hleerla 88 8 uu 86 ; uo 6o z 6z6 z o u
Paklstan 16 86u 111 o8; 16 6u u u16 ; zo - uz
Phlllpplnes 1u o; 8; ;z6 1 6 z ;z z ; 6 81 o 6
kusslan Federatlcn 1z u 1 ;z 1 1o u 8 18 o u1 1 z6 1
Scuth Afrlca uo 88 1 u68 1u; 18; ; 11; zo 11; 11 6; o u
Thalland 6 ; z 81o zo o8 1u 1 6u 1 6 - 6z
ueanda u1 ;o z 11 1z 1 u 8 1 8z z 6z - 6
uk Tanzanla ;1 6z zu z1 ;; 1 u16 1 u86 1o z u11
vlet ham o6 1 z1 18 61z 18 6 8oo 1 1 1 8z ;
Zlmbabwe uz ou 1o 11 zu ;18 6 66 1 o; u66 - z
Bigh-burden ceuntries o 8o: :8 z :6 :: : o z 66 e8 zz oz z o z 8 6
AFk 1 uu ou 6o; ; u;z ;zz z88 8u u 811 u z; z ;16 6
AMk zoo 1zo 11o 1z uu u6u o u 1o zo8 1o o ;;1 ;1
FMk u6u z1 1;; z1 18; ou 8; ;z6 11 ;zu 6 zuo ;; u
Fuk zz6 o1 6; 66 11z zz8 1 uu 1 o6o ; z; zo u6 8
SFAk z 1zu ;o 1 oz8 66 66 ; z 8 1z; 8z zo 8 z61 6z
wPk 1 1 6; u8u o 66 8 8u ; u6 z z6 6 ;z u
C|eba| 8e :o z 6z8 :: z ee 8o 8o ez z e6o o z8 o zz
a
hFw Ahu kFLAPSF lncludes new cases cf unkncwn case type (nct dlsplayed ln thls table).
of the Americas and 66% in the European Region (where
death and failure rates are comparatively high). Eforts
to increase treatment success rates are warranted in
these regions, especially the European Region.
o. Case detectien rates
Te case detection rate (CDR)
1
has been a much-used
indicator of national progress in TB control since the
mid-1990s. For a given country, it is calculated as the
number of notifed cases of TB in one year divided by the
number of estimated incident cases of TB in the same
year, and expressed as a percentage. Te considerable
attention given to the CDR was in line with the two prin-
cipal global targets (case detection and treatment suc-
cess rates) set for TB control during the period 1991 to
2005. Te targets of reaching a CDR of 70% and a treat-
1
Te CDR is actually a ratio rather than a rate, but the term rate
has become standard terminology in this context of this indicator.
zz WB0 RP0R1 2010 (-0#"-56#&3$6-04*4$0/530-
1AL
1reatment success Ier new smear-pesitive cases (%) and cehert size (theusands), :-zee8
a. 1reatment success (%)
1 16 1; 18 1 zooo zoo1 zooz zoo zoou zoo zoo6 zoo; zoo8
Afehanlstan - - u 86 8 8u 8; 86 8 o 8u 8; 88
8aneladesh ;1 6 ; ;; ; 81 8 8u 8 o 1 z z
8razll 1; zo z; uo ;8 ;1 8o ;; ;6 ;6 ; ;z ;1
Cambcdla 1 u 1 1 z z 1 u
Chlna u z u u u u u
uk Ccnec ;u u8 6u ;o 6 ;8 ;; ;8 8 8 8 86 8; 8;
Fthlcpla 61 ;1 ;z ;u ;u 8o ;6 ;6 ;o ; ;8 8u 8u 8u
lndla z z1 18 z; z1 u u 6o ;6 8z 86 86 8; 8;
lndcnesla 1 81 u 8 o 8; 86 86 8; o 1 1 1 1
Kenya ; ;; 6 ;; ; 8o 8o ; 8o 8o 8z 8 8 8
Mczamblque 6 - ;1 ; ;8 ;8 ;6 ;; ; 8 ; 8u
Myanmar 6; ; 8z 8z 81 8z 81 81 81 8u 8u 8u 8 8
hleerla u z ; ; ; ; ; ; ;8 ; ; ;6 8z ;8
Paklstan ;o - 6; z ;o ;u ;; ;8 ; 8z 8 88 1 o
Phlllpplnes 6o ;8 ;1 8; 88 88 88 88 8; 8 88 8 88
kusslan Federatlcn 6 ; 6; 68 6 68 6; 6; 61 6o 8 8 8 ;
Scuth Afrlca 8 61 68 ;z ; 6 61 68 6; 6 ;1 ;u ;u ;6
Thalland 6u ;8 8 68 ;; 6 ; ;u ; ;u ; ;; 8 8z
ueanda uu uo 6z 61 6 6 6o 68 ;o ; ;o ; ;o
uk Tanzanla ; ;6 ;; ;6 ;8 ;8 81 8o 81 81 8z 8 88 8
vlet ham 8 8 8 z z z z z z z z
Zlmbabwe z 6 ;o ; 6 ;1 6; 66 u 68 6o ;8 ;u
Bigh-burden ceuntries o 6 6z 6o 6; ;z ; 81 8u 86 8; 8; 8;
AFk 6o 6 6u ;o 68 ;1 ;o ; ; ;u ;6 ; 8o 8o
AMk o 1 8 6; ; ;6 6 81 8o ; ;8 ; ; ;;
FMk ; 66 ; ; ; 81 8z 8u 8z 8 8 86 88 88
Fuk 6; 8 ;z 6 ; ; ;u ;u ; ;o ;z ;o ;1 66
SFAk 1 z uo u o 6 68 ; 8u 8; 8; 88 88
wPk 8o ;z 1 z 1 o 1 o 1 1 z z z
C|eba| ; u 6o 6u 6u 6 ; ;6 8o 8 8 8u 86 86
b. Cehert size (theusands)
1 16 1; 18 1 zooo zoo1 zooz zoo zoou zoo zoo6 zoo; zoo8
Afehanlstan - - z.o z. z.o .1 6. ;.8 6.8 1o 1o 1z 1 1
8aneladesh 11 o u 8 8 8 u1 u; u 6 8 1oz 1ou 1ou
8razll u6 u u o z; u u1 z 8 u uz u8 8 u1
Cambcdla u.u .1 1z 1 16 1 1u 1; 1 1 z1 1 1 zo
Chlna 11 1; 18 z1o zo8 z1u 11 1u z6; 8 u; u;o u66 u6u
uk Ccnec 16 z z6 6 u1 u u 6z 6 6 66 66
Fthlcpla .1 11 1z 1 z1 o z ; uo u1 ; 8 u1
lndla z6 z1 z z8u u u 8u 6 uzo u8 o; z 616
lndcnesla .o 1z z1 uo u6 z u ;6 1z 1 1; 161 166
Kenya 6. 1 1 zz z; z8 1 1 u u1 uo 8 ;
Mczamblque 11 1 11 - 1z 1 1u 1 16 1; 18 18 18 1
Myanmar ;. .; .z 1o 1z 1; z1 zu z; 1 ; uo u u1
hleerla . zu 11 1 1 16 1; z1 z8 u uo uu u6
Paklstan o.8 - z.8 z .o u.1 6. 1 zo z u8 66 8 1oo
Phlllpplnes o 1z6 z; z1 ; o 68 ;8 81 86 8; 8
kusslan Federatlcn o.1 u o.; o.; 1. .6 u.1 .z 6. z6 z6 1 z z
Scuth Afrlca z8 u ; 81 86 1o1 11u 1z; 1 1uo 1u 1uu
Thalland zo o.1 .; 8.o 1u z zo z; z8 z8 o z o
ueanda 1 1 18 1 1u 1u 1; 1 zo z1 z1 zo z1 z
uk Tanzanla zo z1 zz zu zu zu zu zu z z6 z z z zu
vlet ham 8 u8 u u ; 6 8 6 u
Zlmbabwe .; 1z 1z 1 1 1u 1; 16 1u 1 1 16 11 1o
Bigh-burden ceuntries ; 6; 8; 1z 1 ouu 1 11 1 186 1 z6o 1 uo 1 ;;6 1 6 z o8; z 1z z 1;
AFk 1;8 z z6; z z 6 uo uz u1 z 6u 6 ;; ;6
AMk 1z 1u 1z 111 11o 111 1oz 1o 11o 1z1 11 1z 11u 1o8
FMk u6 1 6o 8 66 6u z ;6 81 8 11u 1z 16 16;
Fuk u u zu u8 zz u1 o u 6o ;u 81 8 1o8 ;o
SFAk 18 6o ;6 u; 1z z 6ou 661 ;8o 86 8 ;u 1 oo
wPk z6 ;z zu 1 6o u6 ; u ; 66 66 661 6u;
C|eba| 1 oo1 1 zu 1 1u; 1 1 1 u; 1 u1 1 1z 1 6u 1 8uz z zoo z 6 z z6 z 8 z ;8


8)03&1035 CL0AL 1URCUL05t5 C0k1R0L z
ment success rate of 85% among sputum smear-positive
cases of pulmonary TB by 2000 were set by the Forty-
fourth World Health Assembly in 1991, with the target
year subsequently reset to 2005.
Given uncertainty in estimates of TB incidence, this
report places less emphasis on the CDR, compared with
past reports (and this will be true of future reports on
global TB control as well). In particular, this report (for
the frst time in the series of reports published since
1997) does not include estimates of the CDR for sputum
smear-positive cases of pulmonary TB (80X 6).
Te best estimate of the CDR of all forms of TB in 2009
was 63% (range, 6067%) (TA8LF u). Te highest rates of
case detection in 2009 are estimated to be in the Euro-
0X 6
Meving away Irem estimates eI the case detectien rate Ier sputum smear-pesitive pu|menary 1
ln 11, the wcrld Fealth Assembly set twc elcbal tar-
eets fcr T8 ccntrcl: tc achleve a case detectlcn rate
(Cuk) cf ;o% fcr new sputum smear-pcsltlve cases cf
pulmcnary T8, and tc successfully treat 8% cf these
cases. The tareets were crlelnally set fcr the year
zooo, and later reset tc zoo. The Cuk ls dened as
the number cf new cases cf sputum smear-pcsltlve pul-
mcnary T8 nctled tc hTPs, dlvlded by the estlmated
number cf lncldent cases cf sputum smear-pcsltlve pul-
mcnary T8 that cccurred ln the same year. Partlcular
attentlcn was elven tc detectlne and curlne pecple wlth
sputum smear-pcsltlve pulmcnary T8 because they are
the mcst lnfectlcus - and thus the mcst llkely, wlthcut
prcper treatment, tc cause further transmlsslcn cf T8 ln
the pcpulatlcn.
The Assembly's tareets ealvanlzed effcrts tc lmprcve T8
ccntrcl at elcbal and ccuntry levels. Frcm 1 cnwards,
the u0TS strateey emphaslzed the detectlcn and treat-
ment cf sputum smear-pcsltlve cases cf pulmcnary T8,
and mcnltcrlne cf prceress tcwards bcth tareets was
elven a (|ustlably) hleh prcle at elcbal and ccuntry
levels. All annual repcrts cn elcbal T8 ccntrcl publlshed
by wF0 frcm 1; tc zoo lncluded estlmates cf the
Cuk fcr sputum smear-pcsltlve cases cf pulmcnary T8.
1
Fcr the rst tlme, thls repcrt dces nct lnclude estlmates
cf the Cuk fcr sputum smear-pcsltlve pulmcnary T8.
lnstead, estlmates cf the Cuk fcr all fcrms cf T8 are
presented.
z
The Cuk fcr all fcrms cf T8 ls dened as
the tctal number cf new cases nctled tc hTPs (shcwn
ln TA8LF z) dlvlded by the tctal number cf estlmated
lncldent cases cf T8 (shcwn ln TA8LF 1).
There are several reascns fcr thls chanee. hTPs ln all
ccuntrles are dlaencslne, nctlfylne and treatlne pecple
wlth all fcrms cf T8, nct |ust thcse wlth sputum smear-
pcsltlve T8 (TA8LF z). The Stcp T8 Strateey (80X u),
launched ln zoo6, emphaslzes the detectlcn and treat-
ment cf pecple wlth BMM GPSNT cf T8. The zo1 elcbal
tareets set wlthln the ccntext cf the MuCs and by the
Stcp T8 Partnershlp (80X ), whlch are ncw the fccus
cf natlcnal and lnternatlcnal effcrts tc ccntrcl T8, are
dened ln terms cf reductlcns ln the dlsease burden
(lncldence, prevalence and mcrtallty) caused by all fcrms
cf T8. The Cuk lndlcatcr lncluded ln the MuC framewcrk
ls the Cuk fcr all T8 cases (80X ). Labcratcry capac-
lty tc dlaencse smear-neeatlve culture-pcsltlve cases cf
pulmcnary T8 ls lncreaslne, ln llne wlth wF0 reccmmen-
datlcns tc lmprcve bacterlclcelcal dlaencsls cf T8 uslne
bcth smear and culture. Further reascns are the results
and reccmmendatlcns arlslne frcm a revlew and assccl-
ated updatlne cf the methcds used tc estlmate dlsease
burden (AhhFX 1), ccnducted between lune zoo8 and
0ctcber zoo by an expert ercup ccnvened by the wF0
Clcbal Task Fcrce cn T8 lmpact Measurement. Amcne
cther ndlnes, thls revlew ldentled reascns why estl-
matlne the Cuk fcr sputum smear-pcsltlve T8 ls mcre
dlfcult than prevlcusly thcueht, ccmpared wlth the
Cuk fcr all fcrms cf T8.

tI estimates eI the C0R Ier smear-pesitive 1 are needed
Ier reperting purpeses, there are twe eptiens. 1he hrst is
te assume that the smear-pesitive C0R is simi|ar te the
C0R Ier a|| Ierms eI 1. tI this is net satisIactery, ceun-
tries and{er internatiena| agencies sheu|d centact WB0
and requests Ier separate estimates eI the C0R Ier smear-
pesitive 1 wi|| be hand|ed en a case-by-case basis.
tt sheu|d be emphasized that the standard eI care Ier
1 diagnesis recemmended by WB0 is (i) sputum smear
micrescepy Ier BMM DBTFT and (ii) expansien eI the use eI
DVMUVSF te diagnese a|| bacterie|egica||y-pesitive (net just
smear-pesitive) cases, tewards the u|timate gea| eI using
cu|ture (er equiva|ents such as me|ecu|ar tests) in the
diagnesis eI a|| cases.
1
ln the elcbal repcrt publlshed ln uecember zoo, the Cuk fcr
smear-pcsltlve cases was estlmated as 6-68%, wlth a best
estlmate cf 6z%. hew cases lnclude relapse cases.
z
l.e. smear-pcsltlve and smear-neeatlve cases cf pulmcnary
T8, and extrapulmcnary cases.
A systematlc revlew cf the prcpcrtlcn cf all T8 cases wlth

sputum smear-pcsltlve T8 ls cf partlcular relevance, and ls
dlscussed ln sectlcn .6 cf AhhFX 1.
pean Region (best estimate 80%; range, 7485%) and
the Region of the Americas (best estimate 79%; range,
7485%), followed by the Western Pacifc Region (best
estimate 70%; range, 6478%). Te African Region has
the lowest estimated rate of case detection (best esti-
mate 50%; range, 4853%). Among the HBCs, the high-
est rates of case detection in 2009 are estimated to be in
Brazil, the Russian Federation, South Africa, Kenya, the
United Republic of Tanzania and China; the lowest rate
is in Nigeria.
While estimated rates of TB incidence are falling
slowly, notifcation rates are increasing in the African
Region and (particularly since around the year 2000)
the Eastern Mediterranean and South-East Asia regions,
za WB0 RP0R1 2010 (-0#"-56#&3$6-04*4$0/530-
indicating that case detection is improving (see FlCukF
z6 in SFCTl0h 6). In the Western Pacifc Region, notif-
cations increased sharply between 2002 and 2006, but
have since stabilized; here, patterns are strongly infu-
enced by China, which accounts for almost 70% of inci-
dent cases in this region (TA8LF 1).
Despite difculties with estimating the case detection
rate (80X 6, AhhFX 1), eforts to increase the percentage
of TB cases that are diagnosed and treated according to
international guidelines are clearly of major importance.
Tis will be necessary to move towards the 7 million
notifcations targeted in the Global Plan for 2015 (and
eventually, to achieve early detection of all cases).
Tere are three main reasons why incident cases of TB
may not be notifed (see also AhhFX 1, TA8LF A.1). Tese
are:
N Cases are diagnosed but not reported. For people
in this category, strengthening surveillance systems,
1AL o
stimates eI the case detectien rate Ier a|| cases (%), :-zee
a
1 zooo zoo zoo
8FST
b
L0w FlCF 8FST L0w FlCF 8FST L0w FlCF 8FST L0w FlCF
Afehanlstan - - - 18 1 z u; u u1 6o
8aneladesh zo 16 z zu zo o 6 o u uu ; u
8razll ; 66 ;u 6z 8u ;o 1oo 86 ;z 1oo
Cambcdla zu 1 z o z 6 6 u8 6 6o z ;o
Chlna ; o u6 u z8 u1 6 81 ; 66 86
uk Ccnec uo o z u uo o u6 8 6
Fthlcpla zo 1; z uz z uz z o uz 61
lndla ;6 6 6u 8o 61 1 ;6 6; 6 8
lndcnesla .8 8.z 1z zz 18 z; 61 1 ;; 6; 6 8
Kenya u6 8 ; o uz 6 ;1 88 8 ;o 1oo
Mczamblque u 6 u 1 z6 8 z uu u6 8 ;
Myanmar 1o 8.6 1 16 1u zo u6 6 6u ;8
hleerla 6.u .u 8.1 ;.6 6. . 1u 11 1; 1 16 zu
Paklstan u.u .6 .u .z z.; u.o ; 1 u6 ;6 6
Phlllpplnes u; u; uu 6; 6 u; 6
kusslan Federatlcn uu 6; ;; 6u ; 8z 68 1oo 8u ;1 1oo
Scuth Afrlca 6 u; ;o u ; 61 1 ;6 8 6 1oo
Thalland u6 6 uo o 6u u 8o 6 ; 8
ueanda 8 z u; ; o u6 z u8 uu 6 u
uk Tanzanla o 68 6; ;6 ;u 68 ; o 8u 6
vlet ham ; z; u 6 u1 68 6 u1 68 u uz ;z
Zlmbabwe u6 6 6o o ; u u1 61 u6 8 6
Bigh-burden ceuntries oo o: o oz o z 6o 6e 68
AFk 8 6 uo 8 6 uo uz uo u o u8
AMk 68 6 ;u ;o 66 ;6 ; ;o 8o ; ;u 8
FMk z zo z6 z zz z8 u6 u1 ;o 6z ;
Fuk 6z 8 6; ;6 ;o 8z 8o ;u 86 8o ;u 8
SFAk u; 6o u uu 6 8 1 66 6 8 ;u
wPk u1 u8 uo u6 66 ;u ;o 6u ;8
C|eba| o6 o o o o o8 6 6 6e 6
- lndlcates data nct avallable.
a
Fstlmates fcr all years are recalculated as new lnfcrmatlcn beccmes avallable and technlques are rened, sc they may dlffer frcm thcse publlshed
prevlcusly. lf nctlcatlcn data frcm a ccuntry had nct been recelved by 16 lune zo1o, the nctlcatlcn rate ln zoo was assumed tc be the same as ln
zoo8. Fstlmates fcr the Phlllpplnes wlll be reassessed ln late zo1o.
b
8est, lcw and hleh lndlcate best estlmates fcllcwed by lcwer and upper bcunds. The lcwer and upper bcunds are dened as the z.th and ;.th
centlles cf cutccme dlstrlbutlcns prcduced ln slmulatlcns. See AhhFX 1 fcr further detalls.
establishing links with the full range of health-care
providers and stronger enforcement of legislation
regarding notifcation of cases (where this is mandat-
ed by law) will help.
N Cases seek care but are not diagnosed. For people
in this category, better diagnostic capacity is needed.
Tis could mean better laboratory capacity as well as
more knowledgeable and better trained staf, espe-
cially in peripheral-level health-care facilities.
N Cases do not seek care. For people in this category,
reasons could include not recognizing any symptoms
of TB and/or no access (fnancial and/or geographi-
cal) to health-care services. To reach cases in this
category, health systems need to be strengthened so
that basic health-care services are available to more
people, and fnancial barriers to diagnosis (and subse-
quently treatment) need to be mitigated or removed.
0X 7
Bew strengthening survei||ance systems can increase netihcatiens eI 1 cases: an examp|e Irem China
ln Chlna, the hTP prcvldes servlces thrcueh a laree
netwcrk cf T8 dlspensarles. At the same tlme, a laree
number cf pecple wlth T8 symptcms seek care frcm
hcspltals. ulaencsls cf T8 and treatment fcr T8 patlents
are prcvlded by these hcspltals. A challenee ls that hcs-
pltals are nct as well-placed tc fcllcw the reccmmended
standards cf T8 care, partlcularly standards that are
deslened tc help patlents tc ccmplete treatment. whlle
pcllcles were ln place, fcr several years lt prcved dlf-
cult tc ensure that pecple wlth T8 symptcms were
referred frcm hcspltals tc T8 dlspensarles.
ln zoou, a new cppcrtunlty tc lmprcve llnkaees
between the hTP and hcspltals arcse. ln respcnse tc
the SAkS (severe acute resplratcry syndrcme) epldemlc,
the ecvernment establlshed a web-based ccmmunlca-
ble dlseases repcrtlne system thrcuehcut the ccuntry.
lt became mandatcry tc repcrt ; lnfectlcus dlseases,
lncludlne T8, wlthln zu hcurs. 8y the end cf zoo8, thls
system ccvered all ccmmunlcable dlsease centres, ;%
cf hcspltals at ccunty-level cr abcve, and 8z% cf tcwn-
shlp level cllnlcs. The system ls used by up tc 68 ooo
facllltles every day, and abcut z ooo cases cf lnfec-
tlcus dlsease are repcrted each day.
ucctcrs ln all health facllltles, lncludlne hcspltals, use
thls system tc repcrt lnfcrmatlcn cn pecple wlth T8
slens and symptcms and refer them tc the nearest T8
dlspensary. The lnfcrmatlcn repcrted lncludes essentlal
ccntact detalls and the dlaencstlc status cf each perscn
wlth T8 slens and symptcms and each ccnrmed T8
case. uata are avallable tc authcrlzed lndlvlduals and
lnstltutlcns as sccn as they are entered lntc the sys-
tem. Staff whc are authcrlzed tc access the database
brcwse the data every day. lf the referred patlents and
ccnrmed cases dc nct arrlve wlthln a day, staff ln T8
dlspensarles retrleve the relevant lnfcrmatlcn frcm the
system and trace anycne whc ls mlsslne (fcr example,
vla telephcne cr vlslts tc the perscn's hcme).
Thrcueh ccllabcratlcn tc help lmplement the T8 ccm-
pcnent cf the web-based repcrtlne system, the Mln-
lstry cf Fealth succeeded ln develcplne a prcductlve
ccllabcratlcn between hcspltals and T8 dlspensarles.
Frcm zoou tc zoo;, the prcpcrtlcn cf T8 suspects and
cases referred frcm hcspltals and arrlvlne ln T8 dlspen-
sarles lncreased substantlally, frcm % tc ;8%. The
ccntrlbutlcn cf hcspltals tc ccnrmed cases cf sputum
smear-pcsltlve pulmcnary T8 dcubled, frcm 16% tc
%. wlth the web-based repcrtlne system servlne as
an lnstrument tc put pcllcy lntc practlce, hcspltals ncw
ccntrlbute abcut a thlrd cf all nctlcatlcns cf sputum
smear-pcsltlve pulmcnary T8 ln Chlna.
Further detalls abcut the web-based survelllance sys-
tem are prcvlded ln 80X 1u.
A case study from China, which illustrates how strength-
ening surveillance can lead to increased notifcations
of TB cases and an increase in the CDR, is provided in
80X ;. Engagement of all care providers is discussed
in the next section. Strengthening of laboratory capac-
ity and human resource development are discussed in
80X 8 and 80X 1o, respectively.
o.o Pub|ic-private and pub|ic-pub|ic mix (PPM)
initiatives
In many countries, one of the best ways to increase case
detection is for NTPs to establish collaboration with the
full range of health-care providers. Tis is component 4
of the Stop TB Strategy (80X u), and its two subcompo-
nents are:
N involvement of all public, voluntary, corporate and
private providers through Public-Private Mix (PPM)
approaches; and
N promotion of the International Standards for Tuber-
culosis Care through PPM initiatives.
Eforts to engage all care providers through PPM initia-
tives, beyond those which fall under the direct respon-
sibility of the NTP (termed non-NTP providers in this
report), are being introduced and scaled up in many
countries. Unfortunately, demonstrating this progress
is not always possible. First, it requires that systematic
recording and reporting of the source of referral and
place of TB treatment is being done. Second, it requires
that data reported at the local level are aggregated, ana-
lysed and reported at the national level.
1
Often, one or
both conditions are not yet met.
Despite this recording and reporting challenge, sub-
stantial progress in engaging non-NTP care provid-
ers through PPM can be documented for an increasing
number of countries. New and compelling data compiled
from 15 countries (including nine HBCs) in 2010, which
demonstrate the major contribution that PPM can make
to case notifcations, are summarized in TA8LF . In
these 15 countries, the contribution of PPM initiatives
typically ranges from between about one ffth to one
third of total notifcations, in the geographical areas in
which PPM has been implemented. Tis has been accom-
panied by maintenance of high rates of treatment suc-
cess (data not shown).
As also illustrated in TA8LF , NTPs have used a vari-
ety of approaches to engage non-NTP care providers,
according to the local context. Tese include incentive-
based schemes for individual and institutional providers
in India and Myanmar; a web-based system for man-
datory reporting of TB cases by all providers in China
1
WHO recommends that the source of referral and the place of treat-
ment should be routinely recorded and reported.
z6 WB0 RP0R1 2010 (-0#"-56#&3$6-04*4$0/530-
(80X ;); and reimbursement for TB care delivered by pri-
vate providers through health insurance, when care con-
forms with agreed-upon standards, in the Philippines. It
is also noticeable that countries have prioritized difer-
ent types of care providers. Tis includes pharmacies in
Cambodia, private hospitals in Nigeria, public hospitals
in China and Indonesia, social security organizations in
Mexico and prison services in Kazakhstan.
In general, only a small proportion of targeted care
providers collaborate actively with NTPs and contribute
to TB case notifcations in most countries. For this rea-
son, it is not surprising that NTPs often give frst priority
to engaging institutional providers with whom estab-
lishing collaborative links may be less demanding and,
for a given amount of efort, will yield a higher number
of notifcations. At the same time, involving front-line
health workers such as community-based informal pro-
viders, private practitioners and pharmacies who are
often the frst point of contact for people with symp-
toms of TB can help to reduce diagnostic delays and
the out-of-pocket expenditures of TB patients. For these
reasons, scaling up PPM, in phases if not at once, should
aim to systematically map and engage all relevant care
providers in TB care and control.
o. Ce||aberative 1{Btv activities
Collaborative TB/HIV activities are essential to ensure
that HIV-positive TB patients are identifed and treated
appropriately, and to prevent TB in HIV-positive people.
1

Tese activities include establishing mechanisms for col-
1AL
Centributien eI PPM te 1 case netihcatiens in se|ected ceuntries
C0uhTk TPFS 0F h0h-hTP CAkF Pk0vluFkS FhCACFu C0vFkACF
huM8Fk 0F CASFS
h0TlFlFu PFk FAk
a
C0hTkl8uTl0h T0 T0TAL
h0TlFlCATl0hS
b
(%)
Anecla ulverse publlc and prlvate prcvlders Ccuntrywlde u 1 1z%
Cambcdla Pharmacles, prlvate cllnlcs and hcspltals Ccuntrywlde 6 o 1;%
Chlna Ceneral publlc hcspltals Ccuntrywlde ; z86 ;%
Chana ulverse publlc and prlvate prcvlders Ccuntrywlde z 1zu 1%
lndla ulverse publlc, prlvate and hC0 prcvlders
1u laree cltles
(o mllllcn pcpulatlcn)
1z uo
6% cf new smear-
pcsltlve cases
lndcnesla Publlc and prlvate hcspltals Ccuntrywlde 8 6z 1%
lslamlc kepubllc
cf lran
ulverse publlc and prlvate prcvlders Ccuntrywlde z 1u z%
Kazakhstan Prlscn health servlces Ccuntrywlde 1 1 8%
Mexlcc Scclal securlty creanlzatlcns
u% cf the eccncmlcally-
actlve pcpulatlcn
u8 (zoo8)
z% cf new smear-
pcsltlve cases
Myanmar
Prlvate practltlcners thrcueh the
prcfesslcnal medlcal asscclatlcn
z6 tcwnshlps
(6.u mllllcn pcpulatlcn)
8 z6 (zoo8) z1%
hepal ulverse publlc and prlvate prcvlders Ccuntrywlde z 1 8%
hleerla Prlvate cllnlcs and hcspltals Ccuntrywlde z u18 u%
Paklstan Prlvate practltlcners, hC0s and hcspltals Ccuntrywlde u 16z 1u%
Phlllpplnes Prlvate cllnlcs and hcspltals o mllllcn pcpulatlcn u
z8% cf new smear-
pcsltlve cases
unlted kepubllc
cf Tanzanla
Prlvate and hC0 hcspltals Ccuntrywlde 11 uz 1%
a
uata frcm zoo, except where specled.
b
Ccntrlbutlcn tc all nctlcatlcns in the geegraphica| areas cevered by PPM ls shcwn, except where specled.
laboration between TB and HIV programmes; infection
control in health-care and congregate settings; HIV test-
ing of TB patients and for those TB patients infected
with HIV CPT and ART; and intensifed TB case-fnding
among people living with HIV followed by IPT for those
without active TB. Testing TB patients for HIV and pro-
viding CPT for HIV-positive TB patients are typically the
responsibility of NTPs; national HIV programmes are
usually responsible for initiating intensifed case-fnding
among HIV-positive people and provision of IPT to those
without active TB. Provision of ART to HIV-positive TB
patients is often the responsibility of national HIV pro-
grammes, but may also be done by NTPs. When NTPs do
not provide ART directly, they are responsible for refer-
ring HIV-positive TB patients to ART services.
Further progress in implementing collaborative TB/
HIV activities was made in 2009, which consolidated the
achievements documented in previous reports. Just over
1.6 million TB patients knew their HIV status in 2009
(26% of notifed cases), up from 1.4 million in 2008 (FlC-
ukF ). Te highest rates of HIV testing were reported
in the European Region, the African Region and the
Region of the Americas, where 86%, 53% and 41% of TB
patients knew their HIV status, respectively (TA8LF 6).
In 55 countries, at least 75% of TB patients knew their
HIV status, including 16 African countries (FlCukF
u), up from 50 countries in total and 11 in the African
1
Interim policy on collaborative TB/HIV activities. Geneva, World
Health Organization, 2004 (WHO/HTM/TB/2004.330; WHO/
HTM/HIV/2004.1).
8)03&1035 CL0AL 1URCUL05t5 C0k1R0L zj
ftCUR
Btv testing Ier 1 patients, a|| ceuntries, zee-zee. The number cf nctled new and retreatment cases ls shcwn ln blue
and the number cf cases fcr whlch the Flv status was reccrded ln the T8 reelster ls shcwn ln erey. The percentaee cf
nctled T8 cases wlth kncwn Flv status ls lndlcated abcve the erey bars.
a
a
The numbers under each year shcw the
number cf ccuntrles repcrtlne data cn Flv
testlne fcllcwed by the percentaee cf tctal
estlmated Flv-pcsltlve T8 cases acccunted fcr
by repcrtlne ccuntrles.
0
1
2
3
4
5
6
7
2003
92
(43%)
2004
84
(47%)
2005
131
(81%)
2006
146
(90%)
2007
169
(98%)
2008
167
(98%)
2009
143
(98%)
4.2% 3.2%
8.5%
12%
20%
22%
26%
C
a
s
e
s

(
m
i
l
l
i
o
n
s
)
huM8Fk 0F T8
PATlFhTS wlTF
Kh0wh Flv STATuS
(TF0uSAhuS)
% 0F
h0TlFlFu
T8 PATlFhTS
TFSTFu F0k Flv
% 0F
TFSTFu T8
PATlFhTS Flv-
P0SlTlvF
% 0F luFhTlFlFu
Flv-P0SlTlvF T8
PATlFhTS STAkTFu
0h CPT
% 0F luFhTlFlFu
Flv-P0SlTlvF T8
PATlFhTS STAkTFu
0h AkT
huM8Fk 0F Flv-
P0SlTlvF PF0PLF
SCkFFhFu F0k T8
(TF0uSAhuS)
huM8Fk 0F Flv-
P0SlTlvF PF0PLF
Pk0vluFu wlTF lPT
(TF0uSAhuS)
AFk ;88 u6 ;6 6 1oz 61
AMk 8; u1 1; 6z ; u u.6
FMk u1 8.6 .6 u o z1 o.
Fuk zuu 86 u. zu z z 1z
SFAk 16 1u 1 ; z 1o o.
wPk 1 11 .1 6u 16 1o 1.6
C|eba| :6: z6 z :68
1AL 6
Btv testing, treatment Ier Btv-pesitive 1 patients and preventien eI 1 ameng peep|e |iving with Btv, by WB0 regien, zee
ftCUR o
Btv testing Ier 1 patients, zee
014
1549
5074
75
No data
Percentage of notified
TB cases with known
HIV status
z8 WB0 RP0R1 2010 (-0#"-56#&3$6-04*4$0/530-
Region in 2008. Te number of HIV-positive TB patients
enrolled on CPT and ART has been increasing in recent
years, especially since 2005 (FlCukF ). By 2009, almost
300 000 HIV-positive TB patients were started on CPT
and almost 140 000 were enrolled on ART. Almost 80%
of TB patients who were known to be HIV-positive were
started on CPT and almost 40% were enrolled on ART
(FlCukF 6, FlCukF ;). Further eforts are needed to
reach the Global Plan target of starting 100% of HIV-
positive TB patients on both CPT and ART by 2015.
Screening for TB among HIV-positive people and
providing IPT to those without active TB have steadily
increased, particularly since 2007 (FlCukF 8, FlCukF ).
In 2009, 1.7 million HIV-positive people were screened
for TB and close to 80 000 of those without active TB
were enrolled on IPT. Te numbers screened are equiva-
lent to about one third of the people living with HIV who
are on ART, about 10% of the people living with HIV who
are estimated to be in need of ART and about 5% of the
estimated total number of HIV-positive people world-
wide. Te numbers started on IPT are less than 1% of the
estimated number of people living with HIV. Intensifed
eforts are needed to approach the Global Plan target of
providing IPT to all those attending HIV care services
who are eligible for it by 2015.
o.6 Management eI drug-resistant 1
Globally, just over 30 000 cases of MDR-TB were noti-
fed to WHO in 2009, mostly by European countries and
South Africa (FlCukF 1o, TA8LF ;). Tis represents 12%
of the estimated number of cases of MDR-TB among all
notifed cases of pulmonary TB in 2009 (TA8LF ;). Coun-
try plans suggest that, overall, the numbers of patients
diagnosed with MDR-TB and started on treatment will
almost double in 2010 and 2011, compared with 2009
(FlCukF 1o). Substantial increases in the numbers of
patients diagnosed with MDR-TB and started on treat-
ment are expected in the three countries where the esti-
mated number of cases is highest: China, India and the
Russian Federation (TA8LF ;).
Tere has been an impressive increase in the share
of notifed cases enrolled on treatment in projects or
programmes approved by the Green Light Committee
(GLC), in which patients are known to be receiving treat-
ment according to international guidelines. Te number
reached around 11 000 in 2009, and is expected to rise
to over 30 000 in 2011 (approximately 60% of all noti-
fcations of MDR-TB that are projected by countries in
that year). Tis remains a small fraction of the estimated
number of TB patients who have MDR-TB (eighth col-
umn from right, TA8LF ;). Much more rapid expansion
of diagnosis and treatment within and outside projects
and programmes approved by the GLC is needed to
approach the targets for MDR-TB that are included in
the Global Plan (FlCukF 11).
National data on treatment outcomes among cohorts
ftCUR
Ce-trimexaze|e preventive therapy and antiretrevira|
therapy Ier Btv-pesitive 1 patients, zee-zee
N
u
m
b
e
r

o
f

T
B

p
a
t
i
e
n
t
s

(
t
h
o
u
s
a
n
d
s
)
2003 2004 2005 2006 2007 2008 2009
0
100
200
300
400
500
Tested HIV-positive
CPT
ART
ftCUR 6
Ce-trimexaze|e preventive therapy Ier Btv-pesitive
1 patients, zee-zee
a
a
humbers under years shcw the number cf ccuntrles repcrtlne data
fcllcwed by the percentaee cf tctal estlmated Flv-pcsltlve T8 cases
acccunted fcr by repcrtlne ccuntrles.
P
e
r
c
e
n
t
a
g
e

o
f

H
I
V
-
p
o
s
i
t
i
v
e

T
B

p
a
t
i
e
n
t
s
0
20
40
60
80
100
2003
27 (30%)
2004
24 (29%)
2005
39 (53%)
2006
55 (64%)
2007
73 (92%)
2008
86 (93%)
2009
63 (75%)
CPT
ftCUR
Antiretrevira| therapy Ier Btv-pesitive 1 patients,
zee-zee
a
a
fcllcwed by the percentaee cf tctal estlmated Flv-pcsltlve T8 cases
P
e
r
c
e
n
t
a
g
e

o
f

H
I
V
-
p
o
s
i
t
i
v
e

T
B

p
a
t
i
e
n
t
s
ART
2003
47 (9%)
2004
24 (25%)
2005
47 (55%)
2006
69 (64%)
2007
93 (85%)
2008
109 (96%)
2009
89 (80%)
0
20
40
60
80
100
8)03&1035 CL0AL 1URCUL05t5 C0k1R0L zo
ftCUR 8
tntensihed 1 case-hnding ameng Btv-pesitive peep|e,
zee-zee. The percentaee cf estlmated Flv-pcsltlve
pecple whc were screened fcr T8 ls shcwn abcve the
llne.
a

a
fcllcwed by the percentaee cf tctal estlmated Flv-pcsltlve pecple

N
u
m
b
e
r

o
f

p
e
o
p
l
e

s
c
r
e
e
n
e
d

(
t
h
o
u
s
a
n
d
s
)
2005
14 (35%)
2006
44 (49%)
2007
72 (59%)
2008
82 (66%)
2009
78 (71%)
0
400
800
1200
1600
2000
0.6%
1.0%
2.0%
4.4%
5.2%
ftCUR
tP1 previsien ameng Btv-pesitive peep|e, zee-zee
a
a
fcllcwed by the percentaee cf tctal estlmated Flv-pcsltlve pecple
wlthcut actlve T8 acccunted fcr by repcrtlne ccuntrles.
P
e
r
c
e
n
t
a
g
e

o
f

H
I
V
-
p
o
s
i
t
i
v
e

p
e
o
p
l
e

w
i
t
h
o
u
t

a
c
t
i
v
e

T
B
2005
10 (21%)
2006
25 (26%)
2007
42 (44%)
2008
43 (51%)
2009
41 (48%)
0
0.1
0.2
0.3
0.4
ftCUR :e
ketihed cases eI M0R-1 (zee-zee) and
prejected numbers eI patients te be enre||ed en
treatment (ze:e-ze::)
a
N
u
m
b
e
r

o
f

p
a
t
i
e
n
t
s

(
t
h
o
u
s
a
n
d
s
)
0
10
20
30
40
50
60
2005
(100)
2006
(107)
2007
(110)
2008
(128)
2009
(91)
2010
(83)
2011
(74)
19
23
30 29
31
50
52 non-GLC
GLC
Notified Projected
a
humbers under years shcw the number cf ccuntrles repcrtlne data.
ftCUR ::
ketihed cases eI M0R-1 (zee-zee) and prejected
numbers eI patients te be enre||ed en treatment
(ze:e-ze::) in the :o ceuntries inc|uded in the C|eba|
P|an (grey), and targets inc|uded in the C|eba| P|an
(ze::-ze:)
a
(b|ue). humbers are fcr smear and/cr culture-
pcsltlve cases cf Muk-T8.
N
u
m
b
e
r

o
f

p
a
t
i
e
n
t
s

(
t
h
o
u
s
a
n
d
s
)
2007 2008 2009 2010 2011 2012 2013 2014 2015
0
50
100
150
200
250
300
a
The updated verslcn cf the Clcbal Plan, ccverlne the years zo11-zo1,
was launched by the Stcp T8 Partnershlp ln 0ctcber zo1o.
ze WB0 RP0R1 2010 (-0#"-56#&3$6-04*4$0/530-
1AL
kumber eI M0R-1 cases estimated, netihed, enre||ed en treatment and expected te be treated,
z high M0R-1 burden ceuntries and WB0 regiens
FSTlMATFu %
0F ALL
hFw T8 CASFS
wlTF Muk-T8
a
FSTlMATFu %
0F ALL
kFTkFATFu T8 CASFS
wlTF Muk-T8
a
T0TAL huM8Fk
0F FSTlMATFu CASFS
0F Muk-T8
lh zoo8
a

(TF0uSAhuS)
FSTlMATFu CASFS
0F Muk-T8 AM0hC
h0TlFlFu CASFS 0F
PuLM0hAk T8
lh zoo
b
(A)
(TF0uSAhuS)
h0TlFlFu
CASFS
0F
Muk-T8
lh
zoo
(8)
h0TlFlFu
CASFS 0F
Muk-T8
AS % 0F
FSTlMATFu
CASFS 0F
Muk-T8
AM0hC
ALL
h0TlFlFu
CASFS 0F
PuLM0hAk
T8 (8/A)
c
CASFS
0F
Muk-T8
Fhk0LLFu
0h
TkFAT-
MFhT
lh
zoo
FXPFCTFu
huM8Fk 0F
CASFS 0F Muk-T8
T0 8F TkFATFu
8FST
d
L0w FlCF 8FST L0w FlCF 8FST L0w FlCF 8FST L0w FlCF zo1o zo11
Armenla
.u ;. 1z u 8 u o. o.u o.6 o.1; o.1u o.1 16 z - 8o 16o
Azerbal|an
zz 1 z6 6 z 6o u.o . u.; - - - - - - - -
8aneladesh
z.z o .6 1 o uo .8 1.o 1 .z o.8 ;. - - u68 1 11 ;;6
8elarus
1z o z uz 1z ;z o.8 o. 1. o.8 o.u 1.u - - - - -
8ulearla
1z o z uz 1z ;z o. o.1 o.8 - - - - - - - -
Chlna
.; .o 6.6 z6 z z8 1oo ; 1zo 66 u;u 1 u8 z1 6 ;o6
uk Ccnec
1.8 o u. ;.; o 18 .6 o. 11 z.o o.; u.z 1 z - -
Fstcnla
1 1z zo u z u o.o o.o; o.1z - - - - - - 8o 8o
Fthlcpla
1.6 o. z.; 1z 6.u z1 .z z.u 8.o 1.8 1.1 z.; z 1 88 ;u6
Cecrela
6.8 .z 8.; z; zu 1 o.; o.6 o.8 o.u o.z o.uo - - - - -
lndla
z. 1.8 z.8 1; 1 zo ; 1zo 66 ; 1 66o 1 16 8 ooo 1 ooo
lndcnesla
z.o o. 6. 1 o uo . o z1 .8 1.o 16 - - zo zo 1 ooo
Kazakhstan
1u 11 18 6 1 6z 8.1 6.u .; 6. . ;.z 6uu 6 1 16 u z1
Kyreyzstan
1z o z uz 1z ;z 1.u o.u z.u o.; o. 1. - - u zzo z1o
Latvla
1z . 1 z z uo o.1; o.1u o.zo - - - - - - 1 1uo
Llthuanla
.o ;. 11 u8 u z o. o.z; o. - - - - - - oo -
Myanmar
u.z .z .6 1o ;.1 1u . 6.u 1z u.u .u .u 81 1 6u 1z zoo
hleerla
1.8 o u. ;.; o 18 11 1. zo 1. o.6 . z8 1 - 8o o
Paklstan
z. o 8.o o ; 1 1.z z .8 z.; zz u 1 68 uoo 1 1oo
Phlllpplnes
u.o .o . z1 1 z 1 8. 1; 6.8 . 8. 1 o; 16 u1 1 uu z oou
kepubllc cf Mcldcva
1 1; zz 1 u z.1 1.; z.u 1. 1. 1.u zu ;1 - - -
kusslan Federatlcn
16 1z zo uz 8 u; 8 o u o z6 u ; o6z zu 8 1u 1z ooo -
Scuth Afrlca
1.8 1. z. 6.; . 8.1 1 1o 16 6.6 . ;.; ; u 111 u 1u ; o1 8 6uz
Ta|lklstan
1; 11 zu 6z ;o u.o z. .1 o. o.; 1.z 1 z - -
ukralne
16 1u 18 uu uo u 8.; 6.8 11 6.u .8 ;.1 8o8 1 - - -
uzbeklstan
1u 1o 18 o 6 6u 8.; 6. 11 z.6 z.1 .1 6u z u6u ;zo 1 o1o
vlet ham
z.; z.o .6 1 1 z . .8 8.1 .1 z. .8 z1; ; o; 6o 1o
Bigh M0R-1
burden ceuntries
. . o. z z: zo 8e e oe zze zee zoe z e :z : zo oz zo o zo
AFk 1. 1. 1.8 6.8 .; 8.1 6 11o zz 1 z6 8 ;8 uo 6 1u z 11 8z
AMk z.1 1.8 z.u 1z 11 1u 8.z ;. . . u.8 .8 z 86 u 1z8 zo 61
FMk z. o. .; z 1u u zu 11 81 1 6. z6 u6 u ;o; 1 16 z o6
Fuk 1z 1o 1 u1 8 uu 81 ; o o u6 u 1 816 z8 68 zo u ; 1;6
SFAk z. 1.8 .1 1; 1 1 1o 11o 1;o 8 ; z 6o z 16 8 1; o
wPk u.8 u.z .u z z1 z6 1zo 1oo 1uo ;1 6 ; z ooo 1 u1z ;z
C|eba| . .e .6 z: : zz ooe e :e ze ze ze e :z z :6 o 6ee : :o
- lndlcates data nct avallable.
a
See Multldrue and extenslvely drue-reslstant T8 'M/Xuk-T8]: zo1o elcbal repcrt cn survelllance and respcnse. wF0/FTM/T8/zo1o..
b
Calculated by applylne the best estlmate cf Muk tc the nctled cases cf pulmcnary T8 (a multlpller cf o. ls used tc determlne the number cf
pulmcnary cases expected tc be culture-pcsltlve lf tested).
c
Percentaee may exceed 1oo% as a result cf ccnservatlve estlmates cf Muk-T8 and/cr nctlcatlcn cf cases cf Muk frcm a prevlcus year.
d
8est, lcw and hleh lndlcate the pclnt estlmate and lcwer and upper bcunds cf the % uncertalnty lnterval.

8)03&1035 CL0AL 1URCUL05t5 C0k1R0L zz
ftCUR :
0iagnestic 051 Ier new and re-treatment 1 cases,
by WB0 regien, zee
a
%

o
f

n
e
w

c
a
s
e
s

t
e
s
t
e
d
AFR
(15)
AMR
(16)
EMR
(11)
EUR
b
(42)
SEAR
(3)
WPR
(11)
Total
(98)
AFR
(22)
AMR
(15)
EMR
(10)
EUR
b
(40)
SEAR
(6)
WPR
(11)
Total
(104)
0
10
20
30
40
0
10
20
30
40
%

o
f

r
e
-
t
r
e
a
t
m
e
n
t

c
a
s
e
s

t
e
s
t
e
d
a
The numbers under each bar shcw the number cf ccuntrles ln each
reelcn repcrtlne data.
b
uata fcr Fuk are frcm zoo8 (data fcr zoo were lnccmplete at the tlme
cf publlcatlcn due tc later deadllnes fcr repcrtlne).
of at least 200 patients are currently limited to nine
countries: Brazil, Kazakhstan, Peru, the Philippines, the
Republic of Moldova, Romania, South Africa, Turkey and
Uzbekistan (FlCukF 1z). Rates of treatment success are
variable, ranging from below 40% to almost 80%. High
rates of default are a common problem (with a median
value of 17%).
One of the most important constraints to rapid expan-
sion of diagnostic and treatment services for MDR-TB is
laboratory capacity. Without greater capacity to diagnose
MDR-TB, the number of cases diagnosed and treated will
remain low. Diagnostic testing for drug susceptibility, or
DST, among new cases of TB remains almost entirely
confned to the European Region and the Region of the
Americas (FlCukF 1). Even in these regions, however,
the percentage of previously treated patients who were
tested for drug resistance was less than 40%, far below
the target of testing all previously treated patients by
2015 that is included in the Global Plan.
Recent eforts to strengthen laboratory services,
under the umbrella of the Global Laboratory Initiative,
are highlighted in 80X 8.
While eforts to improve the diagnosis and treatment
of MDR-TB are urgently needed, the existence of MDR-TB
and XDR-TB also highlights the paramount importance
of preserving the efcacy of the few anti-TB medicines
currently used in TB treatment (80X ).
Limiting the number of cases of MDR-TB (and drug-
susceptible TB) also requires that proper measures for
infection control are in place. Tese measures include
personal protection (for example, masks), administra-
tive controls (for example, in waiting areas for people
attending outpatient services) and environmental meas-
ures such as ventilation systems. Te best indicator to
assess the quality of infection control is the ratio of the
notifcation rate of TB among health-care workers to
the notifcation rate among the general population. Tis
ratio should be approximately 1. Te data required to
calculate this indicator are requested on the WHO data
collection form, but to date the availability of reliable
data is limited. Collection and reporting of data on this
indicator need to be improved.
A total of 64 countries reported that training related
to infection control was done in 2009. For 35 countries,
this included training in tertiary (referral) hospitals.
Among 80 countries that provided data, 55 (69%) report-
ed having a focal point for infection control related to TB
in at least one of their tertiary hospitals. Of 75 countries
that provided data, 36 (48%) had performed an assess-
ment of the status of infection control for TB in at least
part of their network of tertiary hospitals in 2009.
ftCUR :z
1reatment eutcemes Ier patients with M0R-1 in
ceuntries, zee ceherts. The tctal number cf patlents
ln each cchcrt ls shcwn under each ccuntry.
a
P
e
r
c
e
n
t
a
g
e

o
f

c
o
h
o
r
t
Kazakhstan
(1609)
Turkey
(240)
Philippines
(296)
Peru
b
(670)
Uzbekistan
(330)
Republic
of Moldova
(254)
Brazil
(406)
South
Africa
(3815)
Romania
(707)
0
10
20
30
40
50
60
70
80
90
100
Successfully treated Died Failed Defaulted Not evaluated
a
0nly ccuntrles repcrtlne cutccmes fcr zoo cases cf Muk-T8 wlth zo%
patlents stlll cn treatment shcwn. Ccuntrles ranked by prcpcrtlcn
successfully treated (curedccmpleted).
b
uata fcr Peru are frcm zoo6.
zz WB0 RP0R1 2010 (-0#"-56#&3$6-04*4$0/530-
Peru
Haiti
Senegal
Cte dIvoire
Cameroon
DR Congo
Zambia
Swaziland
Lesotho
Djibouti
Ethiopia
Uganda
Kenya
UR Tanzania
India
Bangladesh
Myanmar
Viet Nam
Indonesia
Kazakhstan
Uzbekistan
Kyrgyzstan
Tajikistan
Azerbaijan
Belarus
Republic of Moldova
Georgia
2009: 6 countries
2010: 18 countries
2011: 3 countries
EXPAND-TB
recipient countries
Prclcneed, sustalned mentcrlne and technlcal suppcrt are prcvlded by Flhu and cther CLl partners tc develcp ln-
ccuntry labcratcry capaclty thrcueh tralnlne and mentcrshlp cf lccal labcratcry staff. Prceress refectlne dlfferent
mcdels fcr labcratcry strenethenlne ls lllustrated belcw uslne fcur ccuntry examples.
N Lesethe: an examp|e eI rapid techne|egy transIer. 8etween zoo; and zoo8, the natlcnal reference labcratcry was
establlshed, wlth apprcprlate blcsafety ccntalnment. ln zoo, mlcrcsccpy servlces were relnfcrced, culture and uST
servlces were lmplemented (lncludlne bcth sclld and llquld methcds), and mclecular llne-prcbe assays (LPAs) were
lntrcduced. Thls demcnstrates the feaslblllty cf transferrlne rapld technclcey ln rescurce-llmlted settlnes. Capaclty
tc test fcr Flv lnfectlcn was added tc the mclecular dlaencstlcs faclllty ln zoo, allcwlne early dlaencsls cf Flv lnfec-
tlcn ln lnfants. The equlpment requlred fcr thls was supplled by Flhu; tralnlne and prcclency testlne were prcvlded
by staff frcm the Centers fcr ulsease Ccntrcl ln Atlanta, uSA. kencvatlcn cf a reelcnal culture labcratcry beean ln
zo1o.
0X 8
5trengthening |aberatery services: CLt and XPAk0-1
ulaencsls cf Muk-T8 and lmprcved dlaencsls cf drue-susceptlble T8 requlre substantlal strenethenlne cf labcratcry
servlces ln many ccuntrles. Tc help tc address thls need, a netwcrk cf lnternatlcnal partners fcrmed the Clcbal
Labcratcry lnltlatlve (CLl) ln zoo8; the secretarlat ls hcsted by wF0's Stcp T8 uepartment. The CLl wcrks wlth hTPs,
ncn-ecvernmental creanlzatlcns, technlcal and nanclal partners, and wF0 cfces tc strenethen labcratcry servlces
and enccuraee the adcptlcn cf new dlaencstlc tccls cnce these have been endcrsed by wF0.
FXPAhu-T8 (Fxpandlne Access tc hew ulaencstlcs fcr T8) ls a ma|cr elcbal prc|ect that ls suppcrted by uhlTAlu,
wlth tctal fundlne cf uS$ 88 mllllcn. The ecal cf FXPAhu-T8 ls tc lmprcve capaclty tc dlaencse Muk-T8 ln uperaded
labcratcry servlces. Launched ln zoo8 and expected tc ccntlnue untll zo1, lt ccvers z; ccuntrles (MAP) lncludlne 1
cf the hleh Muk-T8 burden ccuntrles and 1o cf the zz F8Cs. Tareets lnclude the detectlcn cf 1o ooo patlents wlth
Muk-T8 and arcund 1 mllllcn cases cf drue-susceptlble T8. Transfer cf mcdern technclcey, use cf rapld tests and the
lnteeratlcn cf new tccls wlthln hTPs are emphaslzed.
FXPAhu-T8 ls bullt cn the fcundatlcn cf a strcne lnternatlcnal partnershlp. uhlTAlu prcvldes fundlne fcr essentlal
lnstruments, reaeents and supplles. The CLl develcps pcllcles and ncrms, ccnducts labcratcry assessments and
cn-slte mcnltcrlne, and develcps lndlcatcrs and tccls. The Fcundatlcn fcr lnncvatlve hew ulaencstlcs (Flhu) neectl-
ates wlth lndustry cn the prlce cf prcducts, ensures that custcmer suppcrt ls avallable, shares kncwledee ealned
ln the prcduct develcpment prccess, and cffers lcne-term and cnslte mentcrlne cf technclcey transfer. The Clcbal
urue Faclllty (CuF) cccrdlnates and manaees prccurement and dellvery, wcrks cn the prequallcatlcn cf dlaencstlcs
by wF0, and tceether wlth Flhu eneaees wlth lndustry tc neectlate affcrdable prlces and decreases ln prlces cver
tlme.
0X 9
nsuring the ratiena| use eI anti-1 medicines
ln zo1o, uu ccuntrles lncludlne 1 F8Cs repcrted that
rst-llne T8 medlclnes were avallable ln prlvate pharma-
cles. ln zz ccuntrles lncludlne 1z F8Cs, these medlclnes
were avallable wlthcut a prescrlptlcn. Scme seccnd-
llne drues are even mcre freely avallable, such as fuc-
rcqulnclcnes. Serlcus effcrts are requlred tc llmlt the
lrratlcnal use cf T8 medlclnes and thus prevent the
develcpment cf drue reslstance and ampllcatlcn, espe-
clally slnce the mlsuse cf these drues by multlple care
prcvlders has been well dccumented.
hatlcnal leelslatlcn tc ensure that medlclnes are cnly
avallable ln publlc and ncn-publlc health facllltles where
ratlcnal and standardlzed treatment cf T8 ls ln place ls
cne way tc reduce the mlsuse cf rst and seccnd-llne
drues. The capaclty cf natlcnal drue reeulatcry authcrl-
tles may have tc be strenethened fcr thls purpcse.
A rapld assessment cf reeulatcry apprcaches used tc
mlnlmlze the mlsuse cf rst-llne T8 medlclnes ln 8razll,
Chana, lndla, the unlted kepubllc cf Tanzanla and Zam-
bla ln zoo prcvlded valuable lnslehts lntc the dlfferent
strateeles that ccuntrles have used tc date. ln 8razll,
rst-llne T8 medlclnes have never been avallable ln prl-
vate pharmacles and, wlth unlnterrupted avallablllty ln
the publlc sectcr free-cf-charee, a prlvate market has
nct develcped. ln the absence cf any fcrmal leelslatlcn,
Chana and the unlted kepubllc cf Tanzanla have alsc
been successful ln restrlctlne prccurement and dlstrlbu-
tlcn cf T8 medlclnes sc that they are cnly avallable tc
the hTP. Tc a ereat extent, thls has alsc been achleved
ln Zambla. ln these three ccuntrles, T8 medlclnes are
cnly dlstrlbuted tc prlvate, hC0 cr cther health faclll-
tles that are kncwn tc fcllcw the natlcnal euldellnes
and ccmply wlth reccrdlne and repcrtlne requlrements.
Manaelne the dlstrlbutlcn cf T8 medlclnes ln thls way
alsc helps tc enccuraee ccllabcratlcn between the hTP
and cther care prcvlders.
The prlvate sectcr ln lndla ls prcbably the bleeest
prlvate scurce cf T8 medlclnes ln the wcrld. Manaee-
ment cf T8 patlents ln the prlvate sectcr ls kncwn tc
be cf uneven quallty and lt ls cften pcsslble tc buy T8
medlclnes and cther antlblctlcs ln prlvate pharmacles
wlthcut a prescrlptlcn. Tc address thls sltuatlcn wlthln
lndla's federal structure requlres ereater ccllabcratlcn
between aeencles respcnslble fcr drue reeulatlcn at
central and state levels.
Fffectlve reeulatlcn cf the sale and use cf T8 medlclnes,
especlally ln ccuntrles where a dcmestlc pharmaceutl-
cal lndustry ls present, requlres ccncerted effcrt and
ccllabcratlcn amcne Mlnlstrles cf Fealth, drue reeula-
tcry authcrltles, the pharmaceutlcal lndustry, pharmacy
asscclatlcns, asscclatlcns cf health prcfesslcnals and
clvll scclety.
0X 8 $POUJOVFE
N thiepia: an examp|e eI |aberatery integratien. Twc central labcratcrles (lncludlne the natlcnal reference labcra-
tcry) and ve reelcnal labcratcrles have been strenethened and ncw have capaclty tc rapldly test fcr Muk-T8 uslne
mclecular technlques (LPAs). wlth fundlne frcm PFPFAk (the uS Presldent's Fmereency Plan fcr AluS kellef ), these
labcratcrles are alsc ccnductlne Flv testlne uslne mclecular methcds, shcwlne the feaslblllty cf lnteerated labcra-
tcry servlces fcr T8 and Flv. Thls mcdel wlll be pursued fcr all FXPAhu-T8 ccuntrles wlth a hleh-burden cf T8 and
Flv.
N tndia: an examp|e eI |aberatery sca|e-up Ier diagnesis eI M0R-1. A tctal cf u labcratcrles are belne streneth-
ened. These lnclude natlcnal reference labcratcrles, lntermedlate reference labcratcrles, publlc health labcratcrles
and labcratcrles ln medlcal cclleees. Llquld culture and LPAs are belne lntrcduced and staff capaclty strenethened
(thcueh a Clcbal Fund erant fcr whlch Flhu ls a sub-reclplent).
N Myanmar: an examp|e eI pe|itica| cemmitment. 0ne central labcratcry and cne reelcnal labcratcry are belne
strenethened. hew equlpment has been lnstalled, and the ecvernment has refurblshed bcth labcratcrles and prc-
vlded fundlne fcr tralnlne cf labcratcry technlclans. Thls ccmmltment frcm the ecvernment shculd help tc ensure
the sustalnablllty cf labcratcry servlces.
za WB0 RP0R1 2010 (-0#"-56#&3$6-04*4$0/530-
0X 10
0eve|eping human reseurces: an integra| cempenent eI the 5tep 1 5trategy
Fffectlve T8 ccntrcl depends cn hlrlne, tralnlne, deplcylne, mctlvatlne and manaelne sufclent numbers cf health
wcrkers - and ensurlne that they have the apprcprlate prcfesslcnal ccmpetencles - at all levels cf the prlvate and
publlc health systems. Thls ls a ma|cr challenee ln many ccuntrles wlth a hleh burden cf T8. ln zoo6, wF0 estlmated
that ; ccuntrles were faclne a crltlcal shcrtaee cf health wcrkers.
1
Amcne these ccuntrles, 6 (6%) were ln the
Afrlcan keelcn, lncludlne eleht F8Cs (the uemccratlc kepubllc cf the Ccnec, Fthlcpla, Kenya, Mczamblque, hleerla,
ueanda, the unlted kepubllc cf Tanzanla and Zlmbabwe).
The sectlcn cn human rescurce develcpment (Fku) ln the zo1o elcbal T8 data ccllectlcn fcrm requested lnfcrma-
tlcn abcut three maln varlables: (l) the percentaee cf establlshed pcsltlcns
z
that were vacant at the end cf zoo at
perlpheral-level health care unlts, fcr fcur key cateecrles cf health wcrker; (ll) the percentaee cf staff emplcyed ln
perlpheral-level health care unlts whc were tralned by the hTP ln zoo, fcr the same fcur cateecrles cf staff; and
(lll) the percentaee cf staff emplcyed ln perlpheral-level health care unlts whc had been tralned by the hTP at any
tlme, fcr the same fcur cateecrles cf health wcrker.
The ccmpleteness cf repcrtlne ls summarlzed ln the
table (rleht).
Amcne the nlne F8Cs ln the Afrlcan keelcn, twc repcrt-
ed ccmplete data and twc repcrted nc data; fcr the ve
ccuntrles fcr whlch data were lnccmplete, the mlsslne
data related tc the status cf tralnlne. wlth eleht cf these
F8Cs amcne the ; ccuntrles faclne crltlcal shcrtaees cf
health staff, lncludlne three that are ln the llst cf z; hleh
Muk-T8 burden ccuntrles, lack cf cr lnsufclent data cn
Fku cculd be a ma|cr cbstacle tc scallne up lnterven-
tlcns acccrdlne tc the tareets set ln strateelc plans. hlne
cf the zz F8Cs as well as a hleh prcpcrtlcn cf all ccun-
trles dld nct repcrt any data cn "tralnlne ccveraee",
even thcueh thls ls a ma|cr prceramme actlvlty and cne
that has lncreased ccnslderably wlth the avallablllty cf
funds frcm dcncrs such as the Clcbal Fund and uSAlu.
Slnce zoo6, a bcx tc ccllect data cn stafne and tralnlne
has been lncluded ln the reccrdlne and repcrtlne fcrms
reccmmended by wF0. The llmlted avallablllty cf data
sueeests that, ln mcst ccuntrles, these data are nct yet rcutlnely ccllected cr analysed by hTPs. uata cn stafne at
the perlpheral level cculd be cbtalned frcm the Fuman kescurces fcr Fealth (FkF) departments cf the Mlnlstrles cf
Fealth (cr slmllar structures), althcueh cbservatlcns durlne prceramme revlews and cther ccuntry mlsslcns cften
sueeest that ccllabcratlcn between FkF departments and hTPs ls weak.
The ndlnes fcr the 1 ccuntrles that repcrted ccmplete data are summarlzed belcw.
kFCl0h (huM8Fk
0F MFM8Fk
C0uhTklFS)
huM8Fk 0F
C0uhTklFS
TFAT kFP0kTFu
C0MPLFTF uATA
0h Fku (% 0F
kFCl0hAL T0TAL)
huM8Fk 0F
C0uhTklFS TFAT
kFP0kTFu S0MF
uATA 0h Fku
(% 0F kFCl0hAL
T0TAL)
huM8Fk 0F
C0uhTklFS TFAT
ulu h0T kFP0kT
Ah uATA 0h Fku
(% 0F kFCl0hAL
T0TAL)
Afrlcan (u6) 1z (z6%) 1 (z8%) z1 (u6%)
Amerlcas (6) (z%) z (6%) z (6%)
Fastern
Medlterranean
(zz)
1 (%) (1u%) 6 (z;%)
Furcpean () o 8 (1%) u (8%)
Scuth-Fast
Asla (11)
u (6%) u (6%) (z;%)
western
Paclc (6)
1 (6%) (8%) zo (6%)
humber cf
hleh-burden
ccuntrles (cut
cf zz)
; (z%) 1o (u%) (z%)
1eta| (zeo) : (z%) (:6%) :ze (%)

STAFF CATFC0k
huM8Fk 0F C0uhTklFS
% 0F P0STS vACAhT,
zoo
% 0F STAFF TkAlhFu
8 hTP, zoo
% 0F STAFF TkAlhFu
8 hTP AT Ah TlMF
o% 1o-o% 1o% 1o% 1o-o% o% 1o% 1o-o% o%
Medlcal cfcer 1 z; 1u 1 zu 8 8
hurses (lncludlne reelstered nurses, reelstered
mldwlves, enrclled nurses, enrclled mldwlves)
zz z6 1 1o z8 ; 1o u
Fealth asslstants/medlcal asslstants/cllnlcal cfcers 16 o 16 11 zu 1 z
Labcratcry technlclans/mlcrcsccplst ; 16 z8 11 1u z6 u 11 6
Ccmplete and accurate data cn Fku are an essentlal basls fcr ensurlne that the pecple needed tc lmplement all ccm-
pcnents cf the Stcp T8 Strateey are avallable. Thls requlres updatlne cf rcutlne T8 reccrdlne and repcrtlne systems
tc lnclude data cn stafne and tralnlne. 8ulldlne cn these data, ereater ccllabcratlcn amcne hTPs, Mlnlstry cf Fealth
departments respcnslble fcr health wcrkfcrce manaeement and elcbal lnltlatlves such as the Clcbal Feath wcrkfcrce
Alllance are then needed tc ensure that the necessary staff are recrulted and retalned.
1
1he wcrld heclth repcrt 2cc6 - wcrkinc tccether [cr heclth. Ceneva, wcrld Fealth 0reanlzatlcn, zoo6.
z
These pcsltlcns can be multl-purpcse cr speclc tc T8 ccntrcl.
z
. Flnanclne fcr T8 ccntrcl
.: Bigh-burden ceuntries
T
he funding available for TB control in the 22 HBCs
has increased year-on-year since 2002, with the
exception of a small dip in 2009, and is expected to reach
US$ 3.0 billion in 2011 (FlCukF 1u, FlCukF 1, FlCukF
16). Most of this funding has been used to support DOTS
implementation, although the share for MDR-TB (mostly
accounted for by funding in the Russian Federation and
South Africa) has increased since 2007 (FlCukF 1u). Te
relatively small amount of funding reported for collabo-
rative TB/HIV activities refects the fact that funding
for most of these interventions is channelled through
national HIV programmes and nongovernmental organ-
izations rather than via NTPs. National governments
are the largest source of funding (FlCukF 1), account-
ing for 85% of total expected funding in 2011. Financing
from the Global Fund has become increasingly impor-
tant since 2004, and is expected to reach US$ 327 mil-
lion in 2011 (a 10% increase compared with 2010). Other
donor funding is expected to amount to approximately
US$ 100 million in 2011. In absolute terms, 61% of the
funding expected in 2011 is accounted for by just two
countries: the Russian Federation and South Africa (FlC-
ukF 16).
Despite increases in funding and nine completed
rounds of proposals
1
to the Global Fund, NTPs continue
to report funding gaps (FlCukF 1;). Since 2007, these
gaps have been in the range of US$ 0.30.5 billion per
year. In 2011, funding gaps are anticipated for all com-
ponents of the Stop TB Strategy, including for DOTS (the
basic package that underpins the Stop TB Strategy). In
some countries, there are still funding gaps for supplies
of frst-line anti-TB drugs.
Trends in funding for the 22 HBCs as a whole conceal
important variations among countries (TA8LF 8, FlCukF
18, FlCukF 1). Both NTP budgets and funding of NTPs
have been increasing in most countries; the exceptions
include Kenya, Indonesia and Mozambique, where fund-
ing has fallen since 2008 (FlCukF 18). Funding has been
closest to keeping pace with increases in NTP budgets
in Brazil, China, India, the Philippines and the Russian
Federation. In contrast, funding gaps have persisted in
most African countries as well as Cambodia, Myanmar
and Pakistan. In 2011, the Russian Federation, Tailand,
Brazil, South Africa, China, the Philippines and Viet Nam
will rely primarily on domestic funding (including loans
from development banks). In other HBCs, there is much
greater reliance on donor funding, ranging from around
ftCUR :
funding avai|ab|e Ier 1 centre| by seurce eI Iunding,
zz high-burden ceuntries, zeez-ze::
1.5
1.6
1.9
2.0
2.2
2.5
2.6
2.5
2.8
3.0
Unknown
a
Global Fund
Grants (excluding
Global Fund)
Loans
Government,
general health-
care services
(excluding loans)
Government,
NTP budget
(excluding loans)
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
U
S
$

b
i
l
l
i
o
n
s

(
c
o
n
s
t
a
n
t

2
0
1
0

U
S
$
)
b
0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
a
unkncwn scurce applles cnly tc a pcrtlcn cf the budeet fcr Muk-T8
hcspltals ln Scuth Afrlca.
b
See fcctncte
b
cf FlCukF 1u and MFTF0uS.
ftCUR :o
funding avai|ab|e Ier 1 centre| by |ine item, zz high-
burden ceuntries, zeez-ze::
U
S
$

b
i
l
l
i
o
n
s

(
c
o
n
s
t
a
n
t

2
0
1
0

U
S
$
)
b
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
1.5
1.6
1.9
2.0
2.2
2.5
2.6
2.5
2.8
3.0
General health-
care services:
MDR-TB
a
General health-
care services:
DOTS
a
OR/surveys/other
PPM/PAL/
ACSM/CBC
TB/HIV
MDR-TB
DOTS
a
These twc cateecrles shcw fundlne fcr cutpatlent vlslts and lnpatlent
care prcvlded ln eeneral (ncn T8-speclc) cllnlcs and hcspltals. Thls
fundlne ls nct prcvlded thrcueh hTP budeets. The cther cateecrles
shcwn ln the eure are funded thrcueh and repcrted as part cf hTP
budeets.
b
Ccnstant zo1o uS$ means that the amcunts shcwn fcr each year refect
thelr value ln zo1o. ln cther wcrds, chanees between years refect real
chanees ln fundlne, after ad|ustment fcr chanees ln prlces (lnfatlcn).
See alsc MFTF0uS.
1
Te frst round was completed in 2003. Round 9 was completed
(including decisions on which proposals would be approved for
funding) in 2009.
z6 WB0 RP0R1 2010 (-0#"-56#&3$6-04*4$0/530-
1AL 8
k1P budgets, avai|ab|e Iunding, cest eI uti|izatien eI genera| hea|th-care services and teta| 1 centre| cests,
zz high-burden ceuntries, ze:: (U55 mi||iens)
a

hTP
8uuCFT
AvAlLA8LF FuhulhC
FuhulhC
CAP
C0ST 0F
uTlLlZATl0h
0F CFhFkAL
FFALTF-CAkF
SFkvlCFS
T0TAL T8
C0hTk0L
C0STS
c
C0vFkhMFhT
(FXCLuulhC
L0AhS) L0AhS
CkAhTS
(FXCLuulhC
CL08AL Fuhu) CL08AL Fuhu
Afehanlstan z. o o o.8 z.o o u.o 6.
8aneladesh u 1 o o z o u.o u
8razll 61 u o z.; u.o .u u1 1oz
Cambcdla 8 1.o o ;.6 u.6 z . uz
Chlna u o6 o o 88 o.1 o u
uk Ccnec 6z o. o 8.8 .u u o.6 6
Fthlcpla ; 8.u o 1u 8. 6.o 1z u
lndcnesla u 16 o 8. z8 u1 z 11;
lndla 1u; . z6 1 66 o uu 11
Kenya u6 .; 1. o.1 o uo . 1
Myanmar z1 o.6 o 1.8 1o 8. 1.u zz
Mczamblque o o o o .z z6 8.z 8
hleerla 8 6. o . 1u 1z 1u z
Paklstan 8 1u o u.u z u; ;.; 6
Phlllpplnes
b
- - - - - - z; -
kusslan Federatlcn 1 z 1 z1z o 1.u . 1 1 z8
Scuth Afrlca z81 z81 o o o o z8z 6
Thalland 6 8 o o 1.o u.o z.z 6
uk Tanzanla u 8.1 o . 6. 11 1.u 6
ueanda z o.1 1. o. .z 1 o. z
vlet ham 1z 6.z o o. u.; o zo z
Zlmbabwe z1 o o o.6 ;. 1 z. z
Bigh-burden ceuntries z e : 88 z 86 z8 ez
a
Amcunts shcwn ln ccnstant zo1o uS$, fcr ccnslstency wlth cther eures presented ln thls repcrt.
b
uata fcr the Phlllpplnes were under revlew at the tlme thls repcrt went tc press.
c
Tctal T8 ccntrcl ccsts are based cn fundlne requlred as cppcsed tc fundlne actually avallable. The dlfference between tctal T8 ccntrcl ccsts and the
sum cf avallable fundlne and the ccst cf utlllzatlcn cf eeneral health-care servlces ls the fundlne eap.
ftCUR :
funding gaps reperted by k1Ps, zz high-burden ceuntries,
a

zee6-ze::
a
Ccuntrles repcrtlne nc eap cr a neeatlve eap acrcss all llne ltems are
excluded.
b
See fcctncte
b
153
411
310
472
270
337
OR/surveys
ACSM/CBC/
PPM/PAL
TB/HIV
MDR-TB
DOTS, excluding
first-line drugs
DOTS, first-line
drugs
U
S
$

m
i
l
l
i
o
n
s

(
c
o
n
s
t
a
n
t

2
0
1
0

U
S
$
)
b
0
100
200
300
400
500
2006 2007 2008 2009 2010 2011
ftCUR :6
funding avai|ab|e Ier 1 centre| by ceuntry,
zz high-burden ceuntries, zeez-ze::
1.5
1.6
1.9
2.0
2.2
2.5
2.6
2.5
2.8
3.0
Russian
Federation
South Africa
China
India
Brazil
All other HBCs
U
S
$

b
i
l
l
i
o
n
s

(
c
o
n
s
t
a
n
t

2
0
1
0

U
S
$
)
a
0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
a
See fcctncte
b
8)03&1035 CL0AL 1URCUL05t5 C0k1R0L zj
ftCUR :8
k1P budgets and avai|ab|e Iunding, zz high-burden ceuntries, zeez-ze::.
a
The dashed vertlcal llne lndlcates zoo6, the
year ln whlch the Stcp T8 Strateey and the Clcbal Plan tc Stcp T8, zoo6-zo1 were launched.

22 HBCs Afghanistan Bangladesh Brazil Cambodia
China DR Congo Ethiopia India Indonesia
Kenya Mozambique Myanmar Nigeria Pakistan
Philippines Russian Federation South Africa Thailand Uganda
UR Tanzania Viet Nam Zimbabwe
6
34
2002 2005 2008 2011
30
21
9
20
2002 2005 2008 2011
13
13
2002 2005 2008 2011
18
10
2
21
14
43
43
43 1258
1227
704
1286
273
273
258
413
2
23
2002 2005 2008 2011
20
4
5
46
38
12
3
32
31
1
21
14
8
7
63
2002 2005 2008 2011
47
52
37
28
54
35
5
88
50
394
239
208
19
64
8
64
6
39
31
39
45
147
112
112
12
94
71
45
931
2819
2536
2248
0
21
5
5
9
45
25
25
17
64
59
63
3
38
14
36
U
S
$

m
i
l
l
i
o
n
s

(
c
o
n
s
t
a
n
t

2
0
1
0

U
S
$
)
b
NTP budget
Available funding
8
a
Caps ln trend llnes cccur when data are nct
repcrted tc wF0. The numbers shcwn cn each
eure are nal budeets fcr zo1o, the mcst recent
year fcr whlch nal budeet data are avallable.
b
See fcctncte
b
z8 WB0 RP0R1 2010 (-0#"-56#&3$6-04*4$0/530-
ftCUR :
5eurces eI Iunding Ier 1 centre|, zz high-burden ceuntries, ze:e
40% of available funding in India to more than 90% of
available funding in the Democratic Republic of the Con-
go (FlCukF 1).
Tere is also considerable variation in the estimated
cost per patient treated according to the DOTS strat-
egy (FlCukF zo). Tis ranges from under US$ 100 (in
Bangladesh, India, Myanmar, Pakistan and Zimbabwe)
to around US$ 750 in Tailand, US$ 10001500 in Bra-
zil and South Africa and more than US$ 7 500 in the
Russian Federation. In most HBCs, the cost per patient
treated under DOTS is around US$ 150400. As shown
in FlCukF zo, variation in the cost per patient treated
is clearly related to income levels (for example, Brazil
and South Africa are upper-middle income countries,
where prices for inputs such as NTP staf and hospi-
tal care are higher than in low-income countries). Te
major reason why the Russian Federation is an outlier
is the model of care used: high costs are associated with
a policy of lengthy hospitalization of TB patients with-
in an extensive network of TB hospitals and sanatoria.
A further explanation for variation in costs appears to
be the scale at which treatment is provided. Te coun-
tries with relatively low costs for their income level (for
example, Bangladesh, China, India, Indonesia and the
Philippines) are also the countries where the total num-
bers of patients treated are highest (as shown by the size
of the circles in FlCukF zo). A similar pattern exists for
the cost per patient successfully treated, which combines
information about both costs and efectiveness (FlCukF
z1).
1
Tis analysis is for the 22 HBCs and a subset of 85 other countries
that are among the 149 countries considered in the Global Plan. Te
total funding available in the group of 107 countries for which data
were available was adjusted upwards according to the fraction of
cases for which they accounted, to allow direct comparison with the
group of 149 countries considered in the Global Plan. Te Global
Plan excludes high-income countries.
.z Bigh-burden ceuntries and ether ceuntries
Besides the 22 HBCs, 81 other countries have reported
fnancial data to WHO since 2006 that allow assessment
of trends in funding for TB control. Combined, these 103
countries account for 96% of the worlds notifed cases
of TB. Funding for TB control has grown from US$ 3.9
billion in 2006 to a projected US$ 4.7 billion in 2011
(FlCukF zz, FlCukF z). As in HBCs, the largest share
of funding is for DOTS implementation; an increasing
amount is for MDR-TB. National governments account
for 86% of the funding expected in 2011, followed by
the Global Fund (US$ 513 million, or 11% of total fund-
ing) and then by grants from donors besides the Global
Fund (US$ 101 million, or 2%). Loans from development
banks account for the remaining 1% of total funding. Te
funding gaps reported by these 103 countries amount to
US$ 0.6 billion in 2010 and US$ 0.3 billion in 2011 (FlC-
ukF zz).
A comparison of the funding available in the coun-
tries that reported fnancial data with the funding
requirements set out in the Global Plan is provided, by
region and for the period 20112015, in FlCukF zu.
1

Overall, funding falls short of the requirements of the
Global Plan. Te gap is approximately US$ 1 billion in
2011. Given the scale-up of interventions set out in the
plan, this could increase to US$ 3 billion by 2015 with-
out intensifed eforts to mobilize more resources.
Internal sources
Government, NTP budget
(excluding loans)
Government, general
health-care services
(excluding loans)
Loans
External sources
Grants (excluding
Global Fund)
Global Fund
% of total available funding
DR Congo
Bangladesh
Zimbabwe
Myanmar
Uganda
Cambodia
UR Tanzania
Afghanistan
Ethiopia
Nigeria
Mozambique
Pakistan
Kenya
Indonesia
India
Viet Nam
Philippines
China
South Africa
Brazil
Thailand
Russian Federation
0 10 20 30 40 50 60 70 80 90 100
8)03&1035 CL0AL 1URCUL05t5 C0k1R0L zo
ftCUR ze
Cest per 0015 patient treated, inceme |eve| and case|ead, zz high-burden ceuntries, zee.
The ccst per patlent treated ln zoo uS$
a
ls shcwn belcw each clrcle. The slze cf the clrcle ls
prcpcrtlcnal tc the number cf nctled cases. The erey area deplcts the % ccndence lnterval
cf the predlctlcn cf the llnear mcdel, ln whlch each ccuntry was elven equal welehtlne.
a
The ccst per u0TS patlent treated ls based cn a -year averaee cf expendltures,
zoo;-zoo, tc mlnlmlze dlstcrtlcns asscclated wlth ncn-annual expenses cn ltems
such as bulldlnes, equlpment and buffer stccks cf drues.
C
o
s
t

p
e
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s
c
a
l
e
)
GNI per capita (logarithmic scale)
4
6
8
10
5 6 7 8 9
R
2
=0.58
AFGHANISTAN
BANGLADESH
BRAZIL
CHINA
DR CONGO
ETHIOPIA
INDONESIA
INDIA
KENYA
CAMBODIA
MYANMAR
UR TANZANIA NIGERIA
PAKISTAN
PHILIPPINES
RUSSIAN FEDERATION
THAILAND
UGANDA
VIET NAM
SOUTH AFRICA
185
44
1204
203
169
139
164
83
164
250
52
346
92
241
7678
756
222
140
334
1186
86
ZIMBABWE
MOZAMBIQUE 227
ftCUR z:
Cest per smear-pesitive patient successIu||y treated, inceme |eve| and case|ead, zz high-burden
ceuntries, zee8. The ccst per patlent successfully treated ln zoo8 uS$
a
ls shcwn belcw each
clrcle. The slze cf the clrcle ls prcpcrtlcnal tc the number cf smear-pcsltlve patlents whc were
successfully treated. The erey area deplcts the % ccndence lnterval cf the predlctlcn cf the
llnear mcdel, ln whlch each ccuntry was elven equal welehtlne.
a
The ccst per smear-pcsltlve patlent successfully treated ls based cn a -year averaee
cf expendltures, zoo6-zoo8, tc mlnlmlze dlstcrtlcns asscclated wlth ncn-annual
expenses cn ltems such as bulldlnes, equlpment and buffer stccks cf drues.
R
2
=0.55
C
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(
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)
GNI per capita (logarithmic scale)
4
6
8
10
5 6 7 8 9
12 939
117
194
212
194
247
47
198
181
154
311
1662
90
171
1341
858
232
192
91
75
438
AFGHANISTAN
BANGLADESH
BRAZIL
CHINA
DR CONGO
ETHIOPIA
INDONESIA
INDIA
KENYA
CAMBODIA
MYANMAR
UR TANZANIA
NIGERIA
PAKISTAN
PHILIPPINES
RUSSIAN FEDERATION
THAILAND
UGANDA
VIET NAM
SOUTH AFRICA
ZIMBABWE
MOZAMBIQUE 367
e WB0 RP0R1 2010 (-0#"-56#&3$6-04*4$0/530-
. tmpreving the qua|ity eI p|anning and
budgeting Ier 1 centre|
Te quality of fnancial data reported to WHO has stead-
ily improved since data were frst collected in 2002. At
the same time, reported budgets and expenditures are
not always consistent from one year to the next; assess-
ments of the funding required particularly for newer
components of TB control (such as management of
drug-resistant TB) can appear too low (or, less often,
too high); and persistent funding gaps indicate a need to
strengthen resource mobilization eforts based on con-
ftCUR z
funding avai|ab|e Ier 1 centre| by seurce eI Iunding
and Iunding gap, zz high-burden ceuntries and 8: ether
ceuntries,
a
zee6-ze::
Gap
Unknown
c
Global Fund
Grants (excluding
Global Fund)
Loans
Government,
general health-
care services
(excluding loans)
Government,
NTP budget
(excluding loans)
U
S
$

b
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s

(
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2
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1
0

U
S
$
)
b
0
1
2
3
4
5
6
2006 2007 2008 2009 2010 2011
4.0
4.6
5.0
5.3
5.1
5.0
a
These ccuntrles acccunt fcr 6% cf the tctal number cf drue-
susceptlble T8 cases nctled elcbally ln zoo.
b
See fcctncte
b
c
unkncwn scurce applles cnly tc a pcrtlcn cf the budeet fcr Muk-T8
hcspltals ln Scuth Afrlca.
ftCUR zo
funding avai|ab|e Ier 1 centre|, ze:e-ze:: and Iunding needed accerding te the C|eba| P|an, ze::-ze:
a
ftCUR zz
funding avai|ab|e Ier 1 centre| by |ine item and Iunding
gap, zz high-burden ceuntries and 8: ether ceuntries,
a

zee6-ze::
U
S
$

b
i
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i
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s

(
c
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n
s
t
a
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2
0
1
0

U
S
$
)
b
0
1
2
3
4
5
6
4.0
4.6
5.0
5.3
5.1
5.0
Gap
General health-
care services:
MDR-TB
General health-
care services:
DOTS
OR/surveys/other
PPM/PAL/
ACSM/CBC
TB/HIV
MDR-TB
DOTS
2006 2007 2008 2009 2010 2011
a
These ccuntrles acccunt fcr 6% cf the tctal number cf drue-
susceptlble T8 cases nctled elcbally ln zoo.
b
See fcctncte
b
vincing plans and well-justifed budgets. Te WHO TB
planning and budgeting tool was developed in 2006, to
assist with the development of comprehensive plans and
budgets for all relevant components of TB control. When
completed, one advantage of the tool is that it automati-
cally summarizes NTP budgets and sources of funding
in the format requested on the annual WHO TB data col-
lection form. Successes in using the tool to help with the
development and budgeting of strategic plans in Bang-
ladesh, Cambodia and Mongolia between mid-2009 and
mid-2010 are highlighted in 80X 11.
a
Fundlne avallable ln the 1u Clcbal Plan ccuntrles was estlmated uslne budeet data repcrted by 1o; ccuntrles that represent 8% cf drue-susceptlble
T8 cases and ;% cf Muk-T8 cases ln zoo. Fundlne avallable ln zo11 ls based cn prellmlnary budeets that may dlffer frcm nal data that wlll
be repcrted ln zo11. Fcr u0TS and Muk-T8, avallable fundlne lncludes the estlmated ccst cf eeneral health-care servlces fcr bcth lnpatlent and
cutpatlent treatment under exlstlne mcdels cf care. Fundlne needed ls deplcted as an area tc refect uncertalnty abcut epldemlclcelcal and ccst
prc|ectlcns.
b
The Clcbal Plan excludes hleh-lnccme ccuntrles; therefcre, the ercuplnes cf Furcpe, kest cf the wcrld and wcrld all exclude hleh-lnccme ccuntrles.
c
Fcr the purpcses cf the Clcbal Plan, Furcpe lncludes: Armenla, Azerbal|an, 8ulearla, 8elarus, Fstcnla, Cecrela, Kazakhstan, Kyreyzstan, Llthuanla,
Latvla, kepubllc cf Mcldcva, kcmanla, kusslan Federatlcn, Ta|lklstan, Turkmenlstan, ukralne and uzbeklstan.
d
Abcut 6z% cf the fundlne avallable fcr Muk-T8 ln the kest cf the wcrld ls acccunted fcr by Scuth Afrlca.
Europe
b,c
Rest of the World
b
World
b
0
2000
4000
6000
8000
10 000
U
S
$

m
i
l
l
i
o
n
s

(
n
o
m
i
n
a
l
)
2010 2015 2010 2015 2010 2015
Available Needed
Total
DOTS
MDR-TB
d
Laboratories
TB/HIV
0X 11
5trengthening p|anning and budgeting using the WB0 1 P|anning and udgeting tee|:
experiences Irem ang|adesh, Cambedia and Menge|ia
The wF0 T8 plannlne and budeetlne tccl was develcped ln zoo6, tc asslst wlth the develcpment cf ccmprehenslve
plans and budeets fcr all relevant ccmpcnents cf T8 ccntrcl.
1
when ccmpleted, cne advantaee ls that lt autcmatl-
cally summarlzes hTP budeets and scurces cf fundlne ln the fcrmat requested cn the annual wF0 T8 data ccllectlcn
fcrm.
8y mld-zo1o, hTP staff frcm z8 cf the 6 ccuntrles that are ln the llst cf zz F8Cs and/cr z; hleh Muk-T8 burden
ccuntrles had been tralned tc use the tccl and/cr had already used lt. Fere, we hlehlleht hcw the tccl was used tc
help wlth the develcpment and budeetlne cf strateelc plans ln 8aneladesh, Cambcdla and Mcneclla between mld-
zoo and mld-zo1o.
#BOHMBEFTI
8aneladesh ls an F8C and alsc ln the llst cf z; hleh Muk-T8 burden ccuntrles. T8 ccntrcl ls a tcp prlcrlty ln the
natlcnal health aeenda. The hTP ccllabcrates wlth multlple partners tc lmplement T8 ccntrcl. Twc laree hC0s - 8kAC
and the uamlen Fcundatlcn - manaee the lmplementatlcn cf T8 ccntrcl ln deslenated parts cf the ccuntry. untll
zo1o, plannlne and budeetlne fcr T8 ccntrcl was carrled cut separately by each cf the partners lnvclved. Thls made
lt dlfcult fcr bcth the hTP and dcncrs tc have a ccmprehenslve and accurate cvervlew cf the tctal fundlne needed
fcr T8 ccntrcl each year. 0ne ccnsequence was that cnly partlal nanclal data were repcrted tc wF0 each year, thus
underestlmatlne the tctal fundlne requlrements and expendltures. ln May zo1o, the hTP hcsted a wcrkshcp wlth
all cf lts ma|cr lmplementatlcn partners, wlth the alm cf develcplne a ccmprehenslve ve-year plan fcr the years
zo11-zo1 that wculd refect the nanclal needs cf the T8 prceramme as a whcle. The wF0 T8 plannlne and budeet-
lne tccl was used tc set cut the plan tareets, the ma|cr lnputs and actlvltles tc be lmplemented by all partners and
the fundlne requlrements. The results at the end cf the
wcrkshcp are lllustrated ln the eure (see rleht).
The ccmprehenslve ve-year plan and budeet are ncw
used as a wcrklne dccument durlne cccrdlnatlcn meet-
lnes cf the hTP and lts partners, and fcrm the basls fcr
submlsslcn cf prcpcsals tc dcncrs. kevlew and rene-
ment cf the budeet (fcr example tc ldentlfy areas where
dupllcatlcn may exlst amcne actlvltles cr tc lnclude
new actlvltles) wlll need tc be undertaken cn a perlcdlc
basls.
$BNCPEJB
ln zoo, detalled plans fcr dlfferent ccmpcnents cf the Stcp T8 Strateey were develcped. Subsequently, the hTP
asked Manaeement Sclences fcr Fealth (MSF) and wF0 tc prcvlde asslstance wlth budeetlne these plans, ln cccrdl-
natlcn wlth staff frcm natlcnal and prcvlnclal levels. A cne-week tralnlne ccurse ln the use cf the wF0 T8 plannlne
and budeetlne tccl (ln Khmer and Fnellsh) was creanlzed ln September zoo, whlch allcwed partlclpants tc develcp
thelr skllls ln budeetlne and prcmpted further revlew cf the ccntent cf plans. After the wcrkshcp, the multl-year
budeet was updated and ls belne used as a basls fcr rescurce mcblllzatlcn.
.POHPMJB
The hTP was keen tc develcp a lcne-term nanclne plan tc strenethen natlcnal T8 ccntrcl effcrts, partlcularly ln the
ccntext cf a hleh burden cf Muk-T8 and an lnsufclent number cf hcspltal beds fcr patlents wlth Muk-T8. ln February
zo1o, hTP staff used the wF0 T8 plannlne and budeetlne tccl tc prcduce a ccmprehenslve plan and budeet fcr the
years zo1o-zo1, wlth facllltatlcn prcvlded by wF0 staff frcm F0 and the Ccuntry 0fce. ln llne wlth the mcdel cf
care descrlbed ln the natlcnal strateelc plan, a detalled plan and budeet was develcped tc lncrease bed capaclty fcr
patlents wlth Muk-T8. The strateey fcr dclne thls was tc lncrease the use cf cutpatlent treatment fcr patlents wlth
drue-susceptlble T8, thus freelne up the necessary number cf beds (after the establlshment cf apprcprlate lnfectlcn
ccntrcl measures) fcr patlents wlth Muk-T8. The hTP then went cn tc use the wF0 T8 plannlne and budeetlne tccl
tc ccst alternatlve mcdels cf care. ln dclne sc, they demcnstrated the relatlve affcrdablllty cf the natlcnal strateelc
plan, whlch helped tc bulld pclltlcal suppcrt fcr lts lmplementatlcn. The hatlcnal Centre fcr Ccmmunlcable ulseases
ls expected tc prcceed wlth the plan tc lncrease cutpatlent treatment fcr drue-susceptlble T8, as well as bcth ln-
and cutpatlent treatment fcr Muk-T8. ln addltlcn, the plan and budeet can ncw be used fcr rescurce mcblllzatlcn
thrcueh a hatlcnal Strateey Appllcatlcn tc the Clcbal Fund. A further advantaee ls that the Mlnlstry cf Fealth ls ncw
better equlpped tc neectlate wlth the Mlnlstry cf Flnance durlne thelr prceramme-based budeetlne prccess - nct
|ust fcr hleher levels cf fundlne, but alsc fcr mcre predlctable streams cf fundlne.
U
S
$

m
i
l
l
i
o
n
s
General health-
care services
Other
MDR-TB
Programme
management
and supervision
HRD: Staff,
technical
assistance and
training
First-line drugs
Improving
diagnosis
0
10
20
30
40
50
60
70
2011 2012 2013 2014 2015
1
http://www.whc.lnt/tb/dcts/plannlne_budeetlne_tccl/en/lndex.html
z
6. Prceress tcwards elcbal tareets fcr
reductlcns ln dlsease burden
P
rogress made towards achieving the impact targets
set for 2015 to halt and reverse the incidence of TB
by 2015 (MDG Target 6.c), and to halve prevalence and
mortality rates compared with a baseline of 1990 (the
targets set by the Stop TB Partnership) is illustrated
at the global level in FlCukF z and at the regional level
in FlCukF z6, FlCukF z; and FlCukF z8.
1
Progress in
achieving reductions in incidence and mortality is shown
for each of the 22 HBCs in FlCukF z and FlCukF o.
Globally, rates of incidence, prevalence and mortality
are all declining (FlCukF z). Incidence rates are falling
slowly, at around 1% per year, following a peak at just
over 140 cases per 100 000 population in 2004. If cur-
rent trends are sustained, then MDG Target 6.c will be
achieved. Mortality rates have fallen by one third since
1990, and prevalence rates are also in decline. Projec-
tions suggest that the target of halving mortality by
2015 compared with 1990 could be achieved at global
level. Te target of halving the prevalence rate appears
out of reach. It should be noted, however, that there is
more uncertainty about trends in prevalence, compared
with trends in mortality (see also AhhFX 1).
Regionally, incidence rates are declining in fve of
WHOs six regions (FlCukF z6). Te exception is the
South-East Asia Region (where the incidence rate is sta-
ble), largely explained by apparent stability in the TB
incidence rate in India. Further evaluation of trends
in the disease burden in India is needed, and has been
ftCUR z
C|eba| trends in case netihcatien rates and estimated rates eI incidence, merta|ity and preva|ence. Left: Clcbal trends
ln case nctlcatlcn rate (new and relapse cases, all fcrms) (black), estlmated lncldence rate lncludlne Flv-pcsltlve T8
(blue) and estlmated lncldence rate cf Flv-pcsltlve T8 (erey). Centre and rleht: Trends ln estlmated T8 mcrtallty and
prevalence rates 1o-zoo and fcrecast T8 mcrtallty and prevalence rates zo1o-zo1. The hcrlzcntal dashed llnes
represent the Stcp T8 Partnershlp tareets cf a o% reductlcn ln mcrtallty and prevalence rates by zo1 ccmpared wlth
1o. Shaded areas represent uncertalnty bands. Mcrtallty excludes T8 deaths amcne Flv-pcsltlve pecple.
R
a
t
e

p
e
r

1
0
0

0
0
0

p
o
p
u
l
a
t
i
o
n
140
120
100
80
60
40
20
0
35
30
25
20
15
10
5
0
300
250
200
150
100
50
0
1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015 1990 1995 2000 2005
Incidence and notifications Mortality Prevalence
planned for early 2011. Among the fve regions where
incidence rates are falling, the rate of decline varies from
less than 1% per year in the Eastern Mediterranean and
European regions to around 2% per year in the African
Region (since 2004) and 4% per year in the Region of
the Americas. As also illustrated in FlCukF z6, notifca-
tions are closest to estimated incidence in the Region of
the Americas and the European Region, indicating that
the highest rates of case detection are achieved in these
regions (see also SFCTl0h u). As incidence falls slowly,
notifcations are increasing in the African Region and
(particularly since 2000) in the Eastern Mediterranean
and South-East Asia regions, indicating improving rates
of case detection. In the Western Pacifc Region, notif-
cations increased sharply between 2002 and 2006, but
have since stabilized; here, patterns are strongly infu-
enced by China, which accounts for almost 70% of inci-
dent cases in this region (TA8LF 1).
Te latest assessment for the 22 HBCs suggests that
incidence rates are falling or stable in all countries
except South Africa (FlCukF z). Trends in incidence
rates are assumed to be stable in Afghanistan, Bangla-
desh, India, Indonesia, Myanmar and Pakistan, in the
absence of convincing evidence to the contrary (AhhFX
1). Te stability in TB incidence rates in India (which
accounts for 61% of cases in this region) as well as Bang-
ladesh, Indonesia and Myanmar explains the fat trend
in estimated incidence in the South-East Asia Region.
1
See 80X in SFCTl0h of this report for defnitions of the global
targets for TB control.
8)03&1035 CL0AL 1URCUL05t5 C0k1R0L
ftCUR z
1rends in estimated 1 preva|ence rates :e-zee and Ierecast 1 preva|ence rates, ze:e-ze:, by WB0 regien. Shaded
areas represent uncertalnty bands. The hcrlzcntal dashed llnes represent the Stcp T8 Partnershlp tareet cf a o%
reductlcn ln the prevalence rate by zo1 ccmpared wlth 1o. The cther dashed llnes shcw prc|ectlcns up tc zo1.
1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015
500
400
300
200
100
0
400
300
200
100
0
R
a
t
e

p
e
r

1
0
0

0
0
0

p
o
p
u
l
a
t
i
o
n
400
300
200
100
0
120
100
80
60
40
20
0
120
100
80
60
40
20
0
600
500
400
300
200
100
0
Africa The Americas Eastern Mediterranean
Europe South-East Asia Western Pacific
ftCUR z6
stimated incidence and case netihcatien rates by WB0 regien, :e-zee. keelcnal trends ln case nctlcatlcn rates
(new and relapse cases, all fcrms) (black), estlmated lncldence rate lncludlne Flv-pcsltlve T8 (blue) and estlmated
lncldence rate cf Flv-pcsltlve T8 (erey). Shaded areas represent uncertalnty bands.
1990 1995 2000 2005 1990 1995 2000 2005 1990 1995 2000 2005
140
120
100
80
60
40
20
0
300
200
100
0
60
50
40
30
20
10
0
60
50
40
30
20
10
0
200
150
100
50
0
150
100
50
0
R
a
t
e

p
e
r

1
0
0

0
0
0

p
o
p
u
l
a
t
i
o
n
a WB0 RP0R1 2010 (-0#"-56#&3$6-04*4$0/530-
ftCUR z8
1rends in estimated 1 merta|ity rates :e-zee and Ierecast 1 merta|ity rates, ze:e-ze:, by WB0 regien.
Fstlmated T8 mcrtallty excludes T8 deaths amcne Flv-pcsltlve pecple. Shaded areas represent uncertalnty bands.
a

The hcrlzcntal dashed llnes represent the Stcp T8 Partnershlp tareet cf a o% reductlcn ln the mcrtallty rate by zo1
ccmpared wlth 1o. The cther dashed llnes shcw prc|ectlcns up tc zo1.
1990 1995 2000 2005 2010 2015
R
a
t
e

p
e
r

1
0
0

0
0
0

p
o
p
u
l
a
t
i
o
n
60
50
40
30
20
10
0
15
10
5
0
10
8
6
4
2
0
60
50
40
30
20
10
0
40
30
20
10
0
40
30
20
10
0
1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015
In most of the HBCs, notifcations have been getting
closer to estimated incidence in recent years, notably in
Afghanistan, Bangladesh, Cambodia, China, Indonesia,
Pakistan, South Africa and the United Republic of Tan-
zania (FlCukF z).
Prevalence rates are falling in all six WHO regions (FlC-
ukF z;). Te most impressive progress is in the Region
of the Americas, where the Stop TB Partnerships target
of halving the 1990 prevalence rate has been achieved.
Projections suggest that the Western Pacifc and Eastern
Mediterranean regions are on track to achieve the target
by 2015, and the European Region could get close. On
current projections, the African and South-East Asian
regions will not achieve the target.
Mortality rates (excluding TB deaths among HIV-
positive people) are falling in all six WHO regions. Te
best progress towards the 2015 target of halving the
1990 mortality rate is in the Region of the Americas and
the Western Pacifc Region, both of which appear to have
achieved the target already. Te Eastern Mediterranean,
European and South-East Asia regions are close to reach-
ing the target, and could do so before 2015. In the Afri-
can Region, achieving the target appears out-of-reach,
following a major increase in TB incidence and mortality
rates associated with the HIV epidemic throughout the
1990s and up to around 2004.
Among the 22 HBCs, mortality rates appear to be
falling with the possible exception of Afghanistan and
Uganda (FlCukF o). Even allowing for uncertainty in
these estimates, four countries reached the target of
halving the 1990 mortality rate by 2009 (Brazil, Cam-
bodia, China and the United Republic of Tanzania), and
six additional countries (India, Indonesia, Kenya, Myan-
mar, Pakistan and the Russian Federation) have a good
chance of doing so by 2015. In the other HBCs, current
forecasts suggest that the target may not be achieved.
Te reductions in mortality associated with progress
to date in implementing the DOTS strategy (19952006)
and its successor, the Stop TB Strategy (launched in
2006) have saved millions of lives since 1995, and con-
tinued implementation could save millions more in the
years up to 2015 (FlCukF 1).
1
From 1995 to 2009, 49
1
Tese results are based on the following manuscript: Glaziou P et
al. Lives saved by tuberculosis control and prospects for achiev-
ing the 2015 global target for reductions in tuberculosis mortality
(submitted for publication in May 2010).
a
The wldth cf uncertalnty bands narrcws as the prcpcrtlcn cf reelcnal mcrtallty estlmated uslne vltal reelstratlcn reccrds lncreases.
8)03&1035 CL0AL 1URCUL05t5 C0k1R0L
ftCUR z
stimated incidence and case netihcatien rates, zz high-burden ceuntries, :e-zee. Trends ln case nctlcatlcn rates
a

(new and relapse cases, all fcrms) (black), estlmated lncldence rates (blue) and estlmated lncldence rates cf Flv-pcsltlve
T8 (erey). Shaded areas represent uncertalnty bands.
a
Caps ln trend llnes cf nctlcatlcn rates cccur when
data are nct repcrted tc wF0.
1990 1995 2000 2005 1990 1995 2000 2005
1990 1995 2000 2005 1990 1995 2000 2005 1990 1995 2000 2005
0
50
100
150
200
250
0
200
400
600
800
0
50
100
150
200
0
100
200
300
0
50
100
150
0
50
100
150
200
250
0
50
100
150
200
250
300
0
100
200
300
400
0
100
200
300
400
500
0
100
200
300
400
500
0
50
100
150
200
250
0
100
200
300
400
0
100
200
300
400
500
0
200
400
600
800
0
100
200
300
400
500
0
100
200
300
400
500
0
50
100
150
1000
1000
0
50
100
150
200
250
0
50
100
150
200
250
300
0
20
40
60
80
100
120
0
200
400
600
0
50
100
150
R
a
t
e

p
e
r

1
0
0

0
0
0

p
o
p
u
l
a
t
i
o
n
Afghanistan Bangladesh Brazil Cambodia China
DR Congo Ethiopia India Indonesia Kenya
Mozambique Myanmar Nigeria Pakistan Philippines
Russian Federation South Africa Thailand Uganda UR Tanzania
Viet Nam Zimbabwe
million patients were treated, of whom 41 million were
successfully treated in DOTS programmes, saving up to 6
million lives. Tis includes approximately 2 million lives
saved among women and children. From 2010 to 2015,
a further 5 million lives could be saved if current eforts
and levels of achievement in TB control are sustained,
including around 2 million women and children. With
expansion of treatment for MDR-TB and interventions
such as ART for HIV-positive TB patients in the period
20112015, as set out in the Global Plan, even more lives
could be saved.
6 WB0 RP0R1 2010 (-0#"-56#&3$6-04*4$0/530-
ftCUR e
1rends in estimated 1 merta|ity rates :e-zee and Ierecast 1 merta|ity rates ze:e-ze:, zz high-burden ceuntries.
Fstlmated T8 mcrtallty excludes T8 deaths amcne Flv-pcsltlve pecple. Shaded areas represent uncertalnty bands.
The hcrlzcntal dashed llnes represent the Stcp T8 Partnershlp tareet cf a o% reductlcn ln the mcrtallty rate by zo1
ccmpared wlth 1o. The cther dashed llnes shcw prc|ectlcns up tc zo1.
0
20
40
60
80
0
20
40
60
80
100
120
0
20
40
60
80
0
10
20
30
40
50
60
0
10
20
30
40
50
60
70
0
20
40
60
80
100
120
0
20
40
60
80
100
0
50
100
150
200
0
20
40
60
80
0
20
40
60
80
100
0
5
10
15
0
10
20
30
40
70
0
20
40
60
80
0
10
20
30
40
0
50
100
150
200
0
20
40
60
80
0
20
40
60
80
120
0
50
100
150
0
10
20
30
40
0
10
20
30
40
50
60
0
10
20
30
40
50
60
0
10
20
30
40
1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015
1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015 1990 1995 2000 2005 2010 2015
100
50
60
100
R
a
t
e

p
e
r

1
0
0

0
0
0

p
o
p
u
l
a
t
i
o
n
Afghanistan Bangladesh Brazil Cambodia China
DR Congo Ethiopia India Indonesia Kenya
Mozambique Myanmar Nigeria Pakistan Philippines
Russian Federation South Africa Thailand Uganda UR Tanzania
Viet Nam Zimbabwe
ftCUR :
stimated number eI |ives saved :6-zee
and Ierecast number eI |ives saved, ze:e-
ze:. Shaded areas represent uncertalnty
bands. Fcrecast expected values (dashed
llnes) were predlcted by ttlne lce-llnear
mcdels cf tlme-serles fcr the years zoo6-
zoo.
A
n
n
u
a
l

n
u
m
b
e
r

o
f

l
i
v
e
s

s
a
v
e
d

(
m
i
l
l
i
o
n
s
)
0.0
0.2
0.4
0.6
0.8
1.0
0.05
0.00
0.05
0.10
0.15
0.20
0.25
0.0
0.2
0.4
0.6
0.8
1.0
1.2
2000 2005 2010 2015
HIV-negative
HIV-positive
Total
j
;. lmprcvlne measurement cf the
elcbal burden cf T8
F
stimates of TB incidence, prevalence and mortality
and their trend (presented in TA8LF 1 and in FlC-
ukFS z-o) are based on the best available data and
analytical methods. Methods were updated in 2009 fol-
lowing 18 months of work by an expert group convened
under the umbrella of the WHO Global Task Force on
TB Impact Measurement.
1
Improvements to methods
(full details are provided in AhhFX 1) include systematic
documentation of expert opinion and how this has been
used in estimates of the burden of disease caused by TB,
simplifcation of models,
2
updates to parameter values
based on the results of systematic reviews, much greater
use of mortality data from vital registration systems (89
countries for the analyses presented in this report, up
from three in the years up to 2008) and systematic docu-
mentation of uncertainty.
Despite this progress, estimates of the disease burden
need to be further improved in the period up to 2015
(and beyond) using better surveillance systems, more
extensive and in-depth analysis of available surveil-
lance and programmatic data, and additional survey
data. For example, with the exception of Eritrea in 2005,
the last nationwide and population-based surveys of
the prevalence of TB disease in the African Region were
undertaken between 1957 and 1961; only around 10%
of TB-attributable deaths (in HIV-negative people) are
recorded in vital registration systems and reported to
WHO; and most notifcation systems are recording only
around 5070% of estimated cases.
Besides its work on reviewing and updating the meth-
ods that are used to produce estimates of the burden of
disease caused by TB, the WHO Global Task Force on TB
Impact Measurement is thus making concerted eforts
to support countries to pursue two other major strategic
tracks of work (full details are available in a recent WHO
Policy Paper
3
). Tese are:
N Surveys of the prevalence of TB disease, with particu-
lar attention to 21 global focus countries (FlCukF
z). Tese surveys should be carried out according to
WHO guidelines and related Task Force recommenda-
tions;
N Strengthening surveillance of cases and deaths
through notifcation and vital registration systems.
Te ultimate goal is for TB incidence and mortality
to be measured directly from these systems. Te Task
Force has defned a conceptual framework for this
work (FlCukF ) and related tools to help countries
to implement it in practice.
As of mid-2010, all of the countries in the South-East
Asia and Western Pacifc regions where prevalence sur-
veys are recommended (Bangladesh, Cambodia, China,
Indonesia, Myanmar, the Philippines, Tailand and Viet
Nam) were on track with survey implementation. Bangla-
desh (2008), the Philippines (2007) and Viet Nam (2007)
recently completed surveys, and subsequent surveys are
planned close to 2015. Te most notable successes in
2009/2010 among Asian countries were the completion
of nationwide surveys in Myanmar (in April 2010; see
80X 1z) and China (in July 2010). Te results of these
surveys will be of major importance for gaining a better
understanding of the burden of disease (both countries)
and the impact of TB control in the past two decades (in
China, following previous surveys in 1990 and 2000).
Looking forwards, a survey will be implemented in
Cambodia in 2011, following a previous survey in 2002.
Tis will allow assessment of the impact of TB control
since 2002 i.e. the years since DOTS was implemented. A
survey is in the advanced stages of preparation in Tai-
land, and in Indonesia a follow-up to the 2004 survey is
planned for 2013 or 2014.
In the Eastern Mediterranean Region, Pakistan
secured full funding for a survey in 2008, but security
concerns and other factors that afect feld operations
may preclude implementation.
Te greatest challenge in terms of implementation of
prevalence surveys is in the African Region. Nonetheless,
considerable progress was made during 2009 and 2010.
As of July 2010, fve countries were in a strong position to
start surveys in late 2010 or early 2011 (Ethiopia, Ghana,
Nigeria, Rwanda and the United Republic of Tanzania).
Preparations were relatively advanced in Kenya, Malawi,
Uganda, Zambia and South Africa, although funding
gaps remained a major bottleneck in Kenya (dependent
on the approval of funding from a Round 9 grant from
the Global Fund), Uganda (where reprogramming of Glo-
bal Fund grants is needed) and Zambia (where full fund-
ing had been secured but the subsequent suspension of
a Global Fund grant now impedes progress). Intensive
eforts are needed to ensure that countries planning sur-
veys in 2010 and 2011 are able to do so successfully.
In 2009 and 2010, there was substantial progress in
1
For further details, see the Task Force web site at: http://www.
who.int/tb/advisory_bodies/impact_measurement_taskforce/en/
index.html. Te review is also the basis for the TB component of
the forthcoming update to the Global Burden of Disease, due for
publication in 2010.
2
For example, some parameter values are now estimated only at glo-
bal level or for regions, rather than for each country individually.
3
TB impact measurement: policy and recommendations for how to assess
the epidemiological burden of TB and the impact of TB control. Gene-
va, World Health Organization, 2009 (Stop TB policy paper no. 2;
WHO/HTM/TB/2009.416).
8 WB0 RP0R1 2010 (-0#"-56#&3$6-04*4$0/530-
ftCUR z
1he z: g|eba| Iecus ceuntries where a natiena| survey eI the preva|ence eI 1 disease is recemmended in the
peried zee8-ze: (b|ue), and the z additiena| ceuntries that meet criteria (grey) Ier imp|ementing such surveys
ftCUR
framewerk Ier assessment eI 1 survei||ance data (netihcatien and vita| registratien data)
uATA 0uALlT
TkFhuS
uc survelllance data refect
trends ln lncldence and
mcrtallty:
AkF ALL CASFS Ahu
uFATFS CAPTukFu lh
SukvFlLLAhCF uATA:
Ccmpleteness
hc dupllcatlcns, nc mlsclasslcatlcns
lnternal and external ccnslstency
Analyse tlme-chanees ln nctlcatlcns
and deaths alcneslde chanees ln e.e.
case-ndlne, case denltlcns, Flv
prevalence and cther determlnants
"0nlcn" mcdel
lnventcry studles
Capture re-capture studles
Prevalence surveys
lnncvatlve cperatlcnal research
nctlcatlcns - lncldence
vk mcrtallty data - deaths
lMPk0vF survelllance system
FvALuATF trends and lmpact cf T8
ccntrcl
uPuATF estlmates cf T8 lncldence and
mcrtallty
tI apprepriate, CR1tf 1 survei||ance data as
a direct measure eI 1 incidence and merta|ity
8)03&1035 CL0AL 1URCUL05t5 C0k1R0L o
analysing surveillance and programmatic data, with
analyses used to develop recommendations for how
surveillance systems need to be strengthened and to
produce updated estimates of disease burden. Regional
workshops to apply the Task Force framework (FlCukF
) for systematic assessment of surveillance data were
held in the Eastern Mediterranean, European, South-
East Asia and Western Pacifc regions and the Region
of the Americas. Country missions in which the frame-
work was applied were undertaken in the Philippines,
the United Republic of Tanzania and Viet Nam. By July
2010, these workshops and country missions had cov-
ered a total of 70 countries (FlCukF u). A workshop
for 17 countries in the African Region is scheduled for
December 2010.
An important conclusion from workshops and country
missions was that there is an urgent need to strengthen
vital registration systems, to allow better measurement
of mortality (80X 1). Tere is also an urgent need to
introduce electronic recording and reporting systems,
without which it is difcult or impossible to adequately
assess many aspects of data quality. Examples of aspects
of data quality that are difcult or impossible to assess
0X 12
tmp|ementing a natiena| survey eI the preva|ence eI 1 disease: a success stery Irem Myanmar
The u0TS strateey was lntrcduced ln Myanmar ln the late 1os. Case nctlcatlcns lncreased rapldly and by
zoou were hleher than the estlmated number cf lncldent cases publlshed by wF0 ln 1 (the estlmate remalned
unchaneed ln subsequent years as a result cf the lack cf any new data tc re-estlmate the burden cf T8). Tc better
understand the burden cf dlsease caused by T8, the hTP declded that a natlcnal survey cf the prevalence cf T8
dlsease was needed.
lnltlally, a subnatlcnal survey was lmplemented ln the capltal dlvlslcn cf anecn. Thls shcwed that the prevalence cf
T8 was three tlmes the latest natlcnal estlmate. lt alsc shcwed that cne thlrd cf the T8 patlents whc were cn treat-
ment were belne treated by eeneral practltlcners, and cnly z% by facllltles wlth hTP servlces. The patlents whc
were recelvlne treatment frcm eeneral practltlcners were nct reccrded ln rcutlne survelllance data. Subsequently,
the hTP and the Myanmar Medlcal Asscclatlcn wcrked tceether tc strenethen partnershlps between the publlc and
prlvate sectcrs, lncludlne thrcueh franchlslne schemes. Subsequently, prlvate sectcr facllltles beean tc nctlfy cases
tc the hTP, and the hTP ncw supplles antl-T8 medlclnes tc prlvate practltlcners.
The hTP then mcblllzed the fundlne needed fcr a natlcnal survey frcm multlple dcncrs. These lncluded the Three
ulseases Fund, the Ccvernment cf lapan, the 8lll and Mellnda Cates Fcundatlcn and uSAlu. Several technlcal part-
ners were lnvclved, lncludlne wF0, Pcpulatlcn Servlces lnternatlcnal and the kesearch lnstltute fcr T8 - klT - ln
lapan. The purchase cf capltal equlpment and the develcpment cf human rescurce capaclty durlne the pllct survey
ln anecn helped tc leveraee fundlne and lnterest, by ccnvlnclne nanclal and technlcal partners that scme cf the
crltlcal rescurces and capaclty were already ln place.
The natlcnal survey was lnltlated ln lune zoo, and was ccmpleted ln Aprll zo1o. As thls repcrt went tc press, pre-
llmlnary results were expected ln late zo1o.
without case-based and electronic reporting systems
include the extent to which misclassifcations and dupli-
cations exist. In addition, the availability of electronic
data, stored in well-managed relational databases (not
Excel spreadsheets), greatly facilitates data analysis.
More widespread adoption of updated recommendations
on recording and reporting is also required (for example,
to ensure availability of data disaggregated by HIV sta-
tus and source of referral).
An example of experience with implementing a case-
based and electronic recording and reporting system
(from China) in provided in 80X 1u.
Besides improving estimates of the disease burden
caused by TB, better data from surveys and surveillance
combined with better analysis of these data should be of
great value in identifying where and why cases are not
being detected. In turn, fndings should help to identify
which components of the Stop TB Strategy need to be
introduced or scaled-up to improve TB control. Examples
from Cambodia, Myanmar and Viet Nam are highlighted
in the second edition of WHOs guidelines on surveys of
the prevalence of TB disease.
1
1
Te second edition of these guidelines (following publication of
the frst edition in 2007) has been produced as a major collabora-
tive efort among technical and fnancial partners and lead survey
investigators from Asian and African countries. Te guidelines
were in the late stages of preparation at the time this report went
to press, with publication expected before the end of 2010.
ae WB0 RP0R1 2010 (-0#"-56#&3$6-04*4$0/530-
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Pregress in app|ying the 1ask ferce Iramewerk Ier assessment eI 1 survei||ance data, as eI mid-ze:e
a
a
All ccuntrles shcwn ln blue partlclpated ln reelcnal wcrkshcps held frcm Aprll zoo8 tc lune zo1o, wlth the exceptlcn cf the unlted kepubllc cf
Tanzanla where a ccuntry mlsslcn was undertaken ln 0ctcber zoo. Further detalls cf the wcrk dcne ln these wcrkshcps are prcvlded ln AhhFX 1.
0X 13
5trengthening vita| registratien systems Ier accurate measurement and ana|ysis eI 1 merta|ity
The lncldence cf T8 cannct be measured accurately wlth currently avallable dlaencstlc tccls, and the prevalence cf
T8 dlsease wlll be measured thrcueh pcpulatlcn-based surveys ln nc mcre than apprcxlmately zo ccuntrles by zo1.
T8 mcrtallty - the thlrd cf the ma|cr lndlcatcrs fcr whlch elcbal tareets have been set wlthln the MuCs and by the
Stcp T8 Partnershlp - can be measured dlrectly, prcvlded that natlcnal vltal reelstratlcn systems are ln place, wlth
causes cf death ccded acccrdlne tc the lnternatlcnal Classlcatlcn cf ulseases.
Accurate reccrdlne cf mcrtallty levels, trends and causes cf death ls an essentlal publlc eccd. vltal reelstratlcn een-
erates ccntlnucus data representatlve cf entlre pcpulatlcns, lncludlne cause-speclc estlmates cf mcrtallty, trends
and reelcnal dlfferentlals.
ln zoo, o ccuntrles lncludlne fcur F8Cs had well-functlcnlne vltal reelstratlcn systems, acccrdlne tc the fcllcwlne
denltlcn: (l) ccveraee cf at least 8o% cf the pcpulatlcn and (ll) lll-dened causes cf death fcr zo% cf all reelstered
deaths. Mcst cf these o ccuntrles are ln the Furcpean keelcn and the keelcn cf the Amerlcas (AhhFX 1).
keelstratlcn cf clvll events such as blrths and deaths ls an essentlal rst step fcr ccuntrles plannlne tc establlsh
vltal reelstratlcn systems. Thls shculd lnltlally be dcne ln sample areas and then rclled-cut tc the rest cf the ccuntry.
Sample vltal reelstratlcn and pcst-census mcrtallty surveys ccupled wlth verbal autcpsy can be used as an lnterlm
sclutlcn fcr eeneratlne natlcnally representatlve data abcut mcrtallty levels and causes cf deaths.
Tc allcw accurate measurement and analysls cf mcrtallty due tc T8 and cther causes ln all ccuntrles, the develcp-
ment and strenethenlne cf standardlzed reelstratlcn systems and/cr valldated lnterlm measurement systems need tc
feature much hleher cn the elcbal aeenda. hatlcnal ecvernments and the elcbal health ccmmunlty shculd lntenslfy
effcrts tc lmplement vltal reelstratlcn systems and/cr tc lmprcve thelr ccmpleteness and quallty ln all ccuntrles.
8)03&1035 CL0AL 1URCUL05t5 C0k1R0L az
0X 14
tmpreving 1 survei||ance threugh an e|ectrenic and case-based recerding and reperting system Ier 1:
China's experience
The hatlcnal Center fcr Tuberculcsls Ccntrcl and Preventlcn, whlch ls part cf the Chlnese Center fcr ulsease Ccntrcl
and Preventlcn, lntrcduced a case-based and electrcnlc reccrdlne and repcrtlne system fcr T8 ln zoou. The system ls
llnked tc the system fcr survelllance cf all lnfectlcus dlseases, and captures data cn T8 patlents as well as lnfcrma-
tlcn cn actlvltles asscclated wlth hTP manaeement (lncludlne drue manaeement, tralnlne, supervlslcn and nanc-
lne). ln llne wlth new repcrtlne requlrements, data cn Flv status and drue reslstance are avallable fcr T8 patlents,
and T8 amcne mlerants and ln the prlscn sectcr speclcally can be dlstlneulshed.
4USFOHUITSTUWFSTJPO
Streneths cf the rst verslcn cf the system lntrcduced ln zoou lncluded the avallablllty cf lndlvldual-level and real-
tlme data fcr all T8 patlents; data were llnked tc the lnfectlcus dlseases survelllance system and llnkaees cculd be
made between the datasets; and tables tc summarlze ma|cr results cculd be autcmatlcally prcduced. The system
helped tc lncrease the referral and repcrtlne cf cases by hcspltals (see alsc 80X ;).
8FBLOFTTFTSTUWFSTJPO
The lnltlal deslen cf the system resulted ln tcc much data belne ccllected. ln turn, the wcrklcad fcr staff was tcc
hleh and the lnternet server was cverlcaded. Manaeers thcueht that the autcmated cutputs that cculd be prcduced
were tcc llmlted and that the system was relatlvely lnfexlble. lt was alsc ncted that data cn Flv, M/Xuk-T8 and T8
amcne mlerants needed tc be captured.
-FTTPOTMFBSOUBOEEFWFMPQNFOUPGTFDPOEWFSTJPO
lt tcck apprcxlmately twc years tc develcp the rst system and expand lt natlcnwlde. Thls tlme was needed fcr
analysls cf data requlrements and data fcw, the deslen and develcpment cf scftware, pllctlne, tralnlne cf users and
nally the lntrcductlcn cf the new system tc all parts cf
the ccuntry. Slcw lnternet speeds affected the functlcn-
allty cf the system ln the perlphery.
Taklne acccunt cf the streneths, weaknesses, lesscns
learnt and new challenees ln T8 ccntrcl, the system was
further develcped frcm the end cf zoo6. 8y March zoo,
the seccnd verslcn had been lmplemented thrcuehcut
the ccuntry. A ccmparlscn cf the rst and seccnd ver-
slcns ls shcwn ln the table.
%BUBRVBMJUZDPOUSPM
varlcus mechanlsms are used tc ensure the quallty cf
data (lncludlne accuracy, ccmpleteness and tlmellness).
0nly staff whc have recelved the apprcprlate tralnlne
can lnput data; the system has an ln-bullt mechanlsm
fcr data audlt; manuals are avallable cn standard cperatlne prccedures and assesslne data quallty; mlsslne repcrts
are lnvestleated lndlvldually; ccnstant supervlslcn and feedback are prcvlded; and emphasls ls placed cn bulldlne
capaclty tc analyse data.
FlkST vFkSl0h SFC0hu vFkSl0h
Structure Scftware fcr cne
server cnly
Server plus cllent
scftware
uata lnput 0nllne
0nllne fcr server, cfflne
fcr cllent
Ccntents Three "reelstratlcn
bccks" (reelsters
fcr T8 suspects,
T8 patlents and
labcratcry tests) plus
data abcut patlents
cn treatment
Server ccllects ccre data,
lncludlne data cn Flv
status, drue reslstance,
T8 amcne mlerants and
T8 ln the prlscn sectcr;
cther data avallable at
cllent level
0utput 8aslc analyses Fnhanced analyses
az
8. Ccncluslcns
T
his section summarizes the main conclusions that can
be drawn from the fndings included in this report.
It also draws together the main recommendations that
appear in the report, in the form of a Box (80X 1).
Te global burden of TB is falling slowly. Incidence
rates have been declining since 2004 at the global lev-
el, and if this trend is sustained, MDG Target 6.c will
be achieved worldwide. Five of WHOs six regions are
also on track to achieve this target (the exception is
the South-East Asia Region, where the incidence rate
is stable). Mortality rates at global level fell by around
35% between 1990 and 2009, and the target of a 50%
reduction by 2015 could be achieved if the current rate
of decline is sustained. At the regional level, the mortal-
ity target could be achieved in fve of WHOs six regions;
the exception is the African Region (although rates of
mortality are falling in this region). Prevalence is fall-
ing globally and in all six WHO regions. However, the
target of halving 1990 prevalence rates by 2015 may
not be reached at global level. Tree regions are on track
to achieve this target: the Region of the Americas, the
Eastern Mediterranean Region and the Western Pacifc
Region.
Reductions in the disease burden achieved to date fol-
low 15 years of intensive eforts at country level to imple-
ment the DOTS strategy (19952005) and its successor,
the Stop TB Strategy (launched in 2006). Between 1995
and 2009, a cumulative total of 41 million TB patients
were successfully treated in DOTS programmes, and up
to 6 million lives were saved. Te treatment success rate
achieved in DOTS cohorts worldwide has now exceeded
the global target of 85% for two successive years.
Although increasing numbers of TB cases have access
to high-quality treatment for TB as well as access to
0X 15
5ummary eI main recemmendatiens in the ze:e g|eba| 1 centre| repert
&TUJNBUFTPGEJTFBTFCVSEFO
N Survelllance cf cases and deaths needs tc be
strenethened, tcwards the ultlmate ecal cf measurlne
T8 cases and T8 deaths dlrectly frcm nctlcatlcn and
vltal reelstratlcn data. Flectrcnlc systems fcr reccrdlne
and repcrtlne cf data need tc be lntrcduced ln many
ccuntrles, and vltal reelstratlcn systems need tc be
develcped cr strenethened ln mcre than 1oo ccuntrles.
N Prevalence surveys need tc be successfully lmple-
mented ln ccuntrles where these have been planned fcr
zo1o/zo11, partlcularly ln Afrlcan ccuntrles, and ndlnes
frcm surveys ccmpleted ln zo1o need tc be dlsseml-
nated.
N Fstlmates cf the burden cf dlsease ln wcmen and chll-
dren need tc be lmprcved vla mcre analysls cf nctlca-
tlcn and mcrtallty data dlsaeereeated by aee and sex.
N An up-tc-date assessment cf trends ln dlsease bur-
den ln lndla, uslne the latest survelllance, prcerammatlc
and survey data, needs tc be undertaken.
.POJUPSJOHPGQSPHSFTT
N The maln lndlcatcrs that shculd be used tc mcnltcr
prceress ln T8 ccntrcl up tc zo1, llnked tc the MuC and
Stcp T8 Partnershlp tareets, are trends ln lncldence,
prevalence and mcrtallty, the treatment success rate
and the case detectlcn rate fcr all fcrms cf T8. use cf
the case detectlcn rate fcr smear-pcsltlve T8 shculd be
phased cut.
N keccrdlne and repcrtlne cf data needs tc be lmprcved
fcr publlc-prlvate mlx (PPM), human rescurce develcp-
ment (Fku) and lnfectlcn ccntrcl. Fcr PPM and Fku,
data fcr the varlables lncluded ln the reccrdlne and
repcrtlne fcrms reccmmended by wF0 need tc be ccl-
lected. Fcr lnfectlcn ccntrcl, data tc mcnltcr the ratlc
cf the T8 nctlcatlcn rate amcne health care wcrkers tc
the nctlcatlcn rate ln the eeneral pcpulatlcn (fcr whlch
the tareet ls apprcxlmately 1) are cf mcst lmpcrtance.
*NQMFNFOUBUJPOBOEOBODJOHPGUIF4UPQ5#4USBUFHZ
N kates cf treatment success fcr T8 patlents wlth drue-
susceptlble T8 need tc be lmprcved ln the Furcpean
keelcn.
N ulaencsls and treatment cf Muk-T8 need tc be rap-
ldly scaled up. Thls wlll requlre masslve strenethenlne
cf labcratcry capaclty, uslne apprcaches such as thcse
used ln the FXPAhu-T8 prc|ect.
N Further expanslcn cf Flv testlne cf T8 patlents and
hleher rates cf enrclment cf Flv-pcsltlve T8 patlents cn
AkT are requlred.
N Screenlne fcr T8 amcne pecple llvlne wlth Flv, and
prcvlslcn cf lPT tc thcse wlthcut T8, need tc be sub-
stantlally lncreased frcm thelr currently lcw levels.
N Further effcrts tc eneaee all care prcvlders ln T8
ccntrcl are warranted ln many ccuntrles. uata frcm 1
ccuntrles ln thls repcrt shcw remarkable success when
thls ls dcne.
N Fffcrts tc mcblllze fundlne frcm bcth dcmestlc and
external scurces shculd be lntensled sc that fundlne
eaps can be clcsed. The ccntrlbutlcn cf the Clcbal Fund
ls cruclal ln many ccuntrles.
8)03&1035 CL0AL 1URCUL05t5 C0k1R0L a
related interventions such as ART, much more remains
to be done. More than one-third of incident TB cases are
not reported as treated in DOTS programmes, around
90% of patients with MDR-TB are not being diagnosed
and treated according to international guidelines, many
HIV-positive TB cases do not know their HIV status and
most of the HIV-positive TB patients who do know their
HIV status are not yet being provided with ART. Fund-
ing gaps remain large at more than US$ 1 billion per
year, despite increases in funding over the past decade
and substantial fnancing from the Global Fund in many
countries.
Looking forwards, the Stop TB Partnership launched
an updated version of the Global Plan to Stop TB in
October 2010, for the years 20112015. In the fve
years that remain until the target year of 2015, intensi-
fed eforts to plan, fnance and implement the Stop TB
Strategy, according to the updated targets included in
the Global Plan, are needed. Tis could save a cumulative
total of 5 million lives, including 2 million women and
children.

Guia Tuberculose WHO 2

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Ccmpared wlth a ccunterfactual scenarlc dened as the

A systematlc revlew cf the prcpcrtlcn cf all T8 cases wlth

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