searo searo Home About WHO in SEAR SEAR Countries Topics List Regional Health Situation Informati on Sources Related Websites Communi cable Diseases Tubercul osis searo xml_no_dtd Communicable Diseases Department Tuberculosis TB in South-East Asia Epidemiology Goals and Objectives Achievements Key Milestones achieved in 2008 Country Profiles Achievements DOTS coverage DOTS coverage is defined as the population living in administrative areas where DOTS services are available. This indicator serves as a proxy for people with access to DOTS. Population access to DOTS in the Region has been 100% since the end of 2006. Case notifications There has been a significant and steady increase in detection of TB cases in the last five years, as a result of efforts towards universal case detection. More than 1 000 000 sputum smear-positive TB patients and 2 300 000 all forms of TB have been detected and notified in 2009, representing about a 20% increase over 2005 (See figure1). Figure 1: Number of TB cases reported by the 11 Member States of the WHO SEA Region, by type, 2005-2009 TB in SouthEast Asia Factsheets on TB WHO support in the Region Training materials Media centre Publications Related websites Contact us Table 1 shows TB cases notified by type, in each Member States for the year 2009. The 11 Member States of the South-East Asia Region together notified 2 124 370 cases of tuberculosis (new and relapses, all forms), which represents a case notification rate of 119 per 100 000 population. Of those, 1 028 656 were new smear-positive pulmonary cases (62% of all new pulmonary cases). Five countries in the Region (Bangladesh, India, Indonesia, Myanmar and Thailand), are among the 22 countries with the highest burdens of TB (HBCs) globally, and notified a total of 2 190 068 cases, or 94% of all cases notified in the Region. New smear-negative pulmonary and respectively, of all notified new cases. extra-pulmonary cases represented 27% and 14%, Relapse and re-treatment cases The proportions of relapse and re-treatment cases represent 5.5% and 8.7% of all notified cases, respectively. However, the true percentages could be slightly higher, given underreporting by some countries. Table 1: Estimated incidence and cases notified (by type) in Member States of SEA Region, 2009* Estimate TB cases notified d incidenc e - All forms New New New Treatm Treatm Other Countr (in smea smear Type Total extra- Relap ent ent rey thousan runkno notificati pulmon se after after treatm ds) positi negati wn ons ary failure default ent (Confide ve ve nce intervals ) Banglad esh Bhutan 360 (300340) 1.1 (0.9-1.3) 109 402 434 25 375 21 999 285 355 4 099 0 0 0 0 160 875 51 16 9 0 0 1 150 2 247 2 312 1 651 8 366 0 88 665 DPR Korea 82 (70-96) 29 366 India 2 000 (1 600-2 400) 624 617 384 113 233 026 108 361 18 870 73 549 88 976 Indonesi a 430 (350520) 169 213 108 616 11 215 3 710 225 723 1 030 0 294 732 Maldives 0.12 (0.100.14) 45 13 41 1 1 2 1 0 104 Myanma r 200 (160240) 41 357 4 558 1 331 518 3 247 0 133 439 Nepal 48 (39-58) 15 442 Sri Lanka 13 (11-16) 32 491 12 232 50 919 31 509 9 794 7 054 2 598 279 240 0 0 35 407 4 764 1 996 2 358 196 89 124 261 0 9 880 9 143 1 964 575 726 664 0 65 940 406 41 8 3 0 0 4 759 102 545 1 796 2 328 237 Thailand 93 (75-110) TimorLeste 5.6 1 206 3 095 (4.6-6.8) 32 810 20 058 3 300 SEA 1 028 (2 900-3 Region 656 700) 636 755 329 338 127 826 23 706 77 545 SEA Region (2008) 635 943 310 830 122 836 23 681 0.1% 5.6% 3.9% 0.1% N/A** 1 796 1 533 286 1 007 385 Percentage change 2009 vs. 2008 2.1% 82 661 102 151 1 866 2 287 512 -6.6% 0.4% -3.9% 1.7% *Figures may be updated in early 2011 following revision or completion of surveillance data by Member States **The calculation method for estimates changed in 2010, and therefore new and old estimates should not be compared. Treatment outcomes Table 2 shows the treatment success rates among new smear-positive cases and re-treatment cases enrolled for treatment in the Member States during 2008. For new smear-positive cases the treatment success rate is above the target of 85% in the SEA Region as a whole, and this target has been achieved or surpassed in 9 of the 11 countries. The overall cure rate in the Region for new smear-positive cases was 84.2% and the completion rate 3.8% (overall success rate of 88%), for the 1 011 353 cases registered in 2008. The success rate among re-treatment cases is lower, 74% for the whole Region, and ranging from 66% to 82% in the countries. Similarly, while the case fatality rate among new smear-positive cases is low, it is more than double among the re-treatment cases. Default rates are also higher among retreatment cases, and are especially high (for all cases) in India, Sri Lanka and Timor-Leste. Table 2: Treatment outcomes of new smear-positive cases and re-treatment cases notified in 2008 in Member States of the SEA Region (expressed as percentage of the total number of cases notified)* New smear-positive cases* Countri Notifi es ed Succ ess rate Re-treatment cases* Not Case Failu Defa evalua Succ fatal Notifi re ult ted ess ity ed rate rate /trans rate rate fer out Not Case Failu Defa evalua fatal re ult ted ity rate rate /trans rate fer out Bangla desh 106 089 91 4 1 2 2 509 1 - - - - - Bhutan 354 91 3 3 0 3 70 79 3 16 1 1 DPR Korea 28 026 89 2 4 2 2 14 170 82 3 10 3 2 India 615 977 87 4 2 6 1 289 285 74 7 4 13 2 Indone sia 166 376 91 2 1 4 2 5 430 72 4 3 14 7 Maldiv es 53 45 4 0 11 40 0 0 0 0 0 0 Myanm ar 41 247 85 6 3 5 2 8 631 73 12 5 7 3 Nepal 14 640 89 4 1 3 3 1 954 76 10 5 5 5 Sri Lanka 4 646 85 6 2 7 1 393 70 8 2 15 5 Thailan d 33 078 82 7 2 4 4 3 468 66 9 4 7 14 TimorLeste 867 85 5 0 7 3 35 71 11 6 11 0 SEAR 1 011 353 88 4 2 5 1 328 527 74 7 4 12 2 *Figures may be updated in early 2011 following revision or completion of surveillance data from Member States Key milestones achieved in 2009 As a result of the resolution at the Sixtieth Regional Committee held in Bhutan in 2007, the new Stop TB Strategy has been adopted by all 11 countries and it is the basis for national TB control plans. National TB Programme manuals have been also updated and national programme capacity for scaling up interventions under the Stop TB strategy has being built in various technical areas. Management of drugs has been strengthened and no stock-outs of first-line anti-TB drugs have been reported at the national level in all 11 countries; 5 countries are receiving GDF grants; and 6 are transitioning/fully utilizing GDF direct procurement services All 11 countries have nation-wide quality-assured networks for smear microscopy, and laboratories in Bangladesh, India, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand have been accredited for quality assurance for culture and drug susceptibility testing (C and DST). Two supra-national reference laboratories have been set up in the Region. National guidelines for the management of multidrug resistant TB (MDR-TB) have been developed for Bangladesh, Bhutan, India, Indonesia, Myanmar, Nepal, Sri Lanka and Timor-Leste. Sites for the management of MDR-TB under programme conditions are functional in all these countries, and enrollment of patients is ongoing in all except for Bhutan and Sri-Lanka, where enrollment will start in late 2010. in total, 3 000 MDR-TB patients are currently on treatment and the number of MDR-TB treatment sites is expanding. Ten of the 11 countries in the Region established National Coordinating committees for TB/HIV collaborative activities. TB/HIV interventions are widely available in Thailand, which has established a “one-stop shop” approach and India, which implemented an “intensified” package of interventions available to 600 million people in 18 states: intervention are being expanded in Indonesia (in Papua and Java Bali where epidemic is concentrated), Myanmar and Nepal. Medical colleges and private sector providers are increasingly involved in working with national TB control programmes in the Region through public-private mix (PPM) initiatives; the International standards for TB care are being promoted through professional societies in Bangladesh, India, Indonesia, Myanmar, Nepal and Sri Lanka to link with all private and public health professionals. Member States reported that over 360 medical colleges, nearly 20 000 private practitioners, 2 500 NGOs, 150 corporate institutions, 1500 large public and private hospitals and 550 prisons are collaborating in PPM initiatives. There are several hundred community-based interventions in place in the Region, with very encouraging examples of community-based approaches. A wealth of initiatives, particularly for case finding and treatment support, are increasingly being incorporated into routine service delivery by national programmes. However, systematic approaches to social mobilization are yet to be developed and established in countries, with the possible exceptions of Bangladesh and Indonesia. Attention to advocacy, communications and social mobilization (ASCM) in increasing across the Region. A regional framework on ASCM will be finalized by early 2011; seven countries have appointed ACSM focal points and ACSM activities have been included in all Global Fund for Aids Tuberculosis and Malaria proposals. During 2009, external monitoring and evaluation through joint reviews of the national TB programme were undertaken in Bangladesh, Bhutan, India and Sri Lanka. Last update: 10 December 2010 | WHO/SEARO Home| SEARO Search| Suggestions| SEARO Sitemap| Contact us| © WHO Regional Office for South-East Asia 2012 All rights reserved searo searo Home About WHO in SEAR SEAR Countries Topics List Regional Health Situation Information Sources Related Websites Communicable Diseases Tuberculosis TB in South-East Asia Factsheets on TB WHO support in the Region Training materials Media centre Publications Related websites Contact us searo xml_no_dtd Communicable Diseases Department Tuberculosis TB in South-East Asia Epidemiology Goals and Objectives Achievements Key Milestones achieved in 2008 Country Profiles Key Milestones achieved in 2008 DOTS The entire population in the Region now lives within access to DOTS facilities; The overall case detection rate reported in 2007 was 68.5%, close to the global target of 70%, and the overall treatment success rate for the cohort of new smear-positive cases initiated on treatment in 2006 was 87%. By the end of 2008, five* countries—Bhutan, DPR Korea, Maldives, Myanmar and Sri Lanka—had achieved or maintained both global targets for case detection and treatment success under DOTS, based on UN population figures for the Member countries. Strengthening national laboratory networks External quality assurance for smear microscopy is being strengthened in all Member countries through training of laboratory staff. Seven countries— Bangladesh, India, Indonesia, Myanmar, Nepal, Sri Lanka, and Thailand—have at least one national-level laboratory with facilities for mycobacterial culture and drug susceptibility testing for the detection of MDR-TB cases. Bangladesh, Nepal and Sri Lanka are in the process of having their national reference laboratories accredited for quality assurance of culture and drug susceptibility testing, while additional reference laboratories are being accredited in India, Indonesia, Myanmar and Thailand. Recognizing that TB-HIV co-infection must be addressed effectively, national HIV/AIDS and TB programmes in seven countries in the Region have developed national policies and strategies for TB-HIV. National level TB/HIV coordinating bodies have been established. The regional strategic framework for TB/HIV is also being revised and updated. TB/HIV activities are widely available in Thailand and are being expanded in India and Myanmar. India is implementing an intensified package of TB/HIV interventions in the nine states with a high HIV prevalence. There has been a more than 5 fold increase in referrals from HIV counselling and testing centres to the TB services and more than 3 fold increase in referrals from the TB to HIV services over the last 3 years. Indonesia, with a concentrated HIV epidemic, has established interventions in Papua and Java Bali, which are the country’s HIV high-prevalence areas. Cross-referrals between the TB and HIV programmes have been strengthened, and the TB recording and reporting systems in these countries revised to include information on TB/HIV co-infection. Bangladesh, India, Nepal, and Timor-Leste have established MDR-TB case management under their national programmes. Nepal has recently expanded to all five regions in the country, while India is gradually expanding services to additional states. Indonesia and Myanmar are expected to begin enrolling MDR-TB patients in early 2009. Two countries, Bhutan and Sri Lanka, have submitted applications to the Green Light Committee and plan to commence MDR-TB case management in 2009. National guidelines for the management of childhood TB were finalized in Bangladesh, Indonesia and Myanmar. Myanmar and Nepal received their first grants for anti-TB paediatric formulations through the Global Drug Facility (GDF), supported through UNITAID, while paediatric grants were approved for DPR Korea and Sri Lanka. India is introducing infection control measures in health facilities while Indonesia, Myanmar and Thailand will undertake assessments and prepare infection control plans in 2009. Countries have also included measures to address vulnerable populations at higher risk and cross-border issues in their national plans for TB control and Global Fund applications. Public and private partnerships TB technical working groups and/or specific task forces and sub-working groups have been established both at the regional and at national levels in Bangladesh, DPR Korea, India, Indonesia, Myanmar, and Nepal. A major strategy towards improving case detection and treatment success rates has been the inclusion of public health care providers operating outside the Ministry of Health, such as the railways, military and prison health services, as well as private providers in all Member countries where patients seek services through the private health sector. The International Standards of TB Care were endorsed by professional bodies-- medical associations in India, Indonesia, Myanmar, and Nepal. Inter-sectoral collaboration and public-private partnerships for delivery of services were further scaled up in eight Member countries—Bangladesh, India, Indonesia, Myanmar, Nepal, Sri Lanka, Thailand and TimorLeste. Over 350 medical colleges, 22 000 private practitioners, 1 500 large public and private hospitals, 150 corporate institutions, 2,500 nongovernmental organizations and 550 prisons are now working with national TB control programmes. Some recent initiatives in countries were formal inclusion of pre-service training on the principles and practices of TB control and establishing of referral mechanisms through providing lists of DOTS centres to teaching institutes, inclusion of private laboratories in diagnostic network and QA systems, and launching of “IMPACT” a coalition of professional associations for TB control, in India. In 2008, India also formally established a widely inclusive national partnership, becoming the second country in the Region to establish such a partnership, in addition to Indonesia. Indonesia intensified training of private and public hospital and laboratory staff and introduced coordination meetings between community health facilities and hospitals to improve transfer mechanisms between lung clinics and puskesmas. In Myanmar, services have been resumed throughout the network of PSI Sun Quality Clinics and the NTP plans further expansion of public/private mix services through the Myanmar Medical Association. There are also very encouraging examples of community-based approaches in several countries, but these need to be systematically documented and the experiences used to more widely replicate successful models at the national level. Surveillance, monitoring and evaluation TB prevalence and incidence were revised for Timor-Leste based on a review of more recent data and trends in cases notified and for DPR Korea based on an ARTI survey completed in 2007. Annual reports were received from all countries and are being used to finalize the Regional and WHO Global reports for 2009. In five countries in the Region, drug resistance surveys were conducted or will continue through 2008-2009, to assess the extent of anti-TB drug resistance among TB patients. The overall rates of multi-drug resistant TB (MDR-TB) in the Region is 2.8 % among new smear-positive patients and 18.8% among previously treated patients. Surveillance for HIV prevalence among TB patients is undertaken routinely in Thailand and in nine states in India. In Myanmar, Nepal, Sri Lanka and in the remaining states and union territories in India, data from sentinel surveys are used to follow trends in HIV prevalence among TB patients. These surveys are contributing to more accurate estimations of the burden of disease. At the same time, countries are beginning to focus on mechanisms that will ensure that routine case notifications begin to reflect the disease magnitude and trends. Data management software was upgraded in Myanmar and Nepal and further improvements made in the Windows-based EPI centre software in India. Training on data management and analysis for central and international level programme staff were conducted in Bangladesh, India, Myanmar and Thailand. The practice of quarterly and annual internal reviews and larger joint reviews every two/three years, inviting international experts for joint monitoring and evaluation together with national programmes and partners was continued. These have helped to objectively review the performance of the respective national TB programmes, and lead to substantial improvements in programme performance. Resources Domestic funding for TB control continues to account for over half of the funding for national TB control programmes. By the end of 2008, a total of 23 proposals were approved by the Global Fund in support of TB control programmes in the Region. In addition, nine Member countries benefit from funds from other development partners and donor governments with the exception of Bhutan and Maldives where the only external funds are through WHO country budgets. All 11 Member countries continue to access quality-assured affordable anti-TB drugs on a regular basis through grants or direct procurement services of the Global Drug Facility. Operational Research National TB programmes and partners are engaged in carrying forward several operational research projects. Examples are public-private mix (PPM) models in India and Indonesia; field testing of new diagnostics and shorter treatment regimens in India; approaches to community-based TB care in Bangladesh, India, Indonesia, Thailand and Timor-Leste. In addition, some support continues to be received through the small grants scheme under TDR. National workshops on operations research priority setting and dissemination are held regularly in India. Last update: 04 March 2009 | WHO/SEARO Home| SEARO Search| Suggestions| SEARO Sitemap| Contact us| © WHO Regional Office for South-East Asia 2012 All rights reserved searo searo Home About WHO in SEAR SEAR Countries Topics List Regional Health Situation Information Sources Related Websites Communicable Diseases Tuberculosis TB in South-East Asia Factsheets on TB WHO support in the Region Training materials Media centre Publications Related websites Contact us searo xml_no_dtd Communicable Diseases Department Tuberculosis TB in South-East Asia Epidemiology Goals and Objectives Achievements Key Milestones achieved in 2008 Country Profiles Goals and Objectives Goals The overall goal for TB control is to reduce morbidity, mortality and transmission of TB until it is no longer a public health problem in the Region. Objectives The UN Millennium Development Goals (MDGs) provide a benchmark to measure the impact of disease control and prevention programmes, including tuberculosis control. The objectives for tuberculosis control in all Member Countries in the Region are to: reach and thereafter sustain the 2005 targets—achieving at least 70% case detection and 85% treatment success among all TB cases under DOTS (Indicator 24), in order to then, reach the targets of halving TB deaths and prevalence (Indicator 23) by 2015, in turn to “have halted and begun to reverse the incidence of TB” as implicitly stated under Goal 6 of the MDGs. Millennium Development Goals, 2015 Goal 6: Combat HIV/AIDS, malaria and other diseases Target 8: To have halted and begun to reverse the spread (incidence) of priority communicable diseases, including TB Indicator 23: Prevalence and death rates associated with tuberculosis Indicator 24: Proportion of smear-positive pulmonary tuberculosis cases detected and cured under DOTS (the internationally recommended TB control strategy) The Regional Strategic Plan 2006–2015 The Regional Strategic Plan for TB Control (2006-2015) describes the future directions and focus of work for TB control in the Region. The targets and strategies in this document are consistent with the global targets and strategies, but focus on priorities most relevant to this Region and build on what has been achieved during the previous 5-year period. The interventions proposed are grouped under the following 4 strategic approaches: 1. Sustaining and improving the quality of DOTS to reach all TB patients; 2. Forging partnerships to ensure equitable access to an essential standard of care to all TB patients; 3. Establishing interventions to address TB-HIV and MDR-TB; and 4. Strengthening monitoring and surveillance to measure progress towards MDGs. In addition, every effort will be made to ensure that there are adequate finances and human resources to support the implementation of all the planned interventions. Last update: 04 March 2009 | WHO/SEARO Home| SEARO Search| Suggestions| SEARO Sitemap| Contact us| © WHO Regional Office for South-East Asia 2012 All rights reserved