Professional Documents
Culture Documents
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).
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.