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SAARC EPIDEMIOLOGICAL RESPONSE ON
TUBERCULOSIS
2018
SAARC Tuberculosis & HIV/AIDS Centre
(STAC)
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SAARC EPIDEMIOLOGICAL RESPONSE ON
TUBERCULOSIS
2018
SAARC Tuberculosis & HIV/AIDS Centre (STAC)
Thimi, Bhaktapur
P.O.Box No. 9517, Kathmandu, Nepal.
Tel: 6631048, 6632477, 6632601 Fax: 00977-1-6634379
E-mail: [email protected] Website: www.saarctb.org
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© SAARC TB & HIV/AIDS CENTER 2018
All rights reserved. Publications of the SAARC TB & HIV/AIDS CENTER are available on the STAC web site
(www.saarctb.org), SAARC TB & HIV/AIDS CENTER, Thimi, Bhaktapur, Nepal (tel.: +977-1- 6631048; fax:
+977-1-6634379; e-mail: [email protected]). All reasonable precautions have been taken by the SAARC TB &
HIV/AIDS CENTER to verify the information contained in this publication. However, the published material is
being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation
and use of the material lies with the reader. In no event shall the SAARC TB & HIV/AIDS CENTER be liable for
damages arising from its use.
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FOREWORD
Tuberculosis – a disease from early times still remains a major public health problem, in the
SAARC region. In member states of SAARC Region, there has been a considerable development
in TB care services. However, three countries in the region namely India, Pakistan and
Bangladesh are in WHO high TB and High MDR-TB countries list.
All most all SAARC Member States have achieved MDG TB related targets and stop TB targets
in 2015 compared with 1990 as base line. Taking 2015 as base line, the new WHO “End TB”
strategy targets a 95% reduction in TB deaths and 90% incidence by 2035. In SAARC Region
2017, an estimated 3.7 million cases of were reported and about 0.5 million people died of it, the
Gap between, notifications of new TB cases and the estimated no. of incident cases was 1.1
million. The missing cases were a combined result of non-detection and under-reporting of
detected cases.
This report is an excellent review of the current status and future plans for the control of TB in
the SAARC Region. It includes information on burden of tuberculosis in the SAARC region,
including incidence, mortality along with the MDR-TB, TB/HIV confection etc. It also covers
the information of the year 2017 and has been prepared on the basis of information collected
from member countries during the year 2018 and by reviewing other related documents.
This is the sixteenth Report on Tuberculosis (TB) situation of SAARC Region which is being
published by SAARC Tuberculosis and HIV/AIDS Centre (STAC) in a series that started in
2003, which includes a compilation of regional and country-specific achievements, challenges
and plans. The 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, SAARC
Region and Member States level.
I would like to thank the programme managers and experts within SAARC member countries,
who have generated and shared the epidemiological data that has been used in this report.
We look forward to your continued collaboration in our joint efforts to broaden the partnership
for control of tuberculosis in the SAARC region.
_____________________
Dr. Rajendra Prasad Pant
Director
SAARC Tuberculosis and HIV/AIDS Centre
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CONTENTS
ABBREVIATIONS ................................................................................................ vii
EXECUTIVE SUMMARY ..................................................................................... ix
1. INTRODUCTION ................................................................................................. 1
1.1 Introduction of SAARC ............................................................................... 1
1.2 SAARC TB and HIV/AIDS Centre (STAC) ............................................... 1
2. GLOBAL BURDEN OF TUBERCULOSIS ......................................................... 3
2.1 Basic facts about TB .................................................................................... 3
2.2 The Sustainable Development Goals ........................................................... 4
2.3 The End TB Strategy ................................................................................... 6
2.4 Global Epidemiology ................................................................................... 8
3. BURDEN OF TUBERCULOSIS IN SAARC REGION .................................... 12
3.1 SAARC Epidemiology ..............................................................................12
3.2 Notifications and Treatment Success .........................................................13
3.3 Drug Resistance TB ...................................................................................14
4. PROGRESSES ON TB CONTROL IN SAARC MEMBER STATES .............. 17
AFGHANISTAN .............................................................................................18
BANGLADESH ..............................................................................................24
BHUTAN .........................................................................................................29
INDIA ..............................................................................................................35
MALDIVES .....................................................................................................40
NEPAL .............................................................................................................45
PAKISTAN ......................................................................................................50
SRI LANKA ....................................................................................................55
5. TB/HIV CO-INFECTION ................................................................................... 60
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ABBREVIATIONS
ACF : Active Case Finding
ACSM : Advocacy, Communication and Social Mobilization
AIDS : Acquired Immuno - Deficiency Syndrome
ART : Antiretroviral Treatment
BDQ : Bedaquiline
CBDOT : Community Based Dots on Tuberculosis
CBNAAT : Cartridges Based Nucleic Acid Amplification Test
CDR : Case Detection Rate
CFR : Case Fatality Ratio
CFZ : Clofazimine
CI : Confidence Interval
CTB : Challenge TB
DOTS : Directly Observed Treatment Short course
DRS : Drug Resistance Survey
DR-TB : Drug-resistant tuberculosis
DST : Drug Susceptibility Testing
EP-TB : Extra-Pulmonary Tuberculosis
GF : Global Fund to Fight AIDS, Tuberculosis and Malaria
GOB : Government of Bangladesh
HIV : Human Immunodeficiency Virus
IDPs : Internally displaced Population
IEC : Information, Education and Communication
INH : Isoniazid
JEET : Joint Effort for Elimination of Tuberculosis
JICA : Japan International Cooperation Agency
KAP : Knowledge, attitude and practice
LPA : Line Probe Assay
LZD : Linezolid
MDG : Millennium Development Goal
MDR : Multi Drug Resistance
MoH : Ministry of Health
NACP : National AIDS Control Programme
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NFM : New Funding Model
NPTCCD : National Programme for Tuberculosis Control and Chest Diseases
NRL : National Reference Laboratories
NTP : National Tuberculosis Programme
NTRL : National TB Reference laboratory
PBC : Pulmonary Bacteriological Confirmed
PHIs : Peripheral Health Institutions
PLHIV : People Living with HIV
PMDT : Programmatic Management of Drug-Resistant Tuberculosis
PPM : Public-private Mix
PSM : Procurement and Supply Management
RCDC : Royal Centre for Disease Control
RR-TB : Rifampicin resistant tuberculosis
SAARC : South Asian Association for Regional Cooperation
SCC : Short Course Chemotherapy
SDGs : Sustainable Development Goals
SOP : Standard Operating Procedure
SORT : Structured Operational Research and Training
STAC : SAARC TB and HIV/AIDS Centre
STC : SAARC Tuberculosis Centre
TB : Tuberculosis
TRL : TB Reference Laboratory
UHC : Upazila Health Complexe
UN : United Nations
UNAIDS : The Joint United Nations Programme on HIV/AIDS
USAID : United States Agency for International Development
VCCT : Voluntary Counseling and Testing Centre
WHO : World Health Organization
XDR : Extensively Drug-Resistant Tuberculosis
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EXECUTIVE SUMMARY
This is the sixteenth Report on tuberculosis (TB) situation of SAARC Region which is being
published by SAARC Tuberculosis and HIV/AIDS Centre (STAC) in a series that started in
2003. However the name of the report has changed “SAARC Epidemiological Response on
Tuberculosis” from year 2014.The 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,
SAARC Region and Member States level.
The incidence has been falling globally achieving the Millennium Development Goal target. Of
estimated 10 million new cases of TB (133 per 100 000 Population), 6.7 million cases were
notified in 2017, globally there was 3.3 million gap between incident and notified cases.
Globally, an estimated 558 000 people newly eligible for MDR-TB treatment. A total of
approximately 1.3 million people died of TB in 2017 and an additional 0.3 million deaths from
TB among people who were HIV-positive.
The SAARC region, with an estimated incidence of 3.7 million TB cases, carries 37% of the
global burden of TB. Three of the eight Member Countries in the Region are among the 30 high
burden countries (Bangladesh, India and Pakistan) together notified 95% of the region. India
alone accounted to 73% of all notifications in the SAARC region. The SAARC region has 0.1
million total number of an estimated MDR/RR-TB cases among notified pulmonary TB cases in
the year 2017.
In 2017, a total 33404 TB patients with known HIV status has tested in which India accounts
highest number of TB patients with known HIV status who are HIV positive. Total 29074
patients are on ART in the region. The proportion of known HIV-positive TB patients on
antiretroviral therapy (ART) was 87% globally as well as in the SAARC Region in 2017.
All the SAARC Member States have developed their strategic plans for expansion of TB/HIV
collaborative activities and are in the expansion mode. While, all the SAARC Member States
have initiated management of MDR-TB under the National TB Control Programme, one of the
most important constraints to rapid expansion of diagnostic and treatment services for MDR-TB
identified by all the SAARC Member States, is laboratory capacity. Constraints in availability
and retention of adequately trained human resources, is one of the major concerns of all the
SAARC Member States.
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1. INTRODUCTION
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1.1 Introduction of SAARC
SAARC is an organization of eight countries located in the South Asia and it stands for the South
Asian Association for Regional Corporation (SAARC). This is an economic and geopolitical
organization, established to promote socio-economic development, stability, welfare economics,
and collective self-reliance within the Region. The first summit was held in Dhaka, Bangladesh
on 7–8 December 1985 and was attended by the Government Representatives and Presidents
from Bangladesh, Maldives, Pakistan and Sri Lanka, the Kings of Bhutan and Nepal, and the
Prime Minister of India. The dignitaries signed the SAARC Charter on 8 December 1985,
thereby establishing the regional association and to carry out different important activities
required for the development of the Region. The summit also agreed to establish a SAARC
secretariat in Kathmandu, Nepal and adopted an official SAARC emblem. Due to rapid
expansion within the region, Afghanistan received full-member status and some countries are
considered as observers. SAARC respects the principles of sovereign equality, territorial
integrity, and national independence as it strives to attain sustainable economic growth.
1.2 SAARC TB and HIV/AIDS Centre (STAC)
The Centre was established in 1992 as SAARC Tuberculosis Centre (STC) and started
functioning from 1994. The Centre had been supporting the National Tuberculosis Control
Programmes of the SAARC Member States. The Thirty–first session of Standing Committee of
SAARC held in Dhaka on November 09th – 10th 2005, appreciating the efforts of the centre on
TB/HIV co-infection and other works related to HIV/AIDS discipline and approved the
renaming of the Centre as SAARC Tuberculosis and HIV/AIDS Centre (STAC) with additional
mandate to support SAARC Member States for prevention of HIV/AIDS. Since then with its
efforts and effective networking in the Member States the Centre is contributing significantly for
control of both TB and HIV/AIDS.
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Vision, Mission, Goal and Objective of STAC
The vision of the Centre is to be the leading institute to support and guide SAARC Member
States to make the region free of TB and HIV/AIDS and the mission is to support the efforts of
National TB and HIV/AIDS Control Programmes through evidence based policy guidance,
coordination and technical support.
The goal of the Centre is to minimize the mortality and morbidity due to TB and HIV/AIDS in
the Region and to minimize the transmission of both infections until TB and HIV/AIDS cease to
be major public health problems in the SAARC Region and the objective of the Centre is to work
for prevention and control of TB HIV/AIDS in the Region by coordinating the efforts of the
National TB Programmes and National HIV/AIDS Programmes of the SAARC Member
Countries.
Role of STAC
To act as a Regional Co-ordination Centre for NTPs and NACPs in the Region.
To promote and coordinate action for the prevention of TB/HIV co-infection in the Region.
To collect, collate, analyze and disseminate all relevant information regarding the latest
development and findings in the field of TB and HIV/AIDS in the Region and elsewhere.
To establish a networking arrangement among the NTPs and NACPs of Member States and
to conduct surveys, researches etc.
To initiate, undertake and coordinate the Research and Training in Technical Bio-medical,
operational and other aspects related to control of Tuberculosis and prevention of HIV/AIDS
in the Region.
To monitor epidemiological trends of TB, HIV/AIDS and MDR-TB in the Region.
To assist Member States for harmonization of policies and strategies on TB, HIV/AIDS and
TB/HIV co-infection.
To assist National TB Reference Laboratories in the Region in quality assurance of sputum
microscopy and standardization of culture and drug sensitivity testing and implementation of
bio-safety measures.
To carry-out other important works identified by the Programming Committees/Governing
Board.
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2. GLOBAL BURDEN OF TUBERCULOSIS
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2.1 Basic facts about TB
TB is an infectious disease caused by the bacillus Mycobacterium tuberculosis. It typically
affects the lungs (pulmonary TB) but can also affect other sites (extra pulmonary TB). The
disease is spread when people who are sick with pulmonary TB expel bacteria into the air, for
example by coughing. Overall, a relatively small proportion (5–10%) of the estimated 1.7 billion
people infected with M. tuberculosis will develop TB disease during their lifetime. However, the
probability of developing TB disease is much higher among people infected with HIV, and also
higher among people affected by risk factors such as under-nutrition, diabetes, smoking and
alcohol consumption. Overall, about 90% of cases occur among adults, with more cases among
men than women. The male: female ratio among adults is approximately 2:1.
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2.2 The Sustainable Development Goals
In 2016, the MDGs were succeeded by a new set of goals, known as the Sustainable
Development Goals (SDGs). Adopted by the UN in September 2015 following 3 years of
consultations, the SDG framework of goals, targets and indicators is for the period 2016–2030.1
The End TB Strategy was unanimously endorsed by all WHO Member States at the 2014 World
Health Assembly, and is for the period 2016–2035.2
The consolidated goal on health is SDG 3. It is defined as “Ensure healthy lives and promote
well-being for all at all ages”, and 13 targets have been set for this goal (Box 2.1). One of these
targets, Target 3.3, explicitly mentions TB: “By 2030, end the epidemics of AIDS, tuberculosis,
malaria and neglected tropical diseases and combat hepatitis, waterborne diseases and other
communicable diseases”. The language of “ending epidemics” is also now a prominent element
of global health strategies developed by WHO and the Joint United Nations Programme on
HIV/AIDS (UNAIDS) for the post- 2015 era,3 including the End TB Strategy. SDG 3 also
includes a target (Target 3.8) related to universal health coverage (UHC) in which TB is
explicitly mentioned.
1 United Nations. Sustainable Development Goals (https://sustainabledevelopment.un.org/topics/sustainabledevelopmentgoals,
accessed 2 August 2017). 2 Uplekar M, Weil D, Lonnroth K, Jaramillo E, Lienhardt C, Dias HM, et al. WHO’s new End TB Strategy. Lancet. 2015;385(9979):1799–
1801 (http:// www.sciencedirect.com/science/article/pii/ S0140673615605700?via%3Dihub, accessed 2 August 2017). 3 World Health Organization. Accelerating progress on HIV, tuberculosis, malaria, hepatitis and neglected tropical diseases: a new agenda for
2016–2030. Geneva: WHO; 2015 (http://www.who.int/about/structure/ organigram/htm/progress-hiv-tb-malaria-ntd/en/, accessed 21 June 2018).
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Box No. 2.1
Sustainable Development Goal 3 and its 13 targets
SDG3: Ensure healthy lives and promote well-being for all at all ages
Targets
3.1 By 2030, reduce the global maternal mortality ratio to less than 70 per 100 000 live births
3.2 By 2030, end preventable deaths of newborns and children under 5 years of age, with all
countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 live births and
under-5 mortality to at least as low as 25 per 1000 live births
3.3 By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and
combat hepatitis, water-borne diseases and other communicable diseases
3.4 By 2030, reduce by one third premature mortality from non-communicable diseases through
prevention and treatment and promote mental health and well-being
3.5 Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and
harmful use of alcohol
3.6 By 2020, halve the number of global deaths and injuries from road traffic accidents
3.7 By 2030, ensure universal access to sexual and reproductive health-care services, including for
family planning, information and education, and the integration of reproductive health into national
strategies and programmes
3.8 Achieve universal health coverage, including financial risk protection, access to quality essential
health-care services and access to safe, effective, quality and affordable essential medicines and
vaccines for all
3.9 By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air,
water and soil pollution and contamination
3.a Strengthen the implementation of the World Health Organization Framework Convention on
Tobacco Control in all countries, as appropriate
3.b Support the research and development of vaccines and medicines for the communicable and non
communicable diseases that primarily affect developing countries, provide access to affordable
essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement
and Public Health, which affirms the right of developing countries to use to the full the provisions in
the Agreement on Trade-Related Aspects of Intellectual Property Rights regarding flexibilities to
protect public health, and, in particular, provide access to medicines for all
3.c Substantially increase health financing and the recruitment, development, training and retention of
the health workforce in developing countries, especially in least developed countries and small island
developing States
3.d Strengthen the capacity of all countries, in particular developing countries, for early warning, risk
reduction and management of national and global health risks
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2.3 The End TB Strategy
The overall goal is to “End the global TB epidemic”, and there are three high-level, overarching
indicators and related targets (for 2030, linked to the SDGs, and for 2035) and milestones (for
2020 and 2025). The three indicators are:
The number of TB deaths per year;
The TB incidence rate per year; and
The percentage of TB-affected households that experience catastrophic costs as a result
of TB disease.
The 2035 targets are a 95% reduction in TB deaths and a 90% reduction in the TB incidence rate,
compared with levels in 2015. The 2030 targets are a 90% reduction in TB deaths and an 80%
reduction in the TB incidence rate, compared with levels in 2015. The most immediate
milestones set for 2020, are a 35% reduction in TB deaths and a 20% reduction in the TB
incidence rate, compared with levels in 2015. The trajectories of TB incidence and TB deaths
that are required to reach these milestones and targets are shown in Figure 01.
Figure 01: Projected incidence and mortality curves that are required to reach End TB
Strategy targets and milestones, 2015–2035
Source: WHO Global Tuberculosis Report-2018
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The End TB Strategy at a glance (2016–2035) VISION A WORLD FREE OF TB
- zero deaths, disease and suffering due to TB
GOAL END THE GLOBAL TB EPIDEMIC
INDICATORS MILESTONES TARGETS
2020 2025 SDG 2030a End TB 2035
Reduction in number of TB deaths compared
with 2015 (%) 35% 75% 90%
95%
Reduction in TB incidence rate compared with
2015 (%)
20%
(<85/100
000)
50%
(<55/100
000)
80%
(<20/100
000)
90%
(<10/100
000)
TB-affected families facing catastrophic costs
due to TB (%) 0 0 0 0
PRINCIPLES
1. Government stewardship and accountability, with monitoring and evaluation
2. Strong coalition with civil society organizations and communities
3. Protection and promotion of human rights, ethics and equity
4. Adaptation of the strategy and targets at country level, with global collaboration
PILLARS AND COMPONENTS
1. INTEGRATED, PATIENT-CENTRED CARE AND PREVENTION
A. Early diagnosis of TB including universal drug-susceptibility testing, and systematic screening of contacts and
high-risk groups
B. Treatment of all people with TB including drug-resistant TB, and patient support
C. Collaborative TB/HIV activities, and management of co-morbidities
D. Preventive treatment of persons at high risk, and vaccination against TB
2. BOLD POLICIES AND SUPPORTIVE SYSTEMS
A. Political commitment with adequate resources for TB care and prevention
B. Engagement of communities, civil society organizations, and public and private care providers
C. Universal health coverage policy, and regulatory frameworks for case notification, vital registration, quality and
rational use of medicines, and infection control
D. Social protection, poverty alleviation and actions on other determinants of TB
3. INTENSIFIED RESEARCH AND INNOVATION
A. Discovery, development and rapid uptake of new tools, interventions and strategies
B. Research to optimize implementation and impact, and promote innovations
a Targets linked to the Sustainable Development Goals (SDGs)
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With 2015 marking the end of the MDGs and a new era of SDGs, as well as the last year of the
Stop TB Strategy before its replacement with the End TB Strategy, it was an ideal time to revisit
these three HBC lists. Following a wide consultation process, in 2015 WHO defined three HBC
lists for the period 2016–2020: one for TB, one for MDR-TB and one for TB/HIV. Three (viz.
Bangladesh, India and Pakistan) of eight Member States in the SAARC Region are belongings to
high TB and MDR-TB burden countries among 30 high burden countries. However, In SAARC
Region, only India belongs to TB, MDR-TB and TB/HIV Co-infection among 30 high burden
countries, which is shown in Figure 02.
Figure 02: Countries in the three high-burden country lists for TB, TB/HIV and MDR-TB
being used by WHO during the period 2016–2020, and their areas of overlap
Source: WHO Global Tuberculosis Report-2018
2.4 Global Epidemiology
Worldwide, tuberculosis (TB) is one of the top 10 causes of death, and the leading cause from a
single infectious agent above HIV/AIDS); millions of people continue to fall sick with the
disease each year.
In 2017, TB caused an estimated 1.3 million deaths (range, 1.2–1.4 million) among HIV-
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negative people, and there were an additional 300 000 deaths from TB (range, 266 000–335 000)
among HIV-positive people. There were an estimated 10.0 million new cases of TB (range, 9.0–
11.1 million), equivalent to 133 cases (range, 120–148) per 100 000 population.
Globally in 2017, there were an estimated 558 000 new cases (range, 483 000–639 000) of
rifampicin resistant TB (RR-TB), of which almost half were in three countries: India (24%),
China (13%) and the Russian Federation (10%). Among RR-TB cases, an estimated 82% had
multidrug-resistant TB (MDR-TB).
Globally, 3.5% of new TB cases and 18% of previously treated cases had MDR/RR-TB, with the
highest proportions (>50% in previously treated cases) in countries of the former Soviet Union.
In 2017, the best estimate of the proportion of people with TB who died from the disease (the
case fatality ratio, CFR) was 16%, down from 23% in 2000. The CFR needs to fall to 10% by
2020 to reach the first milestones of the End TB Strategy.
.
Table 01: Global Epidemiological Burden of TB (2017)
TB Control Indicators Global
Estimated Population 7.5 billion
Estimated Incidence 10.0 million
(133 cases/100 000)
Estimated Deaths Due to TB 1.3 million
(17 cases/100 000)
Total cases notified 6.7 million
New and relapse notified cases 6.4 million
Treatment Success Rate (2015 cohort) 82%
Estimated MDR/RR- TB cases among notified pulmonary TB cases 0.33 million
Patients with Known HIV Status who are HIV Positive 0.46 million
Patients with Known HIV Status who are HIV Positive on ART 0.37 Million (84%)
Source: WHO Global Tuberculosis Report-2018
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2.4.1 Estimates of TB incidence
Globally in 2017 there were an estimated 10 million incident cases of TB (range, 9 million to
11.1 million), equivalent to 133 cases per 100 000 population. Most of the estimated number of
cases in 2016 occurred in the WHO South-East Asia Region (44%). The 30 high TB burden
countries accounted for 87% of all estimated incident cases worldwide and eight of these
countries accounted for two thirds of the global total: India (27%), China (9%), Indonesia (8%),
the Philippines (6%), Pakistan (5%), Nigeria (4%), Bangladesh (4%) and South Africa (3%)
2.4.2 TB Mortality
Globally, the absolute number of deaths from TB among HIV-negative people has been
estimated to have fallen by 29% since 2000, from 1.8 million in 2000 to 1.3 million in 2017, and
by 5% since 2015 (the baseline year for targets set in the End TB Strategy). The number of TB
deaths among HIV-positive people has fallen by 44% since 2000, from 534 000 in 2000 to
300000 in 2017, and by 20% since 2015. The TB mortality rate (TB deaths among HIV-negative
people per 100 000 population per year) is falling at about 3% per year, and the best estimate for
the overall reduction during 2000–2017 is 42%.
Figure 03: Global trends in estimated TB incidence and mortality rates, 2000–2016. Shaded
areas represent uncertainty intervals.
Source: WHO Global Tuberculosis Report-2017
2.4.3 Trend of Treatment Success Rate
The latest treatment outcome data show treatment success rates of 82% for TB (2016 cohort),
77% for HIV-associated TB (2016 cohort), 55% for MDR/RR-TB (2015 cohort) and 34% for
extensively drug-resistant TB (XDR-TB) (2015 cohort).
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Figure 04: Trend of Treatment success rate for New Smear Positive Cases (1995 - 2016)
Source: Global Tuberculosis Report, WHO-2018
2.4.4 Drug-resistant TB
Globally, 160 684 cases of multidrug-resistant TB and rifampicin-resistant TB (MDR/RR-TB)
were notified in 2017 (up from 153 119 in 2016), and 139 114 cases were enrolled in treatment
(up from 129 689 in 2016).
There are also large gaps in detection and treatment of MDR/RR-TB and HIV-associated TB. In
2017, the number of MDR/RR-TB cases started on treatment was only 25% of the estimated
incidence of 558 000 cases, while the number of notified HIV-positive TB cases was only 51%
of the estimated 920 000 new cases of TB among people living with HIV.
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3. BURDEN OF TUBERCULOSIS IN SAARC REGION ---------------------------------------------------------------------------------------------------------------------
3.1 SAARC Epidemiology
The SAARC region, with an estimated annual incidence of 3.7 million TB cases equivalent to
212 cases per 100 000, carries 37% of the global burden of TB incidence (Table 02). Estimated
incidence by age and sex has shown in table 03.Three of eight Member States in the SAARC
Region are high TB and MDR-TB burden countries among 30 high burden countries. India
accounting for 27% of the world’s TB Cases. An estimated 0.5 million (31 cases per 100 000)
TB deaths in the region, however, India accounted 32 % of Global TB deaths.
Table 02: Estimates of the burden of diseases caused by TB in the SAARC Region 2017
Country
Population
('000)*
Incidence**
Mortality (Excluding
HIV)**
Number ('000) Rate***
Number
('000) Rate ***
Afghanistan 36000 67 189 10 29 (17-43)
Bangladesh 165000 360 221 66 40 (23-52)
Bhutan 779 0.8 178 0.03 20 (13-28)
India 1339000 2790 211 420 32 (28-33)
Maldives 402 0.13 39 0.016 3.7 (3.4-4.1)
Nepal 29000 45 152 6.6 23 (16-30)
Pakistan 197000 518 268 54 27 (21-34)
Sri Lanka 21000 13 65 1.2 6 (4.3-8.0)
Total 1788181 3794 212 558 31 Source: *Global Tuberculosis Report 2018, ** data taken from report sent by member states and Global tuberculosis report
2018, *** Rates are per 100 000 population
Table 03: Estimated TB incidence by age and sex (thousands) *, 2017
Country
Females
Total
Males
Total 0-14 years >14 years
0-14
years >14 years
Afghanistan 3.5 31.0 34.5 3.9 29.0 32.9
Bangladesh 17.0 118.0 135.0 18.0 212.0 230.0
Bhutan 0.05 0.35 0.40 0.06 0.63 0.69
India 107.0 847.0 954.00 117.0 1670.0 1787.0
Maldives 0.0 0.1 0.1 0.0 0.1 0.1
Nepal 2.3 14.0 16.3 2.5 26.0 28.5
Pakistan 27.0 207.0 234.0 30.0 261.0 291.0
Sri Lanka 0.7 4.1 4.8 0.8 7.9 8.7
Total (in
million) 0.2 1.2 1.4 0.2 2.2 2.4 *ranges represents uncertainty intervals
Source: *Global Tuberculosis Report 2018
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3.2 Notifications and Treatment Success
A total 2.6 million TB cases were notified in 2017 in the SAARC region (Table 04). An
increasing trend of total case notification has shown in figure 05. The treatment success rate for
new smear positive cases were 75% (2016 cohort) in the SAARC Region (Figure 06).
Table 04: TB Case notifications (2017) and Treatment Success Rate (2016 Cohort) in
SAARC Region
Country Population ('000)
Total Case
notified
Total (New and
relapse cases)
Treatment
Success (%)
Afghanistan 36000 47406 46640 93
Bangladesh 165000 244201 242639 95
Bhutan 779 881 865 95
India 1339000 1908371 1786681 69
Maldives 402 136 136 83
Nepal 29000 31764 31064 91
Pakistan 197000 368897 359224 92
Sri Lanka 21000 8511 8314 86
Total 1788181 2610167 2475563 75 Source: Data taken from report sent by member states and WHO Global tuberculosis report 2018
Figure 05: Trend of total case notified in the SAARC Region (2010-2017)
Source: SAARC Epidemiological reports & Global tuberculosis report 2018
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Figure 06: Trend of Treatment success rate for new smear positive and relapse cases
(2000-2016)
Source: WHO Global TB Report-2018, SAARC Epidemiological Response on Tuberculosis-2017
3.3 Drug Resistance TB
In the year 2017, the SAARC region has 101198 total number of an estimated MDR/RR-TB
cases among notified pulmonary TB cases. In the Region, laboratory confirmed cases in the same
year were 43691 MDR/RR-TB cases and 2802 XDR-TB cases. However, 40661 MDR/RR-TB
and 2933 XDR-TB patients started on treatment (Table 05).
Table 05: Estimates of Drug-resistant TB care in the SAARC Region, 2017
Country
Estimated
MDR/RR-TB
cases among
notified
pulmonary TB
cases (Total
Number)***
% of TB cases with
MDR-TB Laboratory confirmed
cases
Patients started on
treatment****
New Previously
Treated
MDR/RR-
TB
XDR-
TB
MDR/RR-
TB
XDR-
TB
Afghanistan 1700 3.7 21 279 5 198 5
Bangladesh 3000 1.6 29 944 6 920 6
Bhutan 50 11 18 60 0 60 0
India 84000 2.8 12 39009 2650 35950 2838
Maldives 2 1.7 18 1 0 1 0
Nepal 900 2.2 15 533 13 429 19
Pakistan 11499 3.7 16 2840 128 3081 65
Sri Lanka 47 0.54 3.1 25 0 22 0
Regional 101198 43691 2802 40661 2933 *** Includes cases with unknown previous TB Treatment history
****Includes patients diagnosed before 2016 and patients who were not laboratory- confirmed
Source: Data taken from report sent by member states and WHO Global tuberculosis report 2018
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3.4 TB/HIV Co-infection
In 2017, the region has 33404 TB Patients with known HIV status, among them 29074 (87%)
were on Antiretroviral Therapy. India accounts 32932 TB patients with known HIV status, 87%
patients were on ART, however, only Bhutan had provided 100% ART to TB patients with
Known HIV status in the region. In the SAARC region 10% Children (age <5) house hold contacts
of bacteriologically-confirmed TB cases on Isoniazid treatment (Table 06)
Table 06: Estimates of TB/HIV case in new and relapse TB patients, 2017
Country
Patients with known HIV
status who are HIV positive patients on
Antiretroviral Therapy
(ART)
Children (age <5) house
hold contacts of
bacteriologically-
confirmed TB cases on
preventive treatment
Number % Number % %
Afghanistan 7 <1 3 43 >100
Bangladesh 89 2 84 94 21
Bhutan 5 <1 5 100 NA
India 32932 3 28651 87 11
Maldives NA NA NA NA NA
Nepal 221 1 206 93 1.1
Pakistan 121 <1 97 80 NA
Sri Lanka 29 <1 28 97 43
Regional 33404 29074 87 - Source: Data taken from report sent by member states and WHO Global tuberculosis report 2018
The estimated Population of SAARC region in year 2017 was 1.78 billion which 24% of global
Population. Table 07 shows the comparison between global and SAARC Region on TB indicator
for the year 2017.
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Table 07: Global vs. SAARC Region on TB Indicators, 2017
TB Control Indicators Global SAARC
% of
Global
Estimated Population 7.5 billion 1.78 billion 24
Estimated Incidence 10.0 million 3.7 million
37
(133 cases/100
000)
(212 cases/100
000)
Estimated Deaths Due to TB 1.3 million 0.5 million
43 (17 cases/100 000) (31 cases/100 000)
Total cases notified 6.7 million 2.6 million 39
New and relapse notified cases 6.4 million 2.4 million 38
Treatment Success Rate (2015
cohort) 82% 75% -
Estimated MDR/RR- TB cases
among notified pulmonary TB cases 0.33 million 0.1 million 30
Patients with Known HIV Status
who are HIV Positive 0.46 million 0.03 million 6.5
Patients with Known HIV Status
who are HIV Positive on ART 0.37 Million (84%) 0.029 Million (87%) 8 Source: Data taken from report sent by member states and Global tuberculosis report 2018
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4. PROGRESSES ON TB CONTROL IN SAARC MEMBER STATES
------------------------------------------------------------------------------------------------------------
AFGHANISTAN MALDIVES
BANGLADESH NEPAL
BHUTAN PAKISTAN
INDIA SRI LANKA
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Islamic Republic of Afghanistan is one of the eight countries of the SAARC Region.
Afghanistan officially the Islamic Republic of Afghanistan, is a landlocked country located
within South Asia and Central Asia. It has Population of approximately 36 million (WHO Global
Tuberculosis Report-2018). It is bordered by Pakistan in the south and east; Iran in the west;
Turkmenistan, Uzbekistan, and Tajikistan in the north; and China in the far northeast.
TB Epidemiology
Tuberculosis is a major health problem in Afghanistan. Despite many challenges, the National
Tuberculosis Programme (NTP) has chosen to address the problem with interventions that are
proving successful. Earlier Afghanistan was in WHO 22 high TB burden countries list. But in
2015 WHO has removed Afghanistan from their high burden TB countries list.
In Afghanistan, an estimated annual incidence 67000 (CI: 43000-96000) TB cases equivalent to
189 cases per 100,000 populations and 10000 TB mortality equivalents to 29 cases per 100,000
populations in 2017. The TB case notifications in the year 2017 were 47406 and 93% treatment
success were registered in the year (2016 cohort). In year 2017, an estimated MDR/RR- TB
cases among notified pulmonary TB cases were 1700 (CI: 1000-2300) and the laboratory
confirmed cases on MDR/RR-TB and XDR-TB were 279 and 5 cases respectively. There were 7
TB patients with known HIV status who are HIV positive among them 3 patients (43%) were on
ART.
Major Achievements
NTP Afghanistan with the support of SAARC (STAC) assessed the effectiveness of
extending the active screening approaches at doorsteps through the operational research
“Additional Yield of Active TB Case Finding through Household Survey in Kabul City”
Strategic plan developed for 2017 – 2021
AFGHANISTAN
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Political commitment to DOTS:
Donors supports ensured (GF, JICA for anti-TB medicine and CTB/USAID for
improved TB control procedures beside government contribution to TB control in
the form of co-financing)
National TB guidelines/SOPs revised according to latest WHO recommendations and
disseminated nationally
Widest coverage of DOTS ensured and community based DOTS was initiated
MDR-TB management commenced and successful implementation ensured with
expansion to major provinces
CDR increased annually and sustained accordingly:71% (2017)
Challenges
Programmatic:
Low TB case notification (29% missing cases)
In sufficient diagnostic and treatment facilities for MDR-TB across the country
Within health system
Unreal integrated TB care services
Lower commitment from the health staff
Missed opportunities within health system
Within the community
Lower knowledge about TB in the community
Stigma against the disease
Outside of the system
Security Problem
Geographical limitations
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New Initiatives:
Introducing of Gene Xpert for diagnosis of MDR – TB
TB Screening among IDPs and prisoners by digital mobile x-ray
Future Plans:
Expand MDR TB Management
Promote New Technology in line with WHO recommendation (Gene X-pert)
Promote and sustain TB case findings (active and passive)
Addressing latent TB ( contact investigation and INH preventive therapy )
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Graphical presentations, Afghanistan
Source: Global Tuberculosis Report-2014 & 2015
Trend of incidence and Mortality (2005-2017)
20
05
20
10
20
13
20
14
20
15
20
16
20
17
Mortality Rate 45 39 42 44 37 33 29
Incidance Rate 189 189 189 189 189 189 189
020406080100120140160180200
05
101520253035404550
Incid
en
ce R
ate
/10
0 0
00
po
pn
Mo
rta
lity
Ra
te
Trend of Treatment success rate for new & relapse cases
(2000 - 2016)
Trend of TB case notifications (new and relapse)
2000 - 2017
Estimated TB incidence by age and sex, 2017
Source: WHO Global Tuberculosis Report-2018, SAARC
Epidemiological Response on Tuberculosis -2017
Source: WHO Global Tuberculosis Report- 2018
Source: WHO Global Tuberculosis Report-2018, SAARC
Epidemiological Response on Tuberculosis -2017
Source: WHO Global Tuberculosis Report-2018, SAARC
Epidemiological Response on Tuberculosis -2017
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TB Epidemiology 2017, Afghanistan
Population (2017) 36 million
Estimates of TB burden * 2017
Number
(thousands)
Rate (per 100 000
population)
Mortality (excludes HIV+TB) 10 (6-15) 29 (17-43)
Mortality (HIV+TB only) 0.064 (<0.01-0.17) 0.18 (0.03-0.47)
Incidence (includes HIV+TB) 67 (43-96) 189 (122-270)
Incidence (HIV+TB only) 0.21 (0.14-0.3) 0.6 (0.39-0.86)
Incidence (MDR/RR-TB)** 3.2 (1.5-5.5) 9 (4.3-15)
Estimated TB incidence by age and sex (thousands)*, 2017
0-14 years >14 years Total
Females 3.5 (3.2-3.9) 31 (23-39) 34 (25-44)
Males 3.9 (3.5-4.3) 29 (22-36) 33 (24-42)
Total 7.4 (6.5-8.4) 60 (38-82) 67 (43-96)
TB case notifications, 2017
Total cases notified 47406
Total new and relapse 46640
-% tested with rapid diagnostics at time of diagnosis
-% with known HIV status 48%
- % pulmonary 73%
- % bacteriologically confirmed among pulmonary 61%
Universal Health Coverage and Social protection
TB treatment coverage (notified/estimated incidence), 2017 70% (49-110)
TB cases fatality ratio (estimated mortality/estimated incidence), 2017 0.16 (0.08-0.26)
TB/HIV Care in new and relapse TB
patients, 2017 Number %
Patients with known HIV status who are HIV positive 7 <1%
- On antiretroviral therapy 3 43%
Drug- resistant TB care, 2017 New cases
Previously treated
cases Total Number***
Estimated MDR/RR-TB cases among
notified pulmonary TB cases 1700 (1000-2300)
Estimated % of TB cases with
MDR/RR-TB 3.7% (2-5.9) 21% (15-27)
% notified tested for rifampicin
resistance 6% 95% 5251
MDR/RR-TB cases tested for
resistance to second line drugs 279
Laboratory confirmed cases MDR/RR-TB: 279 XDR-TB:5
Patients started on treatment**** MDR/RR-TB: 198 XDR-TB:5
Treatment success rate and cohort size Success Cohort
New and relapse cases registered in 2016 93% 40287
Previously treated cases, excluding relapse, registered in
2016 90% 568
HIV-positive TB cases, all types, registered in 2016 0% 1
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MDR/RR-TB cases started on second line treatment in
2015 64% 83
XDR-TB cases started on second-line treatment in 2015 0
TB Preventive treatment, 2017
% of HIV+ people (newly enrolled in care) on preventive treatment 4%
% of Children ( aged <5) household contacts of bacteriologically- confirmed TB
cases on preventive treatment >100%
* Ranges represent uncertainty intervals
** MDR is TB resistant to rifampicin and isoniazid; RR is TB resistant to
rifampicin
*** Includes cases with unknown previous TB Treatment history
****Includes patients diagnosed before 2017 and patients who were not laboratory- confirmed Source: WHO Global Tuberculosis Report-2018
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People's Republic of Bangladesh is a country in South Asia. It is bordered by India to its west,
north and east; Myanmar (Burma) to its southeast; and is separated from Nepal and Bhutan by
the Chicken's Neck corridor. To its south, it faces the Bay of Bengal. The total area of the
country is 147,570 km2.
Population of Bangladesh is 165 million (WHO Global Tuberculosis
Report-2018) and it is one of the most densely populated countries in the world.
TB Epidemiology
Bangladesh is among countries with the high burden of TB and MDR-TB. The estimated
mortality and incidence rates of all forms of tuberculosis were 40 (CI: 23-52) and 221 (CI: 161-
291) per 100 000 population respectively in 2017.WHO has estimated 360000 (CI: 265000-
479000) incident cases in 2017.
Total 244201 notified new and relapse cases were detected in 2017, among them total new and
relapse cases were 242639.
The treatment success rate among new and relapse cases is above 90% since 2007, and it was
95% in 2016 cohort. However, in 2016 cohort, the treatment success rate among HIV positive
TB cases was only 49% and MDR/RR cases started on second line treatment in 2015 showed a
78% treatment success rate.
Achievements
Research of “Comparative evaluation of treatment for MDR TB with and without co-
morbidity a retrospective analysis in Bangladesh” has jointly completed by NTP
Bangladesh and SAARC TB and HIV/AIDS Centre, Nepal.
Xpert MTB/RIF was first introduced in Bangladesh in March 2012 with the support of
the TB CARE II project. Till December 2016, a total of 56 Xpert MTB/ RIF machines
were functioning at different settings in the country, including six machines in Dhaka
city.
Implementation of New Drugs; bedaquiline & delamide
Increased case detection
Treatment success rate 95% for DS TB and MDR TB treatment success rate 76% for long
BANGLADESH
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regimen and 83 % for short regimen.
Countrywide implementation of Short Regimen of MDR treatment
Expansion of Gene Expert Sites (51 Sites by 2017, 193 sites till date )
Major Challenges:
• Slow decline of Annual Incidence
• Recent cross border migration Population in Coxbazar
• Management of Child TB and MDR –TB
• Unchanged annual incidence since 1990
• Identification of 33% missing TB cases
• Identification of 80% missing MDR/RR TB cases
• Identification of missing child TB cases ( currently 4.32% of notified TB cases)
• Urban TB
• Insufficient number of latest diagnostics (e.g. Xpert, LPA)
• Infection Control
• Human resource
• Less involvement of Private Sector
• Mandatory notification
• Engagement of Private Sectors in TB Program Management and Reporting
Future Plan
Further expansion of Gene Expert Sites.
Implement mandatory notification
Increase case detection
Expand PMDT sites, shorter regimen and new drugs
Updating guidelines
Specially designed program for urban area
Scale up PPM activity
Capacity building with special attention to DR-TB, Child TB, PSM
Ensure the long-term availability of required funding;
o Increase GOB contribution
Strengthening Supervision and monitoring
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Graphical presentations, Bangladesh
Trend of incidence and Mortality (2005-2017)
Case detection rate and Treatment success rate for new
smear positive cases (2000 - 2016)
Trend of TB case notification (new and relapse)
2000 – 2017
Estimated TB incidence by age and sex, 2017
Source: WHO Global Tuberculosis Report-2018, SAARC
Epidemiological Response on Tuberculosis -2017
Source: WHO Global Tuberculosis Report- 2018
Source: WHO Global Tuberculosis Report-2018, SAARC
Epidemiological Response on Tuberculosis -2017 Source: WHO Global Tuberculosis Report-2018, SAARC
Epidemiological Response on Tuberculosis -2017
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TB Epidemiology 2017, Bangladesh
Population (2017) 165 million
Estimates of TB burden * 2017
Number
(thousands)
Rate (per 100 000
population)
Mortality (excludes HIV+TB)a 66 (38-85) 40 (23-52)
Mortality (HIV+TB only) 0.17 (0.085-0.29) 0.11 (0.05-0.18)
Incidence (includes HIV+TB)a 360 (265-479) 221 (161-291)
Incidence (HIV+TB only) 0.55 (0.27-0.92) 0.33 (0.17-0.56)
Incidence (MDR/RR-TB)** 8.4 (3.8-15) 5.1 (2.3-9)
Estimated TB incidence by age and sex (thousands)*, 2017
0-14 years >14 years Total
Females 17 (16-18) 118 (98-137) 134 (110-158)
Males 18 (17-19) 212 (164-259) 230 (176-284)
Total 35 (32-38) 329 (237-421) 364 (265-479)
TB case notifications, 2017
Total cases notified 244201
Total new and relapse 242639
-% tested with rapid diagnostics at time of diagnosis <1%
-% with known HIV status 2%
- % pulmonary 81%
- % bacteriologically confirmed among pulmonary 74%
Universal Health Coverage and Social protection
TB treatment coverage (notified/estimated incidence), 2017 67% (51-92)
TB cases fatality ratio (estimated mortality/estimated incidence), 2017 0.17 (0.1-0.26)
TB/HIV Care in new and relapse TB patients, 2017 Number %
Patients with known HIV status who are HIV positive 89 2%
- On antiretroviral therapy 84 94%
Drug- resistant TB care, 2017 New cases
Previously
treated cases Total Number***
Estimated MDR/RR-TB cases
among notified pulmonary TB
cases 5800 (3800-7800)
Estimated % of TB cases with
MDR/RR-TB 1.6% (0.74-2.8) 29% (24-35)
% notified tested for rifampicin
resistance 18% 63% 49943
MDR/RR-TB cases tested for resistance to second line drugs 362
Laboratory confirmed cases MDR/RR-TB: 944 XDR-TB:6
Patients started on treatment**** MDR/RR-TB: 920 XDR-TB:6
Treatment success rate and cohort size Success Cohort
New and relapse cases registered in 2016a 95% 222252
Previously treated cases, excluding relapse, registered in
2016 86% 1669
HIV-positive TB cases, all types, registered in 2016 49% 87
MDR/RR-TB cases started on second line treatment in 2015 78% 880
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XDR-TB cases started on second-line treatment in 2015 0
TB Preventive treatment, 2017
% of HIV+ people (newly enrolled in care) on preventive
treatment
% of Children ( aged <5) household contacts of
bacteriologically- confirmed TB cases on preventive
treatment 21% (19-23)
* Ranges represent uncertainty intervals
** MDR is TB resistant to rifampicin and isoniazid; RR is TB resistant to
rifampicin
*** Includes cases with unknown previous TB Treatment history
****Includes patients diagnosed before 2017 and patients who were not
laboratory- confirmed
Source: WHO Global Tuberculosis Report-2018, a: Data sent by NTP Bangladesh
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Bhutan officially the Kingdom of Bhutan, is a landlocked country in South Asia at the eastern
end of the Himalayas. It is bordered to the north by China and to the south, east and west
by India. To the west, it is separated from Nepal by the Indian state of Sikkim, while farther
south it is separated from Bangladesh by the Indian states of Assam and West Bengal. Bhutan's
capital and largest city is Thimphu. It has a land area of 38,394 square kilometers and the altitude
varying from 180m to 7,550 m above sea level. The total Population of Bhutan was estimated to
be 779666 (Data sent by Bhutan NTP-2018) in the year 2017.
TB Epidemiology
National Tuberculosis Control Program under the Department of Public Health started in the
year 1986. NTCP is responsible for programming, planning, resource mobilization, monitoring
and evaluation. National Referral/ Regional Referral and District hospitals diagnose and start the
treatment for TB. The health workers in the basic health units report cases, follow up and refer
TB suspects to the district hospitals for confirmation. In 1991, a tuberculin survey measured the
annual risk of tuberculosis infection to be 1.5%. Bhutan piloted Short Course Chemotherapy
(SCC) in three districts in 1994 and was implemented nationwide in the same year. In 1997 the
Directly Observed Treatment Short Course (DOTS) strategy was adopted nationwide.
The estimated mortality and incidence rates of all forms of tuberculosis were 20 (CI: 13-28) and
178 (CI: 137-226) per 100 000 population respectively in 2017.WHO has estimated 864 (CI:
830-1400) incidence cases in 2017. Total 881 notified new and relapse cases were detected in
2017, among them the notified new and relapse cases were 865.
The treatment success rate among new and relapse cases is above 91% since 2005, and it was 95
% in 2016 cohort. MDR/RR-TB cases started on second line treatment in 2015 showed a 91%
treatment success rate.
BHUTAN
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Achievements
Committed and motivated health staff at central- and peripheral-level care and
prevention delivery points
General awareness from clinicians and providers at health facilities about and
concerning epidemiologic trends (increased extra-pulmonary (EPTB) and multidrug
resistant TB (MDR TB)
Excellent recording and reporting system through TB-ISS, reduced recording burden
and paperwork
Continued support from Royal Government of Bhutan to sustain health financing –
including the procurement of vital anti-tuberculosis drugs.
Study to determine causality of EPTB in Bhutan funded by SAARC TB and
HIV/AIDS Centre
Challenges:
The Kingdom of Bhutan has a relatively small population living in remote areas
Substandard implementation and quality for directly observed therapy (DOT) service
delivery
Infection control practices are poor, inadequate, and poses a sustained and dangerous
threat to transmission in the community and to Bhutan’s health care delivery workforce
Prolonged delays diagnosis (shipment of sputum samples from peripheral microscopy
centers to National Tuberculosis Reference Laboratory (NTRL); affecting the quality of
culture and drug susceptibility testing (DST)
Unstable internet connectivity to optimize the utilization of TB-ISS
Future Plan
Improving Tuberculosis case finding
Improving Quality of tuberculosis diagnosis
Improving Anti-tuberculosis medicine and supply management streamline
Improving Human resource capacity and development
Improving Clinical and programmatic management of tuberculosis cases (non-drug
resistant)
Improving Clinical and programmatic management of drug-resistant cases
Improving Surveillance: recording and reporting
Improving Tuberculosis and HIV programme integration
Improving Pediatric tuberculosis
Improving Extra pulmonary tuberculosis
Community engagement and ACSM
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Operational research and development
National TB Prevalence Survey
New initiatives/ Best practices:
Follow up of TB patients through mobile phone has been initiated through the support of
TB NFM grant.
Line Probe Assay established in Royal Centre for Disease Control (RCDC)
Expansion of rapid diagnostic tool to other sites
Plan to establish SL DST in RCDC
Adopt any newer diagnostic tools as per WHO recommendations
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Graphical presentations, Bhutan
Trend of incidence and Mortality (2005-2017)
Treatment success rate for new smear positive cases
(2000 - 2016)
Trend of TB case notification (new and relapse)
2000 - 2017
Estimated TB incidence by age and sex, 2017
Source: WHO Global Tuberculosis Report-2018, SAARC
Epidemiological Response on Tuberculosis -2017
Source: WHO Global Tuberculosis Report- 2018
Source: Data sent by NTP Bhutan-2018, SAARC Epidemiological
Response on Tuberculosis -2017 Source: WHO Global Tuberculosis Report-2018, SAARC
Epidemiological Response on Tuberculosis -2017
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TB Epidemiology 2016, Bhutan
Population (2017)a 779666
Estimates of TB burden * 2017 Number (thousands)
Rate (per 100 000
population)
Mortality (excludes HIV+TB)a 0.03 20 (CI:13-28)
Mortality (HIV+TB only) <0.01 (<0.01-<0.01) 0.16 (0.11-0.22)
Incidence (includes HIV+TB)a 0.8 (CI: 0.8-1.4) 178 (CI:137-226)
Incidence (HIV+TB only) <0.01 (<0.01-0.01) 0.77 (0.5-1.1)
Incidence (MDR/RR-TB)** 0.18 (0.12-0.25) 22 (15-31)
Estimated TB incidence by age and sex (thousands)*, 2017
0-14 years >14 years Total
Females 0.05 (0.047-0.053) 0.35 (0.32-0.4) 0.4 (0.34-0.46)
Males 0.056 (0.053-0.059) 0.63 (0.51-0.75) 0.68 (0.55-0.82)
Total 0.11 (0.098-0.11) 0.98 (0.74-1.2) 1.1 (0.83-1.4)
TB case notifications, 2017
Total cases notifieda 881
Total new and relapse 865
-% tested with rapid diagnostics at time of diagnosis 51%
-% with known HIV status 100%
- % pulmonary 59%
- % bacteriologically confirmed among pulmonary 86%
Universal Health Coverage and Social protection
TB treatment coverage (notified/estimated incidence), 2017 80% (63-100)
TB cases fatality ratio (estimated mortality/estimated incidence), 2017 0.11 (0.07-0.17)
TB/HIV Care in new and relapse TB patients,
2017 Number %
Patients with known HIV status who are HIV
positive 5 <1%
- On antiretroviral therapy 5 100%
Drug- resistant TB care,
2017 New cases
Previously treated
cases Total Number***
Estimated MDR/RR-TB cases among notified pulmonary TB cases 81 (57-110)
Estimated % of TB cases
with MDR/RR-TB 13% (10-17) 33% (7.5-70) -
% notified tested for
rifampicin resistance 55% 70% 493
MDR/RR-TB cases tested for resistance to second line drugs 0
Laboratory confirmed cases MDR/RR-TB: 60 XDR-TB:0
Patients started on treatment**** MDR/RR-TB: 60 XDR-TB:0
Treatment success rate and cohort size Success Cohort
New and relapse cases registered in 2016 95% 1139
Previously treated cases, excluding relapse,
registered in 2016 100% 6
HIV-positive TB cases, all types, registered in 2016 67% 6
MDR/RR-TB cases started on second line treatment
in 2015 91% 47
XDR-TB cases started on second-line treatment in
2015 0
TB Preventive treatment, 2017
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% of HIV+ people (newly enrolled in care) on
preventive treatment -
% of Children ( aged <5) household contacts of
bacteriologically- confirmed TB cases on preventive
treatment -
* Ranges represent uncertainty intervals
** MDR is TB resistant to rifampicin and isoniazid; RR is TB resistant to
rifampicin
*** Includes cases with unknown previous TB Treatment history
****Includes patients diagnosed before 2017 and patients who were not
laboratory- confirmed
Source: WHO Global Tuberculosis Report-2018, a: data sent by NTP Bhutan-2018
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India, officially the Republic of India is a country in South Asia. It is the seventh-largest country
by area, the second-most populous country with 1339 million people (WHO Global Tuberculosis
Report-2018), and the most populous democracy in the world. The land area is 3,287,263 square
kilometers. Bounded by the Indian Ocean on the south, the Arabian Sea on the south-west, and
the Bay of Bengal on the south-east, it shares land borders with Pakistan to the
west; China, Nepal, and Bhutan to the north-east; and Myanmar and Bangladesh to the east. In
the Indian Ocean, India is in the vicinity of Sri Lanka and the Maldives; in addition,
India's Andaman and Nicobar Islands share a maritime border with Thailand and Indonesia.
TB Epidemiology
In 2017, an estimated 2.79 (CI: 1.8-3.7) million cases occurred and 0.42 (CI: 0.38-0.44) million
people died due to TB. The estimates of TB for India has been revised upwards based on the
newer evidences gained. This apparent increase in the disease burden reflects the incorporation
of more accurate data. With backward calculations, both tuberculosis incidence and mortality
rates are decreasing from 2000 to 2017.
The incidence of TB has reduced from 289 per lakh per year in 2000 to 211 per lakh per year in
2017 and the mortality due to TB has reduced from 56 per lakh per year in 2000 to 32 per lakh
per year in 2017. Moreover, these revisions are interim in nature, with further changes likely
when India conducts its first national tuberculosis prevalence survey in 2017–18.
Achievements
Annual TB notification rate of TB patients in India has increased to 144 cases / lakh
population in 2017 as compared to 135 in 2016
3,90,154 TB patients were notified from private sector in 2017 as compared to 3,31,909
in 2016
Active case finding Targeted to reach 8 crore vulnerable population mapped in 378
districts in 2017
TrueNat – an indigenous rapid molecular test was tested for feasibility of implementation
in the country
Daily Regimen for treatment of drug sensitive TB patients has been scaled up across the
INDIA
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country
Bedaquiline has been rolled out at 21 DR-TB Centres under programmatic settings
National Strategic Plan for 2017-25 has been prepared
Mobile TB Diagnostic vans were provided in tribal area for case detection enhancement
TB Diabetes and TB Tobacco collaborative framework was launched
Guidelines on TB Nutrition was initiated.
New Initiatives:
Active case finding among vulnerable and marginalized population to increase the case
detection
TrueNat – an indigenous rapid molecular test has been used for testing feasibility at
peripheral laboratory to replace microscopy
Challenges:
Sub-optimal involvement of private sector
Treatment outcome of Drug Resistant TB
Reaching the unreached – Slums, Tribal, vulnerable
Co-morbidities – HIV, Diabetes
Issues of poverty, nutrition, overcrowding
Lack of awareness and poor health seeking behaviour lead to delay in diagnosis
Wide geographical variation in the epidemic
Future Plans:
Nutritional support for all TB patients through provision of 500 INR monthly direct
benefit transfer
Joint Effort for Elimination of Tuberculosis (JEET) Project launched on 15th May 2018
for intensified efforts and linkage of free diagnostic and treatment services in private
sector in 45 large cities and 348 districts
Engagement with IMA for sensitization activities in 1000 district level branches
Expansion of CBNAAT laboratories to 1135 from 651 in 2017
Operationalization of Universal drug susceptibility implementation in entire country
Expansion of newer drug regimen including Bedaquiline and Delamanid and shorter
regimen across the country
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Graphical presentations, India
Trend of incidence and Mortality (2005-2017)
Treatment success rate for new smear positive cases
(2000 - 2016)
Trend of TB case notification (new and relapse)
2000 - 2017
Estimated TB incidence by age and sex, 2017
Source: WHO Global Tuberculosis Report-2018 & SAARC
Epidemiological Response on Tuberculosis-2017
Source: WHO Global Tuberculosis Report- 2018
Source: Data sent by NTP India-2018, SAARC Epidemiological
Response on Tuberculosis -2017 Source: WHO Global Tuberculosis Report-2018 & SAARC
Epidemiological Response on Tuberculosis-2017
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TB Epidemiology 2017, India
Population (2017) 1339 million
Estimates of TB burden * 2017 Number (thousands)
Rate (per 100 000
population)
Mortality (excludes HIV+TB)a 420 (CI: 380-440) 32 (CI: 28-33)
Mortality (HIV+TB only) 11 (6.5-16) 0.79 (0.48-1.2)
Incidence (includes HIV+TB)a 2790 (CI: 1870-3770) 211 (CI: 140-281)
Incidence (HIV+TB only) 86 (57-120) 6.4 (4.3-9.0)
Incidence (MDR/RR-TB)** 135 (78-208) 10 (5.6-16)
Estimated TB incidence by age and sex (thousands)*, 2017
0-14 years >14 years Total
Females 107 (100-114) 847 (684-1010) 954 (759-1150)
Males 117 (109-126) 1670 (1220-2120) 1780 (1290-2280)
Total 224 (202-247) 2510 (1680-3350) 2740 (1870-3770)
TB case notifications, 2017
Total cases notified 1908371
Total new and relapse 1786681
-% tested with rapid diagnostics at time of diagnosis 70%
-% with known HIV status 64%
- % pulmonary 85%
- % bacteriologically confirmed among pulmonary 60%
Universal Health Coverage and Social protection
TB treatment coverage (notified/estimated incidence), 2017 65% (47-96)
TB cases fatality ratio (estimated mortality/estimated incidence), 2017 0.16 (0.11-0.22)
TB/HIV Care in new and relapse TB patients, 2017 Number %
Patients with known HIV status who are HIV positive 36440 3%
- On antiretroviral therapy 28651 79%
Drug- resistant TB care, 2017 New cases Previously treated cases Total Number***
Estimated MDR/RR-TB cases among
notified pulmonary TB cases 65000 (54000-76000)
Estimated % of TB cases with
MDR/RR-TB 2.8 % (2-3.5) 12 % (10-13)
% notified tested for rifampicin
resistance 32% 82% 720051
MDR/RR-TB cases tested for resistance to second line
drugs 26832
Laboratory confirmed cases MDR/RR-TB: 39009 XDR-TB:2650
Patients started on treatment**** MDR/RR-TB: 35950 XDR-TB:2838
Treatment success rate and cohort size Success Cohort
New and relapse cases registered in 2016 69% 1763876
Previously treated cases, excluding relapse, registered in
2016 70% 172282
HIV-positive TB cases, all types, registered in 2016 75% 39123
MDR/RR-TB cases started on second line treatment in
2015 46% 26966
XDR-TB cases started on second-line treatment in 2015 28% 2130
TB Preventive treatment, 2017
% of HIV+ people (newly enrolled in care) on preventive
treatment 10%
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% of Children ( aged <5) household contacts of
bacteriologically- confirmed TB cases on preventive
treatment 11 % (10-12)
* Ranges represent uncertainty intervals
** MDR is TB resistant to rifampicin and isoniazid; RR is TB resistant to rifampicin
*** Includes cases with unknown previous TB Treatment history
****Includes patients diagnosed before 2017 and patients who were not laboratory-
confirmed
Source: WHO Global Tuberculosis Report-2018, a: data sent by NTP India-2018
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Republic of Maldives is an island country formed by a number of natural atolls and a few islands
in the Indian Ocean consisting of a double chain of twenty-six atolls, The islands are located
southwest of the Indian subcontinent stretching 860 km north to south and 80 – 129 km east to
west. The population of Maldives in year 2017 was 402071 (Data sent by Maldives, NTP-2018).
The economy of the Maldives depends mainly on tourism, fishing trade, shipping and
construction. Resort islands and modern hotels in Male are the main attractions for the increasing
numbers of tourists.
TB Epidemiology
With increased case notification and treatment coverage, there is high political commitment
towards ending TB in the country. Diagnosis and treatment guidelines adopted by the NTP are in
line with WHO recommended standards. New and more convenient paediatric formulation for
childhood TB cases introduced. Gene Xpert testing services initiated. Quality assured anti-TB
drugs are procured using domestic funding. All TB services are provided free of charge. Case
detection among risk groups (prisons, home for people with special needs, migrants)
strengthened through collaboration between related agencies.
The estimated mortality and incidence rates of all forms of tuberculosis were 3.7 (CI: 3.4-4.1)
and 39 (CI: 30-49) per 100 000 population respectively in 2017.WHO has estimated 136 (CI:
130-220) incidence cases in 2017. Total 136 notified new and relapse cases were detected in
2017.
Achievements
The Government of Maldives is committed to support the program.
Most activities for the program including drug purchase are undertaken through state
funding with limited external support through WHO
Availability of quality assured anti-TB drugs from Global Drug Facility is being
maintained
MALDIVES
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Continuous allocation of funds by the government for the procurement of anti-TB drugs
Direct Observation of the treatment for full course of treatment is in place due to the well
functional DOT centers at all health facilities.
For the last decade, number of notified case has been steadily decreasing.
Screening of all HIV positives cases for active TB is in place in collaboration with the
HIV program since 2003.
National Strategic plan to end TB in Maldives 2018-2022 been launched
Challenges
Still lacks human and financial capacity to implement, fully control and coordinate all TB
related activities in the country.
No capacity is available in country for DST: no adequate system of sputum transport has
been established with external TB laboratory for DST for diagnoses as well as for follow
up for X/MDR patients.
Inadequate levels of collaboration between all care-providers and the National TB
program.
There are no specific treatment facilities for patients with a high default risk.
Lack of human resources and funds
Future Plans
Implementation of WHO Biennium 2018/2019 activities.
Working towards implementing strategies planned to END TB in Maldives by 2022.
Formation National Steering Committee and Technical Working group is also in
progress.
New Initiatives/Best Practices
Practical Approach to lung Health guideline has been developed and has to be endorsed.
Developed and finalized a contact screening protocol and is being implemented.
Develop and finalized MDRTB case management guideline.
Develop and finalized TB case management Guideline.
Maldives has successfully adopted WHO DS TB and DR TB guide line. Technical
discussion is planned to incorporate new available drugs.
Developed and launched a national strategic plan to end TB in Maldives 2018-2022.
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Graphical presentations, Maldives
Trend of incidence and Mortality (2005-2017)
Treatment success rate for new smear positive cases
(2000 - 2017)
Trend of TB case notification (new and relapse)
2000 - 2017
Estimated TB incidence by age and sex, 2017
Source: WHO Global Tuberculosis Report-2018 & SAARC
Epidemiological Response on Tuberculosis-2017
Source: WHO Global Tuberculosis Report- 2018
Source: WHO Global Tuberculosis Report-2018 & SAARC
Epidemiological Response on Tuberculosis-2017 Source: WHO Global Tuberculosis Report-2018 & SAARC
Epidemiological Response on Tuberculosis-2017
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TB Epidemiology 2017, Maldives
Population (2017) 402071
Estimates of TB burden * 2017
Number
(thousands)
Rate (per 100
000 population)
Mortality (excludes HIV+TB) 0.016 (0.015-0.018) 3.7 (3.4-4.1)
Mortality (HIV+TB only) 0 0
Incidence (includes HIV+TB) 0.17 (0.13-0.22) 39 (30-49)
Incidence (HIV+TB only) 0 0
Incidence (MDR/RR-TB)** <0.01 (0-0.012) 0.91 (0.08-2.7)
Estimated TB incidence by age and sex (thousands)*, 2017
0-14 years >14 years Total
Females <0.01 (<0.01-<0.01) 0.055 (0.047-0.062)
0.063 (0.053-
0.072)
Males <0.01 (<0.01-<0.01) 0.099 (0.08-0.12) 0.11 (0.086-0.13)
Total 0.017 (0.015-0.018) 0.15 (0.12-0.19) 0.17 (0.13-0.22)
TB case notifications, 2017
Total cases notified 136
Total new and relapse 136
-% tested with rapid diagnostics at time of diagnosis 45%
-% with known HIV status 100%
- % pulmonary 72%
- % bacteriologically confirmed among pulmonary 100%
Universal Health Coverage and Social protection
TB treatment coverage (notified/estimated incidence), 2017 80% (63-100)
TB cases fatality ratio (estimated mortality/estimated incidence), 2017 0.1 (0.07-0.12)
TB/HIV Care in new and relapse TB patients, 2017 Number %
Patients with known HIV status who are HIV positive 0 0%
- On antiretroviral therapy 0 0%
Drug- resistant TB care, 2017 New cases
Previously treated
cases
Total
Number***
Estimated MDR/RR-TB cases among
notified pulmonary TB cases 2 (0-5)
Estimated % of TB cases with
MDR/RR-TB 1.7 (0.04-9.1) 18% (11-26)
% notified tested for rifampicin
resistance 56% 75
MDR/RR-TB cases tested for resistance to second line drugs 1
Laboratory confirmed cases MDR/RR-TB: 1 XDR-TB:0
Patients started on treatment**** MDR/RR-TB: 1 XDR-TB:0
Treatment success rate Success Cohort
New and relapse cases registered in 2016 83% 168
Previously treated cases, excluding relapse, registered in 2016
HIV-positive TB cases, all types, registered in 2016 100% 1
MDR/RR-TB cases started on second line treatment in 2015 0% 1
XDR-TB cases started on second-line treatment in 2015 0
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TB Preventive treatment, 2017
% of HIV+ people (newly enrolled in care) on preventive treatment 0%
% of Children ( aged <5) household contacts of bacteriologically-
confirmed TB cases on preventive treatment 0%
* Ranges represent uncertainty intervals
** MDR is TB resistant to rifampicin and isoniazid; RR is TB resistant to rifampicin
*** Includes cases with unknown previous TB Treatment history
****Includes patients diagnosed before 2017 and patients who were not laboratory- confirmed
Source: WHO Global Tuberculosis Report-2018
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Nepal is a landlocked country and is located in the Himalayas and bordered to the north by the
China and to the south, east, and west by the India. Nepal is divided into 7 states and 77 districts.
It has an area of 147,181 square kilometers and Population of approximately 29 million (WHO
Global Tuberculosis Report-2018). The urban Population is largely concentrated in the
Kathmandu valley.
TB Epidemiology
Tuberculosis (TB) is still a major public health problem in Nepal. In 2017 WHO has estimated
45000 (CI: 39000-50000) incident cases with the rate of 152 (CI: 134-172) per 100,000
population)). At the same year mortality was 6600 (CI: 4700-8900) with the rate of 23 (CI: 16-30
per 100,000 population). In 2017, total of 31764 new and relapse cases of TB were registered.
Among them, 77% were pulmonary bacteriological confirmed (PBC).
Key Constraint & Challenges
The Nepal NTP has regularly been facing several challenges and constraints, which influence
inability to expand and sustain the vision of the programme. Following are the key challenges
and constraints faced by the NTP in order to reach intended goals and targets of the programme
in last fiscal year.
Challenges:
Insufficient income generation program for patient and their family members.
Inadequate TB management training to medical doctors
Minimum interventions for strengthening PPM component
Lack of operational research regarding increasing retreatment cases
Lack of patient friendly TB treatment service
Existing currier system for slide- not adequate
Inadequate TB IEC materials
Difficult to coordinate with regional and provincial hospitals.
NEPAL
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Action to be taken:
Expansion of CBDOT programme in the country
Strengthen Public Private Mix approach
Strengthen the Community Support System programme
Plan for operational research on TB
Develop and distribute patients centered TB IEC materials
Pilot patient friendly treatment centers in the country
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Graphical presentations, Nepal
Trend of incidence and Mortality (2005-2017)
Treatment success rate for new smear positive cases
(2000 - 2017)
Trend of TB case notification (new and relapse)
2000 - 2017
Estimated TB incidence by age and sex, 2017
Source: WHO Global Tuberculosis Report-2018 & SAARC
Epidemiological Response on Tuberculosis-2017
Source: WHO Global Tuberculosis Report- 2018
Source: WHO Global Tuberculosis Report-2018 & SAARC
Epidemiological Response on Tuberculosis-2017
Source: WHO Global Tuberculosis Report-2018 & SAARC
Epidemiological Response on Tuberculosis-2017
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TB Epidemiology 2017, Nepal
Population (2017) 29 million
Estimates of TB burden * 2017
Number
(thousands)
Rate (per 100 000
population)
Mortality (excludes HIV+TB) 6.6 (4.7-8.9) 23 (16-30)
Mortality (HIV+TB only) 0.26 (0.14-0.42) 0.88 (0.47-1.4)
Incidence (includes HIV+TB) 45 (39-50) 152 (134-172)
Incidence (HIV+TB only) 0.88 (0.49-1.4) 3 (1.7-4.8)
Incidence (MDR/RR-TB)** 1.5 (0.84-2.4) 5.2 (2.9-8.1)
Estimated TB incidence by age and sex (thousands)*, 2017
0-14 years >14 years Total
Females 2.3 (2.2-2.3) 14 (13-14) 16 (15-17)
Males 2.5 (2.4-2.5) 26 (24-29) 29 (26-32)
Total 4.7 (4.5-4.9) 40 (35-45) 45 (39-50)
TB case notifications, 2017
Total cases notified 31764
Total new and relapse 31064
-% tested with rapid diagnostics at time of diagnosis
-% with known HIV status 54%
- % pulmonary 71%
- % bacteriologically confirmed among pulmonary 77%
Universal Health Coverage and Social protection
TB treatment coverage (notified/estimated incidence), 2017 70 % (62-79)
TB cases fatality ratio (estimated mortality/estimated incidence), 2017 0.16 (0.11-0.21)
TB/HIV Care in new and relapse TB
patients, 2017 Number %
Patients with known HIV status who are HIV positive 221 1%
- On antiretroviral therapy 206 93%
Drug- resistant TB care, 2017 New cases
Previously treated
cases Total Number***
Estimated MDR/RR-TB cases among
notified pulmonary TB cases 900 (590-1200)
Estimated % of TB cases with MDR/RR-
TB 2.2 % (1.1-3.6) 15 % (9.6-22)
% notified tested for rifampicin
resistance 15% 29% 5282
MDR/RR-TB cases tested for resistance to second line
drugs 535
Laboratory confirmed cases MDR/RR-TB: 533 XDR-TB:13
Patients started on treatment**** MDR/RR-TB: 429 XDR-TB:19
Treatment success rate and cohort size Success Cohort
New and relapse cases registered in 2016 91% 30601
Previously treated cases, excluding relapse, registered in
2016 88% 1261
HIV-positive TB cases, all types, registered in 2016 78% 46
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MDR/RR-TB cases started on second line treatment in
2015 70% 333
XDR-TB cases started on second-line treatment in 2015
TB Preventive treatment, 2017
% of HIV+ people (newly enrolled in care) on preventive
treatment
% of Children ( aged <5) household
contacts of bacteriologically- confirmed
TB cases on preventive treatment 1.1 (1-1.2)
* Ranges represent uncertainty intervals
** MDR is TB resistant to rifampicin and isoniazid; RR is TB resistant to
rifampicin
*** Includes cases with unknown previous TB Treatment history
****Includes patients diagnosed before 2017 and patients who were not laboratory- confirmed
Source: WHO Global Tuberculosis Report-2018
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Islamic Republic of Pakistan is the second largest country in the South Asia. It is bordered by
India to the east, China in the far northeast, Afghanistan to the west and north, Iran to the
southwest and Arabian Sea in the south. The land area of the country is 796,095 square
kilometers. Population of Pakistan was approximately 197 million (WHO Global Tuberculosis
Report-2018) at the end of 2017.
TB Epidemiology
Pakistan is among countries with the high burden of TB and MDR-TB. The estimated mortality
and incidence rates of all forms of tuberculosis were 27 (CI: 21-34) and 268 (CI: 189-357) per
100,000 population respectively in 2017.WHO has estimated 518000 (CI: 373000-704000)
incidence cases and 54000 (CI: 42000-67000) deaths in 2017.
Total 368987 notified cases detected, among them 359224 total new and relapse cases has noted
in year 2017. Out of this notified number 80% were pulmonary TB cases. Among Pulmonary
cases 48% were bacteriologically confirmed.
Achievements
NRL- Xpert scale up to 106 sites & 94 Xpert sites connected with GxAlert,
Implementation of rapid DST (LPA first and second line), Introduction of Xpert Ultra,
Comprehensive DST coverage 80% of RR/MDR enrolled cases and introduction of
Bedaquiline phenotypic DST
Successfully implemented three cohorts of National SORT-IT courses from 2016 based
on The UNION International standards
Published 40 research papers in international open access peer reviewed journals
Establishment of IRB ethics committee
Challenges
Limited domestic financing for TB
Insufficient Multi sectoral collaboration
Adjustment to revised role & responsibilities after devolution
PAKISTAN
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Implementation of mandatory case notification law
No control over the counter sale of anti TB drugs
160,000 DS TB not notified- 1.5% decline in TB incidence/year
24,000 DRTB cases not notified
Static TB case notification in public sector
Referral mechanism between primary –secondary- tertiary care levels
NRL- Specimen transportation
Limited Funding: more finances are needed to continue SORT beyond 2020 and to
support publication cost and to conduct research on provincial priorities
Future Plan
NRL- Scale up of Xpert to more than 350 facilities & 100% coverage of GxAlert,
Scale up of Xpert Ultra, Scale up of LPA to 12 facilities
Successful completion of third SORT-IT course in Pakistan 2018.
Implementation of fourth and fifth SORT-IT course in 2019-20
IRB ethics committee proceedings/meetings
International Publications 2018-20 i.e. MDR Trial, articles of GIS based intervention ,
KAP on infection control measures among MDR-TB patients, and household contact
tracing among MDR-TB patients etc.
Collaboration with national / international research and academic institutions / health
programs
New initiatives/ Best practices:
NRL- Surveillance for emerging Bedaquiline resistance
Introduction of DST to BDQ, CFZ, LZD for Routine clinical services
Establishment of IRB ethic committee at CMU
Child Inventory Study was first of its kind in world to assess underreporting of child TB
cases in developing country in Pakistan
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Graphical presentations, Pakistan
Trend of incidence and Mortality (2005-2017)
200
5
201
0
201
3
201
4
201
5
201
6
201
7
Mortality Rate 64 33 27 26 23 23 27
Incidance Rate 276 276 275 270 270 268 268
264
266
268
270
272
274
276
278
0
10
20
30
40
50
60
70
Inci
den
ce R
ate
/10
0 0
00
po
pn
Mo
rta
lity
Ra
te
Treatment success rate for new smear positive cases
(2000 - 2016)
Trend of TB case notification (new and relapse)
2000 – 2017
11050
142017
264235 264934 267475288910
308417323856
356390368897
0
50000
100000
150000
200000
250000
300000
350000
400000
2000 2005 2010 2011 2012 2013 2014 2015 2016 2017
Year
Estimated TB incidence by age and sex, 2017
Source: WHO Global Tuberculosis Report-2018 & SAARC
Epidemiological Response on Tuberculosis-2017
Source: WHO Global Tuberculosis Report-2018
Source: WHO Global Tuberculosis Report-2018 & SAARC
Epidemiological Response on Tuberculosis-2017
Source: WHO Global Tuberculosis Report-2018 & SAARC
Epidemiological Response on Tuberculosis-2017
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TB Epidemiology 2017, Pakistan
Population (2017) 197 million
Estimates of TB burden * 2017
Number
(thousands)
Rate (per 100 000
population)
Mortality (excludes HIV+TB) 54 (42-67) 27 (21-34)
Mortality (HIV+TB only) 2.2 (1.1-3.8) 1.1 (0.56-1.9)
Incidence (includes HIV+TB) 518 (373-704) 268 (189-357)
Incidence (HIV+TB only) 7.3 (3.6-12) 3.7 (1.8-6.2)
Incidence (MDR/RR-TB)** 27 (17-39) 14 (8.8-20)
Estimated TB incidence by age and sex (thousands)*, 2017
0-14 years >14 years Total
Females 27 (25-29) 207 (166-248) 235 (185-284)
Males 30 (28-32) 261 (203-319) 291 (223-359)
Total 57 (51-63) 468 (329-607) 525 (373-704)
TB case notifications, 2017
Total cases notified 368897
Total new and relapse 359224
-% tested with rapid diagnostics at time of diagnosis 3%
-% with known HIV status 7%
- % pulmonary 80%
- % bacteriologically confirmed among pulmonary 48%
Universal Health Coverage and Social protection
TB treatment coverage (notified/estimated incidence), 2017 68 %(58-96)
TB cases fatality ratio (estimated mortality/estimated incidence), 2017 0.11 (0.07-0.15)
TB/HIV Care in new and relapse TB
patients, 2017 Number %
Patients with known HIV status who are HIV positive 121 <1%
- On antiretroviral therapy 97 80%
Drug- resistant TB care, 2017 New cases
Previously treated
cases Total Number***
Estimated MDR/RR-TB cases among
notified pulmonary TB cases 15000 (12000-18000)
Estimated % of TB cases with
MDR/RR-TB 4.2 % (3.2-5.3) 16% (15-17)
% notified tested for rifampicin
resistance 11% 47% 54991
MDR/RR-TB cases tested for resistance
to second line drugs 2887
Laboratory confirmed cases MDR/RR-TB: 3475 XDR-TB:128
Patients started on treatment**** MDR/RR-TB: 3016 XDR-TB:65
Treatment success rate and cohort size Success Cohort
New and relapse cases registered in 2016 92% 356390
Previously treated cases, excluding relapse, registered in
2016 78% 9671
HIV-positive TB cases, all types, registered in 2016 -
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MDR/RR-TB cases started on second line treatment in
2015 64% 2544
XDR-TB cases started on second-line treatment in 2015 29% 77
TB Preventive treatment, 2017
% of HIV+ people (newly enrolled in care) on preventive
treatment -
% of Children ( aged <5) household
contacts of bacteriologically- confirmed
TB cases on preventive treatment -
* Ranges represent uncertainty intervals
** MDR is TB resistant to rifampicin and isoniazid; RR is TB resistant to rifampicin
*** Includes cases with unknown previous TB Treatment history
****Includes patients diagnosed before 2017 and patients who were not laboratory- confirmed Source: WHO Global Tuberculosis Report-2018
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The Democratic Socialist Republic of Sri Lanka is an island in the Indian Ocean with an area of
65,610 square kilometers. Sri Lanka has maritime borders with India to the northwest and
the Maldives to the southwest. Population in Sri-Lanka was 21 millions in 2017 (WHO Global
Tuberculosis Report-2018).
TB Epidemiology
A middle-burden country, around 25% of total TB cases are from Colombo District,
predominantly affecting males in the productive age group (15–54 years). Multidrug resistant TB
is not a major problem and TB/HIV co-infection remains low. Treatment success rate above 85%
since 2005. Incidence remains stable but case notification among new and relapse cases
decreased since 2013. Loss to follow-up is low (<5%). The National Strategic Plan 2015–2020
finalized following Joint Monitoring Mission in 2014. National TB Reference Laboratory
(NTRL) upgraded to Biosafety level III in 2015. Gene Xpert services being expanded, a 16-
module machine to be placed at NTRL and 4-module machines at four more sites.
The estimated mortality and incidence rates of all forms of tuberculosis were 6 (CI: 4.3-8) and 65
(CI: 48-84) per 100 000 population respectively in 2017.WHO has estimated 13000 (CI: 9900-
17000) incidence cases in 2017. Total 8511 notified cases were detected, among them 8328
notified new and relapse cases has noted in 2017.
Achievements
reaching and sustaining the global targets:
Treatment success rate for all forms for TB was improved and it was 84.6 in 2016.
NPTCCD has managed to sustain lost to follow rate below 5% since 2011and it was 3.9
% in 2016
Expansion of rapid diagnostic facilities (Xpert MTB/RIF) in all provinces.
o Further strengthening of active case detection among high-risk categories such as
prisoners.
o ‒ Strengthening of activities aimed at private public partnership and involvement
of them in TB care
SRI LANKA
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Improvements in capacity building.
Preparation of training modules for nurses & PHIs of chest clinics & facilitator guide
Further improvement in TB infection control activities in chest clinics;
Sustaining the control of MDR-TB and TB/HIV co-infection; and
Undertaking operational research on TB-related deaths.
Challenges
Maintaining adequate number of trained man power in the face of high turnover of staff
Reduction of deaths among TB patients
Addressing TB control among migratory working population from high burden countries;
Combating stigma related to TB
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Graphical presentations, Sri-Lanka
Trend of incidence and Mortality (2005-2017)
2005
2010
2013
2014
2015
2016
2017
Mortality Rate 7.2 5.9 6.2 6.1 5.6 6 6
Incidance Rate 66 66 66 65 65 65 65
64.464.664.86565.265.465.665.86666.2
0
1
2
3
4
5
6
7
8
Incid
en
ce R
ate
/100
000 P
op
n
Mo
rta
lity
Ra
te
Treatment success rate for new smear positive cases
(2000 - 2016)
Trend of TB case notification (new and relapse)
2000 - 2017
Estimated TB incidence by age and sex, 2017
0
2
4
6
8
10
12
14
0-14 > 14Esti
mate
d
TB
in
cid
en
ce
by
ag
e &
Sex (
'00
0)
Age Group
Female Male
Source: Data sent by NTP-Sir Lanka 2018, & SAARC
Epidemiological Response on Tuberculosis-2017
Source: WHO Global Tuberculosis Report- 2018
Source: Data sent by NTP-Sir Lanka 2018 & SAARC
Epidemiological Response on Tuberculosis-2017
Source: Data sent by NTP-Sir Lanka 2018, SAARC Epidemiological
Response on Tuberculosis -2017
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TB Epidemiology 2017, Sri Lanka
Population (2017) 21 million
Estimates of TB burden * 2017
Number
(thousands)
Rate (per 100 000
population)
Mortality (excludes HIV+TB)a 1.2 6 (4.3-8)
Mortality (HIV+TB only) 0.016 (0.011-0.022) 0.08 (0.05-0.11)
Incidence (includes HIV+TB)a 13 65 (48-84)
Incidence (HIV+TB only) 0.049 (0.035-0.064) 0.23 (0.17-0.31)
Incidence (MDR/RR-TB)** 0.088 (0.034-0.17) 0.42 (0.16-0.8)
Estimated TB incidence by age and sex (thousands)*, 2017
0-14 years >14 years Total
Females
0.68 (0.63-
0.72) 4.1 (3.4-4.7) 4.8 (4-5.6)
Males 0.75 (0.7-0.8) 7.9 (6.2-9.6) 8.7 (6.7-11)
Total 1.4 (1.3-1.6) 12 (8.6-15) 13 (9.9-17)
TB case notifications, 2017
Total cases notifieda 8511
Total new and relapsea 8314
-% tested with rapid diagnostics at time of diagnosis 2%
-% with known HIV status 94%
- % pulmonary 73%
- % bacteriologically confirmed among pulmonary 70%
Universal Health Coverage and Social protection
TB treatment coverage (notified/estimated incidence), 2017 62 % (48-84)
TB cases fatality ratio (estimated mortality/estimated incidence), 2017 0.05 (0.03-0.07)
TB/HIV Care in new and relapse TB
patients, 2017 Number %
Patients with known HIV status who are HIV positive 29 <1%
- On antiretroviral therapy 28 97%
Drug- resistant TB care, 2017 New cases
Previously treated
cases Total Number***
Estimated MDR/RR-TB cases among
notified pulmonary TB cases 47 (17-78)
Estimated % of TB cases with
MDR/RR-TB 0.5%(0.2-1) 4.1% (1.1-10)
% notified tested for rifampicin
resistance 34% 91% 3200
MDR/RR-TB cases tested for
resistance to second line drugs 22
Laboratory confirmed cases MDR/RR-TB: 32 XDR-TB:0
Patients started on treatment**** MDR/RR-TB: 22 XDR-TB:0
Treatment success rate and cohort size Success Cohort
New and relapse cases registered in 2016a 86% 8660
Previously treated cases, excluding relapse, registered in
2016 66% 222
HIV-positive TB cases, all types, registered in 2016 83% 12
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MDR/RR-TB cases started on second line treatment in
2015 77% 13
XDR-TB cases started on second-line treatment in 2015 - 0
TB Preventive treatment, 2017
% of HIV+ people (newly enrolled in care) on preventive
treatment 20%
% of Children ( aged <5) household
contacts of bacteriologically-
confirmed TB cases on preventive
treatment 43% (40-48)
* Ranges represent uncertainty intervals
** MDR is TB resistant to rifampicin and isoniazid; RR is TB resistant to
rifampicin
*** Includes cases with unknown previous TB Treatment history
****Includes patients diagnosed before 2017 and patients who were not laboratory- confirmed Source: WHO Global Tuberculosis Report-2018
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5. TB/HIV CO-INFECTION
---------------------------------------------------------------------------------------------------------------------
TB HIV Co-infection poses a critical challenge for the health-sector and for people living with
HIV and TB. Starting in the 1980s, the HIV epidemic led to a major upsurge in TB cases and TB
mortality in many countries.
In 2017, there were an estimated 1.3 million TB deaths among HIV-negative people (down from
1.7 million in 2000) and there were an additional 300 000 deaths from TB among HIV-positive
People.
Globally, the absolute number of deaths from TB among HIV-negative people has been
estimated to have fallen by 29% since 2000, from 1.8 million in 2000 to 1.3 million in 2017, and
by 5% since 2015 (the baseline year for targets set in the End TB Strategy). The number of TB
deaths among HIV-positive people has fallen by 44% since 2000, from 534 000 in 2000 to
300 000 in 2017, and by 20% since 2015.
There were 464 633 reported cases of TB among people living with HIV in 2017 (51% of the
estimated 920 000 new cases in the same year), of whom 84% were on antiretroviral therapy.
The number of people living with HIV reported to have been started on preventive treatment was
958 559 in 2017.
Improvements in the coverage and quality of data for this indicator are necessary to track the
impact of HIV care, especially antiretroviral therapy (ART), on the burden of TB in people
living with HIV.
Preventing TB deaths among HIV-positive people requires intensified scale-up of TB prevention,
diagnosis and treatment interventions, including earlier initiation of ART among people living
with HIV and those with HIV-associated TB. Increased efforts in joint TB and HIV
programming could facilitate further scale-up and consolidation of collaborative TB/HIV
activities.
Joint activities between national TB and HIV/AIDS programmes are crucial to prevent, diagnose
and treat TB among people living with HIV and HIV among people with TB. These include
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establishing mechanisms for collaboration, such as coordinating bodies, joint planning,
surveillance and monitoring and evaluation; decreasing the burden of HIV among people with
TB (with HIV testing and counseling for individuals and couples, co-trimoxazole preventive
therapy, antiretroviral therapy and HIV prevention, care and support); and decreasing the burden
of TB among people living with HIV (with the three I’s for HIV and TB: intensified case-
finding; TB prevention with isoniazid preventive therapy and early access to antiretroviral
therapy; and infection control for TB). Integrating HIV and TB services, when feasible, may be
an important approach to improve access to services for people living with HIV, their families
and the community.
Table 08: Estimates of TB/HIV care in new and relapse TB patients, 2017
Country
Patients with known HIV status who are
HIV positive patients on Antiretroviral Therapy
(ART)
Number % Number %
Afghanistan 7 <1 3 43
Bangladesh 89 2 84 94
Bhutan 5 <1 5 100
India 32932 3 28651 87
Maldives NA NA NA NA
Nepal 221 1 206 93
Pakistan 121 <1 97 80
Sri Lanka 29 <1 28 97
Regional 33404 29074 87 Source: WHO Global TB Report, 2018
In 2017, a total 33404 TB patients with known HIV status has tested in which India accounts
highest number of TB patients with known HIV status who are HIV positive. Total 29074
patients are on ART in the region which is around 87 % of total TB patients with known HIV
status who are HIV positive in SAARC region.
A total of 464 633 TB cases among HIV-positive people were reported; of these, 84% were on
antiretroviral therapy (ART) globally, and 87% in India. However Bhutan has 100 % patients on
Antiretroviral Therapy (ART) in 2017.