Towards Universal Access to Diagnosis and Treatment of MDR-TB and XDR-TB by 2015

ISBN 978 92 4 150133 0

WHO PROGRESS REPORT 2011

Towards universal access to diagnosis and treatment of multidrug-resistant and extensively drug-resistant tuberculosis by 2015

Stop TB Department

World Health Organization

20 Avenue Appia, CH-1211 Geneva 27, Switzerland

Web site: www.who.int/tb

Information Resource Centre HTM/STB: [email protected]

Towards universal access to diagnosis and treatm

ent of multidrug-resistant and extensively drug-resistant tuberculosis by 2015 W

HO

PROG

RESS REPORT 2011



WHO Library Cataloguing-in-Publication Data

Towards universal access to diagnosis and treatment of multidrug-resistant and extensively drug-resistant tuberculosis

by 2015: WHO progress report 2011.

WHO/HTM/TB/2011.3

1.Tuberculosis, Multi-drug-resistant - therapy. 2.Tuberculosis, Multi-drug-resistant - diagnosis. 3.Drug resistance,

Bacterial. 4.Antitubercular agents. 5.Bacteriological techniques. 6.Program evaluation. I.World Health Organization.

ISBN 978 92 4 150133 0 (NLM classification: WF 360)

© World Health Organization 2011

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Editing and design: Inís Communication – www.iniscommunication.com

Printed in France

WHO/HTM/TB/2011.3

Contents

Contents_________________________________________________________________ iiiAcknowledgements_________________________________________________________ ivAbbreviations______________________________________________________________ vGlossary_ ________________________________________________________________ viExecutive_summary_ ________________________________________________________ 1Introduction_______________________________________________________________4

PART 1: Diagnosis, treatment and care of people affected by M/XDR-TB__________71.1__Planning_and_financing_universal_access_to_MDR-TB_diagnosis,_

care_and__treatment_ _________________________________________________ 71.2__Expanding_diagnostic_capacity_ _______________________________________ 111.3__ Improving_surveillance_of_drug-resistant_TB______________________________ 141.4__Ensuring_access_to_quality-assured_anti-TB_medicines______________________ 151.5__Updating_WHO_policies_and_guidelines_to_manage_M/XDR-TB_ _______________ 161.6__Treating_and_caring_for_people_affected_by_MDR-TB_ _______________________ 181.7.__Status_of_progress_at_country_level_ ____________________________________ 22

PART 2: Prevention of M/XDR-TB through basic TB control_ ___________________292.1__Strengthening_basic_TB_control________________________________________ 292.2__Engaging_all_health-care_providers_ ____________________________________ 292.3__Promoting_regulated_access_to_anti-TB_medicines__________________________ 322.4__Addressing_the_dual_MDR-TB_and_HIV_epidemics_ _________________________ 332.5__Prioritizing_tuberculosis_infection_control_ ______________________________ 34

Annex_1:_Resolution_WHA62.15________________________________________________ 37Annex_2:_Multidrug-resistant_tuberculosis_country_profiles_________________________ 41Annex_3:_Update_on_drug_resistance_surveillance_data_ ____________________________ 97

References_______________________________________________________________ 117

WHO PROGRESS REPORT 2011 Towards universal access to diagnosis and treatment of multidrug-resistant and extensively drug-resistant tuberculosis by 2015iv

This_report_was_produced_by_a_core_team_at_the_World_Health_ Organization_ (WHO):_ Karin_ Bergstrom,_Angelito_Bravo,_Daniel_Chemtob,_Wolfram_Demmer,_Monica_Hannah_Dias,_Dennis_Falzon,_Jean_de_Dieu_Iragena,_ Inés_ García_ Baena,_ Wayne_ van_ Gemert,_Haileysus_ Getahun,_ Tauhidul_ Islam,_ Wieslaw_Jakubowiak,_ Christian_ Lienhardt,_ Knut_ Lonnroth,_Kaspars_Lunte,_Pierre-Yves_Norval,_Delphine_Sculier,_Lana_Velebit_and_Matteo_Zignol._All_members_of_the_core_team_contributed_to_the_writing_of_the_report.

Inés_ García_ Baena,_ Wieslaw_ Jakubowiak_ and_Hazim_Timimi_were_responsible_for_developing_the_country_profiles_and_extracting_data_from_the_WHO_global_TB_data_collection_system._Wolfram_Demmer_and_ Shamsiya_ Muzafarbekova_ provided_ valuable_support;_ Dennis_ Falzon,_ Wayne_ van_ Gemert_ and_Matteo_ Zignol_ were_ responsible_ for_ preparing_ the_annexes_on_drug_resistance_surveillance_data.

Christin_ Chevalley_ provided_ vital_ administra-tive_ support._ Inés_ García_ Baena_ was_ responsible_for_data_validation_for_country_profiles_in_coordina-tion_with_WHO_regional_and_country_offices;_Dennis_Falzon_validated_and_analysed_the_data_reported_by_countries_on_DOTS_and_MDR-TB._Ernesto_Jaramillo_coordinated_the_production_of_the_report;_develop-ment_ of_ its_ structure_ and_ content_ were_ guided_ by_Paul_Nunn_and_Diana_Weil,_coordinators,_under_the_overall_ direction_ of_ Mario_ Raviglione,_ Director_ of_the_WHO_Stop_TB_Department.

In_addition_to_the_core_team,_many_staff_at_WHO_headquarters_and_regional_offices_provided_valuable_input_ to_ the_ report._ Among_ the_ colleagues_ listed_below,_ we_ thank_ in_ particular_ Samiha_ Baghdadi,_Andrei_ Dadu,_ Rafael_ Lopez-Olarte,_ Khurshid_ Alam_Hyder,_ Wilfred_ Nkhoma_ and_ Daniel_ Sagebiel_ for_their_ major_ contributions_ to_ data_ collection_ and_review.

WHO headquarters:_Karin_Bergstrom,_Léopold_Blanc,_ Caroline_ Bogren,_ Angelito_ Bravo,_ Daniel_Chemtob,_Karen_Ciceri,_Wolfram_Demmer,_Katherine_Floyd,_ Christopher_ Fitzpatrick,_ Inés_ García_ Baena,_Christopher_Gilpin,_Malgorzata_Grzemska,_Christian_Gunneberg,_ Jean_ de_ Dieu_ Iragena,_ Tauhidul_ Islam,_Azizkhon_ Jafarov,_ Wieslaw_ Jakubowiak,_ Judith_Mandelbaum-Schmid,_ Fuad_ Mirzayev,_ Paul_ Nunn,_Andrea_ Pantoja,_ Glenn_ Thomas,_ Hazim_ Timimi,_Mukund_Uplekar,_Douglas_Fraser_Wares_and_Karin_Weyer.

WHO African Region:_ Adey_ Bogale,_ Mathurin_Dembele,_Balkissa_Modibo_Hama,_Bah_Keita,_Wilfred_

Nkhoma,_Nicolas_Nkiere_Masheni,_Samuel_Ogiri_and_Kalpesh_Rahevar.

WHO Region of the Americas:_ Mirtha_ del_Granado_and_Rafael_Lopez-Olarte.

WHO Eastern Mediterranean Region:_Samiha_Baghdadi,_Salem_George_Barghout_and_Zafar_Toor.

WHO European Region:_ Ana_ Ciobanu,_ Silviu_Ciobanu,_ Andrei_ Dadu,_ Manfred_ Danilovits,_Masoud_ Dara,_ Edita_ Davidavičienė,_ Desislava_Durcheva,_Abdrahmanova_Elmira,_Jamshid_Gadoev,_Gayane_ Ghukasyan,_ Tsogt_ Gombogaram,_ Jarno_Habicht,_ Sayohat_ Hasanova,_ Iagor_ Kalandadze,_Clara_ Khasanovna,_ Olena_ Kheylo,_ Marija_ Kisman,_Rusudan_ Klimiashvili,_ Vaira_ Leimane,_ Vladimir_Milanov,_Osconbek_Moldokulov,_Dmitry_Pashkevich,_Vija_ Riekstina,_ Aiga_ Rurane,_ Valiantsin_ Rusovich,_Raimunda_ Sadauskiene,_ Javahir_ Suleymanova,_Emilia_ Tontcheva,_ Aigul_ Tursynbayeva,_ Gulnoz_Uzakova_and_Risards_Zaleskis.

WHO South-East Asia Region: Vineet_Bhatia,_Erwin_Cooreman,_Puneet_Kumar_Dewan,_Khurshid_Hyder,_Eva_Nathanson,_Chawalit_Natpratan,_Ranjani_Ramachandran_and_Sabera_Sultana.

WHO Western Pacific Region:_ Graham_Harrison,_Cornelia_Hennig,_Celina_Garfin,_Woo-Jin_Lew,_Huajing_Liang,_YuHong_Liu,_Catherine_Lijinsky,_Huyen_ Khanh_ Pham,_ Daniel_ Sagebiel,_ Fabio_ Scano_and_Kitty_van_Weezebeek.

Development_of_this_report_would_not_have_been_possible_ without_ the_ collaboration_ of_ national_ TB_control_ programme_ managers_ and_ their_ staff,_ who_supplied_the_data_for_the_foundation_of_this_report._Managers_ and_ staff_ of_ sites_ providing_ MDR-TB_treatment_through_the_Green_Light_Committee_gen-erously_provided_data_on_treatment_outcomes._The_authors_sincerely_thank_all_contributors_of_data_for_their_invaluable_cooperation.

The_ authors_ also_ express_ their_ gratitude_ to_ Tim_France_and_Aaron_Andrade_of_Inis Communication_for_providing_technical_editing,_design_and_layout_of_the_report.

We_also_thank_Aamir_Khan,_Chair_of_the_MDR-TB_Working_ Group_ of_ the_ Stop_ TB_ Partnership,_ and_Javid_ Syed,_ TB/HIV_ project_ director,_ Treatment_Action_ Group,_ for_ providing_ careful_ reviews_ of_ the_report.

Development_ and_ publication_ of_ this_ report_were_supported_by_the_generous_financial_contribu-tions_of_the_United_States_Agency_for_International_Development.

Acknowledgements

Towards universal access to diagnosis and treatment of multidrug-resistant and extensively drug-resistant tuberculosis by 2015 WHO PROGRESS REPORT 2011 v

ADR_............... adverse_drug_reaction

CI_................... confidence_interval

DMC_.............. designated_microscopy_centre

DRS_................ drug_resistance_survey

DST_................ drug_susceptibility_testing

EQA_............... external_quality_assurance

FDC_................ fixed-dose_combination

FIND_.............. Foundation_for_Innovative_New_Diagnostics

GDF_............... Global_Drug_Facility

Global Fund_.. The_Global_Fund_to_Fight_AIDS,_Tuberculosis_and_Malaria

HCW_.............. health-care_worker

IPT_................. isoniazid_preventive_therapy

IRL_................. intermediate_reference_laboratory

LPA_................ line_probe_assay

MDR-HBC_.... high_MDR-TB_burden_countries

NSA................ national_strategy_application

IC_................... infection_control

MCLA_............ Ministry_of_Corrections_and_Legal_Assistance_(of_Georgia)

MGIT_............. Mycobacteria_growth_indicator_tube

MoH_............... Ministry_of_Health

MoJ_................ Ministry_of_Justice

MSF_............... Médecins_Sans_Frontières

M/XDR-TB_... multidrug-resistant_tuberculosis_(see_MDR-TB)_and_extensively_drug-resistant_tuberculosis_(see_XDR-TB).

NRL_................ national_reference_laboratory

NGO_............... nongovernmental_organization

NTP_............... national_TB_control_programme_(or_equivalent)

PBSP.............. Philippine_Business_for_Social_Progress

PIU_................. Programme_Implementation_Unit_(of_UNDP)

PMDT_............ programmatic_management_of_drug-resistant_tuberculosis

PPM_............... public–private_mix

PT_.................. proficiency_testing

RNTCP_.......... Revised_National_TB_Control_Programme_(India)

SLD_................ second-line_anti-TB_drug

SRL_................ supranational_reference_laboratory

TB_.................. tuberculosis

TDF_................ Tropical_Disease_Foundation

UNDP_............ United_Nations_Development_Programme

UNITAID_...... International_facility_for_the_purchase_of_diagnostics_and_medicines_for_diagnosis_and_treatment_of_HIV/AIDS,_malaria_and_TB.

USAID_........... United_States_Agency_for_International_Development

Abbreviations

WHO PROGRESS REPORT 2011 Towards universal access to diagnosis and treatment of multidrug-resistant and extensively drug-resistant tuberculosis by 2015vi

Glossary

The_definitions_given_below_apply_to_the_terms_as_used_in_this_document._They_may_have_different_meanings_in_other_contexts.

Countries__WHO_Member_States

DOTS The_internationally-recommended_approach_to_basic_TB_control.

DRS Drug_resistance_survey_is_a_discrete_study_measuring_the_proportion_of_drug_resistance_among_a_sample_of_patients_representative_of_an_entire_patient_population_in_a_country_or_geographical_area.

DST Drug_susceptibility_testing_(defined_as_the_testing_of_a_strain_of_Mycobacterium tuberculosis_for_its_susceptibility_or_resistance_to_one_or_more_anti-TB_drugs).

GLC Green_Light_Committee_is_an_initiative_of_WHO_and_the_Stop_TB_Partnership_that_helps_countries_gain_access_to_high-quality_second-line_anti-TB_drugs_so_they_can_provide_treatment_for_people_with_multidrug-resistant_tuberculosis_(MDR-TB)_in_line_with_the_WHO_guidelines.

MDR-TB Multidrug-resistant_tuberculosis_(defined_as_TB_caused_by_strains_of_Mycobacterium tuberculosis that_are_resistant_to_at_least_isoniazid_and_rifampicin).

New case A_newly_registered_episode_of_TB_in_a_patient_who,_in_response_to_direct_questioning,_denies_having_had_any_prior_anti-TB_treatment_(for_up_to_one_month),_and_in_countries_where_adequate_documentation_is_available,_for_whom_there_is_no_evidence_of_such_history.

PPM Public–private_mix_is_a_comprehensive_approach_for_systematic_involvement_of_all_relevant_health-care_providers_in_TB_control_to_promote_the_use_of_international_standards_for_TB_care_and_achieve_national_and_global_TB_control_targets.

Previously treated case A_newly_registered_episode_of_TB_in_a_patient_who,_in_response_to_direct_questioning_admits_having_been_treated_for_TB_for_one_month_or_more,_or,_in_countries_where_adequate_documentation_is_available,_there_is_evidence_of_such_history._Chemoprophylaxis_should_not_be_considered_treatment_for_TB.

Relapse case A_patient_previously_treated_for_TB_who_was_declared_cured_or_successfully_completed_treatment,_and_is_again_diagnosed_with_bacteriologically_positive_(smear_or_culture)_TB.

XDR-TB Extensively_drug-resistant_tuberculosis_(defined_as_MDR-TB_plus_resistance_to_a_fluoroquinolone_and_at_least_one_second-line_injectable_agent:_amikacin,_kanamycin_and/or_capreomycin).

1

IntroductionAs_ recently_ as_ 10_ years_ ago,_ few_ options_ for_ treat-ment_ and_ care_ were_ available_ to_ those_ affected_ by_multi_drug-resistant_ tuberculosis_ (MDR-TB)_ and_extensively_ drug-resistant_ tuberculosis_ (XDR-TB).a_Later,_accumulating_evidence_indicated_that_the_pro-grammatic_management_of_M/XDR-TB_was_not_only_feasible_ but_ also_ cost_ effective._ The_ World_ Health_Organization_(WHO)_has_recognized_M/XDR-TB_as_a_major_challenge_to_be_addressed_as_part_of_the_Stop_TB_strategy,_ launched_ in_2006._ In_April_2009,_WHO_convened_ a_ ministerial_ meeting_ of_ countries_ with_a_ high_ burden_ of_ MDR-TB_ in_ Beijing,_ China,_ pav-ing_the_way_in_May_2009_for_the_62nd_World_Health_Assembly_ to_ adopt_ resolution_ WHA62.15_ on_ pre-vention_ and_ control_ of_ MDR-TB_ and_ XDR-TB._ The_resolution_ urges_ Member_ States_ to_ take_ action_ on_multiple_ fronts_ towards_ achieving_ universal_ access_to_diagnosis_and_treatment_of_M/XDR-TB_by_2015.

Despite_ the_ important_ progress_ being_ made,_severe_ bottlenecks_ are_ limiting_ the_ response_to_ the_ M/XDR-TB_ epidemic._ Indeed,_ only_ 10%_(24_511/250_000)_ of_ the_ estimated_ MDR-TB_ cases_among_notified_TB_cases_in_2009_in_the_high_MDR-TB_countries,_ and_ 11%_ (30_475/280_000)_ globally_ were_enrolled_ on_ treatment._ Some_ countries_ are_ mak-ing_ progress_ by_ implementing_ policy_ changes_ that_rationalize_the_use_of_hospitals,_such_as_South_Africa,_or_ treating_ patients_ through_ community-based_models_ of_ care,_ such_ as_ the_ Philippines._ However,_diagnostic_ capacity_ remains_ limited._ Furthermore,_the_price_of_some_quality-assured_second-line_drugs_has_ not_ fallen,_ and_ shortages_ of_ drugs_ still_ occur._Overall,_ there_ is_ recognition_ that_ the_ response_ to_MDR-TB_ must_ be_ built_ across_ health_ systems,_ and_corresponding_ plans_ have_ been_ made._ Human_ and_financial_ resources_ are_ grossly_ insufficient_ and_ fre-quently_ inadequate._ If_ domestic_ funding_ is_ not_

a_ Multidrug-resistant_ TB_ (MDR-TB)_ is_ caused_ by_ bacteria_that_ are_ resistant_ to_ at_ least_ isoniazid_ and_ rifampicin,_ the_most_ effective_ anti-TB_ drugs._ MDR-TB_ results_ from_ either_primary_ infection_ with_ resistant_ bacteria_ or_ may_ develop_during_ the_ course_ of_ treatment._ Extensively_ drug-resistant_TB_ (XDR-TB)_ is_ a_ form_ of_ TB_ caused_ by_ bacteria_ that_ are_resistant_ to_ isoniazid_ and_ rifampicin_ (i.e._ MDR-TB)_ as_ well_as_ any_ fluoroquinolone_ and_ any_ of_ the_ second-line_ anti-TB_injectable_agents_(amikacin,_kanamycin_and/or_capreomycin).__ These_ forms_ of_ TB_ do_ not_ respond_ to_ the_ standard_ six-month_treatment_with_first-line_anti-TB_drugs_and_can_take_up_to_two_years_or_more_to_treat_with_drugs_that_are_less_potent,_more_toxic_and_much_more_expensive.

urgently_mobilized,_The_Global_Fund_to_Fight_AIDS,_Tuberculosis_and_Malaria,_as_well_as_UNITAID,_may_become_the_main_–_if_not_only_–_source_of_funding_for_ programmatic_ management_ of MDR-TB in_ sev-eral_countries,_demonstrating_that_commitment_ in_endemic_countries_and_domestic_funding_are_hardly_mobilized_for_this_public_health_priority.

Developing_ and_ adopting_ new_ tools_ may_ help_accelerate_ the_ scale_ up_ of_ adequate_ M/XDR-TB_management;_ the_ introduction_ of_ new_ rapid_ diag-nostic_ tests_ is_ promising_ in_ Ethiopia,_ India_ and_South_ Africa,_ for_ example._ Although_ the_ Xpert_MTB/RIF_ test_ introduced_ in_ 2010_ may_ bring_ diag-nosis_ closer_ to_ patients,_ it_ is_ not_ a_ point-of-care_assay,_ and_ the_ need_ for_ increased_ research_ invest-ment_into_novel_rapid_tests_therefore_remains._Five_candidate_anti-TB_drugs_are_being_evaluated_in_clin-ical_trials,_and_preliminary_results_are_encouraging:_a_new_anti-TB_drug_is_anticipated_on_the_market_in_a_few_years._However,_no_technological_or_manage-rial_innovation_will_make_a_meaningful_difference_to_the_ response if_ access_ to_ care_ for_ the_ poorest_ and_most_ vulnerable_ groups_ is_ not_ increased_ through_strengthened_ and_ properly_ funded_ health-care_systems._ Beyond_ more_ rapid_ implementation_ of_available_tools,_there_is_an_urgent_need_to_fully_fund_a_robust_and_comprehensive_research_portfolio_that_ranges_from_basic_science_to_efforts_to_develop_new_vaccines,_diagnostics_and_treatments._New_and_more_effective_tools_will_ likely_facilitate_care_and_control_of_MDR-TB,_as_long_as_they_become_accessible_to_the_poorest_ populations_ worldwide._ MDR-TB_ is_ one_ of_the_ greatest_ areas_ of_ unmet_ need_ for_ TB_ research._Besides_scaling_up_implementation_of_available_and_new_ tools,_ research_ providing_ evidence_ that_ coun-tries_can_use_to_reach_the_global_target_of_achieving_universal_access_to_MDR-TB_care_in_line_with_resolu-tion_WHA62.15_is_equally_needed.

The_ involvement_ of_ civil_ society_ organizations_and_ communities_ in_ global_ and_ national_ responses_to_ M/XDR-TB_ also_ remains_ very_ limited._ In_ Octo-ber_2010,_WHO_organized_a_consultation_meeting_to_strengthen_their_active_involvement_in_the_response_to_ TB,_ highlighting_ MDR-TB_ as_ an_ urgent_ prior-ity._ It_ is_ time_ to_ focus_ advocacy_ efforts_ at_ country_level,_ and_ not_ only_ global_ level,_ to_ ensure_ that_ the_health_ sector_ receives_ the_ necessary_ resources_ and_the_M/XDR-TB_response_remains_high_on_the_global_health-policy_agenda.

Executive summary

WHO PROGRESS REPORT 2011 Towards universal access to diagnosis and treatment of multidrug-resistant and extensively drug-resistant tuberculosis by 20152

This_ report_ describes_ the_ progress_ being_ made_globally_ towards_ achieving_ universal_ access_ to_diagnosis_and_treatment_of_M/XDR-TB_since_the_min-isterial_meeting_of_high_M/XDR-TB_burden_countries_in_April_2009_in_Beijing,_China,_and_the_adoption_of_WHA62.15_on_prevention_and_control_of_M/XDR-TB,_with_special_focus_on_progress_in_27_countries_where_the_ MDR-TB_ burden_ is_ high.a_ The_ report_ aims_ to_increase_ awareness_ of_ achievements_ and_ gaps_ and,_more_ importantly,_ to_ draw_ global_ attention_ to_ the_need_ for_ more_ decisive_ action_ on_ overcoming_ bot-tlenecks_to_progress,_especially_at_the_country_level._While_there_is_clarity_and_consensus_on_what_to_do,_as_the_62nd_WHA_resolution_indicates,_the_ interna-tional_community_should_no_longer_hesitate_to_fully_implement_the_resolution.

Country progress in responding to the M/XDR-TB epidemic

This_ report_ presents_ the_ key_ findings_ of_ data_ pro-vided_by_countries_to_WHO_on_progress_achieved_on_the_two_major_fronts_in_the_response_to_M/XDR-TB:_(i)_diagnosis,_treatment_and_care_of_people_affected_by_ M/XDR-TB;_ and_ (ii)_ prevention_ of_ M/XDR-TB_through_basic_TB_control.

Diagnosing, treating and caring for people with M/XDR-TB

Planning and funding the response to M/XDR-TB._Of_ the_ 27_ high_ MDR-TB_ burden_ countries,_ 26_have_ updated_ the_ MDR-TB_ component_ of_ their_ TB_national_plans._The_Global Plan to Stop TB 2011–20152_estimates_ that US$ 0.9 billion_ is_ needed_ in_ 2011_ to_address_MDR-TB_(excluding_the_costs_associated_with_laboratory_scale-up)._Funding_for_MDR-TB_care_and_treatment_ has_ increased_ fivefold_ since_ 2009,_ from_US$_0.1_billion_to_US$_0.5_billion_in_2011_in_23/27_coun-tries._ Despite_ this_ important_ progress,_ the_ Global_Fund_may_become_the_sole_source_of_funding_for_sec-ond-line_ drugs_ and_ MDR-TB_ management_ in_ seven_high_ MDR-TB_ burden_ countries_ in_ 2011,_ if_ domes-tic_ funding_ is_ not_ mobilized._ In_ Estonia,_ Latvia,_the_Russian_Federation_and_South_Africa,_domestic_sources_will_provide_most_if_not_all_of_this_funding.

a_ In_this_report,_the_27_high_MDR-TB_burden_countries_refer_to_those_Member_States_estimated_by_WHO_in_2008_to_have_had_at_least_4000_MDR-TB_cases_occurring_annually_and/or_at_least_10%_of_newly_registered_TB_cases_with_MDR-TB._The_countries_are:_ Armenia,_ Azerbaijan,_ Bangladesh,_ Belarus,_ Bulgaria,_China,_Democratic_Republic_of_the_Congo,_Estonia,_Ethiopia,_Georgia,_ India,_ Indonesia,_ Kazakhstan,_ Kyrgyzstan,_ Latvia,_Lithuania,_Myanmar,_Nigeria,_Pakistan,_Philippines,_Republic_of_ Moldova,_ Russian_ Federation,_ South_ Africa,_ Tajikistan,_Ukraine,_Uzbekistan_and_Viet_Nam.

Expanding diagnostic capacity._ WHO_ has_ set_ a_target_of_having_at_least_one_laboratory_with_capac-ity_to_perform_culture_per_5_million_population,_and_one_ laboratory_ with_ capacity_ to_ perform_ drug_ sus-ceptibility_ testing_ (DST)_per_10_million_population._However,_ only_ 5_ of_ the_ 22_ high_ TB_ burden_ coun-tries_and_16/27_high_MDR-TB_burden_countries_had_achieved_ this_ goal_ by_ the_ end_ of_ 2009._ The_ Global_Laboratory_ Initiative,_ a_ powerful_ global_ partner-ship_ around_ TB_ laboratory_ diagnostics,_ has_ proven_crucial_ in_ accelerating_ uptake_ of_ new_ diagnostic_technologies,_ including_ Xpert_ MTB/RIF,_ the_ most_recent_tool_recommended_by_WHO._The_EXPAND-TB_project_ (EXPanding_ Access_ to_ New_ Diagnostics_ for_TB),_established_ in_2008,_aims_to_accelerate_uptake_of_new_TB_diagnostic_technologies_and_is_benefiting_15_ of_ the_ 27_ high_ MDR-TB_ burden_ countries._ Labo-ratory_networks_are_established_in_all_27_countries;_all_have_capacity_to_perform_DST_of_at_least_first-line_anti-TB_ drugs_ at_ the_ central_ or_ national_ reference_laboratory_and_at_regional_ level_ in_some_countries._This_ substantive_ progress_ in_ expanding_ diagnostic_capacity_should_now_be_reflected_in_increasing_num-bers_of_patients_being_enrolled_on_treatment_in_the_next_years.

Improving drug resistance surveillance._Major_progress_ has_ been_ made_ in_ surveillance_ of_ anti-TB_drug_ resistance_ worldwide_ in_ 2008–2010._ In_ the_27_ high_ MDR-TB_ burden_ countries,_ the_ number_ of_new_drug_resistance_surveys_under_way_or_planned_increased_from_1_in_2008_to_10_in_2011;_the_number_of_ countries_ with_ representative_ drug_ resistance_data_ increased_ from_ 19_ to_ 22._ It_ is_ expected_ that_by_ mid-2012,_ all_ 27_ countries_ will_ have_ representa-tive_information_on_drug_resistance._The_number_of_countries_ providing_ testing_ services_ and_ reporting_HIV_status_among_MDR-TB_cases_ is_also_ increasing._As_of_February_2011,_a_total_of_69_countries_world-wide_reported_having_identified_at_least_one_case_of_XDR-TB._ New_ data_ from_ southern_ Africa_ indicate_that_MDR-TB_is_a_growing_problem_in_that_subregion._Recent_ surveys_ in_ Botswana_ (2008)_ and_ Swaziland_(2009)_ suggest_ that_ proportions_ of_ MDR-TB_ have_increased_over_the_past_15_years._This_finding_is_likely_to_be_associated_with_the_growing_HIV_epidemic_ in_the_subregion.

Ensuring access to quality-assured anti-TB drugs._The_number_of_finished_second-line_anti-TB_pharmaceutical_products_available_for_procurement_through_the_Global_Drug_Facility_increased_from_11_in_2008_to_25_in_2010;_the_number_of_suppliers_of_sec-ond-line_ drugs_ (SLDs)_ increased_ from_ 5_ in_ 2008_ to_15_in_2010._Drug_management_remains_a_major_chal-lenge,_with_4/24_countries_still_reporting_stock_outs_of_second-line_drugs_in_2009._Further_progress_could_

3

be_ achieved_ in_ many_ countries_ by_ facilitating_ reg-istration_ and_ importation_ of_ drugs,_ conforming_ to_quality_ assurance_ standards_ set_ by WHO,_ strength-ening_ national_ drug_ management,_ and_ increasing_production_capacity_of_quality-assured_products.

Treating and caring for people affected by M/XDR-TB._ Of_ the_ 4.7_ million_ TB_ cases_ noti-fied_ by_ the_ 27_ high_ MDR-TB_ burden_ countries_ to_WHO_ in_ 2009,_ close_ to_ 250 000_ were_ estimated_ to_have_ MDR-TB._ Only_ 16%_ of_ these_ cases_ were_ noti-fied_ as_ MDR-TB_ (ranging_ from_ 90–100%_ in_ seven_countries_ to_ less_ than_ 5%_ in_ six_ others)._ The_ pro-portion_ of_ notified_ cases_ enrolled_ on_ treatment_ranged_from_1%_to_100%_(median_8%)._Enrolments_out_ of_ expected_ MDR-TB_ among_ notified_ TB_ cases_were_ 10%_ (24_511/250_000)_ in_ the_ 27_ MDR-HBCs_and_11_%_(30_475/280_000)_for_all_cases_worldwide._There_ is_ wide_ variation_ in_ the_ performance_ of_ the_programmes_ as_ far_ as_ treatment_ is_ concerned._Treatment_success_varied_from_25%_to_82%_among_MDR-TB_ patients_ started_ on_ treatment_ in_ 2007_ in_the 13_ MDR-HB_ countries. The_ number_ of_ cases_assessed_represented_45%_of_all_MDR-TB_cases_that_were_ identified_ and_ notified_ by_ these_ countries_ in_the_same_year._Fourteen_countries_reported_no_data_on_outcomes._If_reports_correspond_to_what_is_hap-pening_in_reality,_it_may_be_that_most_people_affected_by_MDR-TB_are_not_diagnosed_and_that_only_a_small_proportion_ of_ those_ in_ whom_ the_ disease_ is_ diag-nosed_are_enrolled_on_treatment._MDR-TB_recording_and_reporting_are_substandard_in_most_high_MDR-TB_burden_countries,_but_this_hardly_explains_the_huge_gap_between_the_need_for_prevention_and_control_of_M/XDR-TB_and_the_response_to_it.

Preventing M/XDR-TB through basic TB control

Strengthening basic TB control through DOTS._There_is_global_progress_in_implementing_basic_DOTS_–_the_fundamental_component_of_the_WHO_Stop_TB_strategy._ However,_ several_ indicators_ give_ reasons_for_concern_about_the_performance_of_DOTS_in_the_high_ MDR-TB_ burden_ countries._ In_ 14/27,_ the_ case_detection_ratio_was_lower_than_70%;_in_17/27,_treat-ment_success_among_new_smear-positive_cases_was_below_ the_ target_ of_ 85%_ in_ 2008._ This_ reflects_ the_high_frequency_of_failure_(median_7%,_range_2–26%)_as_ well_ as_ deaths_ (median_ 5%,_ range_ 3–15%)_ likely_due_ to_ the_ high_ MDR-TB_ burden,_ poor_ diagnostic_coverage_and_inadequate_treatment._Default,_which_can_be_reduced_through_programme_efforts,_ranged_from_2%_to_12%_(median:_7%)_in_these_17_countries.

Engaging all health-care providers._ Including_hospitals_ in_ the_ response_ to_ M/XDR-TB_ is_ critical_for_ timely_ diagnosis_ and_ appropriate_ case-holding._To_ guide_ and_ facilitate_ the_ engagement_ of_ all_ care_

providers_ in_ the_ response_ to_ M/XDR-TB,_ WHO_ has_developed_an_assessment_tool,_which_is_part_of_the_PPM_ toolkit_ launched_ in_ 2010._ A_ task_ force_ to_ pro-mote_ the_ engagement_ of_ all_ care_ providers_ in_ the_programmatic_ management_ of_ drug-resistant_ TB_has_ also_ been_ set_ up_ by_ the_ Stop_ TB_ Partnership’s_MDR-TB_ Working_ Group._ Countries_ such_ as_ Bang-ladesh,_ Pakistan_ and_ the_ Philippines_ are_ forging_successful_ partnerships,_ demonstrating_ both_ the_feasibility_and_necessity_of_engaging_all_health-care_providers.

Promoting regulated access to anti-TB drugs._In_2010,_18/27_high_MDR-TB_burden_countries_reported_availability_ of_ first-line_ anti-TB_ drugs_ in_ private_pharmacies;_ in_12/18_countries_ the_medicines_were_available_ without_ prescription._ Inappropriate_ or_incorrect_ prescribing_ practices_ increase_ the_ risk_of_ treatment_ failure_ and_ drug_ resistance_ and_ its_amplification._Policies_to_regulate_access_to_anti-TB_medicines_ are_ being_ developed_ or_ implemented_ in_Brazil,_Ghana,_India,_the_United_Republic_of_Tanza-nia_and_Zambia_but_have_not_been_fully_introduced_in_ most_ high_ MDR-TB_ burden_ countries._ There_ is_increasing_ evidence_ to_ suggest_ that,_ under_ appro-priate_conditions,_countries_may_restrict_dispensing_practices_ to_ qualified_ providers_ only._ Efforts_ are_under_ way_ in_ Cambodia,_ India_ and_ the_ United_Republic_ of_ Tanzania_ to_ promote_ the_ rational_ use_of_ anti-TB_ drugs_ by_ engaging_ pharmacists_ and_their_associations.

Addressing the dual MDR-TB and HIV epidem-ics._Data_suggest_that_people_living_with_HIV_have_a_higher_risk_of_developing_drug-resistant_TB._Of_the_27_ high_ MDR-TB_ burden_ countries,_ 12_ are_ listed_ as_priorities_of_the_Stop_TB_Partnership’s_TB-HIV_Work-ing_Group_and_carry_the_brunt_of_the_HIV-related_TB_epidemic._ Epidemiological_ data_ on_ the_ association_between_ HIV_ infection_ and_ MDR-TB_ are_ scarce._ Of_the_12_TB/HIV_priority_countries,_4_(Estonia,_Latvia,_the_Republic_of_Moldova_and_Ukraine)_reported_data_on_ MDR-TB_ stratified_ by_ HIV_ status._ TB_ screening_among_people_living_with_HIV,_including_those_with_drug-resistant_ TB,_ is_ expected_ to_ further_ increase_with_the_implementation_of_WHO’s_2010_guidelines_for_intensified_TB_case-finding_and_isoniazid_preven-tive_therapy_for_people_living_with_HIV/AIDS.

Prioritizing infection control._ In_ 2009,_ WHO_published_ its_recommended_policy_on_TB_ infection_control._ A_ total_ of_ 14/27_ high_ MDR-TB_ countries_have_ conducted_ a_ national_ situation_ assessment_of_ TB_ infection_ control_ and_ 11/27_ have_ developed_national_action_plans._Most_countries_are_at_a_pre-liminary_ phase_ in_ implementing_ policy_ and_ have_yet_to_begin_national_assessments_or_draft_national_action_plans.


Major_ progress_ has_ been_ made_ towards_ achieving_global_control_of_tuberculosis_(TB)_over_the_past_two_decades._ During_ 1995–2009,_ a_ total_ of_ 49_ million_patients_ were_ treated_ in_ DOTS_ programmes_ world-wide,_of_whom_41_million_were_successfully_treated,_and_up_to_6_million_lives_were_saved._Incidence_rates_have_ been_ declining_ globally_ and_ in_ all_ subregions_except_in_certain_African_countries_since_2004.1_This_progress_ is_ being_ threatened_ by_ M/XDR-TB,_ a_ form_of_TB_that_ is_more_difficult_and_costly_ to_diagnose,_treat_and_cure_than_drug-susceptible_TB._M/XDR-TB_(multidrug-resistant_ TB_ [MDR-TB]_ plus_ extensively_drug-resistant_ TB_ [XDR-TB])_ is_ particularly_ lethal_in_people_living_with_the_human_immunodeficiency_virus_(HIV)._In_2008,_the_World_Health_Organization_(WHO)_ estimated_ that_ 440 000_ cases_ of_ MDR-TB_emerged_globally;_85%_of_its_global_burden_occurs_in_27_countries.

At_the_ministerial_meeting_of_high_MDR-TB_bur-den_countries_(MDR-HBC)_held_in_Beijing,_China,_in_April_2009,_countries_committed_to_tackling_the_epi-demic_ with_ innovation_ and_ urgency._ In_ May_ 2009,_the_ 62nd_ World_ Health_ Assembly_ urged_ Member_States_ to_achieve_universal_access_ to_diagnosis_and_treatment_of_M/XDR-TB_(Annex_1)._By_October_2009,_27_ MDR-HBCs_ had_ begun_ to_ update_ their_ national_TB_ control_ plans_ to_ include_ a_ component_ on_ drug-resistant_TB_in_compliance_with_the_resolution.

It_is_well_accepted_that_weak_health-care_systems_are_at_the_root_of_M/XDR-TB,_hampering_progress_on_two_major_fronts:_prevention_of_the_M/XDR-TB_epi-demic_ and_ treatment_ of_ those_ affected._ Reflecting_that_notion,_this_report_has_two_parts:_diagnosing,_treating_and_caring_for_people_affected_by_M/XDR-TB_(part_I);_and_preventing_M/XDR-TB_through_basic_TB_control_(part_II).

Part_ I_ describes_ and_ analyses_ progress,_ remain-ing_ challenges_ and_ next_ steps_ for_ five_ elements_ of_the_health-care_system_as_applied_to_the_response_to_M/XDR-TB:_ planning_ and_ financing;_ diagnosis;_ sur-veillance;_ drug_ management;_ and_ treatment_ and_care._ It_also_analyses_ the_status_of_ the_ response_ to_M/XDR-TB_in_27_MDR-HBCs.

Diagnosing_and_treating_MDR-TB_are_proven_cost-effective_ health_ interventions._ However,_ national_budgets_do_not_always_follow_need._Section_1.1_anal-yses_the_progress_made_by_the_MDR-TB_high_burden_

countries_ towards_ filling_ the_ funding_ gaps_ identi-fied_in_the_Global Plan to Stop TB 2011–20152_since_the_62nd_World_Health_Assembly_resolution.

M/XDR-TB_ case-finding,_ unlike_ routine_ TB_case-finding,_ requires_ advanced,_ costly_ and_ labour-intensive_laboratory_technology._Section_1.2_presents_a_comprehensive_overview_of_the_dramatic_changes_that_have_occurred_during_the_past_three_years_to_the_TB_laboratory_landscape._India,_with_the_second_high-est_burden_of_MDR-TB,_has_achieved_major_progress_in_expanding_laboratory_capacity_and_is_hailed_as_an_example_of_the_progress_being_made_globally.

Measuring_ the_ magnitude_ of_ and_ trends_ in_ the_M/XDR-TB_epidemic_is_essential_for_planning_appro-priate_responses_and_assessing_their_epidemiological_impact_on_the_response_being_implemented_by_coun-tries._ Section_ 1.3_ presents_ the_ most_ recent_ data_available_from_drug_resistance_surveys_and_describes_the_actions_being_taken_to_fill_the_remaining_gaps_in_the_surveillance_of_M/XDR-TB,_especially_in_the_high_MDR-HBCs.

Uninterrupted_ and_ timely_ supply_ of_ medicines_that_meet_international_standards_of_quality_assur-ance_ is_ an_ essential_ component_ of_ the_ response_ to_M/XDR-TB._ Alas,_ most_ of_ the_ programmes_ treating_M/XDR-TB_experience_a_variety_of_problems_to_guar-antee_access_to_this_essential_component._Section_1.4_charts_the_progress_of_the_Global_Drug_Facility_(GDF)_and_its_partners_to_correct_the_failures_of_the_market_of_second-line_anti-TB_drugs.

The_ body_ of_ evidence_ on_ programmatic man-agement_ of_ M/XDR-TB_ is_ quite_ dynamic_ thanks_ to_increasing_operational_research_being_conducted_in_MDR-TB_treatment_programmes._In_addition,_treat-ment_and_care_of_people_affected_by_M/XDR-TB_raise_issues_that_were_either_ ignored_or_ less_relevant_ for_treatment_of_drug-susceptible_TB._Section_1.5_refers_to_the_most_recent_policies_and_guidelines_developed_by_WHO_to_guide_countries_in_managing_M/XDR-TB.

The_ programmatic_ management_ of_ drug-resist-ant_TB_ (PMDT)_ is_a_ complex_ intervention_ in_public_health._It_needs_careful_planning,_intensive_technical_assistance_ and_ mentoring_ during_ implementation,_as_well_as_ regular_monitoring._Section_1.6_presents_and_ analyses_ the_ data_ provided_ by_ countries_ on_MDR-TB_ patient_ enrolment_ and_ treatment_ out-comes;_and_the_support_being_provided_by_the_Green_

Introduction

5

Light_Committee_(GLC)_initiative_to_enhance_capac-ity_for_managing_MDR-TB_at_the_country_level.

The_ target_ of_ universal_ access_ to_ diagnosis_ and_treatment_of_MDR-TB_by_2015_set_by_the_62nd_World_Health_Assembly_is_ambitious._It_requires_countries_to_ mobilize_ resources,_ build_ capacity_ and_ properly_coordinate_ operations_ within_ the_ health-care_ sys-tem._ Section_ 1.7_ analyses_ the_ current_ capacity_ and_major_limitations_in_each_of_the_27_MDR-HBCs.

Part_ II_ describes_ and_ analyses_ the_ progress,_remaining_ challenges_ and_ next_ steps_ in_ some_elements_of_the_health-care_system_as_applied_to_pre-vention_of_TB_and_strengthening_of_basic_TB_control,_including_ DOTS,_ role_ of_ all_ health-care_ providers,_access_to_drugs,_collaboration_with_HIV_programmes,_and_ infection_ control._ Other_ elements_ relevant_ to_the_prevention_of_TB,_though_not_discussed_in_this_report,_include_co-morbidities_that_are_emerging_as_major_ risk_ factors_ for_ TB_ and_ contributing_ to_ poor_treatment_ outcomes,_ such_ as_ smoking,_ diabetes,_and_alcohol_or_substance_dependency._WHO_is_work-ing_with_partners_to_develop_policy_for_collaboration_with_ national_ TB_ control_ programmes_ (NTP)_ and_groups_ addressing_ these_ conditions._ Options_ are_also_being_explored_with_some_countries_to_pilot-test_interventions_that_may_contribute_to_tackling_social_and_economic_determinants_ that_prevent_access_ to_diagnosis_and_treatment_of_MDR-TB_and_simultane-ously_increase_the_risk_of_TB.

DOTS_–_the_cornerstone of_the_Stop_TB_strategy_–_is_essential_but_not_sufficient_to_prevent_and_con-trol_MDR-TB._However,_success_in_managing_MDR-TB_depends_ to_ a_ large_ extent_ on_ a_ solid_ DOTS_ pro-gramme._Section_2.1_presents_the_status_of_DOTS_in_the_27_MDR-HBCs_and_indicates_areas_in_urgent_need_of_improvement.

There_ is_ compelling_ evidence_ that_ the_ public-health_sector_is_not_the_first_choice_for_those_seeking_care._The_same_applies_to_those_affected_by_TB._Sec-tion_2.2_considers_ the_role_of_health_care_providers_engaged_in_the_response_to_TB_and_MDR-TB_and_pro-vides_two_successful_country_experiences.

Uninterrupted_ access_ to_ the_ right_ combina-tion_of_anti-TB_drugs_meeting_international_quality_standards_ is_ fundamental_ to_ prevent_ creation_ or_amplification_of_drug_resistance._Section_2.3_charts_progress_in_introducing_national_policies_to_regulate_access_to_anti-TB_drugs._Successful_implementation_of_ these_ policies_ will_ stop_ the_ practice_ of_ irregular_and_self-prescribed_treatment.

There_are_increasing_reports_suggesting_that_HIV_is_a_ risk_ factor_ for_development_of_M/XDR-TB._Sec-tion_ 2.4_ summarizes_ the_ advances_ being_ made_ to_engage_ partners_ around_ joint_ TB-HIV_ control_ pro-grammes._Full_ implementation_of_the_WHO_TB-HIV_

policy_can_have_a_major_impact_in_preventing_a_major_M/XDR-TB_epidemic_among_countries_where_HIV_ is_prevalent.

The_ high_ lethality_ observed_ in_ nosocomial_ out-breaks_ of_ MDR-TB,_ especially_ among_ those_ living_with_HIV,_fuelled_renewed_global_interest_in_TB_infec-tion_control._Section_2.5_provides_an_update_on_the_most_ relevant_ achievements_ in_ implementing_ the_new_WHO_policy_on_TB_infection_control.

Methods, sources of data and derivation of indicators

The_data_used_for_this_report_were_based_on_the_most_recent_ information_ made_ available_ by_ countries_ to_WHO_ until_ 22_ February_ 2011._ The_ sources_ of_ this_information_were_the_following:

1)_ WHO’s_ global_ TB_ database,a_ managed_ by_ the_Stop_ TB_ Department’s_ Monitoring_ and_ Evaluation_Unit,_which_houses_the_historic_TB_data_on_surveil-lance,_epidemiology,_ strategy_and_finance_collected_annually_by_WHO._Since_July_2009,_the_department_has_been_collecting_these_data_through_a_web-based_system_(www.stoptb.org/tme)_that_allows_real-time_validation_ while_ data_ are_ being_ entered_ directly_ by_national_ surveillance_ authorities_ and_ WHO_ staff_ in_countries_and_regions.

2)_ Information_ collected_ by_ the_ WHO_ secretar-iat_of_the_“Global_project_on_anti-tuberculosis_drug_resistance_ surveillance”_ on_ survey_ activity_ and_results_(Section 2.3).

3)_Information_collected_by_GLC_secretariat_about_project_ approvals,_ patient_ enrolment_ and_ per-formance_ as_ reported_ directly_ by_ projects_ to_ the_secretariat_(Section 1.6,_sub-section_on_GLC).

4)_Other_information_relevant_to_MDR-TB_control_available_ from_ WHO_ on_ planning,_ budgets,_ models_of_ care,_ incentives,_ supranational_ laboratory_ link-age,_systems_of_patient_data_management,_and_drug_supply_ extracted_ from_ project_ mission_ reports_ and_workshops.

5)_ A_ questionnaire_ applied_ to_ the_ 27_ MDR-HBCs_to_collect_complementary_information_not_available_elsewhere_ (for_ example,_ TB_ care_ in_ prisons),_ which_features_in_the_country_profiles_(Annex_2)._All_these_profiles_were_cleared_by_ individual_countries_ahead_of_finalization_of_this_report.

6)_ Qualitative_ data_ provided_ by_ countries_ illus-trating_ experience_ in_ public–private_ mix_ (PPM)_approaches_(Section 2.2)_and_box on_M/XDR-TB_care_in_South_Africa.

a_ www.who.int/tb/country/data/download


The_quantitative_indicators_used_are_expressed_as_absolute_ counts,_ simple_ proportions_ and_ rates_ per_population._Methods_used_to_derive_the_estimates_of_TB_incidence_and_of_incident_episodes_of_MDR-TB_have_been_described_in_detail_elsewhere.3,4_The_estimated_number_of_cases_of_MDR-TB_among_notified_cases_of_

pulmonary_ TB_ (Annex 3.1)_ were_ derived_ using_ the_measured_ or_ modeled_ estimate_ of_ MDR_ prevalence_applied_to_new,_retreated_or_combined_pulmonary_TB_cases_as_notified_by_countries_in_2009._In_interpreting_this_indicator_and_using_it_as_a_benchmark,_the_reader_is_referred_to_the_note_at_the_foot_of_Annex 3.1.

Towards universal access to diagnosis and treatment of multidrug-resistant and extensively drug-resistant tuberculosis by 2015 WHO PROGRESS REPORT 2011 7

PART 1:

Diagnosis, treatment and care of people affected by M/XDR-TB

1.1 Planning and financing universal access to MDR-TB diagnosis, care and treatment

PlanningThe_target_set_by_the_62nd_World_Health_Assembly5_on_MDR-TB_required_countries_to_update_the_MDR-TB_component_of_national_TB_plans._These_updates_and_accompanying_ budgets,_ are_ essential_ to_ identify_gaps,_ mobilize_ additional_ resources_ and_ monitor_implementation_progress._As_of_the_end_of_2010,_26_of_the_27_high_MDR-TB_burden_countries_(MDR-HBC)_had_updated_plans,_which_focus_mainly_on_the_oper-ational_ aspects_ of_ MDR-TB_ management,_ approved_or_endorsed_by_their_national_governments.

The_ analysis_ of_ updated_ country_ plans_ shows_promising_governmental_commitment_and_financial_contributions_ to_ ensuring_ sustainable_ scale-up_ of_MDR-TB_diagnosis,_treatment_and_care;_however,_not_all_MDR-TB_components_are_adequately_financed._The Global Plan to Stop TB 2011–2015 (the_Global_plan),2_developed_by_WHO_and_the_Stop_TB_Partnership,_has_the_target_of_achieving_universal_access_to_diagnosis_and_treatment_of_MDR-TB_by_2015.

WHO,_in_cooperation_with_partners_and_through_its_regional_and_country_offices,_has_provided_tech-nical_ assistance_ for_ most_ MDR-HBC_ in_ developing_and_ implementing_ M/XDR-TB_ response_ plans._ Five_training_courses_for_global_and_local_consultants_to_further_develop_the_necessary_skills_to_support_the_planning,_ implementation,_ and_ monitoring_ and_evaluation_of_the_MDR-TB_component_of_TB_control_programmes_have_been_conducted._In_addition,_using_a_ planning_ and_ budgeting_ tool,_ WHO_ and_ partners_facilitated_ three_ workshops_ to_ assist_ 19_ MDR-HBCs_with_developing_the_budget_for_M/XDR-TB_response_plans_based_on_country_scale-up_targets_and_in_line_with_the_Global Plan to Stop TB 2011–2015._2

WHO_regional_offices_are_also_developing_regional_plans._ In_ the_ WHO_ European_ Region,_ for_ example,_where_15_of_the_27_MDR-HBCs_are_located,_the_WHO_Regional_Director_has_established_a_Special_Project_to_Prevent_and_Combat_M/XDR-TB_in_the_region._In_

order_to_scale_up_comprehensive_responses_and_pre-vent_ and_ control_ M/XDR-TB,_ a_ consolidated_ action_plan_is_being_developed_to_function_as_a_road_map_for_countries_and_partners._The_plan_ is_being_prepared_in_region-wide_consultations_with_experts,_patients_and_communities_and_is_aligned_with_the_objectives_of_ the_ Global Plan to Stop TB 2011–2015;2_ it_ follows_the_same_targets_set_by_the_Global_Plan_and_World_Health_Assembly_resolution_WHA62.15._The_plan_will_be_submitted_for_endorsement_by_the_WHO_Regional_Committee_ for_ Europe,_ at_ its_ next_ meeting_ to_ be_held_in_Baku,_Azerbaijan,_in_September_2011.

Financing

To_ ensure_ universal_ access_ to_ MDR-TB_ diagnosis,_treatment_ and_ care,_ Member_ States_ were_ urged_by_ the_ World_ Health_ Assembly_ to_ use_ all_ possible_financing_mechanisms_–_both_domestic_and_external_–_to_fill_the_funding_gaps_identified_in_the_Global Plan to Stop TB 2011–2015,2_and_to_increase_investment_in_M/XDR-TB._ From_ the_ five_ main_ groups_ of_ funding_sources,_namely_government,_loans,_grants_from_the_Global_Fund_to_Fight_AIDS,_Tuberculosis_and_Malaria_(Global_ Fund),_ other_ donors_ and_ patients_ them-selves,_it_is_clear_that_out-of-pocket_payments_by_TB_patients_are_not_a_ solution_ for_financing_ the_scale-up_of_MDR-TB_diagnosis,_treatment_and_care.6_With_the_ costs_ of_ MDR-TB_ treatment_ typically_ several_thousands_of_US_dollars_per_patient_in_low-_and_mid-dle-income_ countries,_ a_ reliance_ on_ out-of-pocket_expenditures_ for_ MDR-TB_ diagnosis_ and_ treatment_would_ mean_ catastrophic_ health_ _ expenditures_ for_TB_patients_and_their_households._ It_may_also_ lead_to_ treatment_ of_ unknown_ quality,_ delivered_ in_ the_private_sector_without_a_link_to_the_national_TB_con-trol_ programme,_ which_ in_ turn_ can_ increase_ the_risk_ of_ emergence_ of_ further_ drug_ resistance,_ poor_treatment_outcomes_and_increased_transmission_of_MDR-TB_strains.

The_ Beijing Ministerial “Call for Action”7_ requires_countries_to_proceed_with_three_main_actions:

_� To_prepare_a_strategy,_a_plan_and_a_sound_budget_for_ addressing_ MDR-TB._ Countries_ were_ offered_the_ possibility_ of_ using_ the_ TB_ planning_ and_

e_ Azerbaijan_did_not_report_financial_data_to_WHO_but_according_to_approved_proposals_submitted_to_Global_Fund_rounds,_they_will_receive_funding_from_the_Global_Fund_to_treat_805_patients.


budgeting_ tool,a_ a_ comprehensive_ tool_ to_ help_countries_ plan_ and_ budget_ comprehensively_within_the_framework_of_both_the_Stop_TB_strat-egy_and_the_Global_Plan.2

_� To_explore_government_funding_in_middle-income_countries.

_� To_ integrate_ TB_ and_ MDR-TB_ budgets_ into_ the_general_health_system_financing_strategy.

The_ following_ section_ analyses_ the_ cost_ of_ MDR-TB_care_ and_ treatment_ as_ reported_ to_ WHO_ for_ 2008–2011_and_the_sources_of_funding_for_those_needs_since_the_WHA_resolution_and_the_Beijing_Call_for_Action._It_also_summarizes_the_main_funding_requirements_that_ 27_ MDR-HBC_ countries_ (Annex_ 2)_ have_ esti-mated_to_support_the_plans_to_scale_up_MDR-TB_care__and_ treatment_ for_ 2011–2015._ These_ are_ compared_with_the_Global_Plan_funding_estimates.

How much countries have budgeted for MDR-TB care and treatment for 2008–2011b

Since_ 2008,_ 23_ MDR-HBCc_ have_ reported_ financial_data_to_WHO,_which_allows_assessment_of_trends_in_funding_for_MDR-TB_care_and_treatment._Combined,_these_ countries_ account_ for_ more_ than_ 80%_ of_ the_global_ estimated_ number_ of_ incident_ MDR-TB_ cas-es.d_ Funding_ for_ MDR-TB_ care_ and_ treatment_ has_increased_fivefold_since_2009,_from_US$_0.1_billion_to_US$_0.5_billion_in_2011_(Figure_1).

How the required funding will be mobilized in 2011

While_ domestic_ funding_ for_ MDR-TB_ has_ increased_since_2009,_it_is_not_expected_to_further_increase_in_2011._ The_ Global_ Fund_ however_ has_ stepped_ into_the_ financing_ of_ MDR-TB_ and_ will_ be_ accounting_for_ around_ 18%_ of_ total_ MDR-TB_ control_ needs_ in_2011._Almost_21%_of_the_MDR-TB_costs_are_expected_to_ be_ unfunded_ unless_ new_ sources_ of_ funding_ are_identified_ (Box_ 1_ and_ Figure_ 1)._ In_ the_ Democratic_Republic_ of_ the_ Congo,_ Indonesia,_ the_ Philippines_and_ Ukraine,_ more_ than_ half_ of_ the_ funding_ needs_will_not_be_covered_(Table_1)._In_absolute_terms,_55%_of_ the_ MDR-TB_ care_ and_ treatment_ needs_ in_ 2011_are_ accounted_ for_ by_ three_ countries:_ the_ Russian_

a_ http://www.who.int/tb/dots/planning_ _budgeting_tool/en/index.html

b_ The_budget_for_MDR-TB_includes_two_categories:_second-line_drugs_and_MDR-TB_management._“MDR-TB_management”_in_the_ financial_ section_ of_ the_ online_ WHO_ TB_ data_ collection_form_does_not_include_second-line_drugs,_staff_working_in_TB_control,_nor_routine_TB_control_programme_management_and_supervision_(http://www.stoptb.org/tme/)

c_ 27_ MDR-TB_ HBC_ minus_ Belarus,_ Azerbaijan,_ Lithuania_ and_Tajikistan.

d_ At_ the_ time_ of_ writing,_ latest_ available_ estimates_ are_ from_2008.

FIGURE 1

MDR-TB care and treatment costs by sources of funding. 23 high MDR-TB burden countries, 2008–2011*

Source: www.who.int/tb/data

* At the time of writing, latest available estimates are from 2008._Excludes 4 countries (Azerbaijan, Belarus, Lithuania and Tajikistan) that did not report budget data. The 23 countries account for 83% of the global estimated number of incident MDR-TB cases.

Unknown applies to South Africa, 2008.

Other 20%

52%

18%

15%

15%

New 30%

Relapse 12%

xAfter default

3%

US$

mill

ions

(con

stan

t 201

0 U

S$)

US$

bill

ions

(con

stan

t 201

0 U

S$)

2008 2009 2010 2011

2012 2013 2014 2015

700

600

500

400

300

200

100

0

1.2

1.0

0.8

0.6

0.4

0.2

0.0

Gap

Unknown

Loans

Global Fund

Grants (excluding Global Fund)

Government, general health services for MDR (excluding loans)Government, MDR budget (excluding loans)

All other MDR-TB HBC

Indonesia

India

Kyrgyzstan

China

Kazakhstan

Tajikistan

Russian Federation

US$

mill

ions

(con

stan

t 201

0 U

S$)

8

7

6

5

4

3

2

1

0

Infection Control

MDR-TB treatment (incl. drugs for adverse events)

Improving diagnosis for MDR

M&E and Operational Research for MDR

ACSM for MDR

DRH for MDR Personnel, Technical Assistance and Training

2011 2012 2013 2014 2015

Num

ber o

f pat

ient

s

Annual enrolment

Cumulative enrolment

2008 2009 2010 2011

0% 20% 40% 60% 80% 100%

Countries with available survey/surveillance data*

27

24

21

18

15

12

9

6

3

0

Countries with surveys underway/planned

Azerbaijan (2.4)Indonesia (6.4)

China (65.9)Nigeria (2.1)India (73.1)

Pakistan (9.3)DR Congo (2.2)Viet Nam (3.5)

Bangladesh (3.6)Bulgaria (0.4)

Ethiopia (2)Philippines (7.6)

Myanmar (4.8)Uzbekistan (2.9)

Tajikistan (1)Russian Fed (30.6)

Ukraine (7.2)Kazakhstan (7.3)

Rep Moldova (1.5)Armenia (0.2)

Latvia (0.1)South Africa (9.6)

Kyrgyzstan (0.8)Lithuania (0.3)

Georgia (0.4)Estonia (0.1)Belarus (0.9)

Enrolled on MDR treatment

Notified; no information on enrolment

No information on notification or enrolment

35 000

30 000

25 000

20 000

15 000

10 000

5000

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

After failure Cat II 22%

After failure Cat I 13%

40%

15%

15%

30%

Yes

No

In preparation

Unknown

Yes

No

In preparation

Unknown

% total estimated MDR cases in noti�ed

BOX 1 Role of Global Fund in financing of the MDR-TB response, 2011–2012

Total funding needs for MDR-TB care and treatment rise to US$ 0.6 billion in the 24 MDR-HBC in 2011 (Table 1), of which US$ 0.1 billion (or 18%) is expected to be available from the Global Fund. Nineteen of the MDR-HBC will benefit from Global Fund financial support for a total of 27 749 patients; Estonia, Latvia, the Philippines, South Africa and the Ukraine, do not have a Global Fund grant for 2011 covering MDR-TB.e The Global Fund supports 19/24 MDR-HBC; in 10/19 countries, covers at least 90% of the total cost of SLDs and MDR-TB management. Ten of the nineteen countries supported by the Global Fund will receive funding for over 90% of their MDR-TB budget. For the remaining nine countries also supported by the Global Fund, contributions range from 4% of SLDs and MDR-TB management costs in the Russian Federation to 78% in Viet Nam.

Globally, the Global Fund will finance US$ 0.2 billion in 2011 for MDR-TB diagnosis, care and treatment. This total (up to Round 10 and National Strategy Application [NSA]) includes: a) the grants to the 20 MDR-HBC; b) the grants to other non MDR-HBC, such as Nepal, Peru and Romania (US$ 0.01 billion); and, c) two thirds of laboratory costs (Service Delivery Areas). These funds are aimed at treating 34 885 MDR-TB cases. In 2012, of the US$ 0.9 billion needed to support MDR-TB expansion plans, the Global Fund is expected to fund US$ 0.3 billion.


Federation,_ South_ Africa_ and_ Ukraine,_ mainly_through_domestic_funding.

In_ 2011,_ the_ Global_ Fund_ may_ become_ the_ sole_source_of_funding_for_second-line_drugs_and_MDR-TB_management_ for_ seven_ MDR-HBC:_ Armenia,_ Bang-ladesh,_ Bulgaria,_ Georgia,_ Tajikistan,_ Kyrgyzstan_and_ Uzbekistan._ In_ nine_ other_ MDR-HBC_ –_ the_

Democratic_Republic_of_the_Congo,_Ethiopia,_India,_Indonesia,_Kazakhstan,_Myanmar,_Nigeria,_the_Rus-sian_ Federation_ and_ Viet_ Nam_ –_ the_ Global_ Fund_is_expected_to_contribute_at_ least_4%_of_the_budget_needed_for_MDR-TB._Domestic_ funding_for_MDR-TB_is_expected_to_be_extensively_used_in_Estonia,_Latvia,_South_Africa_and_the_Russian_Federation.

TablE 1

MDR-TB budget, available funding, cost of use of general health-care services for MDR-TB, total MDR-TB control costs (all in US$ millions) and expected number of patients to treat, 24 high MDR-TB burden countries, 2011*

Available fundingCost of

utilization of general

health-care services for

MDR-TB

Total MDR-TB control

costs

Expected number

of MDR-TB patients to treat

MDR-TB budget

Government (excluding

loans) Loans

Grants (excluding

Global Fund)

Global Fund

Funding gap

Armenia 1 0 0 0 1 0 1 1 160

Bangladesh 5 0 0 0 5 0 1 6 776

Bulgaria 0 0 0 0 0 0 1 1 60

China** 34 3 0 0 30 0 0 34 6 706

Democratic Republic of the Congo 5 0 0 0 1 5 0 5 0

Estonia 1 1 0 0 0 0 1 1 80

Ethiopia 5 0 0 2 1 2 1 6 746

Georgia 0 0 0 0 0 0 1 2 470

Indonesia 27 1 0 1 6 19 1 29 1 000

India 54 1 5 10 35 3 9 62 15 000

Kazakhstan 18 8 0 0 10 0 42 60 4 215

Kyrgyzstan 1 0 0 0 1 0 1 2 210

Latvia 1 1 0 0 0 0 2 3 140

Republic of Moldova 2 0 0 0 2 0 1 3 450

Myanmar 2 0 0 0 1 1 0 2 600

Nigeria 4 0 0 0 2 1 0 4 0

Pakistan 7 0 0 0 7 0 2 9 1 100

Philippines 35 0 0 0 0 35 1 36 2 004

Russian Federation 129 123 0 0 5 0 2 131 0

Tajikistan 2 0 0 0 2 0 0 2 400

Ukraine 83 18 0 0 0 65 24 107 3 040

Uzbekistan 3 0 0 0 3 0 1 4 1 010

Viet Nam 1 0 0 0 0 0 0 1 910

South Africa 20 20 0 0 0 0 76 96 8 642

High MDR-TB countries 437 175 5 15 113 130 170 607 47 719

Source: www.who.int/tb/data

* Excludes 3 countries (Azerbaijan, Belarus and Lithuania) that did not report budget data. The 24 countries account for 84% of the global estimated number of incident MDR-TB cases.`

** Data in the table only apply to the Global Fund MDR-TB pilot areas in China. China government budget contributes to MDR-TB care and control through health insurance schemes and support to medical facilities and human resources


Aligning budgets for MDR-TB care scale-up 2011–2015 with the Global Plan to Stop TB 2011–2015

Looking_ahead,_ to_2011–2015,_ the_Global_Plan2_has_recommended_that_1_million_MDR-TB_patients_should_be_treated_worldwide_at_a_cost_of_around_US$_7.9_bil-lion.c_Updates_of_the_MDR-TB_component_of_national_TB_control_plans_have_been_prepared_by_all_27_high_MDR-TB_burden_countries_(Annex_2),_aiming_to_treat_448_730_patients._25_of_the_MDR-HBCs,d_accounting_for_ over_ 80%_ the_ world’s_ global_ estimated_ number_of_incident_MDR-TB_cases,_have_updated_plans_that_include_a_budget,_the_amount_of_which_is_published_annually7_and_appears_ in_the_MDR-TB_country_pro-files_ (Annex_ 2_ and_ Figure_ 2)._ They_ have_ estimated_their_ combined_ funding_ needs_ for_ that_ period_ at_US$_5_billion,_ increasing_annually_ from_US$_0.6_bil-lion_ in_ 2011_ to_ US$_ 1.2_ billion_ in_ 2015._ The_ largest_share_of_funding_requirements_for_MDR-TB_care_and_treatment_ is_ expected_ for_ China,_ India,_ Indonesia,_Kazakhstan,_Kyrgyzstan,_Tajikistan_and_the_Russian_

a_ http://www.who.int/tb/dots/planning_budgeting_tool/en/index.html

b_ Country_office_and_headquartersc_ Best_estimated_ At_ the_ time_ of_ writing,_ Latvia_ and_ South_ Africa_ had_ not_

reported_2012–2015_budget_for_MDR-TB.

BOX 2 Strengthening planning and budgeting to scale up MDR-TB management: the experience of the Democratic Republic of the Congo

The Democratic Republic of the Congo is a high MDR-TB burden country that accounts for around 1% of the world’s estimated number of incident MDR-TB cases. The Plan d’action TB-MR DR Congo 2011–2015 envisages substantial developments in MDR-TB diagnosis, treatment and surveillance, as well as management and human resource capacity. The WHO TB planning and budgeting toola was used by the national TB control programme (NTP), assisted by WHO,b as a basis for costing the MDR-TB expansion plan. An annual budget ranging from US$ 5 million to US$ 7 million (Figure 3) will be needed to carry out the five-year plan, which includes:

– a cumulative total of 4800 MDR-TB patients put on treatment throughout the country, largely employing an ambulatory model of care;

– six laboratories (1 national, 5 provincial) undertaking culture and DST on solid media by 2013, two of which will also have capacity for liquid media and three for molecular testing;

– two drug resistance surveys performed;

– 24 provincial MDR-TB focal points in place;

– related trainings and MDR-TB coordination meetings.

Having identified the needs to scale up MDR-TB care and treatment, the NTP should now identify sustainable funding to meet the plan needs. Of the 25 MDR-HBC reporting data to WHO in 2011, the Democratic Republic of the Congo showed the highest funding gap accounting for 85% of the MDR-TB budget (Figure 3). If the current level of funding, i.e. US$ 0.8 million in 2011, is not increased in DR Congo, the funding gap for the MDR-TB plan will range between US$ 4 million and US$ 6 million annually.

FIGURE 2

Estimates of funding needed to scale up MDR-TB management, by country, 25 high MDR-TB burden countries, 2012–2015*

Source: National MDR response plans (Armenia, Bulgaria, DR Congo, Estonia, Georgia, Kazakhstan, Nigeria, Moldova, Tajikistan, China), TB control plan 2011–2015 (Bangladesh, Ethiopia), MDR-scale up workshops in Cairo 2010 (Indonesia, Philippines, Myanmar, Viet Nam, Pakistan), First Green Light Committee forum, Geneva, Switzerland 13–14 October 2009 (Azerbaijan, Belarus, India, Kyrgyzstan, Russian Federation, Ukraine, Uzbekistan).

* Excludes 2 countries (Latvia and South Africa) that did not report budget data. The 25 countries account for 82% of the global estimated number of incident MDR-TB cases.

US$

bill

ions

(con

stan

t 201

0 U

S$)

2012 2013 2014 2015

1.2

1.0

0.8

0.6

0.4

0.2

0.0


Indonesia

India

Kyrgyzstan

China

Kazakhstan

Tajikistan

Russian Federation


Federation._ The_ costs_ of_ purchasing_ second-line_drugs_is_expected_to_increase_from_30%_to_50%_of_the_total_required_funding.

To_achieve_the_Global_Plan_targets,_countries_need_to_persevere_in_their_efforts_to_reach_the_remaining_0.5_million_MDR-TB_patients_and_use_resources_more_cost_ effectively_ to_ reduce_ the_ economic_ burden_ on_patients_and_health_systems.

1.2 Expanding diagnostic capacity

Lack_of_diagnostic_capacity_has_been_a_crucial_barrier_preventing_ an_ effective_ response_ to_ the_ challenges_of_ HIV-associated_ and_ drug-resistant_ TB,_ with_ less_than_5%_of_the_estimated_global_burden_of_MDR-TB_patients_ currently_ being_ detected._ Expanded_

capacity_ to_ diagnose_ MDR-TB_ is_ therefore_ a_ global_priority_ for_ TB_ control._ To_ address_ these_ diagnos-tic_challenges_the_Global_Laboratory_Initiative_(GLI)_was_established_in_2008_as_a_Working_Group_of_the_Stop_TB_Partnership;_the_GLI_Secretariat_is_hosted_by_the_Stop_TB_Department_of_WHO.a

The Global Laboratory Initiative

The_GLI_works_closely_with_national_TB_control_pro-grammes,_ nongovernmental_ organizations_ (NGOs),_technical_and_financial_agencies,_scientific_and_aca-demic_ institutions,_ and_ WHO_ offices_ at_ country_and_ regional_ levels_ in_ strengthening_ TB_ laboratory_services._ GLI_ activities_ include_ global_ policy_ guid-ance_on_appropriate_laboratory_technology_and_best_practices,_effective_technology_transfer_and_coordi-nation_ of_ technical_ assistance,_ laboratory-related_advocacy_ and_ resource_ mobilization,_ laboratory_capacity_development,_ interface_with_other_ labora-tory_ networks_ to_ ensure_ appropriate_ integration,_standardized_laboratory_quality_assurance,_as_well_as_effective_knowledge_sharing._Membership_of_the_GLI_has_continued_to_grow,_and_more_than_100_interna-tional_partners_have_joined_forces_to_accelerate_and_expand_access_to_quality-assured_TB_diagnostic_serv-ices_within_integrated_laboratory_systems.

EXPAND TB

The_ EXPAND-TB_ project_ (EXPanding_ Access_ to_ New_Diagnostics_ for_ TB)_ established_ in_ 2008_ aims_ to_accelerate_ uptake_ of_ new_ TB_ diagnostic_ technol-ogies_ (commercial_ liquid_ culture_ systems,_ rapid_

a_ http://www.stoptb.org/wg/

FIGURE 3

Budget for MDR-TB management, by line item, Democratic Republic of the Congo, 2011–2015

Other 20%

52%

18%

15%

15%

New 30%

Relapse 12%

xAfter default

3%

US$

mill

ions

(con

stan

t 201

0 U

S$)

US$

bill

ions

(con

stan

t 201

0 U

S$)

2008 2009 2010 2011

2012 2013 2014 2015

700

600

500

400

300

200

100

0

1.2

1.0

0.8

0.6

0.4

0.2

0.0

Gap

Unknown

Loans

Global Fund




Indonesia

India

Kyrgyzstan

China

Kazakhstan

Tajikistan

Russian Federation

US$

mill

ions

(con

stan

t 201

0 U

S$)

8

7

6

5

4

3

2

1

0

Infection Control




ACSM for MDR


2011 2012 2013 2014 2015

Num

ber o

f pat

ient

s

Annual enrolment


2008 2009 2010 2011

0% 20% 40% 60% 80% 100%


27

24

21

18

15

12

9

6

3

0

















35 000

30 000

25 000

20 000

15 000

10 000

5000

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009



40%

15%

15%

30%

Yes

No

In preparation

Unknown

Yes

No

In preparation

Unknown


FIGURE 4

Implementation schedule for EXPAND-TB recipient countries

0–14

15–49

50–7475 and higher

Data not available

Annual enrolment


2009: 6 countries

2010: 18 countries including India (43 laboratories)

2011: 3 countries

30 000

25 000

20 000

15 000

10 000

5000

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Num

ber o

f pat

ient

s

Countries served through GDF’s MDR-TB mechanism

Countries not served through GDF’s MDR-TB mechanism

Peru

Haiti

Senegal

Côte d’Ivoire

DR Congo

LesothoSwaziland

Djibouti

Belarus

Republic of Moldova UzbekistanKyrgyzstanTajikistan

IndiaMyanmar

EthiopiaUganda

KenyaUR Tanzania

Zambia

Cameroon

Vietnam

Indonesia

Kazakhstan

AzerbaijanGeorgia

Bangladesh


speciation_and_molecular_line_probe_assays,_recently_endorsed_by_WHO8)_ into_adequate_ laboratory_serv-ices_ in_ 27_ recipient_ countries_ (Figure_ 4)._ Project_partners_ include_ WHO,_ GLI,_ the_ Foundation_ for_Innovative_New_Diagnostics_(FIND)a_and_the_Stop_TB_Partnership’s_Global_Drug_Facility_(GDF);b_funding_is_provided_by_UNITAID_and_other_donors.

During_ the_ first_ 18_ months_ of_ the_ EXPAND-TB_project,_ a_ wide_ range_ of_ activities_ was_ initiated_ in_23/27_ recipient_ countries._ These_ include_ labora-tory_needs_assessment_and_gaps_analyses,_upgrades_and_ renovation_ of_ laboratory_ infrastructure,_ train-ing_ of_ staff,_ diagnostic_ policy_ reform_ and_ country_validation_ of_ new_ technologies._ Technology_ trans-fer_has_subsequently_started_in_16_countries,_and_4_countries_now_routinely_diagnose_MDR-TB_patients,_paving_the_way_for_eventual_routine_surveillance_of_drug_resistance.

GeneXpert MTB/RIF system

With_ support_ from_ the_ United_ States_ National_Institutes_ of_ Health_ (NIH),_ FIND_ has_ partnered_with_ Cepheid_ (California,_ USA)_ and_ the_ University_of_Medicine_and_Dentistry_of_New_Jersey_ (UMDNJ,_New_York,_USA)_to_develop_a_real-time,_automated,_molecular_test_for_simultaneous_detection_of_TB_and_rifampicin_resistance._The_test,_called_Xpert_MTB/RIF,_is_a_cartridge-based_polymerase_chain_reaction_(PCR)-based_test_that_uses_the_GeneXpert_device.

Evidence_ from_ laboratory_ validation,_ field_ eval-uation_ and_ large-scale_ demonstration_ studies_coordinated_by_FIND_was_reviewed_by_WHO_in_late-2010_following_the_systematic_process_for_evidence_assessment_developed_for_TB_diagnostics._This_pro-cess_confirmed_that_the_Xpert_MTB/RIF_system_was_highly_sensitive_(98%)_and_specific_(98%)_in_detect-ing_TB_and_rifampicin_resistance_(a_reliable_proxy_for_MDR)_directly_from_sputum,_in_less_than_two_hours._The_assay_is_robust_enough_to_be_performed_outside_of_ conventional_ laboratories,_ at_ decentralized_ (dis-trict_ and_ sub-district)_ levels_ of_ the_ health_ system_but_requires_uninterrupted_and_stable_power_supply,_with_ a_ maximum_ of_ 20_ tests_ possible_ to_ be_ run_ in_one_ 4-module_ device_ per_ day._ FIND_ has_ negotiated_preferential_pricing_for_the_public_sector_in_low-_and_middle-income_ countries,_ as_ well_ as_ for_ donor_ and_technical_ support_ agencies_ and_ NGOs_ supporting_these_countries.c

Widespread_ implementation_ of_ Xpert_ MTB/RIF_would_ greatly_ advance_ the_ diagnostic_ capacity_ for_

a_ http://www.finddiagnostics.orgb_ http://www.stoptb.org/gdfc_ http://www.finddiagnostics.org/programs/tb/find-

negotiated-prices/xpert_mtb_rif.html

TB_and_MDR-TB;_its_accuracy_and_ease_of_use_repre-sents_a_major_milestone_for_global_TB_and_MDR-TB_care_ and_ control._ A_ global_ consultation,_ convened_by_WHO_in_December_2010,_outlined_the_operational_requirements_for_Xpert_MTB/RIF_implementation.d

Xpert_ MTB/RIF_ is_ not_ a_ point-of-care_ test_ and_cannot_be_used_ to_monitor_ response_ to_ treatment._Introduction_therefore_needs_to_be_accompanied_by_strengthening_of_overall_laboratory_services_to_pro-vide_ the_ necessary_ laboratory_ back-up_ for_ patient_monitoring_and_further_drug-susceptibility_testing.

Much_ progress_ has_ been_ achieved_ on_ new_ tools_for_ diagnosis_ and_ treatment_ of_ MDR-TB_ over_ the_past_two_years._The_Xpert_MTB/RIF_test,_for_example,_allows_significant_decentralization_of_MDR-TB_diag-nosis_but_is_unfortunately_not_a_point-of-care_assay,_and_ the_ need_ for_ increased_ research_ investment_into_ novel_ rapid_ tests_ suitable_ for_ use_ at_ patient_and_community_ level_ therefore_remains._Given_the_availability_of_new_diagnostics_and_increased_fund-ing_ sources_ for_ laboratory_ strengthening,_ country_capacity_ development_ has_ evolved_ into_ a_ complex_and_dynamic_process,_requiring_much_more_detailed_analysis_of_ local_ infrastructure,_diagnostic_policies,_and_human_and_financial_resources_than_before._WHO_has_therefore_developed_a_framework_for_implemen-tation_of_TB_diagnostics_to_guide_this_process.e

The WHO-GLI Supranational Reference Laboratory Network

The_ TB_ Supranational_ Reference_ Laboratory_Network_(SRLN)_was_created_in_1994_to_support_the_WHO-International_ Union_ Against_ Tuberculosis_and_ Lung_ Disease_ (IUATLD)_ global_ project_ on_ anti-TB_drug_resistance_surveillance._The_original_ terms_of_reference_required_that_each_of_the_Supranational_Reference_ Laboratories_ (SRLs)_ support_ their_ own_and_ at_ least_ two_ other_ countries_ with_ DST_ profi-ciency_ testing_ (PT),_ to_ provide_ external_ quality_assurance_ during_ drug_ resistance_ surveys,_ and_ to_provide_ training_ on_ culture_ and_ DST._ In_ 2010,_ the_SRLN_comprised_29_laboratories,_almost_a_doubling_of_ the_ 16_ original_ SRLs_ established_ in_ 1994.f_ Given_the_ pressing_ need_ to_ scale_ up_ laboratory_ services,_an_expanded_focus_for_SRL_activities_became_urgent,_especially_in_Africa_where_there_are_only_three_SRLs_and_ where_ the_ need_ for_ laboratory_ strengthening_is_ most_ pressing._ A_ global_ consultation_ of_ the_ SRL_network_ was_ therefore_ convened_ by_ WHO_ in_ 2010,_

d_ http://www.who.int/tb/laboratory/roadmap_xpert_mtb_rif_rev23dec2010.pdf

e_ http://www.who.int/tb/laboratory/whopolicyframework_july10_revnov10.pdf

f_ http://www.who.int/tb/challenges/mdr/srl_network_mar10.pdf


in_Geneva._Revised_terms_of_reference,_and_eligibil-ity_and_inclusion_criteria,_were_developed,_endorsed_and_subsequently_disseminated._Following_this_con-sultation,_the_national_reference_laboratories_(NRLs)_of_ Benin,_ Cameroon,_ Kenya,_ Madagascar,_ Rwanda_and_the_United_Republic_of_Tanzania_were_assessed_in_late-2010_as_possible_SRL_candidates_for_Africa._An_assessment_of_laboratories_in_Pakistan_and_Uganda_is_planned_for_early_2011.

Country progress in scaling up access to diagnosis of drug-resistant TB

Laboratory_ networks_ are_ well_ established_ in_ all_ 27_MDR-HBCs;_ all_ have_ capacity_ to_ perform_ DST_ of_ at_least_first-line_anti-TB_drugs_at_the_central/NRL_level_and_also_at_regional_level_in_some_of_the_countries._Most_of_the_countries_have_functional_links_with_the_SRLs,_ which_ provide_ proficiency_ testing,_ external_quality_assurance_and_TB_laboratory-related_techni-cal_ assistance._ The_ exceptions_ are_ countries_ where_the_ NRL_ is_ already_ part_ of_ the_ SRL_ (China,_ India,_Latvia_ and_ South_ Africa)_ or_ the_ country_ is_ part_ of_the_ European_ Union_ and_ implements_ sufficiently_high_ standards_ for_ laboratory_ services_ (Estonia,_Lithuania)._ Some_ of_ the_ bigger_ countries_ (such_ as_

the_ Russian_ Federation)_ have_ functional_ links_ to_several_SRLs_based_on_need_and_technical_specialty_(e.g._for_molecular_testing).

The_majority_of_countries_report_introduction_of_liquid_culture_and_DST_systems_at_least_at_the_central_level,_and_more_than_half_of_the_27_countries_report_using_the_newer_line_probe_assay_(LPA)-based_DST_as_well._The_extent_of_ introduction_of_these_newer_TB_diagnostic_techniques_varies_by_country._With_active_scale-up_ as_ a_ result_ of_ activities_ such_ as_ EXPAND-TBa_ the_ number_ of_ laboratory-confirmed_ MDR-TB_cases_ is_ expected_ to_ increase_ dramatically_ over_ the_next_few_years._ Introduction_of_the_Xpert_MTB/RIF_assay_ is_ expected_ to_ accelerate_ this_ trend_ and_ cul-minate_ in_ improved_ access_ to_ MDR-TB_ diagnostic_services._Linking_the_increases_in_diagnostic_capac-ity_to_increased_access_to_appropriate_treatment_and_patient_management_will_be_essential_for_successful_MDR-TB_control.

a_ The_ EXPAND-TB_ (Expanding_ Access_ to_ New_ Diagnostics_for_ TB)_ Project_ is_ a_ collaboration_ between_ WHO,_ the_ Global_Laboratory_ Initiative_ (GLI),_ the_ Foundation_ for_ Innovative_New_Diagnostics_(FIND)_and_the_Stop_TB_Partnership’s_Global_Drug_Facility_(GDF)._The_EXPAND-TB_Project_aims_to_diagnose_at_least_129_000_patients_with_MDR-TB_by_2013.

BOX 3 TB laboratory scale-up and engagement of private laboratories in India

The laboratory network of the Revised National TB Control Programme (RNTCP) in India currently consists of four designated NRLs at national level, 27 intermediate reference laboratories (IRLs) at the state level, and over 12 700 designated microscopy centres (DMCs) at the periphery. The IRL network was primarily intended, under the DOTS programme, for external quality assessment of sputum smear microscopy, surveillance for drug-resistant tuberculosis, and (very limited) culture and DST services for MDR-TB diagnosis.

To support the RNTCP 2012 goal to provide all acid-fast bacteria smear-positive retreatment patients with an MDR-TB assessment, and to provide follow-up cultures for an estimated 32 000 MDR-TB patients enrolled annually by 2015, the Government of India embarked on an ambitious plan to scale up laboratory capacity, with the support of several partners including private sector laboratories. Testing targets under this plan are for 160 000 people suspected of MDR-TB to have a quality-assured culture and drug-susceptibility test by 2015, and for over 330 000 follow-up cultures annually to be done to monitor MDR-TB patients receiving treatment. To achieve these service delivery targets, the national laboratory network is being strengthened substantially. In the public sector, 43 laboratories are being upgraded to accommodate high-throughput LPA, which will form the primary method for DST for patients suspected of MDR-TB. Automated liquid culture systems are being installed in 33 of these laboratories to monitor treatment.

The RNTCP has also collaborated with FIND in validation and demonstration studies of the Xpert MTB/RIF assay. In 2011–2012, India plans to introduce this newly WHO-endorsed technology at 18 sites. This should enable a diagnostic service for approximately 8 million people and aims to improve both the quality and accuracy of TB diagnosis for all TB suspects accessing healthcare services through either the private or public health sectors. The FIND-negotiated preferential pricing structure for the Xpert MTB/RIF assay is expected to favour strengthened public sector collaboration with the private health sector for TB diagnostic services.

The laboratory expansion plan for India is one of the most extensive in the world and provides a model for large-scale implementation of culture and DST services in collaboration with the private sector, a largely untapped resource in laboratory capacity development.


1.3 Improving surveillance of drug-resistant TB

Surveillance_ of_ anti-TB_ drug_ resistance_ is_ a_ cru-cial_ component_ of_ any_ TB_ control_ programme._Surveillance_ is_ needed_ to:_ a)_ measure_ the_ burden_of_drug-resistant_TB_and_accurately_plan_treatment_programmes_with_second-line_drugs;_b)_assess_epide-miological_trends_as_a_reflection_of_the_effectiveness_of_ implemented_ drug-resistant_ TB_ prevention_ and_control_ activities;_ c)_ design_ effective_ empirical,_standardized_regimens_for_the_treatment_of_TB,_par-ticularly_for_patients_who_have_already_been_treated_for_TB_and_return_with_the_disease;_and_d)_promptly_identify_local_outbreaks_of_drug-resistant_TB_in_order_to_respond_in_a_timely_way.

In_2008,_an_estimated_390_000–510_000_cases_of_MDR-TB_ emerged_ globally_ (best_ estimate,_ 440_000_cases)._ Globally,_ 3.3%_ (95%_ confidence_ interval_ (CI:_3.0–3.6))_of_incident_new_TB_cases_are_estimated_to_have_ MDR-TB._ Estimates_ by_ country_ are_ given_ in_Annex_3.1.

Since_ the_ launch_ of_ the_ global_ anti-tuberculosis_drug_ resistance_ surveillance_ project_ in_ 1994,_ drug_resistance_ data_ have_ been_ systematically_ collected_and_analysed_from_119_countries_worldwide_(62%_of_all_ countries_ of_ the_ world)._ Only_ 48_ countries_ can_rely_ on_ continuous_ surveillance_ systems_ based_ on_routine_diagnostic_DST_of_all_patients._The_remain-ing_ 71_ countries_ have_ relied_ on_ special_ surveys_ of_representative_ samples_ of_ patients._ Since_ 2006_WHO_has_also_been_collecting_and_analysing_data_on_resistance_to_second-line_anti-TB_drugs_with_a_total_of_61_countries_or_settings,_reporting_results_of_DST_to_ second-line_ drugs_ conducted_ during_ the_ course_of_ surveys_ of_ surveillance_ activities_ (Annex_ 3.4)._By_March_2011,_a_ total_of_69_countries_ reported_to_have_identified_at_least_one_case_of_XDR-TB_(Map_1)._Data_ on_ national_ trends_ in_ the_ drug-resistant_ TB_epidemic_are_available_ from_83_settings_worldwide._Such_data_are_critical_to_understand_whether_TB_and_drug-resistant_TB_prevention_and_control_measures_under_implementation_by_ncontrol_programmes_are_effective._In_two_Russian_oblasts,_Orel_and_Tomsk,_it_was_possible_to_document_a_reversal_of_the_MDR-TB_epidemic_in_new_TB_cases,_believed_to_be_due_to_the_implementation_of_effective_control_measures._This_is_an_important_sign_demonstrating_that_even_in_set-tings_greatly_affected_by_drug_resistance,_it_is_feasible_to_control_and_reverse_the_spread_of_the_disease.

Progress in 2008–2010

In_ 2008–2010,_ great_ progress_ has_ been_ made_ in_expanding_coverage_of_drug_resistance_surveillance_worldwide._ Several_ countries,_ including_ Botswana,_

China,_Mongolia,_Mozambique,_Myanmar,_Namibia,_Paraguay_ and_ Swaziland,_ have_ concluded_ country-wide_ surveys;_ Indonesia,_ Mexico,_ Tajikistan_ and_Uganda_have_finished_sub-national_surveys_(details_of_these_surveys_are_given_in_Annex_3.5).

The_ survey_ in_ China_ revealed_ a_ proportion_ of_MDR-TB_of_5.7%_in_new_TB_cases_(95%CI:_4.6–7.1)_and_25.6%_in_previously_treated_cases_(95%CI:_21.7–30.0)._These_ findings_ suggest_ that_ China_ is_ the_ country_with_ the_ greatest_ burden_ of_ MDR-TB_ globally._ New_data_from_Southern_African_countries_indicate_that_MDR-TB_is_a_growing_problem_in_that_region._Surveys_in_Botswana_and_Swaziland_revealed_a_proportion_of_MDR-TB_ in_ new_ cases_ of_ 2.5%_ (95%CI:_ 1.5–3.5)_ and_7.7%_ (95%CI:_ 4.8–10.5),_ respectively._ In_ both_ set-tings,_the_proportions_of_MDR-TB_have_increased_in_the_past_15_years._This_alarming_finding_is_associated_with_the_growing_HIV_epidemic_in_that_region.

In_ 2008,_ representative_ drug_ resistance_ surveil-lance_data_were_not_available_from_8/27_MDR-HBCs:_Bangladesh,_ Belarus,_ Bulgaria,_ China,_ Kyrgyzstan,_Nigeria,_Pakistan_and_Tajikistan._By_the_end_of_2010,_China_had_reported_results_of_a_nationwide_survey;_Bulgaria_ and_ Nigeria_ had_ recently_ finished_ nation-wide_ surveys;_ Bangladesh,_ Belarus,_ Kyrgyzstan_and_Tajikistan_were_in_the_middle_of_implementing_nationwide_surveys;_and_enrolment_of_patients_into_a_nationwide_survey_was_starting_in_Pakistan.

The_number_of_countries_or_settings_able_to_report_high-quality_ continuous_ surveillance_ data_ has_ sig-nificantly_increased_in_the_past_two_years_(Figure_5)._Belarus,_Georgia,_ the_Former_Yugoslav_Republic_of_Macedonia,_ Jordan,_ the_ Republic_ of_ Moldova_ and_

FIGURE 5

Status of drug resistance surveillance, 27 high MDR-TB burden countries, 2011

Other 20%

52%

18%

15%

15%

New 30%

Relapse 12%

xAfter default

3%

US$

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2008 2009 2010 2011

2012 2013 2014 2015

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Indonesia

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Kyrgyzstan

China

Kazakhstan

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Infection Control




ACSM for MDR


2011 2012 2013 2014 2015

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35 000

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0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009



40%

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Yes

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12_ oblasts_ of_ the_ Russian_ Federation_ now_ have_advanced_surveillance_systems_able_to_report_results_of_routine_DST_conducted_among_all_TB_cases._Fur-thermore,_a_growing_number_of_countries,_including_Bolivia,_ Chile,_ Colombia,_ El_ Salvador,_ Lebanon,_Mongolia,_and_parts_of_Bangladesh_have_been_able_to_ routinely_ test_ previously_ treated_ TB_ cases_ and_report_the_results_for_surveillance_purposes._Details_are_provided_in_Annexes_3.2_and_3.3.

The_ importance_ of_ linking_ HIV_ information_ to_DST_results_ is_becoming_increasingly_recognized_by_NTPs,_which_can_use_the_information_to_determine_the_extent_of_overlap_between_the_HIV_and_MDR-TB_epidemics_ for_ implementation_ of_ targeted_ preven-tion_and_control_measures._While_very_few_settings_were_able_to_report_HIV_ information_ linked_to_rep-resentative_drug_resistance_surveillance_data_before_2008,_a_growing_number_of_countries,_including_Bot-swana,_ Estonia,_ Latvia,_ the_ Republic_ of_ Moldova,_Mozambique,_ Namibia_ and_ Swaziland,_ have_ since_been_able_to_do_so.

Continuous_ surveillance_ of_ drug-resistant_ TB,_which_is_based_on_DST_of_all_TB_patients,_represents_the_ gold_ standard_ for_ surveillance_ as_ reiterated_ by_recent_ resolutions_ of_ the_ World_ Health_ Assembly._Several_countries,_including_most_of_the_MDR-HBCs,_are_not_yet_in_a_position_to_offer_DST_of_all_their_TB_cases_and_therefore_special_surveys_still_represent_an_important_ tool_ to_ measure_ the_ magnitude_ of_ drug_resistance._Routine_surveillance_linked_to_patient_care_should_ be_ initially_ implemented_ among_ previously_treated_TB_cases_and_gradually_expanded_to_cover_all_TB_cases,_ultimately_replacing_special_surveys.

However,_until_ access_ to_DST_ for_all_TB_patients_can_ be_ attained,_ special_ surveys_ remain_ the_ most_feasible_ approach_ to_ investigate_ the_ magnitude_ of_drug_resistance.

1.4 Ensuring access to quality-assured anti-TB medicines

Second-line_ anti-TB_ drugs_ (SLDs),_ the_ most_ active_medicines_ against_ drug-resistant_ forms_ of_ TB,_are_ expensive,_ toxic,_ and_ need_ to_ be_ taken_ for_ a_long_ time_ (at_ least_ 18–21_ months)._ Containing_ the_spread_of_drug-resistant_TB_will_be_easier_with_drug_regimens_ that_ are_ shorter,_ safer,_ more_ effective,_appropriate_ for_ joint_ treatment_ with_ antiretroviral_therapies_(ART),_child-friendly_and_amenable_to_rou-tine_ programmatic_ conditions._ Much_ progress_ has_been_made_over_recent_years_with_the_development_of_new_drugs_that_are_active_against_MDR-TB.9_Five_products_ are_ being_ assessed_ in_ clinical_ trials:_ three_in_ Phase_ IIb_ trials_ (TMC207,_ OPC67683,_ Linezolid)_and_two_in_Phase_1_trials_(PNU-100480,_SQ109)_and_preliminary_results_are_promising._In_the_meantime,_the_ response_ to_ drug-resistant_ TB_ still_ depends_ on_rational_use_of_the_currently_available_drugs.

The_ market_ of_ quality-assured_ SLDs_ has_ serious_limitations_ for_ guaranteeing_ uninterrupted_ drug_supply._ Drug_ management_ in_ MDR-TB_ is_ further_complicated_by_length_of_treatment,_relatively_short_shelf-life_and_storage_conditions_for_some_products,_and_the_number_of_drugs_needed_in_approved_regi-mens._The_Global_Drug_Facility_(GDF),_an_ initiative_

map 1

Global distribution of countries reporting at least one XDR-TB case by March 2011

0–14

15–49


Data not available

Annual enrolment


2009: 6 countries


2011: 3 countries

30 000

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Peru

Haiti

Senegal

Côte d’Ivoire

DR Congo

LesothoSwaziland

Djibouti

Belarus


IndiaMyanmar

EthiopiaUganda

KenyaUR Tanzania

Zambia

Cameroon

Vietnam

Indonesia

Kazakhstan

AzerbaijanGeorgia

Bangladesh


of_the_Stop_TB_Partnership_that_procures_TB_pharma-ceuticals/diagnostics_and_related_medical_devices,_is_making_strides_to_address_the_challenges_of_procur-ing_ second-line_ anti-TB_ drugs_ in_ a_ timely_ manner,_meeting_ best_ international_ standards._ Since_ 2007,_GDF_has_procured_medicines_for_74_countries_includ-ing_22/27_MDR-HBCs_(Map_2).

The_SLDs_procured_by_GDF_are_WHO_prequalified,_approved_ by_ stringent_ drug_ regulatory_ authori-ties_ or,_ in_ exceptional_ cases,_ extensively_ assessed_by_an_expert_review_panel_convened_by_WHO._Major_milestones_achieved_since_the_issue_of_the_WHA_reso-lution_on_MDR-TB_are_listed_in_Box_4.a

There_are,_however,_other_drug_management_and_procurement_ issues_ that_ need_ to_ be_ addressed_ in_order_to_guarantee_uninterrupted_delivery_of_quality_drugs_in_a_timely_manner._Greater_political_commit-ment_ and_ action_ by_ drug_ registration_ authorities_from_ some_ countries_ are_ urgently_ needed_ to_ facil-itate_ and_ fast_ track_ the_ importation_ of_ WHO_quality-assured_ drugs._ Official_ recognition_ of_ the_quality_assurance_standard_of_WHO-endorsed_drugs_would_take_away_the_need_for_extensive_quality_test-ing_procedures_at_country_level,_which_creates_delays_for_drug_delivery_and_disbursement._Strengthening_national_drug_management_and_monitoring_capacity_continue_to_be_priorities_as_evidenced_by_supply_dis-ruptions_in_some_countries_at_both_the_central_and_

a_ Roadmap_for_MDR-TB_management_scale_up:_The_Global_Drug_Facility_ (GDF)._ Increasing_ access_ to_ MDR-TB_ drugs_ through_innovation_ and_ action._ http://www.stoptb.org/assets/documents/resources/publications/plan_strategy/GDF%20ROADMAP%20FOR%20MDR%20TB%202010%20Final.pdf

peripheral_levels._In_addition,_country_programmes_that_do_not_meet_or_delay_reporting_on_programmatic_performance_metrics_will_delay_donor_funding,_lead-ing_to_delays_in_procurement_and_delivery_of_SLDs.

The_registration_and/or_importation_of_SLDs_are_complex_issues_ in_some_countries,_requiring_a_ long_time_for_completion._Important_progress_is_observed_in_ countries_ including_ the_ Russian_ Federation,_ for_example,_ where_ recent_ changes_ in_ legislation_ limit_the_registration_period_to_a_maximum_210_days_after_submission._ There_ were_ 19_ countries_ that_ reported_no_ SLD_ stock_ outs._ Information_ on_ SLD_ stock_ out_was_ unavailable_ for_ Armenia,_ Belarus_ and_ Paki-stan._Two_countries_reported_stock_outs_of_at_ least_1_day_at_either_central_or_peripheral_level;_two_coun-tries_at_central_level;_and_one_country_at_peripheral_level._ These_ examples_ clearly_ indicate_ the_ need_ for_strengthening_ planning_ and_ drug_ management_skills_ in_the_countries_concerned._ In_general,_a_ low_number_of_countries_reported_stock_outs_at__central_and_peripheral_levels._This_could_be_attributed_to_the_progress_ in_ the_ supply_ system,_ drug_ management_and_ improvements_ in_ forecasting._ Still_ more_ work_needs_to_be_done_to_ensure_sustainable_supply_and_address_growing_need.

1.5 Updating WHO policies and guidelines to manage M/XDR-TB

The_ complexity_ of_ the_ programmatic_ management_of_ MDR-TB_ and_ the_ limited_ body_ of_ evidence_ for_patient_management_have_pushed_WHO_to_regularly_

map 2

Global distribution of countries served by the Green Light Committee (GLC) or Global Drug Facility (GDF), 2007–2010

0–14

15–49


Data not available

Annual enrolment


2009: 6 countries


2011: 3 countries

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Peru

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Senegal

Côte d’Ivoire

DR Congo

LesothoSwaziland

Djibouti

Belarus


IndiaMyanmar

EthiopiaUganda

KenyaUR Tanzania

Zambia

Cameroon

Vietnam

Indonesia

Kazakhstan

AzerbaijanGeorgia

Bangladesh


update_ guidance_ to_ countries._ In_ 2011,_ new_ guide-lines_for_MDR-TB_management;_pharmacovigilance,_and_ethics_of_prevention,_treatment_and_care_will_be_released,_ adding_ to_ the_ policy_ on_ infection_ control_released_in_2009.

Guidelines for the programmatic management of M/XDR-TB

The_ 2011_ Update_ of_ the_ WHO guidelines for the programmatic management of drug-resistant tubercu-losis_ is_ intended_ as_ a_ tool_ for_ health_ professionals_to_ respond_ to_ the_ 62nd_ World_ Health_ Assembly_resolution_urging_Member_States_to_develop_a_com-prehensive_ framework_ for_ the_ management_ and_care_of_DR-TB.10_The_recommendations_in_the_guide-lines_ aim_ to_ address_ the_ most_ topical_ questions_ in_MDR-TB_ control_ that_ require_ guidance_ be_ given_ to_countries,_using_the_best_available_evidence_through_appropriate_ review_ of_ data,_ and_ provide_ reference_for_ countries_ developing_ their_ national_ guidelines_and_ policies_ to_ scale_ up_ detection_ and_ treatment_of_ MDR-TB._ The_ update_ focuses_ on_ the_ detection_and_ treatment_ of_ drug-resistant_ TB_ particularly_ in_

resource-limited_ settings,_ and_ is_ limited_ to_ topics_not_being_covered_by_other_WHO_policy_documents_concurrently.

Introducing pharmacovigilance to TB control practice

Clinicians_treating_TB_patients_are_usually_well_aware_of_ the_ associated_ adverse_ drug_ reactions_ (ADR)_ of_anti-TB_drugs._The_combination_of_drugs_a_patient_is_exposed_to,_and_the_length_of_treatment,_increase_the_likelihood_of_ADRs,_some_of_which_are_severe._Most_patients_ on_ treatment_ for_ drug-resistant_ TB_ expe-rience_ at_ least_ one_ side-effect,_ and_ a_ recent_ study_has_ shown_ that_ two_ thirds_ of_ such_ patients_ have_had_ at_ least_ one_ drug_ stopped_ temporarily_ or_ per-manently_ as_ a_ result_ of_ ADRs.11_These_ events_ affect_patient_adherence_and_damage_public_confidence_in_the_national_treatment_programme.

Pharmacovigilance,_ a_ more_ systematic_ surveil-lance_ of_ drug-related_ problems,_ is_ urgently_ needed_for_ several_ reasons._ Firstly,_ as_ national_ TB_ con-trol_ programmes_ are_ not_ usually_ measuring_ ADRs_directly,_ the_ contribution_ of_ ADRs_ to_ death,_ treat-ment_ default_ and_ failure_ can_ therefore_ only_ be_presumed._Secondly,_the_widespread_recognition_by_health_workers_that_anti-TB_drugs_often_cause_ADRs_is_poorly_reflected_in_the_published_information_on_the_subject._There_is_a_dearth_of_literature_about_anti-TB_ drug-induced_ mortality,_ morbidity_ and_ loss_ in_quality_of_life,_particularly_in_low-resource_settings._Thirdly,_ with_ the_ increasing_ use_ of_ more_ extensive_regimens_for_drug-resistant_TB,_with_the_added_use_of_ART_in_patients_with_HIV-associated_TB,_and_with_the_ imminent_ advent_ of_ new_ classes_ of_ drugs_ to_treat_ TB,_ the_ case_ for_ improved_ pharmacovigilance_becomes_even_stronger.

Events_ linked_ to_ medications_ need_ to_ be_ rec-ognized_ in_a_ timely_ fashion_ in_order_ to_ implement_measures_ to_ reduce_ harm_ and_ relieve_ symptoms._Health-care_workers_need_to_be_informed_and_trained_about_the_methodology_and_routes_for_reporting._A_Handbook on the pharmacovigilance of medicines used in the treatment of tuberculosis_due_to_be_launched_in_mid-2011_will_give_practical_advice_on_the_subject_to_TB_health-care_workers._This_handbook_aims_to_sat-isfy_this_particular_need_which_has_been_neglected_in_the_domain_of_TB_for_too_long.

Preventing, diagnosing and treating TB on solid ethical grounds

The_emergence_of_MDR-TB_has_increased_the_visibil-ity_of_ethical_dilemmas_that_were_usually_neglected_or_marginally_addressed_ in_the_past._ In_2010,_WHO_launched_ the_ Guidance on ethics of tuberculosis pre-vention, care and control.12_ The_ guidance_ supports_

BOX 4 Milestones of GDF in improving procurement of second-line anti-TB drugs

• Increased the number of finished second-line anti-TB pharmaceutical products/manufacturers available for procurement through GDF from 11 in 2008 to 25 in 2010;

• Tripled the number of suppliers of anti-MDR-TB products from 5 in 2008 to 15 in 2010;

• Negotiated stable prices for 12–24 months, for all products with no volume commitments; thus avoiding treatment cost fluctuations due to market volatility, currency fluctuations and manufacturing cost increases;

• Implemented a strategic rotating stockpile of 5 800 treatments funded by UNITAID, increasing access to drugs in emergency cases;

• Taken steps towards innovation, including a strategic revolving stockpile, a market allocation system and improved forecasting tools, all highly innovative approaches;

• Conducted trainings in MDR-TB drug management and procurement skills in Peru (March 2010), Rwanda (May), Georgia (July 2010), India (October 2010).


countries_and_their_national_TB_control_programmes,_TB_service-providers,_policy-makers_and_civil_society_to_implement_TB_prevention,_care_and_control_efforts_in_ an_ ethical_ manner._ The_ document_ is_ the_ first_ of_its_ kind_ to_ address_ a_ broad_ range_ of_ ethical_ issues_arising_ in_ TB_ programmes,_ ranging_ from_ informed_consent_and_isolation_to_health-care_workers’_rights_and_ obligations,_ and_ clinical_ and_ epidemiological_studies._Teaching_and_training_modules,_along_with_cases_studies_for_interactive_group_discussions,_will_be_produced_in_2011_to_facilitate_the_adoption_of_the_guidance.

1.6 Treating and caring for people affected by MDR-TB

Notification of MDR-TB cases and enrolment on treatment

In_ 2009,_ among_ the_ 4.7_ million_ new,_ relapsed_ and_retreated_TB_patients_notified_by_the_27_MDR-HBCs,_close_ to_ 250_000_ cases_ were_ estimated_ to_ have_MDR-TB._These_cases_would_be_detectable_if_DST_was_more_ widely_ available,_ especially_ in_ the_ previously_treated_and_other_TB_patients_at_risk_of_drug-resist-ant_ TB._ However,_ only_ 16%_ of_ these_ cases_ were_notified_ to_ WHO_ by_ countries;_ notification_ ranged_from_90–100%_in_seven_countries_but_was_less_than_5%_in_six_others_(Figure_6).

Twenty-five_ countries_ reported_ information_on_enrolments_on_MDR-TB_treatment_among_their_notified_ cases:_ the_ proportion_ of_ notified_ cases_that_ were_ enrolled_ on_ treatment_ ranged_ from_ 1%_to_100%_in_these_countries_(median_10%)._The_pro-portion_ of_ notified_ cases_ that_ were_ enrolled_ on_treatment_ranged_ from_1%_to_100%_(median_8%)._Of_the_expected_MDR-TB_among_notified_TB_cases,_enrolments_ represented_ 10%_ (24_511/250_000)_in_ the_ 27_ MDR-HBCs_ and_ 11%_ (30_475/280_000)_globally._ The_ low_ level_ of_ notification_ is_ due_ to_under-detection_ as_ a_ result_ of_ limited_ laboratory_capacity_ in_many_resource-challenged_settings,_as_well_as_problems_with_reporting_of_data._Drug-sus-ceptibility_testing_is_often_of_unknown_quality_and_as_a_result_MDR-TB_may_be_incorrectly_diagnosed._Enrolment_ is_ also_ subject_ to_ under-reporting._Treatment_ facilities_ are_ often_ deficient_ in_ low-resource_ settings,_ with_ limitations_ in_ availability_of_drugs._There_is_also_a_lack_of_information_about_the_quality_of_care:_only_one_third_of_the_patients_enrolled_in_2009_in_the_MDR-HBCs_were_in_projects_monitored_by_the_GLC.

Treatment outcomes in high MDR-TB burden countriesa

This_ section_ presents_ the_ treatment_ outcome_ data_for_MDR-TB_patients_as_reported_to_WHO_by_the_MDR-HBCs._Globally,_13_countries_provided_final_outcome_data_ on_ treatments_ for_ MDR-TB_ cases_ who_ started_treatment_in_2007_(Table_2)._Nine_countries_reported_outcomes_ from_ sites_ where_ TB_ management_ and_drug_ quality_ are_ monitored_ by_ the_ GLC,_ while_ in_four_–_Bangladesh,_Bulgaria,_Kazakhstan_and_South_Africa_–_no_GLC_project_was_in_place_in_2007.

Outcomes_ were_ reported_ for_ cohorts_ composed_of_a_total_of_7063_MDR-TB_cases._Information_on_out-come_ was_ missing_ for_ 0–23%_ of_ the_ cases_ included_(median: 3%)._ The_ size_ of_ the_ cohorts_ varied_ from_57_cases_in_Armenia_to_3815_in_South_Africa_(median_size: 132)._The_number_of_cases_assessed_represented_45%_ of_ all_ MDR-TB_ cases_ that_ were_ identified_ and_notified_ (country_ range: 23%_ to_ >100%),_ but_ less_than_ a_ fifth_ of_ all_ the_ MDR-TB_ cases_ expected_ to_have_occurred_among_the_TB_cases_notified_by_these_countries_ in_ the_ same_ year._ In_ Bangladesh,_ Demo-cratic_ Republic_ of_ the_ Congo,_ Kazakhstan,_ Latvia_

a_ Treatment_outcomes_for_MDR_patients_treated_in_2007

FIGURE 6

MDR-TB cases notified and enrolled on treatment, 2009*

* As a proportion of the estimated number of MDR-TB cases among notified TB patients; this MDR-TB estimate (in thousands) is indicated in brackets next to the country names.

Other 20%

52%

18%

15%

15%

New 30%

Relapse 12%

xAfter default

3%

US$

mill

ions

(con

stan

t 201

0 U

S$)

US$

bill

ions

(con

stan

t 201

0 U

S$)

2008 2009 2010 2011

2012 2013 2014 2015

700

600

500

400

300

200

100

0

1.2

1.0

0.8

0.6

0.4

0.2

0.0

Gap

Unknown

Loans

Global Fund




Indonesia

India

Kyrgyzstan

China

Kazakhstan

Tajikistan

Russian Federation

US$

mill

ions

(con

stan

t 201

0 U

S$)

8

7

6

5

4

3

2

1

0

Infection Control




ACSM for MDR


2011 2012 2013 2014 2015

Num

ber o

f pat

ient

s

Annual enrolment


2008 2009 2010 2011

0% 20% 40% 60% 80% 100%


27

24

21

18

15

12

9

6

3

0

















35 000

30 000

25 000

20 000

15 000

10 000

5000

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009



40%

15%

15%

30%

Yes

No

In preparation

Unknown

Yes

No

In preparation

Unknown



and_the_Philippines,_treatment_success_was_reported_to_ be_ higher_ than_ 60%._ Countries_ reported_ deaths_in_ 4%–45%_ (median:_ 11%)_ and_ default_ in_ 3%–36%_of_ cases_ (median:_ 21%)._ In_ countries_ with_ success_below_60%,_defaults_were_high_(median:_25%)_and_in_one,_a_non-GLC_site,_low_success_was_associated_with_the_highest_levels_of_death_and_failure_among_the_13_countries._(Table_2).

The_ data_ on_ treatment_ outcomes_ of_ MDR-TB_patients_remain_incomplete,_with_very_few_countries_

having_ outcomes_ reported_ for_ all_ the_ MDR_ cases_detected._ This_ probably_ reflects_ different_ degrees_of_challenges_in_diagnostics,_capacity_for_treatment_or_ in_ the_ reporting_ and_ organization_ of_ data._ The_low_levels_of_success_and_the_high_degrees_of_failure_and_default_may_be_a_result_of_inadequate_regimens_when_ addressing_ MDR-TB_ patients_ with_ additional_drug_ resistance._High_deaths_are_ to_be_expected_ in_settings_with_a_high_frequency_of_HIV/MDR-TB_and_where_access_to_ART_is_problematic.

TablE 2

Treatment outcomes for MDR-TB patient cohorts in the 27 high MDR-TB burden countries, 2007

Country

MDR-TB cases notified in

2007 Cohort Cured Completed

% Successfully

treated Died Failed DefaultedNo

information

Armenia 125 57 25 5 53% 6 5 14 2

Azerbaijan 196 – – – – – – – –

Bangladesh* 0 106 86 1 82% 10 0 9 0

Belarus 870 – – – – – – – –

Bulgaria* 82 76 15 4 25% 34 13 6 4

China 79 – – – – – – – –

DR Congo 15 147 9 80 61% 20 6 21 11

Estonia 80 81 44 2 54% 11 6 18 0

Ethiopia 145 – – – – – – – –

Georgia 269 61 5 18 38% 12 2 15 9

India 146 – – – – – – – –

Indonesia 0 – – – – – – – –

Kazakhstan* 5568 1609 1088 149 77% 72 64 57 179

Kyrgyzstan 322 132 60 6 50% 7 11 47 1

Latvia 98 99 58 5 64% 15 5 15 1

Lithuania 314 – – – – – – – –

Myanmar 600 – – – – – – – –

Nigeria 45 – – – – – – – –

Pakistan 0 – – – – – – – –

Philippines 568 296 155 32 63% 32 11 62 4

Republic of Moldova 896 254 124 9 52% 21 21 75 4

Russian Federation 5297 – – – – – – – –

South Africa* 7350 3815 845 756 42% 778 182 365 889

Tajikistan 0 – – – – – – – –

Ukraine 0 – – – – – – – –

Uzbekistan 484 330 106 74 55% 32 33 76 9

Viet Nam 0 – – – – – – – –

* Treatment outcome data not from GLC project.


Supporting countries to scale up management of MDR-TB through the Green Light Committee Initiative

The_ Green_ Light_ Committee_ (GLC)_ Initiative_ helps_countries_gain_access_to_quality-assured_second-line_anti-TB_drugs_for_the_treatment_of_MDR-TB,_in_line_with_the_WHO_guidelines._The_initiative_consists_of_a_secretariat,_the_GLC_(an_expert_review_WHO_advi-sory_ body)_ and_ the_ Global_ Drug_ Facility_ (the_ drug_procurement_arm).

From_ its_ inception_ until_ 2010,_ the_ GLC_ has_approved_ 234_ applications_ from_ 133_ projects_ in_ 83_countries._ It_has_approved_applications_ from_these_sites_ for_ over_ 100_000_ MDR-TB_ patients_ (Table_ 3)._The_ overall_ approval_ rate_ of_ applications_ received_was_94%_(234/248)._For_patients_approved_for_treat-ment,_ 75%_ correspond_ to_ programmes_ expanding_treatment_cohorts._Forty-three_projects_in_24_coun-tries_enrolled_more_patients_ in_2009_than_ in_2008._Provisional_ data_ about_ new_ enrolments_ from_ 28_of_ the_ 65_ countries_ implementing_ GLC_ projects_ by_2010_amounted_to_well_over_10_000,_so_enrolments_are_expected_to_exceed_levels_achieved_in_2009._This_reflects_the_progress_made_implementing_program-matic_ management_ of_ drug-resistant_ tuberculosis_(PMDT)_ as_ a_ result_ of_ country-wide_ MDR-TB_ treat-ment_scale-up_plans.

Since_2000,_303_technical_assistance_missions_have_been_ carried_ out_ through_ the_ GLC_ Initiative;_ more_than_50%_were_carried_out_between_2008_and_2010.

Enrolment and treatment outcomes in programmes supported by the GLC

A_total_of_29_418_MDR-TB_cases_were_reported_to_be_enrolled_on_treatment_in_92_GLC-approved_projects_

(54_countries)_from_2000_to_2009._Figure_7_shows_the_annual_and_cumulative_number_of_patients_enrolled_during_ this_ period._ Over_ 50%_ of_ the_ total_ number_of_patients_on_treatment_was_enrolled_in_2008_and_2009._ Thirty_ percent_ of_ cases_ enrolled_ had_ no_ pre-vious_ anti-TB_ treatment_ history,_ while_ 50%_ were_reported_as_having_previously_received_anti-TB_treat-ment._In_the_remainder,_prior_history_was_unknown_or_could_not_be_classified_in_one_of_the_other_catego-ries_shown_in_Figure_8.

TablE 3

Number of applications and patients approved by the Green Light Committee, 2000–2010

Year No. of GLC applications approved

No. of patients approved

2000 2 1 000

2001 3 1 180

2002 1 800

2003 9 2 099

2004 17 4 630

2005 12 2 191

2006 25 12 954

2007 24 5 212

2008 39 19 652

2009 44 13 389

2010 58 42 033

TOTAL 234 105 140

FIGURE 7

Annual and cumulative number of MDR-TB patients enrolled on treatment in GLC-approved projects, 2000–2009

0–14

15–49


Data not available

Annual enrolment


2009: 6 countries


2011: 3 countries

30 000

25 000

20 000

15 000

10 000

5000

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Num

ber o

f pat

ient

s



Peru

Haiti

Senegal

Côte d’Ivoire

DR Congo

LesothoSwaziland

Djibouti

Belarus


IndiaMyanmar

EthiopiaUganda

KenyaUR Tanzania

Zambia

Cameroon

Vietnam

Indonesia

Kazakhstan

AzerbaijanGeorgia

Bangladesh


Outcome_ data_ were_ available_ for_ 12_535_ MDR-TB_cases_enrolled_in_programmes_using_the_GLC_over_the_period_2000_to_2007._The_number_of_projects_report-ing_outcomes_increased_progressively_to_44_in_2007,_while_the_number_of_cohorts_with_information_avail-able_and_the_overall_number_of_cases_on_treatment_also_ increased_ (Table_ 4)._ The_ proportion_ of_ cases_successfully_ completing_ treatment_ has_ remained_stable_over_time_although_a_dip_in_overall_success_in_

2006–2007_ has_ been_ observed._ This_ was_ accompa-nied_by_an_increase_in_the_number_of_cases_reported_without_treatment_outcomes_ in_2006–2007,_ largely_as_ a_ result_ of_ delayed_ recovery_ of_ outcome_ results_in_a_number_of_countries._The_overall_proportion_of_deaths_and_failures_also_decreased_slightly_over_time._These_observations_are_not_ indicative_of_the_global_achievements_of_the_programmes_using_the_GLC_as_they_ mask_ wide_ variations_ in_ the_ performance_ of_individual_ projects._ For_ instance,_ success_ ranged_between_ 41%_ and_ 77%,_ and_ death_ from_ 5%_ to_ 24%_in_the_15_projects_reporting_>25_cases_and_with_out-come_ information_ on_ >90%_ of_ patients_ started_ on_treatment_in_2006.

Alignment with WHO policy/guidelines/training material

Among_ the_ 27_ MDR-HBCs,_ 23_ have_ developed_guidelines_ for_ the_ programmatic_ management_ of_drug-resistant_ TB_ (PMDT)._ Some_ 21_ countries_ have_developed_ training_ materials_ for_ MDR-TB_ and_ 22_countries_ have_ organized_ training_ specifically_ for_MDR-TB.

Models of care for PMDT

Among_ the_ 27_ MDR-HBCs,_ 24_ require_ hospitaliza-tion_ of_ MDR-TB_ cases_ during_ the_ intensive_ phase_of_ treatment._ MDR-TB_ drugs_ are_ free_ of_ charge_ in_all_ countries,_ but_ achieving_ a_ diagnosis_ can_ cost_ a_great_deal._All_MDR-HBCs_provide_social_support_to_promote_ adherence_ to_ treatment._ Social_ support_may_ include_ food_ packages,_ transportation_ vouch-ers,_ counselling_ and_ psychosocial_ support,_ among_others.

FIGURE 8

Distribution by history of previous treatment of MDR-TB cases enrolled on treatment in projects approved by the Green Light Committee, 2000–2009 (N=29 418)

Other 20%

52%

18%

15%

15%

New 30%

Relapse 12%

xAfter default

3%

US$

mill

ions

(con

stan

t 201

0 U

S$)

US$

bill

ions

(con

stan

t 201

0 U

S$)

2008 2009 2010 2011

2012 2013 2014 2015

700

600

500

400

300

200

100

0

1.2

1.0

0.8

0.6

0.4

0.2

0.0

Gap

Unknown

Loans

Global Fund




Indonesia

India

Kyrgyzstan

China

Kazakhstan

Tajikistan

Russian Federation

US$

mill

ions

(con

stan

t 201

0 U

S$)

8

7

6

5

4

3

2

1

0

Infection Control




ACSM for MDR


2011 2012 2013 2014 2015

Num

ber o

f pat

ient

sAnnual enrolment


2008 2009 2010 2011

0% 20% 40% 60% 80% 100%


27

24

21

18

15

12

9

6

3

0

















35 000

30 000

25 000

20 000

15 000

10 000

5000

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009



40%

15%

15%

30%

Yes

No

In preparation

Unknown

Yes

No

In preparation

Unknown


TablE 4

Treatment outcomes for TB patient cohorts receiving second-line treatment in projects approved by the Green Light Committee, by year, 2000–2007

Year Number of Projects

Cohort size (N)

Treatment success*(%)

Died (%) Failed (%) Defaulted (%) No information**

(%)

2000 4 342 71% 11% 10% 8%

2001 6 1015 64% 14% 9% 13%

2002 7 945 63% 13% 8% 15% 1%

2003 9 965 63% 12% 8% 16% 1%

2004 12 1216 62% 10% 7% 19% 2%

2005 23 2379 65% 9% 8% 15% 3%

2006 32 2174 58% 9% 8% 15% 10%

2007 44 3499 40% 9% 5% 15% 31%

* Refers to patients who were cured or completed treatment.

** Includes patients who Transferred Out, were Still on Treatment and Unknown.


1.7. Status of progress at country level

Table_5_summarizes_the_key_epidemiology,_strategy_and_ financial_ indicators_ contained_ in_ the_ country_profiles_ for_ the_ 27_ MDR-HBCs_ (Annex_ 2)._ The_ pro-files_ are_ aimed_ at_ informing_ policy-makers_ and_their_ partners_ about_ the_ situation_ in_ each_ country_and_to_assess_progress_and_prioritize_actions_in_the_effort_to_control_MDR_and_reduce_the_mortality_asso-ciated_ with_ it._ They_ are_ based_ on_ the_ most_ recent_data_available_that_countries_have_reported_to_WHO,_either_through_the_WHO_annual_data_collection_or_in_response_to_a_questionnaire_designed_specifically_for_the_purpose_of_the_current_publication._Data_on_case_notification_and_enrolment_may_not_always_be_linked_at_a_national_level_and_while_all_data_published_in_the_country_ profiles_ have_ been_ validated_ by_ countries,_some_ inconsistencies_ may_ remain._ Indicators_ cov-ered_ in_ the_ MDR_ country_ profiles_ include:_ MDR-TB_burden,_diagnostic_capacity,_drug_management,_sta-tus_of_MDR_expansion_plans,_human_resources_and_financial_ flows_ and_ major_ bottlenecks_ hindering_progress_to_achieve_universal_access_to_MDR-TB_care.

While_nearly_all_countries_report_having_a_nation-ally-endorsed_ PMDT_ expansion_ plan,_ the_ actual_number_of_MDR-TB_patients_diagnosed_and_enrolled_on_ treatment_ remains_ very_ low._ In_ 2009,_ only_ 16%_of_expected_cases_of_MDR-TB_among_TB_cases_noti-fied_by_the_27_countries_were_reported_to_WHO,_and_less_ than_ 10%_ in_ 10_ of_ the_ countries._ Treatment_success_ of_ MDR-TB_ patients_ started_ on_ treatment_in_ 2007_ was_ only_ reported_ by_ 13_ counties._ No_ out-come_data_were_yet_available_for_the_countries_with_the_ highest_ caseload_ of_ MDR-TB_ (China,_ India_ and_the_ Russian_ Federation)._ Success_ tended_ to_ be_ low_as_a_result_of_high_mortality_in_Bulgaria_and_South_

Africa,_ as_ well_ as_ high_ defaults_ and_ missing_ infor-mation_in_the_remainder_of_MDR-HBCs._Nationwide_data_from_anti-TB_drug_resistance_surveillance_were_available_in_17_countries. _Not_all_these_data_are_fully_representative_and_in_three_countries_(Belarus,_Bul-garia_and_Ukraine)_the_country-wide_drug_resistance_levels_used_in_this_report_are_still_based_on_modelled_estimates. _In_the_Russian_Federation,_estimates_are_averaged_over_a_number_of_quality-assured_centres_throughout_ the_ country. _ In_ three_ countries,_ data_refer_ to_ surveys_ dating_ from_ before_ 2005_ (Kaza-khstan,_ the_ Philippines_ and_ South_ Africa)._ While_drug_resistance_survey_data_have_improved_in_recent_years,_and_a_number_of_countries_such_as_Bulgaria,_Nigeria_ and_ Uzbekistan_ are_ currently_ completing_surveys,_more_efforts_are_needed_to_improve_cover-age_and_commence_surveys_in_other_countries._Only_14_former_Soviet_Union_countries_and_South_Africa_had_more_than_one_ laboratory_performing_DST_per_10_million_population;_the_remainder_had_less_than_one._Quality_of_DST_varies_markedly_between_labora-tories_and_even_a_ratio_above_one_does_not_necessarily_imply_adequate_diagnostic_capacity._National_ infec-tion_control_plans_were_present_in_only_11_countries,_although_information_on_the_degree_of_implementa-tion_was_not_available.

Table_6_presents_a_summary_of_the_major_bottle-necks_to_diagnose,_treat_and_care_MDR-TB_patients,_as_ identified_by_ the_countries._The_bottlenecks_can_be_grouped_into_six_major_categories,_which_include:_case_finding;_ laboratory_capacity;_weak_programme_management;_ human_ resource_ capacity;_ financing;_and_ access_ to_ quality-assured_ second-line_ drugs._Most_ of_ the_ countries_ identified_ weak_ programme_management_and_ limited_human_resource_capacity_as_common_bottlenecks.


Tab

lE 5

Stat

us o

f cap

acit

y fo

r pro

gram

mat

ic m

anag

emen

t of M

/XD

R-TB

in 2

7 hi

gh M

DR-

TB b

urde

n co

untr

ies

Coun

try

Estim

ated

case

s of

MDR

-TB

amon

g no

tified

case

s of

pulm

onar

y TB,

200

9 (in

thou

sand

s)

Notifi

ed ca

ses

of M

DR-T

B,

2009

Case

s of

MDR

-TB

enro

lled

on

trea

tmen

t in

2009

Trea

tmen

t suc

cess

fo

r MDR

-TB

patie

nts s

tart

ed o

n tr

eatm

ent i

n 20

07

Natio

nwid

e su

rvey

/ su

rvei

llanc

e da

ta o

n M

DR

TB av

aila

ble

Num

ber o

f DST

la

bora

torie

s pe

r 10

mill

ion

popu

latio

n,

2009

*

Natio

nal

Refe

renc

e La

bora

tory

20

09

Stoc

k out

of

seco

nd-li

ne

drug

s**

Natio

nal

Guid

elin

es fo

r PM

DT

PMDT

ex

pans

ion

plan

offi

cially

ap

prov

ed b

y 20

10

Natio

nal

infe

ctio

n co

ntro

l pla

n

Arm

enia

0.18

156

134

53%

Yes

3.2

Yes

No

Yes

Yes

Yes

Aze

rbai

jan

2.40

––

–N

o2.

3Ye

sYe

sYe

sN

o

Bang

lade

sh3.

60–

352

82%

No

<0.

1Ye

sN

oYe

sYe

sYe

s

Bela

rus

0.90

1 34

2–

–Ye

s22

.8Ye

s–

Yes

Yes

Bulg

aria

0.42

4343

25%

Yes

29.2

Yes

No

Yes

Yes

No

Chin

a66

474

458

–Ye

s1.

0Ye

sN

oYe

sN

oYe

s

DR 

Cong

o2.

2091

176

61%

No

0.2

Yes

No

Yes

–N

o

Esto

nia

0.08

8686

57%

Yes

14.9

Yes

No

Yes

Yes

No

Ethi

opia

2.00

233

88–

Yes

0.2

Yes

No

Yes

Yes

Yes

Geo

rgia

0.37

369

266

38%

Yes

2.3

Yes

No

Yes

Yes

No

Indi

a73

1 66

01 

136

–N

o0.

1Ye

sYe

sYe

sYe

sN

o

Indo

nesi

a6.

40–

20–

No

0.2

No

No

Yes

Yes

Yes

Kaza

khst

an7.

303 

644

3 20

977

%Ye

s14

.1Ye

sN

oYe

sN

o

Kyrg

yzst

an0.

8078

554

550

%N

o5.

5Ye

sN

oYe

sYe

sN

o

Latv

ia0.

1413

112

464

%Ye

s4.

4Ye

sN

oYe

sYe

sYe

s

Lith

uani

a0.

3332

232

2–

Yes

12.2

Yes

No

Yes

Yes

No

Mya

nmar

4.80

815

64–

Yes

0.4

Yes

No

Yes

Yes

No

Nig

eria

2.10

28–

–N

o0.

2Ye

sN

oYe

sYe

s–

Paki

stan

9.30

4936

8–

No

0.6

Yes

–Ye

sYe

sN

o

Phili

ppin

es7.

601 

073

491

63%

Yes

0.3

Yes

No

Yes

Yes

Yes

Repu

blic

 of M

oldo

va1.

501 

069

334

52%

Yes

11.1

Yes

No

Yes

Yes

Yes

Russ

ian 

Fede

ratio

n31

14 6

868 

143

–Ye

s19

.3N

oN

oN

oYe

s–

Sout

h Af

rica

9.60

9 07

04 

143

42%

Yes

3.2

Yes

Yes

Yes

Yes

Yes

Tajik

ista

n1.

0031

952

–N

o1.

4Ye

sN

oYe

sYe

sN

o

Ukr

aine

7.20

3 48

23 

186

–Ye

s10

.1Ye

sYe

sYe

sYe

sN

o

Uzb

ekis

tan

2.90

654

464

55%

No

0.7

Yes

No

Yes

Yes

–

Viet

 Nam

3.50

217

307

–Ye

s0.

2Ye

sN

oYe

sYe

sYe

s

250

40 7

9824

 511

* DS

T lab

orator

y sho

uld be

1 pe

r 10 m

illion

popu

lation

, as p

er W

HO gu

idelin

es.

** S

tock o

ut is d

efine

d as s

horta

ge of

anti-

TB dr

ugs in

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TablE 6

Bottlenecks to scaling up management of MDR-TB in 27 high MDR-TB burden countries

Armenia Access to quality-assured second-line drugs: weak drug management.

Azerbaijan Laboratory capacity and quality assurance: limited laboratory capacity.

Qualified M/XMDR-TB treatment (human resources, facilities): limited human resource capacity to manage MDR-TB.

Financing: lack of funds for first-line drugs and weak commitment of NTP.

Bangladesh Programme management: a significant number of diagnosed patients are not receiving treatment. 

Laboratory capacity and quality assurance: limited laboratory capacity.

Qualified M/XMDR-TB treatment (human resources, facilities): limited human resource capacity to manage MDR-TB.

Financing: funds to be identified for full scale-up. Delays in disbursing funds are causing delays in starting treatment.

Belarus Qualified M/XMDR-TB treatment (human resources, facilities): limited human resource capacity for MDR-TB.

Access to quality-assured second-line drugs: decentralized drug procurement system is not efficient.

Bulgaria Qualified MDR/XDR-TB treatment (human resources, facilities): need to increase the number of staff involved in MDR-TB management at central level and MDR-TB treatment sectors.

China Issues in case-finding or enrolment for treatment: delays in diagnosis and treatment initiation in selected sites.

Laboratory capacity and quality assurance: new tools need to be incorporated in the national plan and match treatment capacity.

Qualified M/XMDR-TB treatment (human resources, facilities): human resource capacity for MDR-TB is limited in quantity and quality; facilities for infection control are insufficient.

Access to quality-assured second-line drugs: no quality assurance for second-line drugs outside the Global Fund project area.

DR Congo Programme management: delay in signing memorandum of understanding between Expand-TB and Ministry of Health; insufficient implementation of MDR-TB.

Laboratory capacity and quality assurance: weak laboratory capacity.

Qualified M/XMDR-TB treatment (human resources, facilities): limited human resource capacity.

Access to quality-assured second-line drugs: weak drug management.

Estonia Qualified MDR/XDR-TB treatment (human resources, facilities): limited access to some third-line drugs (linezolid, clofazimine) for treatment of patients with XDR-TB. 

Ethiopia Issues in case-finding or enrolment for treatment: huge backlog of diagnosed cases.

Qualified M/XMDR-TB treatment (human resources, facilities): limited human resource capacity and high staff turnover.

Georgia Issues in case-finding or enrolment for treatment: involvement of private health-care providers needs strengthening.

Financing: need to increase NTP staff salaries and incentives for patients.

India Laboratory capacity and quality assurance: although expanding, limited laboratory capacity for diagnosis and follow-up of MDR-TB patients. Limited availability of second-line drugs and DST. Need for implementation of high-throughput diagnostics. Specimen transportation infrastructure is needed in the general health system.

Qualified MDR/XDR-TB treatment (human resources, facilities): limited human resource capacity to undertake required pre-implementation training and assessments.

Financing: funding envelope is limited and unable to accommodate scale-up as envisaged with rising costs of second-line drugs. 

Continues…


Indonesia Programme management: at early stages of initiating programmatic management of drug-resistant TB; poor commitment of decision-makers and related sectors for uninterrupted funding and to ensure the continuation of such activities; delay in initiating the programme.

Laboratory capacity and quality assurance: limited laboratory capacity for culture and DST. Only five NRLs are certified to carry out DST of first- and second-line drugs. Expansion of the TB laboratory network requires more capability for MDR-TB culture and identification, and should accord with expansion of the programmatic management of drug-resistant TB.

Kazakhstan Programme management: weak implementation capacity at the regional level.

Kyrgyzstan Qualified MDR/XDR-TB treatment (human resources, facilities): limited human resource capacity.

Other: unstable political situation.

Latvia

Lithuania Programme management: lack of appointed manager and supervisors for national TB control.

Laboratory capacity and quality assurance: insufficient quality control for DST carried out by NRLs or SRLs.

Access to quality-assured second-line drugs: supply interruptions caused by the existing decentralized drug procurement system.

Myanmar Issues in case-finding or enrolment for treatment: for the pilot phase, only Category 2 failures are included. The pilot phase will end in summer 2011; thereafter the patient categories for DST will be expanded to include Category 1 failures.

Laboratory capacity and quality assurance: limited to Yangon and Mandalay; quality is good according to SRL in Bangkok and FIND.

Qualified M/XMDR-TB treatment (human resources, facilities): for pilot phase, human resources situation is under control but for expansion, training and additional staff are needed.

Financing: dependent on external resources.

Nigeria Programme management: delayed Global Fund grant negotiation as a result of lack of MDR-TB response plan.

Laboratory capacity and quality assurance: limited laboratory capacity.

Qualified M/XMDR-TB treatment (human resources, facilities): limited hospitalization capacity; limited human resource capacity.

Access to quality-assured second-line drugs: additional drugs to be procured under Global Fund Round 9.

Pakistan Issues in case-finding or enrolment for treatment: delay in negotiating Global Fund grant. 

Programme management: limited experience.

Qualified MDR/XDR-TB treatment (human resources, facilities): limited number of prepared facilities and human resources.

Other: under-budgeting (using Global Fund Round 6) resulted in a request for half of the intended number of treatment target. MDR-TB care in prisons to be addressed after strengthening DOTS services.

Philippines Issues in case-finding or enrolment for treatment: patient enrolment remained below target enrolment; delay in the start of treatment caused by long waiting times for the results of culture and DST.

Programme management: limited monitoring of patients from case-finding to initiation of treatment; limited implementation of standardized treatment regimen; long installation process of culture and treatment centres.

Laboratory capacity and quality assurance: rapid diagnosis is not used.

Qualified MDR/XDR-TB treatment (human resources, facilities): not yet accessible nationwide.

Other: the transition from the TDF to PBSP was a major challenge.

Republic of Moldova

Issues in case-finding or enrolment for treatment: late diagnosis of MDR-TB.

Programme management: training for staff needed.

Laboratory capacity and quality assurance: insufficient rapid tests for drug resistance to detect MDR-TB and XDR-TB.

Qualified MDR-/XDR-TB treatment (human resources, facilities): insufficient human resources.

Financing: limited financial resources for MDR-TB.

Continues…


Russian Federation Programme management: insufficient integration of TB control with the health-care system.

Qualified M/XMDR-TB treatment (human resources, facilities): limited human resource capacity for MDR-TB.

Access to quality-assured second-line drugs: continuing supply of second-line drugs for GLC-approved projects and in other regions; potential risk of discontinued support from the Global Fund. 

South Africa Issues in case-finding or enrolment for treatment: gap between patient diagnosis and enrolment for treatment.

Programme management: centralized model; poor patient tracking mechanism.

Tajikistan Issues in case-finding or enrolment for treatment: weak integration with primary health-care providers.

Programme management: weak health systems and integration with the health system; no electronic-based data management system.

Qualified MDR/XDR-TB treatment (human resources, facilities): limited human resource capacity for MDR-TB management; weak infection control measures; low adherence to treatment of MDR-TB patients; work overloading and low motivation of primary health-care personnel.

Financing: weak domestic financing.

Ukraine Programme management: frequent changes of management in the Ministry of Health. 

Laboratory capacity and quality assurance: low laboratory capacity; quality assurance is partially implemented.

Qualified M/XMDR-TB treatment (human resources, facilities): patient-oriented approach is not implemented.  Financing: lack of financing.

Uzbekistan Programme management: weak health systems and integration with the health system.

Qualified MDR/XDR-TB treatment (human resources, facilities): limited human resource capacity for MDR-TB.

Viet Nam Qualified M/XMDR-TB treatment (human resources, facilities): limited human resources capacity for MDR-TB.

Access to quality-assured second-line drugs: delays in drug delivery; weak drug management capacity.


BOX 5 South Africa – Scaling up access to M/XDR-TB care

South Africa, a high MDR-TB burden country, is making strides towards universal access to diagnosis and treatment of M/XDR-TB care. Since 2007, the country accelerated efforts to diagnose everyone with MDR-TB, including the use of new tools like line probe assays (LPA) (see Table 1).

Table 1. Distribution of annual volume of TB diagnostics tests in South Africa

Year Culture Microscopy DST LPA DST MGIT

2004 273 829 1 815 333 34 542

2005 349 246 2 300 241 36 871

2006 481 757 2 720 813 48 049

2007 581 671 2 927 017 5963 64 943

2008 729 424 3 373 134 23 126 58 887

2009 759 643 3 276 347 61 423 39 334

2010 (Q1 & 2)

422 106 2 224 766 45 133 15 704

The original strategy of hospitalization till culture conversion and poor tracing mechanisms are the major reasons for thousands of diagnosed MDR-TB patients without access to treatment, while transmission is maintained in the community. In 2009 a process was begun to decentralize management of MDR-TB by engaging communities and primary health-care services, while reducing hospitalization until smear conversion. This policy is freeing up ~2 000 hospital beds and increasing access to treatment (see Table 2). In parallel, the WHO policy for infection control is being adopted countrywide, and collaboration with the HIV programme has improved dramatically. Scaling-up of isoniazid preventive therapy (IPT) to prevent TB, for example, has resulted in more than 50 000 people living with HIV started on IPT between January and June 2010 as part of the HIV testing campaign. The response to MDR-TB in South Africa is totally funded with domestic sources.

Table 2. Number of M/XDR-TB patients diagnosed and enrolled on treatment, by year, 2007–2009

Year MDR-TB XDR-TB

Diagnosed Enrolled on treatment

Diagnosed Enrolled on treatment

2007 7 429 3 334 458 474

2008 8 198 4 031 488 391

2009 9 070 4 143 594 431


2.1 Strengthening basic TB control

As_drug-resistant_TB_is_largely_a_man-made_condition,_its_prevention_relies_heavily_on_the_effectiveness_with_which_control_efforts_succeed_to_treat_TB_patients_in_both_the_public_and_the_private_sectors._Poor_treat-ment_adherence_is_an_important_cause_of_emergence_and_ spread_ of_ MDR-TB._ Having_ a_ strong_ and_ sus-tained_ control_ programme_ for_ drug-susceptible_ TB_in_place_provides_a_solid_foundation_on_which_to_add_a_component_for_MDR-TB_treatment._With_a_vision_of_a_“TB-free_world”,_the_WHO_Stop_TB_strategy_aims_to_address_all_the_major_constraints_and_challenges_to_ global_ TB_ control,_ including_ DOTS,_ the_ interna-tionally-recommended_approach_to_basic_TB_control._In_2009,_180_countries_were_implementing_DOTS.

Data_ on_ DOTS_ implementation,_ which_ are_ col-lected_ annually_ from_ countries,_ demonstrate_ the_continuing_ progress_ achieved_ in_ basic_ TB_ control._The_global_detection_of_TB_cases_has_increased_over_the_years_but_still_falls_short_of_the_70%_target._The_best_global_estimate_ in_2009_was_63%._The_low_lev-els_of_detection_in_the_African_and_South_East_Asia_Regions_were_largely_responsible_for_this_low_figure._Low_detection_may_be_a_combined_result_of_ failure_by_patients_to_seek_TB_care,_poor_diagnostic_capacity_and_ineffectual_reporting_of_diagnosed_cases.

Globally,_ 86%_ of_ new_ sputum_ smear-positive_cases_ of_ pulmonary_ TB_ who_ were_ treated_ in_ 2008_had_ a_ successful_ outcome,_ a_ little_ above_ the_ global_target_ of_ 85%._ Despite_ the_ attainment_ of_ this_ glo-bal_ target,_ closer_ scrutiny_ of_ regional_ and_ national_surveillance_ data_ indicate_ that_ future_ progress_ in_basic_TB_control_may_be_threatened._Treatment_suc-cess_in_new_TB_cases_has_increased_since_1995_in_all_regions_except_the_European_Region_in_recent_years,_where_deaths_and_failures_have_increased._Improve-ments_ in_ success,_ seen_ in_ most_ other_ regions_ in_recent_years,_appear_to_be_levelling_off._Among_pre-viously_ treated_ TB_ cases,_ overall_ success_ was_ 72%_in_2008,_with_higher_ levels_of_default_ (10%),_death_(7%)_and_failure_of_treatment_(5%)_than_among_the_new_cases_(5%,_4%_and_2%_respectively)._In_the_Euro-pean_Region,_where_overall_success_ in_retreated_TB_

patients_had_declined_to_47%_by_2008,_21%_of_cases_failed_treatment_(reaching_29%_in_the_Russian_Feder-ation_and_32%_in_Kazakhstan)_and_12%_defaulted_(up_to_25%_in_Azerbaijan_and_21%_in_Armenia)._This_high_level_of_failure_in_countries_of_eastern_Europe,_which_have_some_of_the_highest_levels_of_drug-resistant_TB_in_the_world,_most_probably_mirrors_the_inadequate_treatment_of_this_sub-group_of_patients._Treatment_interruption_among_both_new_and_retreated_patients_is_expected_to_compound_this_problem.

Table_7_focuses_on_the_key_performance_indicators_for_basic_TB_control_in_the_27_MDR-HBCs._These_coun-tries_reported_4.4_million_new_and_relapsed_TB_cases_out_of_the_5.8_million_reported_globally_ in_2009._In_14_ of_ these_ countries,_ however,_ the_ case_ detection_ratio_ was_ lower_ than_ the_ 70%_ target._ Moreover,_ in_15_ of_the_27_MDR-HBCs,_TB_incidence_was_stable_or_increasing_in_2009._In_more_than_half_the_countries_(17),_ treatment_ success_ among_ new_ smear-positive_cases_was_below_the_target_of_85%_in_2008._Fourteen_of_these_countries_were_from_eastern_Europe.

Poor_ performance_ in_ identifying_ TB_ cases_ may_also_mean_that_many_of_the_drug-resistant_TB_cases_are_ also_ escaping_ detection._ An_ incremental_ trend_in_ TB_ incidence_ is_ expected_ to_ enlarge_ the_ pool_ of_drug-resistant_TB_cases_in_some_countries._The_per-formance_of_TB_programmes_in_certain_countries_is_being_undermined_by_the_high_levels_of_drug_resist-ance._Early_identification_of_drug_resistance_even_in_TB_patients_not_previously_treated,_and_the_institu-tion_of_adequate_treatment,_could_reduce_a_number_of_ avoidable_ deaths,_ improve_ success_ rates_ and_reduce_ amplification_ and_ transmission_ of_ resistant_TB_strains.

2.2 Engaging all health-care providers

In_ most_ resource-poor_ countries_ with_ a_ high_ TB_burden,_ patients_ with_ symptoms_ suggestive_ of_TB_seek_care_ from_a_wide_array_of_health-care_ pro-viders,_ who_ are_ often_ not_ linked_ to_ national_ TB_control_programmes._Evidence_indicates_that_many_of_ these_ patients_ are_ managed_ in_ inappropriate,_

PART 2:

Prevention of M/XDR-TB through basic TB control


non-standardized_ways_with_anti-TB_drugs_of_ques-tionable_ quality.13_ Most_ of_ these_ patients_ are_ not_notified_to_the_national_TB_control_programme_and_their_treatment_outcomes_are_not_known._Hospitals_in_particular,_draw_patients_from_far_and_wide_and_in_many_settings_are_not_close_to_areas_of_need,_without_proper_ links_ with_ peripheral_ health_ centres_ to_ fol-low-up_patients_on_treatments_of_long_duration._The_engagement_ of_ hospitals_ is_ vital_ to_ curb_ the_ emer-gence_and_spread_of_drug-resistant_TB.

Within_ hospitals,_ managing_ the_ flow_ of_ TB_patients_ through_ the_ various_ departments_ and_

ensuring_quality_diagnosis_and_ treatment_ presents_challenges._ Infection_ control_ in_ high-burden_ coun-try_hospital_settings_is_weak_or_absent.

To_ address_ this_ problem_ of_ inappropriate_ man-agement_of_TB_patients_outside_national_TB_control_programmes,_engaging_all_relevant_health-care_pro-viders_in_TB_care_and_control_through_‘public–private_mix’_ (PPM)_ approaches_ is_ an_ essential_ component_of_ the_WHO_Stop_TB_strategy._PPM_for_TB_care_and_control_ represents_ a_ comprehensive_ approach_ for_systematic_ involvement_ of_ all_ relevant_ health-care_providers_ in_TB_control_ to_promote_the_use_of_

TablE 7

TB incidence and detection of TB (2009) and treatment outcomes for new smear-positive TB cases (2008) in 27 high MDR-TB burden countries

Estimated incidence*

(thousands)

Notified new and relapse

cases

Estimated case detection rate*

(all forms)

Treatment outcomes, new smear-positive, 2008 (%)

Incidence declining?Success Unfavourable**

Armenia 2.2 (1.8–2.7) 1 560 70 (58–85) 73 20 No

Azerbaijan 9.7 (7.9–12) 7 301 75 (63–93) 56 15 No

Bangladesh 360 (300–440) 160 875 44 (37–54) 91 6 No

Belarus 3.8 (3.1–4.5) 5 250 140 (120–170) 71 19 Yes

Bulgaria 3.1 (2.7–3.6) 2 683 86 (75–100) 85 14 Yes

China 1 300 (1 100–1 500) 965 257 75 (66–86) 94 3 Yes

DR Congo 250 (200–300) 112 222 46 (38–56) 87 9 Yes

Estonia 0.4 (0.36–0.47) 361 89 (77–100) 60 39 Yes

Ethiopia 300 (240–360) 148 936 50 (42–62) 84 7 Yes

Georgia 4.5 (4–5.1) 4 732 100 (93–120) 73 23 No

India 2 000 (1 600–2 400) 1 351 913 67 (56–83) 87 12 No

Indonesia 430 (350–520) 292 754 67 (56–83) 91 7 No

Kazakhstan 26 (21–30) 20 508 80 (68–96) 64 34 Yes

Kyrgyzstan 8.7 (7.1–11) 5 765 66 (55–81) 84 14 No

Latvia 1 (0.88–1.1) 951 94 (83–110) 33 10 Yes

Lithuania 2.3 (2–2.7) 1 895 81 (70–95) 82 18 No

Myanmar 200 (160–240) 128 343 64 (53–78) 85 13 No

Nigeria 460 (370–550) 88 589 19 (16–24) 78 15 Yes

Pakistan 420 (340–500) 264 248 63 (52–78) 90 7 No

Philippines 260 (210–310) 146 565 57 (47–70) 88 7 Yes

Republic of Moldova 6.4 (5.2–7.7) 4 347 68 (56–83) 62 31 No

Russian Federation 150 (130–180) 126 227 84 (72–100) 57 38 Yes

South Africa 490 (400–590) 360 183 74 (61–91) 76 17 No

Tajikistan 14 (11–17) 6 125 44 (36–54) 82 17 No

Ukraine 46 (38–56) 36 075 78 (65–95) 62 33 Yes

Uzbekistan 35 (29–42) 17 540 50 (41–61) 81 16 No

Viet Nam 180 (130–230) 95 036 54 (42–72) 92 6 No

* Numbers in parentheses indicate uncertainty intervals.

** Excludes treatment outcomes that have not been evaluated.


international_ standards_ for_ TB_ Care_ and_ achieve_national_and_global_TB_control_targets._PPM_for_drug-resistant_TB_can_increase_detection_and_management_of_MDR-TB_in_line_with_international_standards,_by_establishing_effective_referral_ links_and/or_building_the_ capacity_ of_ providers_ and_ institutions_ outside_national_TB_control_programmes_to_adequately_diag-nose,_treat_and_report_drug-resistant_patients,_in_the_same_way_as_PPM_has_been_shown_to_do_for_drug-sus-ceptible_TB.

Currently,_ PPM_ is_ being_ scaled_ up_ globally,_increasing_the_number_of_TB_patients_that_are_being_managed_ according_ to_ international_ standards,_and_ thereby_ helping_ to_ prevent_ MDR-TB._ PPM_ pro-viders_ detect_ and_ manage_ a_ significant_ proportion_of_TB_cases_ in_many_countries,_as_ seen_ in_ the_data_reported_in_the_WHO Global TB Report 2010_(Table_8)._Bangladesh,_Pakistan_and_the_Philippines_are_exam-ples_ of_ countries_ that_ have_ successfully_ engaged_with_ key_ private_ sector_ providers_ for_ the_ scale-up_

of_PMDT_(Boxes_6_and_7)._To_guide_and_facilitate_the_engagement_ of_ all_ health-care_ providers_ in_ PMDT,_WHO_ has_ developed_ tools_ for_ PPM_ approaches_ to_MDR-TB_which_are_part_of_the_recently_launched_PPM_toolkit.14_ A_ task_ force_ to_ promote_ the_ engagement_of_ all_ health-care_ providers_ in_ PMDT_ has_ also_ been_set_up_by_the_MDR-TB_Working_Group_of_the_Stop_TB_Partnership.

Increasing_TB_case_detection_may_thus_require_a_multi-pronged_approach._The_more_widespread_use_of_electronic_ systems_ for_ reporting_TB_surveillance_data_ has_ been_ shown_ to_ lead_ to_ increased_ com-pleteness_ of_ reporting,_ even_ across_ different_ types_of_ health-care_ providers.15_ Data_ from_ 15_ countries_show_that_the_contribution_to_total_notification_by_various_ health-care_ providers_ outside_ the_ national_TB_ control_ programme_ exceeds_ one_ third_ of_ noti-fied_ cases_ in_ countries_ with_ some_ of_ the_ heaviest_TB_ caseloads_ in_ the_ world,_ such_ as_ in_ China_ and_India_ (Table_8)._Different_methods_have_been_used_

TablE 8

Contribution of public–private mix approaches to TB case notifications in selected countries

CountryTypes of non-NTP care providers engaged Coverage

Number of cases notified

per year*

Contribution to total

notifications** (%)

Angola Diverse public and private providers Countrywide 4591 12%

Cambodia Pharmacies, private clinics and hospitals Countrywide 6550 17%

China General public hospitals Countrywide  337 286  37%

Ghana Diverse public and private providers Countrywide 2124 15%

India Diverse public, private and NGO providers

14 large cities (50 million population)

12 450 36% of new smear-positive cases 

Indonesia Public and private hospitals Countrywide 38 362 13%

Islamic Republic of Iran

Diverse public  and private providers Countrywide 8829 93%

Kazakhstan Prison health services Countrywide 1515 8%

Mexico Social security organizations  43% of the economically- active 

population 

3438 (2008)

29% of new smear-positive cases

Myanmar Private practitioners through the professional medical association 

26 townships (6.4 million population)

8526(2008)

21%

Nepal Diverse public and private providers Countrywide 2519 8%

Nigeria Private clinics and hospitals Countrywide 29418 34%

Pakistan Private practitioners, NGOs and hospitals Countrywide 43 162 14%

Philippines Private clinics and hospitals 30 million population  3994 28% of new smear-positive cases

United Republic of Tanzania

Private and NGO hospitals  Countrywide 11 492 19%

* Data from 2009, except where specified.

** Contribution to all notifications is shown, except where specified.

NGO = nongovernmental organization

Source: Global tuberculosis control: WHO report 2010. Geneva, World Health Organization, 2010 (WHO/HTM/TB/2010.7).


to_ engage_ health-care_ providers_ outside_ national_TB_ control_ programmes_ in_ case_ detection_ and_ sur-veillance_for_TB,_including_incentives_to_individuals_and_ institutions,_ and_ extending_ health_ insurance_coverage.

2.3 Promoting regulated access to anti-TB medicines

Successful_ treatment_ of_ tuberculosis_ requires_ that_an_ appropriate_ regimen_ of_ quality-assured_ drugs_is_ taken_ by_ patients_ for_ a_ certain_ period_ of_ time._Self-prescription_ and_ self-administration_ of_ anti-TB_ drugs_ is_ thought_ to_ promote_ drug_ resistance_and_is_facilitated_by_lack_of_regulation_in_the_access_to_ drugs._ In_ 2010,_ 44_ countries_ including_ 18_ MDR-HBCs_ reported_ that_ first-line_ anti-TB_ medicines_were_ available_ in_ private_ pharmacies_ (Table_ 9)._ In_22_ countries,_ including_ 12_ MDR-HBCs,_ these_ medi-cines_were_available_without_prescription.16_A_study_conducted_by_the_TB_Alliance_and_IMS_Health_in_10_countries_ in_ 2010,_ revealed_ that_ 74_ different_ first-line_ fixed-dose_ combination_ (FDC)_ dosage_ variants_were_in_use_in_the_private_sector._In_India_alone,_48_

distinct_dosage_combinations_of_FDCs_were_available_in_ the_private_ sector._This_means_ that_a_ considera-ble_amount_of_anti-TB_drugs_are_being_dispensed_in_a_non-standardized_and_uncontrolled_way,_including_over-the-counter,_ increasing_the_risk_for_treatment_failure_and_drug_resistance.

Documentation_of_regulatory_approaches_used_to_minimize_the_misuse_of_first-line_anti-TB_medicines_was_ recently_ undertaken_ in_ Brazil,_ Ghana,_ India,_the_ United_ Republic_ of_ Tanzania_ and_ Zambia._ The_assessment_ shows_ that_ it_ is_ possible_ for_ countries,_under_ appropriate_ conditions,_ to_ restrict_ anti-TB_drug_prescription_and_dispensing_to_quality-assured_providers_ only._ Experience_ shows_ that_ successfully_controlling_the_dispensing_of_TB_drugs,_especially_in_countries_where_a_domestic_pharmaceutical_industry_is_present,_requires_concerted_effort_and_collabora-tion_ among_ ministries_ of_ health,_ drug_ regulatory_authorities,_the_pharmaceutical_industry,_pharmacy_associations,_ associations_ of_ health_ professionals_and_civil_society,_in_order_to_garner_full_support_and_help_enforce_regulation_of_sales_of_TB_drugs_outside_quality-assured_ facilities._ The_ positive_ experiences_in_ these_ countries_ should_ be_ replicated_ and_ evalu-ated_in_other_countries.

BOX 6 Implementing PMDT through private sector in Bangladesh

In Bangladesh, programmatic management of drug-resistant tuberculosis was started with support from the public sector and the Damien Foundation (Bangladesh) (DFB). DFB is one of the main partners of the national TB control programme in Bangladesh and provides both DOTS and PMDT through a network of NGO hospitals, and through linking with private, informal providers (‘village doctors’) that are active in rural areas of Bangladesh. These providers refer suspected TB cases and supervise treatment of drug-susceptible and -resistant TB cases.

MDR-TB activities started in 1997 and have become completely integrated with routine programme activities. This initiative has full programmatic support from the public sector. Village doctors provide ambulatory treatment to 80% of the MDR-TB cases in the DFB catchment area, and have contributed to a remarkably high cure rate (90%) and low default rate (5%) among MDR-TB cases. After learning from this experience, the public sector recently started its first GLC-approved project for drug-resistant TB patients in a public sector tertiary hospital.

BOX 7 Scaling up public–private approaches in the Philippines

The Philippines has not waited for PPM to be fully consolidated, mainstreamed and scaled up before embarking on PPM for PMDT. Instead PPM for PMDT has been one step ahead. The first GLC-approved initiative for PMDT was established in 2000 at Makati Medical Center (MMC), a private hospital in Manila, which hosts the Tropical Disease Foundation. Initially all MDR-TB cases were treated in the MMC MDR treatment centre (MTC). Gradually, satellite treatment centres were established within the public and private sectors. All DOTS units (including PPM) refer MDR-TB suspects directly to MTCs, while other facilities refer MDR-TB suspects to DOTS units for initial evaluation and possible onward referral to MTCs. MDR-TB treatment outcomes have gradually improved, and the treatment success rate reached 73–74% in 2003–2005. An additional positive outcome is the decrease in the proportion of patients with a history of previous treatment with fluoroquinolones. This proportion dropped from 30% in 2001 to zero in 2007. Resistance to fluoroquinolones also decreased from 45% in 2006 to 12% in 2007.


In_ addition,_ efforts_ have_ been_ undertaken_ by_some_ countries,_ such_ as_ Cambodia,_ India_ and_ the_United_Republic_of_Tanzania,_to_promote_the_rational_use_ of_ anti-TB_ drugs_ by_ engaging_ pharmacists_ and_their_ associations._ WHO_ and_ the_ International_Pharmaceutical_ Federation_ are_ jointly_ developing_a_statement_on_the_role_of_pharmacists_in_the_fight_against_TB.

2.4 Addressing the dual MDR-TB and HIV epidemics

People_ living_ with_ HIV_ have_ a_ high_ risk_ of_ drug-resistant_TB_and_of_the_27_MDR-HBCs,_12_also_belong_to_the_TB/HIV_priority_list_that_endure_the_brunt_of_the_HIV-related_TB_epidemic._The_response_to_over-come_ the_ drug-resistant_ TB_ problem_ should_ also_encompass_ TB/HIV_ interventions._ There_ have_ been_some_efforts_to_strengthen_synergy_between_the_two_areas_of_focus,_including_the_systematic_recommen-dation_of_HIV_testing_as_an_integral_part_of_TB_drug_

resistance_surveillance,_regardless_of_the_state_of_the_HIV_ epidemic.18_ Almost_ all_ TB_ drug_ resistance_ sur-veys_reported_to_WHO_in_recent_years_also_collected_information_ on_ HIV_ status,_ and_ some_ countries_ –_such_as_Estonia,_Latvia_and_the_Republic_of_Moldova_–_ routinely_ report_ the_ HIV_ status_ of_ patients_ with_drug-resistant_TB.

In_2009,_there_were_1.7_million_people_living_with_HIV_screened_for_TB_in_101_countries._Map_3_shows_the_distribution_of_HIV_testing_for_TB_patients_in_the_12_ MDR-HBCs_ that_ are_ also_ TB/HIV_ priority_ coun-tries._ TB_ screening_ among_ people_ living_ with_ HIV,_including_those_with_drug-resistant_TB,_is_expected_to_further_increase_with_the_implementation_of_the_recent_release_of_the_2010_WHO Guidelines for inten-sified TB case-finding and isoniazid preventive therapy for people living with HIV,19_that_provide_clear_recom-mendations_for_national_AIDS_and_TB_programmes,_and_those_providing_HIV_services_ to_scale_up_these_activities._ The_ new_ guidelines_ have_ already_ been_adopted_ by_ Cambodia_ and_ South_ Africa._ Scale-up_of_IPT_to_prevent_TB_has_been_spectacular_in_South_Africa_with_more_than_50_000_people_living_with_HIV_starting_IPT_between_January_and_June_2010_as_part_of_an_HIV_testing_campaign.

Similarly,_there_have_been_efforts_to_harmonize_TB_and_ HIV_ laboratory-strengthening_ efforts_ through_the_‘Expand_TB’_project_involving_13_priority_TB/HIV_countries,_including_the_promotion_of_an_integrated_platform_ for_ HIV_ diagnosis,_ viral_ load_ assessment_and_ diagnosis_ of_ drug-resistant_ TB_ in_ Ethiopia._People_living_with_HIV_and_diagnosed_with_drug-sus-ceptible_or_drug-resistant_TB_should_be_regarded_as_eligible_for_ART_regardless_of_CD4_count._ART_should_be_started_as_soon_as_possible_after_initiation_of_TB_or_ M/XDR-TB_ treatment._ These_ recommendations_are_both_included_in_the_2010_WHO_ART_guidelines20_and_ in_ the_upcoming_WHO_guidelines_on_program-matic_ management_ of_ MDR-TB._ However,_ more_research_ is_ urgently_ needed_ and_ priority_ research_questions_on_drug-resistant_ TB_and_ HIV_have_been_defined_ in_ the_ 2010_ WHO_ TB/HIV_ priority_ research_agenda.21_The_TB/HIV_Working_Group_of_the_Stop_TB_Partnership_has_prioritized_the_convergence_of_drug-resistant_TB_and_HIV_in_eastern_Europe_and_Central_Asia_regions,22_and_garnered_increased_political_com-mitment_to_expedite_the_response.

At_the_country_level,_there_is_limited_epidemiolog-ical_data_about_an_association_between_HIV_infection_and_MDR-TB._Of_the_12_countries_with_the_greatest_burden_of_MDR-TB_and_HIV-associated_TB,_only_Esto-nia_and_Ukraine_reported_data_on_MDR-TB_stratified_by_ HIV_ status,_ either_ through_ routine_ surveillance_(Estonia)_or_drug_resistance_survey_(Ukraine)._Prev-alence_of_HIV_among_MDR-TB_patients_ranged_from_

TablE 9

Size and characteristics of the private-sector market for anti-TB drugs17

Country Incident cases

(2008)

Coverage by first line,

private sector drugs*

% of private

market that uses loose

drugs^

India 1 982 628 117% 23%

Indonesia 429 730 116% 91%

Philippines 257 317 86% 16%

Pakistan 409 392 65% 36%

China 1 301 322 23% 98%

Thailand 92 087 17% 94%

Russian Federation 150 898 13% 100%

Viet Nam 174 593 7% 90%

Bangladesh 359 671 7% 11%

South Africa 476 732 3% 34%

Weighted average 66% 52%

Global Total 9 369 038

10 country total, as % of global incidence

60% 39%

From: Wells W et al. Size and Usage Patterns of Private TB Markets in the High Burden Countries. 2011 (in press).

* Percentage of all incident MDR-TB cases that can be treated by first-line drugs in the private-sector market (average across four first-line drugs, assuming a daily 6–8-month regimen). Data for this and other columns, unless noted, are for Q4 2008–Q3 2009.^ Shaded entries are >90%.


7.2%_ in_ Estonia_ to_ 23.8%_ in_ Ukraine._ Three_ other_MDR-HBCs,_which_are_not_on_the_list_of_the_63_priority_TB/HIV_countries,_also_reported_routine_surveillance_data:_Latvia,_Lithuania_and_the_Republic_of_Moldova.

The_ extent_ of_ MDR-TB_ disease_ among_ people_living_ with_ HIV_ is_ poorly_ documented_ in_ the_ MDR-HBCs,_ especially_ in_ the_ 12_ that_ carry_ the_ brunt_ of_MDR-TB_ and_ HIV-related_ TB._ The_ publication_ WHO Policies on collaborative TB/HIV activities and provider initiated HIV testing_recommends_that_all_TB_patients_and_suspects,_including_those_with_MDR-TB,_should_be_tested_for_HIV._Expanding_HIV_testing_for_MDR-TB_patients_ and_ suspects,_ and_ routine_ surveillance_data_on_HIV_status_of_MDR-TB_patients,_are_urgently_needed_in_the_27_MDR-HBCs.

2.5 Prioritizing tuberculosis infection control

TB_ infection_ control_ (IC)_ measures_ are_ effective_ at_preventing_transmission_of_TB,_and_complement_the_effect_ of_ chemotherapy_ in_ interrupting_ the_ trans-mission_chain,_the_backbone_of_the_Stop_TB_strategy._The_ WHO policy on TB infection control in health-care facilities, congregate settings and households,_ pub-lished_ in_2009,23_guides_ countries_ to_ implement_ IC_

measures_in_TB_hospital_wards,_outpatient_settings_where_ TB_ is_ diagnosed_ and_ treated,_ and_ congre-gate_settings._However,_emphasis_and_prioritization_should_focus_on_implementing_simple_and_econom-ical_measures,_e.g._identifying_potentially_infectious_cases_ (triage);_ separating_ them_ into_ a_ proper_ envi-ronment;_enhancing_the_use_of_masks;_minimizing_the_ time_ spent_ in_ health-care_ settings_ and_ assur-ing_health-care_worker_protection._These_procedures_should_target_MDR-TB_care_settings,_and_be_context-sensitive,_emphasizing_the_importance_of_developing_“Safe_health-care_facilities”.

In_order_to_implement_these_activities,_WHO_and_other_ partners_ have_ developed_ a_ global_ policy_ and_provided_ specific_ technical_ assistance_ to_ countries._The_ development_ of_ the_ global_ WHO_ policy_ on_ TB_IC_has_been_followed_by_the_preparation_of_both_an_advocacy_ strategy_ document24_ and_ of_ a_ framework_document_ for_ implementing_ the_ WHO_ TB_ IC_ pol-icy.25_This_latter_document_should_be_very_practical_for_ countries,_ by_ providing_ downloadable_ posters,_flow_charts,_facility_diagrams,_checklists_and_moni-toring_ and_ evaluation_ tools._ Regional_ and_ national_trainings_ have_ already_ reached_ several_ hundred_professionals_ and_ some_ countries_ have_ started_ to_prepare_their_national_TB_IC_action_plans._By_embed-ding_TB_IC_plans_into_broader_ones_(i.e._MDR-TB,_HIV,_

map 3

Global distribution of HIV testing services for TB patients in 12 high MDR-TB burden countries that are also TB/HIV priority countries, 2009

0–14

15–49


Data not available

Annual enrolment


2009: 6 countries


2011: 3 countries

30 000

25 000

20 000

15 000

10 000

5000

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Num

ber o

f pat

ient

s



Peru

Haiti

Senegal

Côte d’Ivoire

DR Congo

LesothoSwaziland

Djibouti

Belarus


IndiaMyanmar

EthiopiaUganda

KenyaUR Tanzania

Zambia

Cameroon

Vietnam

Indonesia

Kazakhstan

AzerbaijanGeorgia

Bangladesh


health_ system_ strengthening,_ general_ IC),_ meas-ures_ of_ TB_ IC_ are_ progressively_ incorporated_ into_national_plans_funded_by_major_donors_(e.g._Global_Fund,_United_States_Agency_for_International_Devel-opment_ (USAID),_ etc.)._ Each_ WHO_ region_ has_ now_entered_ into_ a_ phase_ of_ elaborating/scaling_ up_ its_own_specific_TB_IC_regional_activities._WHO_and_other_partners_are_also_providing_the_framework_and_often_the_ funding_ for_ country-level_ technical_ assistance._WHO_also_developed_a_new_indicator_for_monitoring_TB_IC,_and_the_cost_analysis_of_TB_IC_implementation_worldwide_has_been_integrated_into_the Global Plan to Stop TB 2011–2015.2

Twenty_ MDR-HBCs_ have_ reported_ some_ kind_ of_data_on_TB_IC_(four_from_the_African_Region,_eight_from_ the_ European_ Region,_ one_ from_ the_ Eastern_Mediterranean_ Region,_ four_ from_ the_ South-East_Asia_ Region_ and_ three_ from_ the_ Western_ Pacific_Region)._Fourteen_countries_reported_to_have_under-gone_a_national_TB_IC_situation_assessment_(Armenia,_Bulgaria,_Belarus,_Estonia,_Ethiopia,_Georgia,_Indo-nesia,_Kazakhstan,_Latvia,_Republic_of_Moldova,_the_Philippines,_Tajikistan,_Ukraine_and_Viet_Nam)_and_four_are_currently_undergoing_assessment_(Bangla-desh,_China,_India_and_Pakistan)_(Figure_9)._Eleven_countries_ have_ developed_ a_ national_ TB_ infection_control_ action_ plan_ (Armenia,_ Bangladesh,_ Bela-rus,_ China,_ Ethiopia,_ Indonesia,_ Latvia,_ Republic_of_Moldova,_the_Philippines,_South_Africa_and_Viet_Nam)_and_one_as_a_pilot_project_only_(India),_while_eight_countries_(Azerbaijan,_Bulgaria,_Georgia,_Kaza-khstan,_Myanmar,_Pakistan,_Tajikistan_and_Ukraine)_are_currently_preparing_one_(Figure_10)._Eight_coun-

tries_(29.6%)_reported_having_a_person_in_charge_of_TB_IC_in_at_least_one_of_their_tertiary_hospitals.

Surveillance_ of_ TB_ among_ health-care_ workers_(HCW)_is_part_of_the_national_policy_ in_a_few_coun-tries._In_2009,_six_MDR-HBCs_(22.2%)_reported_to_the_WHO_global_TB_data_collection_system_the_incidence_rate_of_TB_among_HCW._This_enabled_WHO_to_calcu-late_ the_ ratio_ of_ TB_ notification_ rate_ (all_ forms)_ in_HCW_(all_ staff)_over_ the_TB_notification_rate_ in_ the_general_population,_in_order_to_have_an_estimate_of_the_positive_impact_of_TB_IC_measures_at_health-care_facility_level.

TB_ IC_ is_ still_ in_ a_ preliminary_ implementa-tion_ phase_ in_ most_ countries._ More_ MDR-TB_ HBCs_are_ making_ steady_ progress_ in_ their_ prepared-ness_toward_TB_ IC_field_ implementation._Yet_other_countries_still_lack_the_institutional_capacity_to_ade-quately_ address_ TB_ IC,_ and_ have_ not_ yet_ started_their_ TB_ IC_ national_ assessment_ or_ drafted_ their_national_ action_ plan._ These_ specific_ countries_ may_benefit_from_upcoming_regional/national_trainings_organized_by_WHO_and_other_partners,_followed_by_TB_ IC_ technical_ assistance._ All_ these_ components_are_ essential_ tools_ for_ enabling_ the_ preparation_of_ national_ TB_ action_ plans,_ which_ should_ subse-quently_allow_countries_to_embed_TB_IC_plans_ into_broader_activities_(i.e._MDR-TB,_HIV,_health_system_strengthening,_ general_ IC_ etc.),_ budgeted_ by_ their_own_governments_and/or_by_partners,_such_as_Glo-bal_ Fund._ Regardless_ of_ their_ current_ stage_ in_ the_implementation_ process,_ country_ political_ com-mitment_was_and_remains_essential_for_progress_in_their_implementation_phase.

FIGURE 9

Percentage of MDR-TB HBCs with a TB IC national assessment (N=27)

FIGURE 10

Percentage of MDR-TB HBCs with a TB IC national action plan prepared (N=27)

Other 20%

52%

18%

15%

15%

New 30%

Relapse 12%

xAfter default

3%

US$

mill

ions

(con

stan

t 201

0 U

S$)

US$

bill

ions

(con

stan

t 201

0 U

S$)

2008 2009 2010 2011

2012 2013 2014 2015

700

600

500

400

300

200

100

0

1.2

1.0

0.8

0.6

0.4

0.2

0.0

Gap

Unknown

Loans

Global Fund




Indonesia

India

Kyrgyzstan

China

Kazakhstan

Tajikistan

Russian Federation

US$

mill

ions

(con

stan

t 201

0 U

S$)

8

7

6

5

4

3

2

1

0

Infection Control




ACSM for MDR


2011 2012 2013 2014 2015

Num

ber o

f pat

ient

s

Annual enrolment


2008 2009 2010 2011

0% 20% 40% 60% 80% 100%


27

24

21

18

15

12

9

6

3

0

















35 000

30 000

25 000

20 000

15 000

10 000

5000

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009



40%

15%

15%

30%

Yes

No

In preparation

Unknown

Yes

No

In preparation

Unknown

% total estimated MDR cases in noti�ed Other 20%

52%

18%

15%

15%

New 30%

Relapse 12%

xAfter default

3%

US$

mill

ions

(con

stan

t 201

0 U

S$)

US$

bill

ions

(con

stan

t 201

0 U

S$)

2008 2009 2010 2011

2012 2013 2014 2015

700

600

500

400

300

200

100

0

1.2

1.0

0.8

0.6

0.4

0.2

0.0

Gap

Unknown

Loans

Global Fund




Indonesia

India

Kyrgyzstan

China

Kazakhstan

Tajikistan

Russian Federation

US$

mill

ions

(con

stan

t 201

0 U

S$)

8

7

6

5

4

3

2

1

0

Infection Control




ACSM for MDR


2011 2012 2013 2014 2015

Num

ber o

f pat

ient

s

Annual enrolment


2008 2009 2010 2011

0% 20% 40% 60% 80% 100%


27

24

21

18

15

12

9

6

3

0

















35 000

30 000

25 000

20 000

15 000

10 000

5000

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009



40%

15%

15%

30%

Yes

No

In preparation

Unknown

Yes

No

In preparation

Unknown



ANNEX 1:

Resolution WHA62.15

SIXTY-SECOND WORLD HEALTH ASSEMBLY WHA62.15Agenda item 12.9 22 May 2009

Prevention and control of multidrug-resistant tuberculosis and extensively drug-resistant tuberculosis

The_Sixty-second_World_Health_Assembly,

Having_considered_the_reports_on_the_prevention_and_control_of_multidrug-resistant_tuberculosis_and_exten-sively_drug-resistant_tuberculosis;

Noting_the_progress_made_since_1991_towards_achieving_the_international_targets_for_2005,_the_acceleration_of_efforts_following_the_establishment_of_the_Stop_TB_Partnership_in_response_to_resolution_WHA51.13,_and_more_recently_following_resolution_WHA58.14_encouraging_Member_States_to_ensure_availability_of_sufficient_resources_to_achieve_the_internationally_agreed_goal_relevant_to_tuberculosis_contained_in_the_United_Nations_Millennium_Declaration_by_2015;

Aware_that_the_development_of_the_Stop_TB_strategy_as_a_holistic_approach_to_tuberculosis_prevention_and_control_and_represents_a_significant_expansion_in_the_scale_and_scope_of_tuberculosis_control_activities_as_a_part_of_strengthening_health_systems_within_the_context_of_primary_health_care_and_addressing_social_deter-minants_of_health;

Noting_ that_ the_ Stop_ TB_ Partnership’s_ Global_ Plan_ to_ Stop_ TB_ 2006–2015_ sets_ out_ the_ activities_ oriented_towards_implementing_the_Stop_TB_strategy_and_achieving_the_international_targets_for_tuberculosis_control_set_by_the_Stop_TB_Partnership_–_in_line_with_the_target_of_the_internationally_agreed_development_goal_rel-evant_to_tuberculosis_contained_in_the_United_Nations_Millennium_Declaration_to_“have_halted_by_2015_and_begun_to_reverse_the_incidence_of_major_diseases”_–_of_halving_tuberculosis_prevalence_and_death_rates_by_2015_compared_with_1990_levels;

Noting_that_the_care_and_control_of_tuberculosis_have_progressed_significantly_during_the_past_decade_and_the_incidence_of_new_cases_is_estimated_to_have_fallen_slightly_each_year_since_2003;

Aware_that_a_significant_proportion_–_an_estimated_37%_of_tuberculosis_cases_worldwide_remain_un-notified_and_receive_either_no_treatment_or_inappropriate_treatment;

Recognizing_ that_ the_ rates_of_ tuberculosis_ are_ disproportionately_ high_ in_high-risk_populations_ including_indigenous_populations;

Recognizing_that_emergence_and_spread_of_multidrug-resistant_and_extensively,_drug-resistant_tuberculosis_is_facilitated_by_not_detecting_sufficient_cases_of_tuberculosis_and_not_treating_them_appropriately_by_DOTS-based_treatment;


Concerned_that_the_highest_levels_of_multidrug-resistance_reported_in_WHO’s_fourth_global_report_on_anti-tuberculosis_ drug_ resistance1_ –_ an_ estimated_ half_ a_ million_ multidrug-resistant_ cases_ occurring_ globally,_including_ 50_ 000_ cases_ of_ extensively_ drug-resistant_ tuberculosis_ –_ pose_ a_ threat_ to_ global_ public_ health_security;

Recognizing_that_there_is_an_urgent_need_to_invest_in_research_for_development_of_new_diagnostics,_medicines_and_vaccines_and_in_operational_research_to_prevent_and_manage_tuberculosis,_including_multidrug-resistant_and_extensively_drug-resistant_tuberculosis;_while_exploring_and,_where_appropriate,_promoting_a_range_of_incentive_schemes_for_research_and_development_including_addressing,_where_appropriate,_the_de-linkage_of_the_costs_of_research_and_development_and_the_price_of_health_products;

Noting_that_less_than_3%_of_the_estimated_total_number_of_multidrug-resistant_and_extensively_drug-resist-ant_cases_of_tuberculosis_receive_treatment_according_to_WHO_recommended_standards;

Concerned_that_the_disease_transmission_occurs_mostly_in_communities_where_there_is_a_lack_of_appropriate_infection_control;

Concerned_that_the_insufficient_demand_from_countries_for_internationally_quality-assured_anti-tuberculo-sis_medicines_resulting_in_an_inadequate_supply_through_the_Green_Light_Committee_mechanism_has_been_a_major_bottleneck_to_treating_multidrug-resistant_and_extensively_drug-resistant_tuberculosis_and_that_qual-ity-assured_fixed-dose_drug_combinations,_developed_as_a_tool_to_prevent_the_emergence_of_resistance,_are_not_widely_used;

Aware_that_the_delays_in_implementing_the_Global_Plan_to_Stop_TB_2006–2015_will_result_in_increasing_numbers_of_ tuberculosis_ cases_ and_ deaths,_ including_ those_ due_ to_ multidrug-resistant_ and_ extensively_ multidrug-resistant_tuberculosis_and_to_the_impact_of_HIV,_and_therefore_in_delays_in_achieving_by_2015_the_international_targets_ for_ tuberculosis_ control_and_ the_ internationally_agreed_development_goal_ relevant_ to_ tuberculosis_contained_in_the_United_Nations_Millennium_Declaration;

Recalling_resolution_WHA60.19_on_tuberculosis_control_in_which_the_Health_Assembly_urged_Member_States_to_ develop_ and_ implement_ long-term_ plans_ for_ tuberculosis_ including_ multidrugresistant_ and_ extensively_drug-resistant_tuberculosis_prevention_and_control_in_line_with_the_Global_Plan_to_Stop_TB_2006–2015,_within_the_overall_health_development_plans,_and_resolution_WHA58.33_on_achieving_universal_coverage;

Welcoming_the_Beijing_Call_for_Action_on_tuberculosis_control_and_patient_care_given_jointly_by_represent-atives_of_27_Member_States_ carrying_a_high_burden_of_multidrug-resistant_and_extensively_drug-resistant_tuberculosis,_civil_society,_the_private_sector_and_others_to_address_the_alarming_threat_of_multidrug-resist-ant_and_extensively_drug-resistant_tuberculosis,

1. URGES all Member States:

(1)_to_achieve_universal_access_to_diagnosis_and_treatment_of_multidrug-resistant_and_extensively_drug-resist-ant_tuberculosis_as_part_of_the_transition_to_universal_health_coverage,_thereby_saving_lives_and_protecting_communities,_by_means_of:

(a)_developing_a_comprehensive_framework_for_management_and_care_of_multidrugresistant_and_exten-sively_ drug-resistant_ tuberculosis,_ that_ includes_ directly-observed_ treatment,_ community-based_ and_patient-centered_ care,_ and_ which_ identifies_ and_ addresses_ the_ needs_ of_ persons_ living_ with_ HIV,_ the_poor_ and_other_vulnerable_groups,_ such_ as_prisoners,_mineworkers,_migrants,_drug_users,_ and_ alcohol_dependants,_as_well_as_the_underlying_social_determinants_of_tuberculosis_and_multidrug-resistant_and_extensively_drug-resistant_tuberculosis;

(b)_strengthening_health_information_and_surveillance_systems_to_ensure_detection_and_monitoring_of_the_epidemiological_profile_of_multidrug-resistant_and_extensively_drug_resistant_tuberculosis_and_moni-tor_achievement_in_its_prevention_and_control;


(c)_aiming_to_ensure_the_removal_of_financial_barriers_to_allow_all_tuberculosis_patients_equitable_access_to_tuberculosis_care,_that_their_rights_are_protected,_and_that_they_are_treated_with_respect_and_dignity_in_accordance_with_the_local_legislation;

(d)_making_available_sufficiently_trained_and_motivated_staff_in_order_to_enable_diagnosis,_treatment_and_care_of_tuberculosis_including_multidrug-resistant_and_extensively_drug-resistant_tuberculosis,_as_an_inte-gral_part_of_efforts_to_address_the_overall_health_workforce_crisis;

(e)_strengthening_laboratory_systems,_through_increasing_capacity_and_adequate_human_resources,_and_accelerating_access_to_faster_and_quality-assured_diagnostic_tests;

(f)_ engaging_ all_ relevant_ public_ and_ private_ health-care_ providers_ in_ managing_ tuberculosis_ including_multidrug-resistant_and_extensively_drug-resistant_tuberculosis_and_tuberculosis-HIV_coinfection_accord-ing_to_national_policies,_and_strengthening_primary_health_care_in_early_detection,_effective_treatment_and_support_to_patients;

(g)_ensuring_that_national_airborne_infection-control_policies_are_developed_(as_part_of_general_infection_prevention_and_control_programmes)_and_implemented_in_every_health-care_facility_and_other_high-risk_settings_and_that_there_is_sufficient_awareness_of_tuberculosis_infection_control_in_the_community;

(h)_ensuring_uninterrupted_supply_of_first-_and_second-line_medicines_for_tuberculosis_treatment,_which_meet_WHO_prequalification_standards_or_strict_national_regulatory_authority_standards,_and_that_quality-assured_fixed-dose_combination_medicines_of_proven_bioavailability_are_prioritized_within_a_system_that_promotes_treatment_adherence;

(i)_strengthening_mechanisms_to_ensure_that_tuberculosis_medicines_are_sold_on_prescription_only_and_that_they_are_prescribed_and_dispensed_by_accredited_public_and_private_providers;

(j)_undertaking_effective_advocacy,_communication_and_social_mobilization,_avoiding_stigmatization_and_discrimination,_and_spreading_community_awareness_about_policies_and_plans_for_prevention_and_control_of_tuberculosis_including_multidrug-resistant_and_extensively_drug-resistant_tuberculosis;

(k)_establishing_national_targets_in_order_to_accelerate_access_to_treatment_according_to_WHO_guidelines,_for_multidrug-resistant_and_extremely_drug-resistant_tuberculosis_patients;

(2)_to_enhance_quality_and_coverage_of_DOTS_in_achieving_70%_detection_rate_and_85%_success_rate_of_tubercu-losis_treatment,_thereby_preventing_secondary_multi-drug_resistant_tuberculosis;

(3)_to_use_all_possible_financing_mechanisms_in_order_to_fulfil_the_commitments_made_in_resolutions_WHA58.14_and_WHA60.19,_including_the_commitment_to_ensure_sustainable_domestic_and_external_financing,_thereby_filling_the_funding_gaps_identified_in_the_Global_Plan_to_Stop_TB_2006–2015;

(4)_to_increase_investment_by_countries_and_all_partners_substantially_in_operational_research_and_research_and_development_for_new_diagnostics,_medicines_and_vaccines_to_prevent_and_manage_tuberculosis_including_multidrug-resistant_and_extensively_drug-resistant_tuberculosis;

2. REQUESTS the Director-General:

(1)_to_provide_technical_support_to_Member_States_in_order_to_develop_and_implement_response_plans,_based_on_ a_ comprehensive_ framework_ for_ management_ of_ care,_ for_ the_ prevention_ and_ control_ of_ tuberculosis_including_multidrug-resistant_and_extensively_drug-resistant_tuberculosis;

(2)_to_provide_support_to_Member_States_in_developing_and_implementing_strategies_to_engage_all_relevant_public,_voluntary,_corporate_and_private_health-care_providers_in_the_training_for_and_scaling_up_of_prevention_and_control_of_tuberculosis_including_multidrug-resistant_and_extensively_drug-resistant_tuberculosis_and_all_aspects_of_tuberculosis-HIV_coinfection;


(3)_to_advise_and_support_Member_States_to_bring_the_standards_of_national_drug_regulatory_agencies_in_line_with_international_standards,_thus_enabling_national_pharmaceutical_manufacturers_to_produce_material_of_assured_quality_to_be_sold_in_the_local_and_international_markets;

(4)_to_provide_support_to_Member_States_for_upgrading_laboratory_networks_to_be_able_to_undertake_diagnosis_and_monitoring_of_multidrug-resistant_and_extensively_drug-resistant_tuberculosis_and_facilitate_systematic_evaluations_of_newer_and_faster_diagnostic_technology;

(5)_to_strengthen_the_Green_Light_Committee_mechanism_to_help_to_expand_access_to_concessionally-priced_and_quality-assured_first-_and_second-line_medicines,_to_encourage_and_assist_the_local_pharmaceuticals_in_high-burden_countries_to_get_qualification_within_the_Green_Light_Committee_mechanism;

(6)_to_explore_and,_where_appropriate,_promote_a_range_of_incentive_schemes_for_research_and_development_including_addressing,_where_appropriate,_the_de-linkage_of_the_costs_of_research_and_development_and_the_price_of_health_products;

(7)_to_work_with_countries_to_develop_country_indicators_and_to_support_monitoring_and_evaluation_of_the_implementation_of_the_measures_outlined_in_this_resolution;

(8)_ to_report_ through_the_Executive_Board_to_the_Sixty-third_and_Sixty-fifth_World_Health_Assemblies_on_overall_progress_made.

Eighth_plenary_meeting,_22_May_2009_A62/VR/8

=_=_=

Armenia ................................. 43

Azerbaijan ............................. 45

Bangladesh .......................... 47

Bulgaria .................................. 49

Belarus .................................... 51

Democratic Republic of the Congo ....................... 53

China ....................................... 55

Estonia ................................... 57

Ethiopia .................................. 59

Georgia .................................. 61

Indonesia .............................. 63

India ........................................ 65

Kyrgyzstan ............................ 67

Kazakhstan ........................... 69

Lithuania ............................... 71

Latvia ...................................... 73

Republic of Moldova ........ 75

Myanmar ............................... 77

Nigeria .................................... 79

Philippines ............................ 81

Pakistan ................................. 83

Russian Federation ........... 85

South Africa ......................... 87

Tajikistan ................................ 89

Ukraine ................................... 91

Uzbekistan ............................ 93

Viet Nam ............................... 95

41

Country profile included

GLC-approved, 2000–2010

Requested approval for additional patients (“expanding”)

ANNEX 2:

Multidrug-resistant tuberculosis country profiles

Symbol Key:

 TB

  HIV

 MDR-TB

High TB burden

High HIV burden

High MDR-TB burden

Armenia

| High MDR-TB burden | Multidrug-resistant tuberculosis profile

Progress towards universal access to diagnosis and treatment of MDR-TBand XDR-TB:Estimated MDR-TB cases among notified pulmonary TB, notified casesand cases started on treatment (as reported to WHO) 2009

Estimated Notified Enrolled0

50

100

150

200

Population (millions) 2009 3

MDR-TB estimates of burden *% of new TB cases with MDR-TB 9.4 (7.3–12) [DRS 2007]% of retreatment TB cases with MDR-TB 43 (38–49) [DRS 2007]MDR-TB cases among incident total TB casesin 2008

480 (380–580)

MDR-TB cases among new pulmonary TBcases notified in 2009

110 (85–140)

MDR-TB cases among retreated pulmonaryTB cases notified in 2009

74 (66–83)

MDR-TB notified cases 2009 NewRetreat-

ment TotalConfirmed cases of MDR-TB 80 76 156MDR-TB patients started treatment 134

% of MDR-TB patients living with HIV/AIDS No representative data availableOdds of HIV-positive TB patient havingMDR-TB over odds of HIV-negative TBpatient having MDR-TB

No representative data available

Estimates of burden * 2009(All forms of TB) Number (thousands)

Rate(per 100 000 pop)

Mortality (excluding HIV/AIDS) 0.38 (0.26–0.55) 12 (8.4–18)Prevalence (incl HIV/AIDS) 3.3 (1.3–5.6) 107 (43–182)Incidence (incl HIV/AIDS) 2.2 (1.8–2.7) 73 (59–88)Case detection, all forms (%) 70 (58–85)

Number of laboratories 2008 2009 2010Sputum smear (per 100 000 population) 1.8 1.8 1.9Culture (per 5 million population) 1.6 1.6 1.6DST (per 10 million population) 3.2 3.2 3.2LPA (per 10 million population) 0 3.2Number of DST units for which externalquality assurance was carried out

National reference laboratory in 2009 YesLink to supra-national laboratory Borstel, Germany

First-line DST routinely performed for: all patients

MDR-TB patients who started treatment (2009) and projected numbers to treat

2009 2011 2013 20150

100

200

300

400

GLC-approved

Non-GLC

GLC-approved plan

National plan

Treatment outcomes 2007 cohort GLC Non-GLCCohort size 57% Treatment success 53% Deaths 11

Drug management 2009First-line drugs available in privatepharmacies

Yes

First-line drugs available withoutprescription

Yes

Drug management 2010Second-line drug procurementissuesDrugs provided to treat side-effects Yes

Stock-outs (at least 1 day) 2009Centrallevel

Peripherallevel

First-line drugs No NoSecond-line drugs

MDR-TB management 2009Guidelines for programmaticmanagement of DR-TB developed

Yes, not including XDR-TB

Training material developed NoTraining conducted specifically forDR-TB

Yes

TB infection control national situationassessment carried out

Yes, started in 2010

in the scope of MDR-TB YesNational infection control planavailable

Yes

Tertiary hospitals with person incharge of TB infection control

0

TB notification rate (all forms) inhealth care workers (all staff) overrate in general population

0

Recording and reporting forMDR-TB in place

YesPaper-based

Representative survey/surveillancedata on MDR-TB available

Class B routinesurveillance data (2009);nationwide survey (2007)

* Ranges represent uncertainty intervals Generated: March 7, 2011 Source: www.who.int/tb/data

DST = drug susceptibility testing; LPA = line probe assay; GLC = Green Light Committee; NTP = National TB control programme or equivalent

Armenia  MDR-TBGenerated: February 23, 2011  

Source: www.who.int/tb/data

text variable holder

Nametext variable holder

Armenia

* Ranges represent uncertainty intervals

Please refer to Abbreviations on page v


Model of care for MDR-TB treatment 2010MDR-TB patients hospitalized during intensivephase

Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages, transport vouchers/reimbursement,counselling/psychosocial support, hygiene packages, education; supportadapted to patient's situation

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health Yes includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisons NTPPrison care coordinated with NTP Yes

MDR-TB budget (bar) and available funding (dotted line) (US$ millions)

2008 2009 2010 2011 2012 2013 2014 20150

0.5

1

1.5

2

MDR-TB Management

Second-line drugs

National plan **

Financing (US$ millions) 2010 2011Total NTP budget 7 6MDR-TB financing component: second-line drugs budget <1 <1 total MDR-TB budget <1 <1 available funding <1 <1 funding gap 0 0

% of budget funded 100 100 % available funding from domestic sources % available funding from Global Fund 100 100

WHO TB planning and budgeting tool used

MDR-TB budget by source of funding (US$ millions)

2008 2010 2012 2014-2

-1

0

1

2Government, NTP budget

Loans

Global Fund

Grants (excl. Global Fund)

Gap

National plan ***

MDR-TB budget required per MDR-TB patient to be treated (US$ per patient)

2008 2010 2012 20140

2000

4000

6000

8000

1000012000

Budget required

National plan

Progress since 2009 World Health Assembly resolution 62.15 † Bottlenecks in 2010

Programme management: NTP and MSF share responsibilities.

Laboratory capacity and quality assurance: MGIT and PCR are used.

Qualified M/XMDR-TB treatment (human resources, facilities): managedby a committee on drug resistance, based on WHO recommendations.Specialists are trained in MDR-TB by international experts. There is anMDR-TB Department in the Republican TB Dispensary.

TB infection control: the Ministry of Health approved a TB infection controlplan in 2010.

Financing: NTP (Ministry of Health), MSF and the Global Fund.

Recording and reporting: technical assistance needed for newelectronic system.

Access to quality-assured second-line drugs: weak drugmanagement.



** No breakdown by line item available for 2012–2015

*** No breakdown by sources of funding available for 2012–2015

† Resolution WHA 62.15 “Prevention and control of multi-drug resistant tuberculosis and extensively drug-resistant tuberculosis” and Annex 1.


Armenia (continued)


Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages, transport vouchers/reimbursement,counselling/psychosocial support, hygiene packages, education; supportadapted to patient's situation

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health Yes includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisons NTPPrison care coordinated with NTP Yes


2008 2009 2010 2011 2012 2013 2014 20150

0.5

1

1.5

2

MDR-TB Management

Second-line drugs

National plan **





2008 2010 2012 2014-2

-1

0

1


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

2000

4000

6000

8000

1000012000

Budget required

National plan


Programme management: NTP and MSF share responsibilities.

Laboratory capacity and quality assurance: MGIT and PCR are used.

Qualified M/XMDR-TB treatment (human resources, facilities): managedby a committee on drug resistance, based on WHO recommendations.Specialists are trained in MDR-TB by international experts. There is anMDR-TB Department in the Republican TB Dispensary.

TB infection control: the Ministry of Health approved a TB infection controlplan in 2010.

Financing: NTP (Ministry of Health), MSF and the Global Fund.

Recording and reporting: technical assistance needed for newelectronic system.




Azerbaijan




500

1000

1500

20002500


MDR-TB estimates of burden *% of new TB cases with MDR-TB 22 (19–26) [DRS 2007]% of retreatment TB cases with MDR-TB 56 (52–60) [DRS 2007]MDR-TB cases among incident total TB casesin 2008

4 000 (3 300–4 700)


1 000 (880–1 200)


1 300 (1 200–1 400)


ment TotalConfirmed cases of MDR-TBMDR-TB patients started treatment





Mortality (excluding HIV/AIDS) 1 (0.73–1.4) 12 (8.2–16)Prevalence (incl HIV/AIDS) 15 (6.5–26) 172 (73–289)Incidence (incl HIV/AIDS) 9.7 (7.9–12) 110 (89–132)Case detection, all forms (%) 75 (63–93)

Number of laboratories 2008 2009 2010Sputum smear (per 100 000 population) 0.8 0.8 0.8Culture (per 5 million population) 1.1 1.1DST (per 10 million population) 2.3 2.2LPA (per 10 million population)Number of DST units for which externalquality assurance was carried out


First-line DST routinely performed for: (no patient groups identified)


2009 2011 2013 20150

1000

2000

3000

GLC-approved

Non-GLC

GLC-approved plan

National plan

Treatment outcomes 2007 cohort GLC Non-GLCCohort size% Treatment success % Deaths


No

First-line drugs available withoutprescriptionDrug management 2010Second-line drug procurementissues

Possibility of waivers

Drugs provided to treat side-effects Yes


Peripherallevel

First-line drugs Yes YesSecond-line drugs Yes

MDR-TB management 2009Guidelines for programmaticmanagement of DR-TB developedTraining material developedTraining conducted specifically forDR-TBTB infection control national situationassessment carried out in the scope of MDR-TBNational infection control planavailable

Under preparation

Tertiary hospitals with person incharge of TB infection controlTB notification rate (all forms) inhealth care workers (all staff) overrate in general populationRecording and reporting forMDR-TB in place

PartiallyWeak implementation ofold electronic recordingand reporting system; startof support to electronicsystem by WHO: 02/2011


Routine surveillance datanot representative; surveyin the city of Baku (2007);nationwide survey plannedfor 2011



Azerbaijan  MDR-TBGenerated: February 23, 2011  



Nametext variable holder

Azerbaijan





Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages, counselling/psychosocial support, hygienepackages;transportation being considered (GFATM Round 7, 2007)

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health Yes includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisons MoHPrison care coordinated with NTP Yes


2007 2008 2012 2013 2014 20150

5

10

15

20

25

MDR-TB Management

Second-line drugs

National plan **

Financing (US$ millions) 2010 2011Total NTP budgetMDR-TB financing component: second-line drugs budget total MDR-TB budget available funding funding gap % of budget funded % available funding from domestic sources % available funding from Global Fund



20072008201220132014201505

10

15

2025

Government, NTP budget

Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

5000

10000

15000

20000

Budget required

National plan


Issues in case-finding or enrolment for treatment: as of 2011, cultures aretaken from all new patients and re-treatment patients. This allows quickidentification of drug resistance and adequate provision of treatment.

Programme management: a new TB control plan and strategy wereapproved by country authority for 2011–2015.

Recording and reporting: with WHO support, TB data Recording andreporting forms were revised and standardized. The TB reporting formswill be used from 2011.

Laboratory capacity and quality assurance: the NRL was certified andquality-assured in 2010 by the SRL. There are no human resourcesconstraints. In 2010, four second-level laboratories were established atinter-regional level. The NRL and third-level laboratory in the prison sectorare fully equipped with reagents for culture and DST of first-line drugs.

Qualified M/XMDR-TB treatment (human resources, facilities): TBdoctors were trained in MDR-TB management in WHO collaboratingcenters abroad in 2010.

TB infection control: "Guidelines on infection control" were developed in2010.

Laboratory capacity and quality assurance: limited laboratorycapacity.

Qualified M/XMDR-TB treatment (human resources,facilities): limited human resource capacity to manageMDR-TB.

Financing: lack of funds for first-line drugs and weakcommitment of NTP.







Azerbaijan (continued)


Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages, counselling/psychosocial support, hygienepackages;transportation being considered (GFATM Round 7, 2007)



2007 2008 2012 2013 2014 20150

5

10

15

20

25

MDR-TB Management

Second-line drugs

National plan **




20072008201220132014201505

10

15

2025


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

5000

10000

15000

20000

Budget required

National plan


Issues in case-finding or enrolment for treatment: as of 2011, cultures aretaken from all new patients and re-treatment patients. This allows quickidentification of drug resistance and adequate provision of treatment.

Programme management: a new TB control plan and strategy wereapproved by country authority for 2011–2015.

Recording and reporting: with WHO support, TB data Recording andreporting forms were revised and standardized. The TB reporting formswill be used from 2011.

Laboratory capacity and quality assurance: the NRL was certified andquality-assured in 2010 by the SRL. There are no human resourcesconstraints. In 2010, four second-level laboratories were established atinter-regional level. The NRL and third-level laboratory in the prison sectorare fully equipped with reagents for culture and DST of first-line drugs.

Qualified M/XMDR-TB treatment (human resources, facilities): TBdoctors were trained in MDR-TB management in WHO collaboratingcenters abroad in 2010.

TB infection control: "Guidelines on infection control" were developed in2010.



Financing: lack of funds for first-line drugs and weakcommitment of NTP.



Bangladesh

| High TB burden | High MDR-TB burden | Multidrug-resistant tuberculosis profile



1000

2000

3000

4000


MDR-TB estimates of burden *% of new TB cases with MDR-TB 2.2 (0.0–5.6) [model 2008]% of retreatment TB cases with MDR-TB 15 (0.0–40) [model 2008]MDR-TB cases among incident total TB casesin 2008

9 800 (1 000–19 000)


3 000 (0–7 500)


600 (0–1 600)


ment TotalConfirmed cases of MDR-TBMDR-TB patients started treatment 352





Mortality (excluding HIV/AIDS) 83 (60–110) 51 (37–68)Prevalence (incl HIV/AIDS) 690 (320–1 100) 425 (197–697)Incidence (incl HIV/AIDS) 360 (300–440) 225 (183–271)Case detection, all forms (%) 44 (37–54)

Number of laboratories 2008 2009 2010Sputum smear (per 100 000 population) 0.6 0.6 0.6Culture (per 5 million population) 0.1 <0.1 <0.1DST (per 10 million population) 0.1 <0.1 <0.1LPA (per 10 million population)Number of DST units for which externalquality assurance was carried out

National reference laboratory in 2009 YesLink to supra-national laboratory Antwerp, Belgium

First-line DST routinely performed for: cases failing a retreatment regimen,cases failing one or more retreatment regimens


2009 2011 2013 20150

1000

2000

3000

40005000

GLC-approved

Non-GLC

GLC-approved plan

National plan



Yes


No

Drug management 2010Second-line drug procurementissues

No (registration waived)



Peripherallevel

First-line drugs No NoSecond-line drugs No No



Training material developed YesTraining conducted specifically forDR-TB

Yes


Yes (2009). Notsystematically done


Yes


1


0


PartiallyPaper-based


No representative dataavailable; nationwidesurvey under way



Bangladesh  TB  MDR-TBGenerated: February 23, 2011  



Bangladesh





Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: transport cost reimbursement, counselling/psychosocialsupport, vocational training

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health Yes includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisons NTP (MOH) Treatment

as per National MDR-TB Guidelines

Prison care coordinated with NTP Yes


2007200820092010201120122013201420150

5

10

15

MDR-TB Management

Second-line drugs

National plan **

Financing (US$ millions) 2010 2011Total NTP budget 25 46MDR-TB financing component: second-line drugs budget <1 4 total MDR-TB budget <1 5 available funding <1 5 funding gap 0 0


WHO TB planning and budgeting tool used Yes (2010)


2007 2009 2011 2013 20150

5

10


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

1000200030004000500060007000

Budget required

National plan


TB infection control:TB infection control measures have beenimplemented.

Access to quality-assured second-line drugs: in place.

Programme management: a significant number of diagnosedpatients are not receiving treatment.



Financing: funds to be identified for full scale up. Delays indisbursing funds are causing delays in starting treatment.







Bangladesh (continued)

Bulgaria




100

200

300

400500


MDR-TB estimates of burden *% of new TB cases with MDR-TB 13 (0.0–25) [model 2008]% of retreatment TB cases with MDR-TB 42 (12–72) [model 2008]MDR-TB cases among incident total TB casesin 2008

460 (98–810)


260 (0–530)


160 (44–270)







Mortality (excluding HIV/AIDS) 0.25 (0.19–0.36) 3.3 (2.5–4.8)Prevalence (incl HIV/AIDS) 3.8 (1.2–6.6) 51 (16–88)Incidence (incl HIV/AIDS) 3.1 (2.7–3.6) 41 (36–47)Case detection, all forms (%) 86 (75–100)

Number of laboratories 2008 2009 2010Sputum smear (per 100 000 population) 0.5 0.5 0.5Culture (per 5 million population) 21.7 21.9 20.0DST (per 10 million population) 29.0 29.2 5.3LPA (per 10 million population) 1.3 1.3Number of DST units for which externalquality assurance was carried out 1 1

National reference laboratory in 2009 YesLink to supra-national laboratory Rome, Italy

First-line DST routinely performed for: new cases, all retreatment cases, casesfailing a retreatment regimen, cases that are contacts of MDR-TB cases


2009 2011 2013 20150

50

100

150

200250

GLC-approved

Non-GLC

GLC-approved plan

National plan



Yes


No



Drugs provided to treat side-effectsAvailability of free ancillarydrugs assured by hospitalsduring the intensive phase


Peripherallevel



Yes, including XDR-TB


Yes


Yes


Under preparation


YesElectronic


Class B routinesurveillance data (2008);nationwide survey underway



Bulgaria  MDR-TBGenerated: February 23, 2011  



Bulgaria





Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages; additional support needed to cover transportcosts

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health Yes includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisons MoH and MoJPrison care coordinated with NTP Yes


2007200820092010201120122013201420150

0.5

1

1.5

2

2.5

MDR-TB Management

Second-line drugs

National plan **





2007 2009 2011 2013 20150

0.5

1

1.5

22.5


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

5000

10000

15000

2000025000

Budget required

National plan


Issues in case-finding or enrolment for treatment: NGOs are involved insupporting TB health facilities in active case-finding and contact tracing toensure early diagnosis for all TB cases, including MDR-TB.

Programme management: monthly review of GLC cohort of MDR-TBpatients by Expert Committee. Algorithm for management of inpatient andoutpatient treatment and care was successfully introduced in 2009.

Recording and reporting: strengthened through the development of anElectronic Patient Information System.

Laboratory capacity and quality assurance: EQA system for cultures andDST of first-line drugs introduced in 2010.

Access to quality-assured second-line drugs: second-line drugs procuredthrough GLC.

Infection control: to be strengthened through improved infection controlplans; regular supervisory visits; upgraded and well maintained laboratoryequipment; and improved environmental control.

Financing: public financing ensured to cover the costs of inpatient treatmentfor MDR-TB patients.

Qualified MDR/XDR-TB treatment (human resources,facilities): need to increase the number of staff involved inMDR-TB management at central level and MDR-TB treatmentsectors.

Other: insufficient social support to MDR-TB patients.







Bulgaria (continued)

Belarus




500

1000

1500



800 (260–1 300)


530 (0–1 100)


370 (100–630)


ment TotalConfirmed cases of MDR-TB 464 840 1 342MDR-TB patients started treatment






Number of laboratories 2008 2009 2010Sputum smear (per 100 000 population) 15.5 1.6Culture (per 5 million population) 47.0 20.8DST (per 10 million population) 22.7 22.8LPA (per 10 million population)Number of DST units for which externalquality assurance was carried out

National reference laboratory in 2009 YesLink to supra-national laboratory Stockholm, Sweden

First-line DST routinely performed for:


2009 2011 2013 20150

200

400

600

8001000

GLC-approved

Non-GLC

GLC-approved plan

National plan


Drug management 2009First-line drugs available in privatepharmaciesFirst-line drugs available withoutprescriptionDrug management 2010Second-line drug procurementissues

Strict customs regulations

Drugs provided to treat side-effects


Peripherallevel

First-line drugsSecond-line drugs

MDR-TB management 2009Guidelines for programmaticmanagement of DR-TB developedTraining material developedTraining conducted specifically forDR-TBTB infection control national situationassessment carried out

Yes (2009)


Yes


YesElectronic


Class B routinesurveillance data (2008);nationwide survey underway



Belarus  MDR-TBGenerated: February 23, 2011  



Belarus





Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages, transport vouchers/reimbursement,counselling/psychosocial support; exploring possibility of treatment programsfor alcohol-dependent individuals and injecting drug users for DR-TB (2008)

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health Yes includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisons Ministry of Interior,

Department of medicalservices for penitentiarysystem



2012 2013 2014 20150

2

4

6

8




2012 2013 2014 20150

2

4

6

8


2008 2010 2012 20140

2000

4000

6000

800010000

Budget required

National plan


Qualified M/XMDR-TB treatment (human resources,facilities): limited human resource capacity for MDR-TB.

Access to quality-assured second-line drugs: decentralizeddrug procurement system is not efficient.

TB infection control: weak infection control.







Belarus (continued)

Democratic Republic of the Congo

| High TB burden | High HIV burden | High MDR-TB burden | Multidrug-resistant tuberculosis profile



500

1000

1500

20002500


MDR-TB estimates of burden *% of new TB cases with MDR-TB 1.8 (0.0–4.3) [model 2008]% of retreatment TB cases with MDR-TB 7.7 (0.0–18) [model 2008]MDR-TB cases among incident total TB casesin 2008

5 600 (530–11 000)


1 500 (0–3 700)


670 (0–1 600)


ment TotalConfirmed cases of MDR-TB 91 91MDR-TB patients started treatment 176





Mortality (excluding HIV/AIDS) 50 (35–67) 76 (54–102)Prevalence (incl HIV/AIDS) 430 (200–700) 645 (302–1 061)Incidence (incl HIV/AIDS) 250 (200–300) 372 (302–448)Case detection, all forms (%) 45 (38–56)

Number of laboratories 2008 2009 2010Sputum smear (per 100 000 population) 2.1 2.2 2.1Culture (per 5 million population) <0.1 <0.1 0.1DST (per 10 million population) 0.2 0.2 0.3LPA (per 10 million population)Number of DST units for which externalquality assurance was carried out


First-line DST routinely performed for: all retreatment cases, cases failing aretreatment regimen, cases failing one or more retreatment regimens, casesthat are contacts of MDR-TB cases


2009 2011 2013 20150

200

400

600

8001000

GLC-approved

Non-GLC

GLC-approved plan

National plan



No


No

Drug management 2010Second-line drug procurementissuesDrugs provided to treat side-effects No


Peripherallevel

First-line drugs Yes NoSecond-line drugs No No




Yes


No

in the scope of MDR-TBNational infection control planavailable

No


YesPaper-based at peripherallevel. Electronic atprovincial and nationallevels


Routine surveillance datanot representative; surveyin the city of Kinshasa(1999)



Democratic Republic of the Congo  TB   HIV  MDR-TBGenerated: February 23, 2011  



Name





Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages, counselling/psychosocial support; patientsupport groups with former TB patients

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisonsPrison care coordinated with NTP


2007 2008 2009 2010 2011 2012 2013 2014 20150

2

4

6

8

MDR-TB Management

Second-line drugs

National plan **

Financing (US$ millions) 2010 2011Total NTP budget 64 64MDR-TB financing component: second-line drugs budget 1 2 total MDR-TB budget 4 5 available funding <1 funding gap 3 5

% of budget funded 18 % available funding from domestic sources % available funding from Global Fund 78

WHO TB planning and budgeting tool used Yes(2007-2008)


2007 2009 2011 2013 20150

2

4

6


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

5000

10000

15000

Budget required

National plan


Programme management: delay in signing memorandum ofunderstanding between Expand-TB and Ministry of Health;insufficient implementation of MDR-TB.

Recording and reporting: weak; limited capacity at peripheraland provincial levels.

Laboratory capacity and quality assurance: weak laboratorycapacity.

Qualified M/XMDR-TB treatment (human resources,facilities): limited human resource capacity.


TB infection control: no national policy.

Other: no access to drugs for managing side-effects.







Democratic Republic of the Congo (continued)


Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages, counselling/psychosocial support; patientsupport groups with former TB patients

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisonsPrison care coordinated with NTP


2007 2008 2009 2010 2011 2012 2013 2014 20150

2

4

6

8

MDR-TB Management

Second-line drugs

National plan **

Financing (US$ millions) 2010 2011Total NTP budget 64 64MDR-TB financing component: second-line drugs budget 1 2 total MDR-TB budget 4 5 available funding <1 funding gap 3 5

% of budget funded 18 % available funding from domestic sources % available funding from Global Fund 78



2007 2009 2011 2013 20150

2

4

6


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

5000

10000

15000

Budget required

National plan


Programme management: delay in signing memorandum ofunderstanding between Expand-TB and Ministry of Health;insufficient implementation of MDR-TB.

Recording and reporting: weak; limited capacity at peripheraland provincial levels.

Laboratory capacity and quality assurance: weak laboratorycapacity.

Qualified M/XMDR-TB treatment (human resources,facilities): limited human resource capacity.


TB infection control: no national policy.

Other: no access to drugs for managing side-effects.



China




10000200003000040000500006000070000

Population (millions) 2009 1 346

MDR-TB estimates of burden *% of new TB cases with MDR-TB 5.7 (5.0–6.6) [DRS 2007]% of retreatment TB cases with MDR-TB 26 (23–28) [DRS 2007]MDR-TB cases among incident total TB casesin 2008

100 000 (79 000–120 000)


51 000 (44 000–59 000)


15 000 (13 000–17 000)







Mortality (excluding HIV/AIDS) 160 (100–220) 12 (7.5–17)Prevalence (incl HIV/AIDS) 1 900 (760–3 000) 138 (56–225)Incidence (incl HIV/AIDS) 1 300 (1 100–1 500) 96 (83–109)Case detection, all forms (%) 75 (66–86)

Number of laboratories 2008 2009 2010Sputum smear (per 100 000 population) 0.2 0.2 0.2Culture (per 5 million population) 2.3 3.1 3.5DST (per 10 million population) 0.8 1.0 1.2LPA (per 10 million population) <0.1 <0.1Number of DST units for which externalquality assurance was carried out 0 11

National reference laboratory in 2009 YesLink to supra-national laboratory Hong Kong SAR, China



2009 2011 2013 20150

5000

10000

15000

2000025000

GLC-approved

Non-GLC

GLC-approved plan

National plan



No


No


Complex importationprocedures



Peripherallevel





Yes


Under preparation


Yes


YesElectronic andpaper-based.


Routine surveillance datanot representative;representative survey dataavailable from nationwideTB drug-resistance survey(2007), and fromdrug-resistance surveys in10 provinces (WHOproject)



China  TB   HIV  MDR-TBGenerated: February 23, 2011  



Name





Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages, transport vouchers/reimbursement (limited topoorest)

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health No includes a budget No part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisons NoPrison care coordinated with NTP


2007200820092010201120122013201420150

20

40

60

80

MDR-TB Management

Second-line drugs

National plan **

Financing (US$ millions) 2010 2011Total NTP budget 239 285MDR-TB financing component: second-line drugs budget 8 14 total MDR-TB budget 15 35 available funding 12 35 funding gap 2 0

% of budget funded 84 100 % available funding from domestic sources 46 10 % available funding from Global Fund 54 90

WHO TB planning and budgeting tool used No


2007 2009 2011 2013 20150

20

40

60


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

2000

4000

6000

8000

1000012000

Budget required

National plan

Progress since 2009 World Health Assembly resolution 62.15 Bottlenecks in 2010

Programme management: national MDR-TB strategic plan (in draft).

Laboratory capacity and quality assurance: plan for national TB laboratorynetwork system (in draft).

Access to quality-assured second-line drugs: quality-assured second-linedrugs available from Global Fund project.

Financing: funding mechanism for MDR-TB under development throughinsurance and government investment.

Issues in case-finding or enrolment for treatment: delays indiagnosis and treatment initiation in selected sites.

Recording and reporting: timeliness and veracity of individualcase reporting system is unsatisfactory.

Laboratory capacity and quality assurance: new tools need tobe incorporated in the national plan and match treatmentcapacity.

Qualified M/XMDR-TB treatment (human resources,facilities): human resource capacity for MDR-TB is limited inquantity and quality; facilities for infection control areinsufficient.

Access to quality-assured second-line drugs: no qualityassurance for second-line drugs outside the Global Fundproject area.




*** Data in the table only apply to the Global Fund MDR-TB pilot areas in China. China government budget contributes to MDR-TB care and control through health insurance schemes and support to medical facilities and human resources.

† No breakdown by sources of funding available for 2012–2015

†† Resolution WHA 62.15 “Prevention and control of multi-drug resistant tuberculosis and extensively drug-resistant tuberculosis” and Annex 1.


China (continued)


Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages, transport vouchers/reimbursement (limited topoorest)

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health No includes a budget No part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisons NoPrison care coordinated with NTP


2007200820092010201120122013201420150

20

40

60

80

MDR-TB Management

Second-line drugs

National plan **





2007 2009 2011 2013 20150

20

40

60


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

2000

4000

6000

8000

1000012000

Budget required

National plan

Progress since 2009 World Health Assembly resolution 62.15 Bottlenecks in 2010

Programme management: national MDR-TB strategic plan (in draft).

Laboratory capacity and quality assurance: plan for national TB laboratorynetwork system (in draft).

Access to quality-assured second-line drugs: quality-assured second-linedrugs available from Global Fund project.

Financing: funding mechanism for MDR-TB under development throughinsurance and government investment.

Issues in case-finding or enrolment for treatment: delays indiagnosis and treatment initiation in selected sites.

Recording and reporting: timeliness and veracity of individualcase reporting system is unsatisfactory.

Laboratory capacity and quality assurance: new tools need tobe incorporated in the national plan and match treatmentcapacity.

Qualified M/XMDR-TB treatment (human resources,facilities): human resource capacity for MDR-TB is limited inquantity and quality; facilities for infection control areinsufficient.

Access to quality-assured second-line drugs: no qualityassurance for second-line drugs outside the Global Fundproject area.



Estonia

| High HIV burden | High MDR-TB burden | Multidrug-resistant tuberculosis profile



20

40

60

80100



93 (71–120)


48 (36–63)


34 (26–43)



% of MDR-TB patients living with HIV/AIDS 7.2 [2009 routine surveillance]Odds of HIV-positive TB patient havingMDR-TB over odds of HIV-negative TBpatient having MDR-TB

0.8 (0.2-2.1) [2009 routinesurveillance]




Number of laboratories 2008 2009 2010Sputum smear (per 100 000 population) 0.6 0.6 0.6Culture (per 5 million population) 7.5 7.5 7.5DST (per 10 million population) 14.9 14.9 14.9LPA (per 10 million population) 0 0Number of DST units for which externalquality assurance was carried out 0 0

National reference laboratory in 2009 YesLink to supra-national laboratory Solna, Sweden



2009 2011 2013 20150

20

40

60

80100

GLC-approved

Non-GLC

GLC-approved plan

National plan



No


No





Peripherallevel





Yes


Yes (during jointWHO/ECDC/GLC countrymission, 23-27 August2010)


No

Tertiary hospitals with person incharge of TB infection controlTB notification rate (all forms) inhealth care workers (all staff) overrate in general population

0.8


YesElectronic


Class A routinesurveillance data (2009)



Estonia   HIV  MDR-TBGenerated: February 23, 2011  



Name





Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages, transport vouchers/reimbursement,counselling, social support



2007200820092010201120122013201420150

0.2

0.4

0.6

0.8

1

MDR-TB Management

Second-line drugs

National plan **

Financing (US$ millions) 2010 2011Total NTP budget <1 <1MDR-TB financing component: second-line drugs budget <1 <1 total MDR-TB budget <1 <1 available funding <1 <1 funding gap 0 0

% of budget funded 100 100 % available funding from domestic sources 100 100 % available funding from Global Fund



2007 2009 2011 2013 20150

0.2

0.4

0.6

0.81


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

5000

10000

15000

2000025000

Budget required

National plan


Qualified MDR/XDR-TB treatment (human resources,facilities): limited access to some third-line drugs (linezolid,clofazimine) for treatment of patients with XDR-TB.

TB infection control: problems with case management andisolation of XDR-TB patients after specific TB treatment hasterminated.

Other: limited palliative care; limited counselling capacity foralcohol-dependent individuals and injecting drug users.







Estonia (continued)


Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages, transport vouchers/reimbursement,counselling, social support



2007200820092010201120122013201420150

0.2

0.4

0.6

0.8

1

MDR-TB Management

Second-line drugs

National plan **

Financing (US$ millions) 2010 2011Total NTP budget <1 <1MDR-TB financing component: second-line drugs budget <1 <1 total MDR-TB budget <1 <1 available funding <1 <1 funding gap 0 0




2007 2009 2011 2013 20150

0.2

0.4

0.6

0.81


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

5000

10000

15000

2000025000

Budget required

National plan


Qualified MDR/XDR-TB treatment (human resources,facilities): limited access to some third-line drugs (linezolid,clofazimine) for treatment of patients with XDR-TB.

TB infection control: problems with case management andisolation of XDR-TB patients after specific TB treatment hasterminated.

Other: limited palliative care; limited counselling capacity foralcohol-dependent individuals and injecting drug users.



Ethiopia




500

1000

1500

2000


MDR-TB estimates of burden *% of new TB cases with MDR-TB 1.6 (0.90–2.7) [DRS 2005]% of retreatment TB cases with MDR-TB 12 (6.4–21) [DRS 2005]MDR-TB cases among incident total TB casesin 2008

5 200 (2 400–8 000)


1 500 (870–2 600)


420 (230–740)







Mortality (excluding HIV/AIDS) 53 (36–74) 64 (43–90)Prevalence (incl HIV/AIDS) 470 (220–780) 572 (265–947)Incidence (incl HIV/AIDS) 300 (240–360) 359 (291–432)Case detection, all forms (%) 50 (42–62)

Number of laboratories 2008 2009 2010Sputum smear (per 100 000 population) 1.5 1.4 1.9Culture (per 5 million population) 0.1 0.1 0.4DST (per 10 million population) 0.2 0.2 0.2LPA (per 10 million population) 0 0.8Number of DST units for which externalquality assurance was carried out 0 7

National reference laboratory in 2009 YesLink to supra-national laboratory Bilthoven, Netherlands



2009 2011 2013 20150

500

1000

1500

20002500

GLC-approved

Non-GLC

GLC-approved plan

National plan



No


No


Registration of SLDmandatory



Peripherallevel

First-line drugs Yes YesSecond-line drugs No No




Yes


Yes (2008)


Yes


100

TB notification rate (all forms) inhealth care workers (all staff) overrate in general populationRecording and reporting forMDR-TB in place

YesElectronic (Excel-based)


Routine surveillance datanot representative;nationwide survey (2005)



Ethiopia  TB   HIV  MDR-TBGenerated: February 23, 2011  



Name





Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages, counselling/psychosocial support, education

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health Yes includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisons NGO & MoHPrison care coordinated with NTP Yes


2007 2008 2009 2010 2011 2012 2013 2014 20150

1

2

3

4

5

6

MDR-TB Management

Second-line drugs

National plan **





2007 2009 2011 2013 201501

2

3

4

56


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

10000

20000

30000

Budget required

National plan


Laboratory capacity and quality assurance: NRL capacity is huge andexpansion of diagnostic services to regions is almost completed.

Issues in case-finding or enrolment for treatment: huge backlogof diagnosed cases.

Programme management: MDR-TB service limited to twosites (Addis Ababa and Gondar).

Qualified M/XMDR-TB treatment (human resources,facilities): limited human resource capacity and high staffturnover.

Access to quality-assured second-line drugs: strict drugregulations pursuant to contract with International DispensaryAssociation.

TB infection control: limited to MDR-TB treatment sites, poorlypracticed in other facilities.







Ethiopia (continued)


Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages, counselling/psychosocial support, education

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health Yes includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisons NGO & MoHPrison care coordinated with NTP Yes


2007 2008 2009 2010 2011 2012 2013 2014 20150

1

2

3

4

5

6

MDR-TB Management

Second-line drugs

National plan **





2007 2009 2011 2013 201501

2

3

4

56


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

10000

20000

30000

Budget required

National plan


Laboratory capacity and quality assurance: NRL capacity is huge andexpansion of diagnostic services to regions is almost completed.

Issues in case-finding or enrolment for treatment: huge backlogof diagnosed cases.

Programme management: MDR-TB service limited to twosites (Addis Ababa and Gondar).

Qualified M/XMDR-TB treatment (human resources,facilities): limited human resource capacity and high staffturnover.

Access to quality-assured second-line drugs: strict drugregulations pursuant to contract with International DispensaryAssociation.

TB infection control: limited to MDR-TB treatment sites, poorlypracticed in other facilities.



Georgia




100

200

300

400


MDR-TB estimates of burden *% of new TB cases with MDR-TB 10 (8.9–12) [DRS 2009]% of retreatment TB cases with MDR-TB 31 (27–35) [DRS 2009]MDR-TB cases among incident total TB casesin 2008

670 (550–780)


220 (170–280)


160 (130–180)







Mortality (excluding HIV/AIDS) 0.21 (0.19–0.23) 4.8 (4.4–5.3)Prevalence (incl HIV/AIDS) 4.9 (1.1–8.7) 116 (27–205)Incidence (incl HIV/AIDS) 4.5 (4–5.1) 107 (94–119)Case detection, all forms (%) 100 (93–120)

Number of laboratories 2008 2009 2010Sputum smear (per 100 000 population) 0.7 0.7 0.7Culture (per 5 million population) 2.3 2.3 2.4DST (per 10 million population) 2.3 2.3 2.4LPA (per 10 million population) 2.3 2.4Number of DST units for which externalquality assurance was carried out 1




2009 2011 2013 20150

100

200

300

400

500600

GLC-approved

Non-GLC

GLC-approved plan

National plan



Yes


Yes


Product registrationmandatory



Peripherallevel





Yes


Yes (2008)


Under preparation


0


YesElectronic (web-based)





Georgia  MDR-TBGenerated: February 23, 2011  



Name





Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages, transport vouchers/reimbursement, hygienepackages, counselling/psychosocial support, housing support, education,financial incentives

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health Yes includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisons MCLA, NTPPrison care coordinated with NTP Yes


2007200820092010201120122013201420150

2

4

6

8

10

12

MDR-TB Management

Second-line drugs

National plan **

Financing (US$ millions) 2010 2011Total NTP budget 9 8MDR-TB financing component: second-line drugs budget 1 <1 total MDR-TB budget 2 <1 available funding 2 <1 funding gap 0 0




2007 2009 2011 2013 201502

4

6

8

1012


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

5000

10000

15000

20000

Budget required

National plan


TB infection control: improved infection control measures implemented inthe penitentiary sector.

Recording and reporting: routine linkage of laboratory information and drugmanagement module established.

Issues in case-finding or enrolment for treatment: involvementof private health-care providers needs strengthening.

Financing: need to increase NTP staff salaries and incentivesfor patients.

Other: outpatient care needs further strengthening.







Georgia (continued)


Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages, transport vouchers/reimbursement, hygienepackages, counselling/psychosocial support, housing support, education,financial incentives

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health Yes includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisons MCLA, NTPPrison care coordinated with NTP Yes


2007200820092010201120122013201420150

2

4

6

8

10

12

MDR-TB Management

Second-line drugs

National plan **





2007 2009 2011 2013 201502

4

6

8

1012


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

5000

10000

15000

20000

Budget required

National plan


TB infection control: improved infection control measures implemented inthe penitentiary sector.

Recording and reporting: routine linkage of laboratory information and drugmanagement module established.

Issues in case-finding or enrolment for treatment: involvementof private health-care providers needs strengthening.

Financing: need to increase NTP staff salaries and incentivesfor patients.

Other: outpatient care needs further strengthening.



Indonesia




1000200030004000500060007000



9 300 (0–21 000)


5 600 (1 400–19 000)


840 (0–2 300)


ment TotalConfirmed cases of MDR-TBMDR-TB patients started treatment 20






Number of laboratories 2008 2009 2010Sputum smear (per 100 000 population) 2.2 2.2 2.2Culture (per 5 million population) 1.3 0.9 0.9DST (per 10 million population) 0.9 0.2 0.3LPA (per 10 million population) 0 0Number of DST units for which externalquality assurance was carried out 0 0

National reference laboratory in 2009 NoLink to supra-national laboratory Adelaide, Australia



2009 2011 2013 20150

1000200030004000500060007000

GLC-approved

Non-GLC

GLC-approved plan

National plan



Yes


No


Complicated importationprocedures & shortage ofKanamycin in GDF



Peripherallevel

First-line drugs No YesSecond-line drugs No No




Yes


Yes (2008)


Yes


YesPaper-based and electronic


Routine surveillance datanot representative; surveyin Mimika district, Papuaprovince (2004) and inCentral Java province(2006); survey in East Javaprovince under way



Indonesia  TB   HIV  MDR-TBGenerated: February 23, 2011  



Name





No

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: incentive for transport and nutrition/food, moral/ religioussupport, simple skills to make handicrafts (income generated activities)

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health Yes includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisons NoPrison care coordinated with NTP


2007200820092010201120122013201420150

20

40

60

80

100

120

MDR-TB Management

Second-line drugs

National plan **

Financing (US$ millions) 2010 2011Total NTP budget 71 85MDR-TB financing component: second-line drugs budget 1 2 total MDR-TB budget 7 2 available funding 2 <1 funding gap 5 2

% of budget funded 30 24 % available funding from domestic sources 7 % available funding from Global Fund 79 100



2007 2009 2011 2013 20150

20

40

60

80

100120


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

10000

20000

30000

40000

5000060000

Budget required

National plan


Programme management: significantly improved.

Qualified M/XMDR-TB treatment (human resources, facilities): sufficient.

Access to quality-assured second-line drugs: available via the GLC.

TB infection control: in place.

Programme management: at early stages of initiatingprogrammatic management of drug-resistant TB; poorcommitment of decision-makers and related sectors foruninterrupted funding and to ensure the continuation of suchactivities; delay in initiating the programme.

Recording and reporting: electronic recording and reportingneeds to be adjusted and strengthened.

Laboratory capacity and quality assurance: limited laboratorycapacity for culture and DST. Only five NRLs are certified tocarry out DST of first- and second-line drugs. Expansion of theTB laboratory network requires more capability for MDR-TBculture and identification, and should accord with expansion ofthe programmatic management of drug-resistant TB.







Indonesia (continued)


No

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: incentive for transport and nutrition/food, moral/ religioussupport, simple skills to make handicrafts (income generated activities)

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health Yes includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisons NoPrison care coordinated with NTP


2007200820092010201120122013201420150

20

40

60

80

100

120

MDR-TB Management

Second-line drugs

National plan **

Financing (US$ millions) 2010 2011Total NTP budget 71 85MDR-TB financing component: second-line drugs budget 1 2 total MDR-TB budget 7 2 available funding 2 <1 funding gap 5 2

% of budget funded 30 24 % available funding from domestic sources 7 % available funding from Global Fund 79 100



2007 2009 2011 2013 20150

20

40

60

80

100120


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

10000

20000

30000

40000

5000060000

Budget required

National plan


Programme management: significantly improved.

Qualified M/XMDR-TB treatment (human resources, facilities): sufficient.

Access to quality-assured second-line drugs: available via the GLC.


Programme management: at early stages of initiatingprogrammatic management of drug-resistant TB; poorcommitment of decision-makers and related sectors foruninterrupted funding and to ensure the continuation of suchactivities; delay in initiating the programme.

Recording and reporting: electronic recording and reportingneeds to be adjusted and strengthened.

Laboratory capacity and quality assurance: limited laboratorycapacity for culture and DST. Only five NRLs are certified tocarry out DST of first- and second-line drugs. Expansion of theTB laboratory network requires more capability for MDR-TBculture and identification, and should accord with expansion ofthe programmatic management of drug-resistant TB.



India




20000

40000

60000

80000

Population (millions) 2009 1 198


99 000 (79 000–120 000)


23 000 (18 000–28 000)


50 000 (43 000–57 000)


ment TotalConfirmed cases of MDR-TB 1 660 1 660MDR-TB patients started treatment 1 136





Mortality (excluding HIV/AIDS) 280 (160–430) 23 (14–36)Prevalence (incl HIV/AIDS) 3 000 (1 300–5 000) 249 (105–419)Incidence (incl HIV/AIDS) 2 000 (1 600–2 400) 168 (137–202)Case detection, all forms (%) 67 (56–83)

Number of laboratories 2008 2009 2010Sputum smear (per 100 000 population) 1.1 1.1 1.1Culture (per 5 million population) <0.1 <0.1 0.1DST (per 10 million population) 0.1 0.1 0.2LPA (per 10 million population) <0.1 <0.1Number of DST units for which externalquality assurance was carried out 0 12

National reference laboratory in 2009 YesLink to supra-national laboratory Chennai, India

First-line DST routinely performed for: cases failing a retreatment regimen,cases failing one or more retreatment regimens, cases that are contacts ofMDR-TB cases


2009 2011 2013 20150

10000

20000

30000

40000

GLC-approved

Non-GLC

GLC-approved plan

National plan



Yes


Yes

Drug management 2010Second-line drug procurementissuesDrugs provided to treat side-effects No


Peripherallevel

First-line drugs No NoSecond-line drugs Yes Yes




Yes


Pilot sites only (2010)


Pilot sites only (2010)


0


YesPaper-based and electronic(Reporting system foraggregate data)


Routine surveillance datanot representative; surveysin 9 districts/states1995-2006; 3 subnationalDRS surveys conducted2006-2010 and 1subnational DRS surveyunder way



India  TB   HIV  MDR-TBGenerated: February 23, 2011  



Name





Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: inadequate access to social schemes; Eli Lilly and GermanLeprosy and TB Relief Association providing food support in some states

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health Yes includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisonsPrison care coordinated with NTP


2007200820092010201120122013201420150

10

20

30

40

50

60

MDR-TB Management

Second-line drugs

National plan **





2007 2009 2011 2013 20150

10

20

30

40

5060


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

1000

2000

3000

4000

Budget required

National plan


Laboratory capacity and quality assurance: expanding.

Access to quality-assured second-line drugs: adequate availability; timelyprocurement and delivery; cost limits treatment options within fundingenvelope.

TB infection control: national guidelines on airborne infection controlcontaining section on MDR-TB ward and laboratories are prioritized forimplementation.

Recording and reporting: no comprehensive integratedelectronic MDR-TB system in place.

Laboratory capacity and quality assurance: although expanding,limited laboratory capacity for diagnosis and follow-up ofMDR-TB patients. Limited availability of second-line drugs andDST. Need for implementation of high-throughput diagnostics.Specimen transportation infrastructure is needed in the generalhealth system.

Qualified MDR/XDR-TB treatment (human resources,facilities): limited human resource capacity to undertakerequired pre-implementation training and assessments.

Financing: funding envelope is limited and unable toaccommodate scale-up as envisaged with rising costs ofsecond-line drugs.







India (continued)


Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: inadequate access to social schemes; Eli Lilly and GermanLeprosy and TB Relief Association providing food support in some states



2007200820092010201120122013201420150

10

20

30

40

50

60

MDR-TB Management

Second-line drugs

National plan **





2007 2009 2011 2013 20150

10

20

30

40

5060


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

1000

2000

3000

4000

Budget required

National plan


Laboratory capacity and quality assurance: expanding.

Access to quality-assured second-line drugs: adequate availability; timelyprocurement and delivery; cost limits treatment options within fundingenvelope.

TB infection control: national guidelines on airborne infection controlcontaining section on MDR-TB ward and laboratories are prioritized forimplementation.

Recording and reporting: no comprehensive integratedelectronic MDR-TB system in place.

Laboratory capacity and quality assurance: although expanding,limited laboratory capacity for diagnosis and follow-up ofMDR-TB patients. Limited availability of second-line drugs andDST. Need for implementation of high-throughput diagnostics.Specimen transportation infrastructure is needed in the generalhealth system.

Qualified MDR/XDR-TB treatment (human resources,facilities): limited human resource capacity to undertakerequired pre-implementation training and assessments.

Financing: funding envelope is limited and unable toaccommodate scale-up as envisaged with rising costs ofsecond-line drugs.



Kyrgyzstan




200

400

600

8001000



1 400 (350–2 400)


480 (0–980)


320 (90–550)







Mortality (excluding HIV/AIDS) 1.2 (0.84–1.8) 22 (15–32)Prevalence (incl HIV/AIDS) 13 (5.2–22) 236 (95–401)Incidence (incl HIV/AIDS) 8.7 (7.1–11) 159 (130–192)Case detection, all forms (%) 66 (55–81)

Number of laboratories 2008 2009 2010Sputum smear (per 100 000 population) 2.3 2.2 2.2Culture (per 5 million population) 12.0 10.0 8.1DST (per 10 million population) 1.8 5.5 5.4LPA (per 10 million population)Number of DST units for which externalquality assurance was carried out

National reference laboratory in 2009 YesLink to supra-national laboratory Gauting, Germany



2009 2011 2013 20150

200

400

600

8001000

GLC-approved

Non-GLC

GLC-approved plan

National plan



Yes


Yes





Peripherallevel





Yes

TB infection control national situationassessment carried out in the scope of MDR-TBNational infection control planavailable

No

Tertiary hospitals with person incharge of TB infection controlTB notification rate (all forms) inhealth care workers (all staff) overrate in general populationRecording and reporting forMDR-TB in place Start of support to

electronic system byWHO: 01/2011





Kyrgyzstan  MDR-TBGenerated: February 23, 2011  



Name




Model of care for MDR-TB treatment 2010MDR-TB patients hospitalized during intensivephaseTreatment (drugs and care) free of chargePatient support available (GLC projects) YesType of support: limited food and transportation support



2007200820092010201120122013201420150

20

40

60

80

100

MDR-TB Management

Second-line drugs

National plan **

Financing (US$ millions) 2010 2011Total NTP budgetMDR-TB financing component: second-line drugs budget total MDR-TB budget available funding 2 <1 funding gap <1 <1

% of budget funded % available funding from domestic sources % available funding from Global Fund 100 100



2007 2009 2011 2013 2015-20

0

20

40

60

80100


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

20000

40000

60000

80000100000

Budget required

National plan


Recording and reporting: technical assistance needed fortraining in electronic MDR-TB data management.

Qualified MDR/XDR-TB treatment (human resources,facilities): limited human resource capacity.

Access to quality-assured second-line drugs: nationallegislation regarding drug procurement.

Other: unstable political situation.







Kyrgyzstan (continued)

Model of care for MDR-TB treatment 2010MDR-TB patients hospitalized during intensivephaseTreatment (drugs and care) free of chargePatient support available (GLC projects) YesType of support: limited food and transportation support



2007200820092010201120122013201420150

20

40

60

80

100

MDR-TB Management

Second-line drugs

National plan **

Financing (US$ millions) 2010 2011Total NTP budgetMDR-TB financing component: second-line drugs budget total MDR-TB budget available funding 2 <1 funding gap <1 <1




2007 2009 2011 2013 2015-20

0

20

40

60

80100


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

20000

40000

60000

80000100000

Budget required

National plan


Recording and reporting: technical assistance needed fortraining in electronic MDR-TB data management.

Qualified MDR/XDR-TB treatment (human resources,facilities): limited human resource capacity.

Access to quality-assured second-line drugs: nationallegislation regarding drug procurement.

Other: unstable political situation.



Kazakhstan




1000200030004000500060007000



8 100 (6 400–9 700)


2 100 (1 600–2 600)


5 300 (4 800–5 800)


ment TotalConfirmed cases of MDR-TB 981 2 329 3 644MDR-TB patients started treatment 3 209





Mortality (excluding HIV/AIDS) 3.5 (2.4–5.2) 22 (16–33)Prevalence (incl HIV/AIDS) 33 (11–57) 211 (69–367)Incidence (incl HIV/AIDS) 26 (21–30) 163 (136–192)Case detection, all forms (%) 80 (68–96)





2009 2011 2013 20150

2000

4000

6000

800010000

GLC-approved

Non-GLC

GLC-approved plan

National plan



Yes


Yes

Drug management 2010Second-line drug procurementissuesDrugs provided to treat side-effects


Peripherallevel


MDR-TB management 2009Guidelines for programmaticmanagement of DR-TB developedTraining material developedTraining conducted specifically forDR-TBTB infection control national situationassessment carried out

Yes (2010)


Under preparation


18


7.5


YesData collectionpaper-based, entered inelectronic database





Kazakhstan  MDR-TBGenerated: February 23, 2011  



Name





Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages, transport vouchers/reimbursement, hygienepackages, financial incentives

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health Yes includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisons MoJPrison care coordinated with NTP Yes


2007200820092010201120122013201420150

10

20

30

40

50

60

70

MDR-TB Management

Second-line drugs

National plan **





2007 2009 2011 2013 20150

10203040506070


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

5000

10000

15000

Budget required

National plan


Programme management: weak implementation capacity atthe regional level.







Kazakhstan (continued)


Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages, transport vouchers/reimbursement, hygienepackages, financial incentives



2007200820092010201120122013201420150

10

20

30

40

50

60

70

MDR-TB Management

Second-line drugs

National plan **





2007 2009 2011 2013 20150

10203040506070


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

5000

10000

15000

Budget required

National plan


Programme management: weak implementation capacity atthe regional level.



Lithuania




100

200

300

400


MDR-TB estimates of burden *% of new TB cases with MDR-TB 11 (8.8–13) [DRS 2009]% of retreatment TB cases with MDR-TB 52 (47–57) [DRS 2009]MDR-TB cases among incident total TB casesin 2008

330 (270–390)


140 (110–160)


190 (170–210)







Mortality (excluding HIV/AIDS) 0.3 (0.2–0.45) 9 (6.2–14)Prevalence (incl HIV/AIDS) 2.6 (0.98–4.5) 80 (30–137)Incidence (incl HIV/AIDS) 2.3 (2–2.7) 71 (61–82)Case detection, all forms (%) 81 (70–95)

Number of laboratories 2008 2009 2010Sputum smear (per 100 000 population) 0.3 0.4 <0.1Culture (per 5 million population) 0 6.1 1.5DST (per 10 million population) 12.0 12.2 12.3LPA (per 10 million population) 3.0 3.1Number of DST units for which externalquality assurance was carried out 0 1

National reference laboratory in 2009 YesLink to supra-national laboratory Solna, Sweden

First-line DST routinely performed for: new cases, all retreatment cases, casesfailing a retreatment regimen, cases failing one or more retreatment regimens,cases that are contacts of MDR-TB cases


2009 2011 2013 20150

500

1000

1500

2000

GLC-approved

Non-GLC

GLC-approved plan

National plan



Yes


No





Peripherallevel





No


Yes


No


YesElectronic reporting(national level) andpaper-based reporting(regional level)





Lithuania  MDR-TBGenerated: February 23, 2011  



Name





Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages, hygiene packages



2007 2012 2013 2014 20150

5

10

15

20

MDR-TB Management

Second-line drugs

National plan **




2007 2012 2013 2014 20150

5

10

15


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

2000

4000

6000

800010000

Budget required

National plan


Recording and reporting: the system is well organized. Programme management: lack of appointed manager andsupervisors for national TB control.

Laboratory capacity and quality assurance: insufficient qualitycontrol for DST carried out by NRLs or SRLs.

Access to quality-assured second-line drugs: supplyinterruptions caused by the existing decentralized drugprocurement system.







Lithuania (continued)


Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages, hygiene packages



2007 2012 2013 2014 20150

5

10

15

20

MDR-TB Management

Second-line drugs

National plan **




2007 2012 2013 2014 20150

5

10

15


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

2000

4000

6000

800010000

Budget required

National plan


Recording and reporting: the system is well organized. Programme management: lack of appointed manager andsupervisors for national TB control.

Laboratory capacity and quality assurance: insufficient qualitycontrol for DST carried out by NRLs or SRLs.

Access to quality-assured second-line drugs: supplyinterruptions caused by the existing decentralized drugprocurement system.



Latvia




50

100

150



170 (140–200)


95 (78–120)


47 (37–59)







Mortality (excluding HIV/AIDS) 0.098 (0.084–0.14) 4.4 (3.7–6.1)Prevalence (incl HIV/AIDS) 1.1 (0.28–1.9) 48 (13–83)Incidence (incl HIV/AIDS) 1 (0.88–1.1) 45 (39–51)Case detection, all forms (%) 94 (83–110)


National reference laboratory in 2009 YesLink to supra-national laboratory



2009 2011 2013 20150

100

200

300

GLC-approved

Non-GLC

GLC-approved plan

National plan



No


No





Peripherallevel





Yes


Yes (1998)


Yes


YesPaper-based in regions,electronic database atnational TB registry





Latvia  MDR-TBGenerated: February 23, 2011  



Name





Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: transport vouchers

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health Yes includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisons MoJ and MoHPrison care coordinated with NTP Yes


2007200820092010201120122013201420150

0.2

0.4

0.6

0.8

1

MDR-TB Management

Second-line drugs

National plan **





2007 2009 2011 20132015-1

-0.5

0

0.5


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

1000

2000

3000

4000

50006000

Budget required

National plan








Latvia (continued)


Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: transport vouchers

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health Yes includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisons MoJ and MoHPrison care coordinated with NTP Yes


2007200820092010201120122013201420150

0.2

0.4

0.6

0.8

1

MDR-TB Management

Second-line drugs

National plan **





2007 2009 2011 20132015-1

-0.5

0

0.5


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

1000

2000

3000

4000

50006000

Budget required

National plan




Republic of Moldova




500

1000

1500



2 100 (1 700–2 400)


650 (560–740)


840 (810–880)


ment TotalConfirmed cases of MDR-TB 289 780 1 069MDR-TB patients started treatment 334





Mortality (excluding HIV/AIDS) 0.94 (0.65–1.3) 26 (18–37)Prevalence (incl HIV/AIDS) 9.5 (4–16) 264 (112–446)Incidence (incl HIV/AIDS) 6.4 (5.2–7.7) 178 (145–215)Case detection, all forms (%) 68 (56–83)

Number of laboratories 2008 2009 2010Sputum smear (per 100 000 population) 1.6 1.6 1.7Culture (per 5 million population) 5.5 5.6 5.6DST (per 10 million population) 11.0 11.1 11.2LPA (per 10 million population) 2.8 0Number of DST units for which externalquality assurance was carried out 0 0




2009 2011 2013 20150

200

400

600

8001000

GLC-approved

Non-GLC

GLC-approved plan

National plan



No


No


No



Peripherallevel





Yes


Yes


Yes


6


0.3


YesElectronic





Republic of Moldova  MDR-TBGenerated: February 23, 2011  



Name





Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages, transport vouchers/reimbursement, hygienepackages

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health Yes includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisonsPrison care coordinated with NTP Yes


2007 2008 2009 2010 2011 2012 2013 2014 20150

1

2

3

4

MDR-TB Management

Second-line drugs

National plan **





2007 2009 2011 2013 20150

1

2

3


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

1000200030004000500060007000

Budget required

National plan


Recording and reporting: sufficient.

Access to quality-assured second-line drugs: not an issue.

Issues in case-finding or enrolment for treatment: latediagnosis of MDR-TB.

Programme management: training for staff needed.

Laboratory capacity and quality assurance: insufficient rapidtests for drug resistance to detect MDR-TB and XDR-TB.

Qualified MDR-/XDR-TB treatment (human resources,facilities): insufficient human resources.

TB infection control: training of staff; revision of the nationalinfection control plan; mission for technical assistance focusedon environmental controls.

Financing: limited financial resources for MDR-TB.

Other: insufficient community involvement.







Republic of Moldova (continued)


Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages, transport vouchers/reimbursement, hygienepackages



2007 2008 2009 2010 2011 2012 2013 2014 20150

1

2

3

4

MDR-TB Management

Second-line drugs

National plan **





2007 2009 2011 2013 20150

1

2

3


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

1000200030004000500060007000

Budget required

National plan


Recording and reporting: sufficient.

Access to quality-assured second-line drugs: not an issue.

Issues in case-finding or enrolment for treatment: latediagnosis of MDR-TB.

Programme management: training for staff needed.

Laboratory capacity and quality assurance: insufficient rapidtests for drug resistance to detect MDR-TB and XDR-TB.

Qualified MDR-/XDR-TB treatment (human resources,facilities): insufficient human resources.

TB infection control: training of staff; revision of the nationalinfection control plan; mission for technical assistance focusedon environmental controls.

Financing: limited financial resources for MDR-TB.

Other: insufficient community involvement.



Myanmar




1000

2000

3000

40005000



9 300 (6 400–12 000)


3 900 (3 000–5 200)


970 (690–1 400)


ment TotalConfirmed cases of MDR-TB 815 815MDR-TB patients started treatment 64






Number of laboratories 2008 2009 2010Sputum smear (per 100 000 population) 0.8 0.8 0.8Culture (per 5 million population) 0.2 0.2 0.2DST (per 10 million population) 0.2 0.4 0.4LPA (per 10 million population) 0.4Number of DST units for which externalquality assurance was carried out 2

National reference laboratory in 2009 YesLink to supra-national laboratory Bangkok, Thailand

First-line DST routinely performed for: cases failing a retreatment regimen,cases failing one or more retreatment regimens


2009 2011 2013 20150

200

400

600

8001000

GLC-approved

Non-GLC

GLC-approved plan

National plan



Yes


Yes


No



Peripherallevel





Yes


Yes


Under preparation


2


YesPaper-based


Routine surveillance datanot representative;nationwide surveys (2003,2007, 2011)



Myanmar  TB   HIV  MDR-TBGenerated: February 23, 2011  



Name





Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages, transport vouchers/reimbursement,counselling/psychosocial support

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health Yes includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisons NoPrison care coordinated with NTP No


2007 2008 2009 2010 2011 2012 2013 2014 201501

2

3

4

5

6

78

MDR-TB Management

Second-line drugs

National plan **

Financing (US$ millions) 2010 2011Total NTP budget 14 18MDR-TB financing component: second-line drugs budget <1 2 total MDR-TB budget <1 2 available funding <1 2 funding gap <1 <1

% of budget funded 165 66 % available funding from domestic sources % available funding from Global Fund 93



2007 2009 2011 2013 2015-20

2

4

68


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

2000

4000

6000

800010000

Budget required

National plan


Programme management: the two new molecular laboratories inMandalay and Yangon (Expand-TB project) will start clinical work duringthe first quarter of 2011. A harmonization plan for laboratory and clinicalcapacity will be developed in March 2011.

Recording and reporting: a support mission for electronic MDR-TBrecording and reporting will take place in May 2011.

Access to quality-assured second-line drugs: no delay in drug delivery.

TB infection control: measures are implemented in MDR-TB hospitals andin pilot sites. All health-care workers use respirators.

Issues in case-finding or enrolment for treatment: for the pilotphase, only Category 2 failures are included. The pilot phasewill end in summer 2011; thereafter the patient categories forDST will be expanded to include Category 1 failures.

Laboratory capacity and quality assurance: limited to Yangonand Mandalay; quality is good according to SRL in Bangkokand FIND.

Qualified M/XMDR-TB treatment (human resources,facilities): for pilot phase, human resources situation is undercontrol but for expansion, training and additional staff areneeded.

Financing: dependent on external resources.

Other: decentralization of MDR-TB management ischallenging, especially in remote and hard-to-reach areas,given the duration of treatment and difficulties in managingside-effects.







Myanmar (continued)

Nigeria




500

1000

1500

20002500


MDR-TB estimates of burden *% of new TB cases with MDR-TB 1.8 (0.0–4.3) [model 2008]% of retreatment TB cases with MDR-TB 7.7 (0.0–18) [model 2008]MDR-TB cases among incident total TB casesin 2008

11 000 (1 300–20 000)


1 500 (0–3 500)


630 (0–1 500)








Number of laboratories 2008 2009 2010Sputum smear (per 100 000 population) 0.6 0.7 0.9Culture (per 5 million population) <0.1 0.1 0.3DST (per 10 million population) 0.2 0.2 0.6LPA (per 10 million population) 0.1 0.2Number of DST units for which externalquality assurance was carried out 1 3

National reference laboratory in 2009 YesLink to supra-national laboratory Milan, Italy



2009 2011 2013 20150

100200300400500600700

GLC-approved

Non-GLC

GLC-approved plan

National plan



Yes


Yes



Peripherallevel

First-line drugs No YesSecond-line drugs No No




Yes


No

in the scope of MDR-TBNational infection control planavailableTertiary hospitals with person incharge of TB infection control

15


No





Nigeria  TB   HIV  MDR-TBGenerated: February 23, 2011  



Name





Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages and transport reimbursement



2007 2008 2009 2010 2011 2012 2013 2014 20150

1

2

3

4

5

MDR-TB Management

Second-line drugs

National plan **

Financing (US$ millions) 2010 2011Total NTP budget 37 39MDR-TB financing component: second-line drugs budget <1 2 total MDR-TB budget 3 4 available funding 2 3 funding gap 1 <1




2007 2009 2011 2013 201501

2

3

45


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

10000

20000

30000

4000050000

Budget required

National plan


Access to quality-assured second-line drugs: available for 80 patients.

Financing: Government, partners and the Global Fund.

Programme management: delayed Global Fund grantnegotiation as a result of lack of MDR-TB response plan.


Qualified M/XMDR-TB treatment (human resources,facilities): limited hospitalization capacity; limited humanresource capacity.

Access to quality-assured second-line drugs: additional drugsto be procured under Global Fund Round 9.

TB infection control: only adequately functioning on MDR-TBwards and at two other treatment centres.







Nigeria (continued)

Philippines




1000200030004000500060007000



13 000 (8 900–17 000)


5 600 (4 200–7 700)


2 000 (1 400–2 700)


ment TotalConfirmed cases of MDR-TB 1 050 23 1 073MDR-TB patients started treatment 491







National reference laboratory in 2009 YesLink to supra-national laboratory Tokyo, Japan



2009 2011 2013 20150

500

1000

1500

20002500

GLC-approved

Non-GLC

GLC-approved plan

National plan



Yes


Yes


Registration is needed butcurrently with waiver forcompassionate reasons.Registration process isongoing.



Peripherallevel

First-line drugs Yes YesSecond-line drugs No No




Yes


Yes


Yes


PartiallyElectronic (web-based) in3 treatment centres onlybut will expand in 2011


Routine surveillance datanot representative;nationwide survey (2004);second nationwide surveyplanned for 2011



Philippines  TB  MDR-TBGenerated: February 23, 2011  



Name





No

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages, transport vouchers/reimbursement,counselling/psychosocial support, housing support, education

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health Yes includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisons Department of HealthPrison care coordinated with NTP Yes


2007200820092010201120122013201420150

10

20

30

40

MDR-TB Management

Second-line drugs

National plan **

Financing (US$ millions) 2010 2011Total NTP budget 94 97MDR-TB financing component: second-line drugs budget 3 total MDR-TB budget 34 35 available funding 8 <1 funding gap 26 35

% of budget funded 24 <1 % available funding from domestic sources 2 100 % available funding from Global Fund 98



2007 2009 2011 2013 20150

10

20

30


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

5000

10000

15000

2000025000

Budget required

National plan


Issues in case-finding or enrolment for treatment: continuous patientenrolment during the transition from the Tropical Disease Foundation to thePhilippine Business for Social Progress.

Recording and reporting: electronic recording and reporting for MDR-TBavailable in 3/10 treatment centres.

Issues in case-finding or enrolment for treatment: patientenrolment remained below target enrolment; delay in the startof treatment caused by long waiting times for the results ofculture and DST.

Programme management: limited monitoring of patients fromcase-finding to initiation of treatment; limited implementation ofstandardized treatment regimen; long installation process ofculture and treatment centres.

Recording and reporting: laboratory and clinical data are notharmonized.

Laboratory capacity and quality assurance: rapid diagnosis isnot used.

Qualified MDR/XDR-TB treatment (human resources,facilities): not yet accessible nationwide.

Access to quality-assured second-line drugs: issues of productregistration of drugs resulted in delays in drug delivery; delaysin shipments orders placed in 2009 caused by the transitionfrom TDF to PBSP.

TB infection control: no specific infection control policy andguidelines for (MDR-)TB.

Other: the transition from TDF to PBSP was a majorchallenge.




No




2007200820092010201120122013201420150

10

20

30

40

MDR-TB Management

Second-line drugs

National plan **





2007 2009 2011 2013 20150

10

20

30


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

5000

10000

15000

2000025000

Budget required

National plan




Issues in case-finding or enrolment for treatment: patientenrolment remained below target enrolment; delay in the startof treatment caused by long waiting times for the results ofculture and DST.Programme management: limited monitoring of patients fromcase-finding to initiation of treatment; limited implementation ofstandardized treatment regimen; long installation process ofculture and treatment centres.Recording and reporting: laboratory and clinical data are notharmonized.Laboratory capacity and quality assurance: rapid diagnosis isnot used.Qualified MDR/XDR-TB treatment (human resources,facilities): not yet accessible nationwide.Access to quality-assured second-line drugs: issues of productregistration of drugs resulted in delays in drug delivery; delaysin shipments orders placed in 2009 caused by the transitionfrom TDF to PBSP.TB infection control: no specific infection control policy andguidelines for (MDR-)TB.Other: the transition from TDF to PBSP was a majorchallenge.





Philippines (continued)

Pakistan




2000

4000

6000

800010000


MDR-TB estimates of burden *% of new TB cases with MDR-TB 2.8 (0.0–8.0) [model 2008]% of retreatment TB cases with MDR-TB 35 (0.0–75) [model 2008]MDR-TB cases among incident total TB casesin 2008

15 000 (1 200–29 000)


6 000 (0–17 000)


3 300 (0–6 900)








Number of laboratories 2008 2009 2010Sputum smear (per 100 000 population) 0.6 0.6 0.6Culture (per 5 million population) 0.4 0.4 0.4DST (per 10 million population) 0.6 0.6 0.6LPA (per 10 million population) 0 <0.1Number of DST units for which externalquality assurance was carried out 0 0




2009 2011 2013 20150

1000

2000

3000

4000

50006000

GLC-approved

Non-GLC

GLC-approved plan

National plan



Yes


Yes



Peripherallevel

First-line drugs No NoSecond-line drugs Don't know Don't know




Yes


At MDR-TB pilot sites only


Under preparation


29


YesElectronic and paper-based


No representative dataavailable; nationwidesurvey planned for 2011



Pakistan  TB  MDR-TBModel of care for MDR-TB treatment 2010MDR-TB patients hospitalized during intensivephase

No




2007200820092010201120122013201420150

10

20

30

40

MDR-TB Management

Second-line drugs

National plan **





2007 2009 2011 2013 20150

10

20

30


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

5000

10000

15000

2000025000

Budget required

National plan




Issues in case-finding or enrolment for treatment: patientenrolment remained below target enrolment; delay in the startof treatment caused by long waiting times for the results ofculture and DST.

Programme management: limited monitoring of patients fromcase-finding to initiation of treatment; limited implementation ofstandardized treatment regimen; long installation process ofculture and treatment centres.

Recording and reporting: laboratory and clinical data are notharmonized.

Laboratory capacity and quality assurance: rapid diagnosis isnot used.

Qualified MDR/XDR-TB treatment (human resources,facilities): not yet accessible nationwide.

Access to quality-assured second-line drugs: issues of productregistration of drugs resulted in delays in drug delivery; delaysin shipments orders placed in 2009 caused by the transitionfrom TDF to PBSP.

TB infection control: no specific infection control policy andguidelines for (MDR-)TB.

Other: the transition from TDF to PBSP was a majorchallenge.




No




2007200820092010201120122013201420150

10

20

30

40

MDR-TB Management

Second-line drugs

National plan **





2007 2009 2011 2013 20150

10

20

30


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

5000

10000

15000

2000025000

Budget required

National plan




Issues in case-finding or enrolment for treatment: patientenrolment remained below target enrolment; delay in the startof treatment caused by long waiting times for the results ofculture and DST.Programme management: limited monitoring of patients fromcase-finding to initiation of treatment; limited implementation ofstandardized treatment regimen; long installation process ofculture and treatment centres.Recording and reporting: laboratory and clinical data are notharmonized.Laboratory capacity and quality assurance: rapid diagnosis isnot used.Qualified MDR/XDR-TB treatment (human resources,facilities): not yet accessible nationwide.Access to quality-assured second-line drugs: issues of productregistration of drugs resulted in delays in drug delivery; delaysin shipments orders placed in 2009 caused by the transitionfrom TDF to PBSP.TB infection control: no specific infection control policy andguidelines for (MDR-)TB.Other: the transition from TDF to PBSP was a majorchallenge.

Generated: February 23, 2011  



Name





Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages, transport vouchers/reimbursement,counselling/psychosocial support; treatment supporters hired (Islamabad,2009)

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health Yes includes a budget Yes part of NTPMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisonsPrison care coordinated with NTP


2007200820092010201120122013201420150

10

20

30

40

MDR-TB Management

Second-line drugs

National plan **

Financing (US$ millions) 2010 2011Total NTP budget 54 60MDR-TB financing component: second-line drugs budget <1 7 total MDR-TB budget 1 7 available funding 1 7 funding gap <1 <1




2007 2009 2011 2013 20150

10

20

30


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

5000

10000

15000

2000025000

Budget required

National plan


Issues in case-finding or enrolment for treatment: delay innegotiating Global Fund grant.

Programme management: limited experience.

Qualified MDR/XDR-TB treatment (human resources,facilities): limited number of prepared facilities and humanresources.

Other: under-budgeting (using Global Fund Round 6) resultedin a request for half of the intended number of treatment target.MDR-TB care in prisons to be addressed after strengtheningDOTS services.







Pakistan (continued)

Russian Federation




10000

20000

30000

40000



38 000 (30 000–45 000)


17 000 (13 000–21 000)


14 000 (12 000–15 000)


ment TotalConfirmed cases of MDR-TB 5 816 2 314 14 686MDR-TB patients started treatment 8 143







National reference laboratory in 2009 No

Link to supra-national laboratory Solna, Sweden (Russia does nothave an official link to one SRL)



2009 2011 2013 20150

5000

10000

15000

2000025000

GLC-approved

Non-GLC

GLC-approved plan

National plan



Yes


Yes



Peripherallevel

First-line drugs No NoSecond-line drugs No Yes


No


Yes


No

in the scope of MDR-TB NoNational infection control planavailableTertiary hospitals with person incharge of TB infection control

419


YesData collectionpaper-based, entered inelectronic database


Class B national routinesurveillance data (2009);Class A subnationalsurveillance data from 12regions (2008)



Russian Federation  TB   HIV  MDR-TBGenerated: February 23, 2011  



Name





Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: differs between regions and MDR-TB projects

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health Yes includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisonsPrison care coordinated with NTP No


2007200820092010201120122013201420150

100

200

300

400

500

600

700

MDR-TB Management

Second-line drugs

National plan **

Financing (US$ millions) 2010 2011Total NTP budget 1 258 1 278MDR-TB financing component: second-line drugs budget 132 131 total MDR-TB budget 133 132 available funding 133 132 funding gap 0 0




2007 2009 2011 2013 20150

100200300400500600700


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

10000

20000

30000

40000

Budget required

National plan


Access to quality-assured second-line drugs: a new law on drugs becameeffective on 1 September 2010. The legislation provides for equalconditions for every national and international manufacturer and introducesa maximum permissible deadline of 210 days for drug registration,regardless of the manufacturer’s origin. This will allow new and effectivedrugs to be available on the market more quickly.

Programme management: insufficient integration of TB controlwith the health-care system.

Recording and reporting: electronic recording and reportingunder approval by the Ministry of Health; some pilot projectsexist; federal government budget is available for softwaremodules but not for training.


Access to quality-assured second-line drugs: continuing supplyof second-line drugs for GLC-approved projects and in otherregions; potential risk of discontinued support from the GlobalFund.

Other: extensive hospitalization in some regions.







Russian Federation (continued)


Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: differs between regions and MDR-TB projects

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health Yes includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisonsPrison care coordinated with NTP No


2007200820092010201120122013201420150

100

200

300

400

500

600

700

MDR-TB Management

Second-line drugs

National plan **

Financing (US$ millions) 2010 2011Total NTP budget 1 258 1 278MDR-TB financing component: second-line drugs budget 132 131 total MDR-TB budget 133 132 available funding 133 132 funding gap 0 0




2007 2009 2011 2013 20150

100200300400500600700


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

10000

20000

30000

40000

Budget required

National plan


Access to quality-assured second-line drugs: a new law on drugs becameeffective on 1 September 2010. The legislation provides for equalconditions for every national and international manufacturer and introducesa maximum permissible deadline of 210 days for drug registration,regardless of the manufacturer’s origin. This will allow new and effectivedrugs to be available on the market more quickly.

Programme management: insufficient integration of TB controlwith the health-care system.

Recording and reporting: electronic recording and reportingunder approval by the Ministry of Health; some pilot projectsexist; federal government budget is available for softwaremodules but not for training.


Access to quality-assured second-line drugs: continuing supplyof second-line drugs for GLC-approved projects and in otherregions; potential risk of discontinued support from the GlobalFund.

Other: extensive hospitalization in some regions.



South Africa




2000

4000

6000

800010000


MDR-TB estimates of burden *% of new TB cases with MDR-TB 1.8 (1.5–2.3) [DRS 2002]% of retreatment TB cases with MDR-TB 6.7 (5.5–8.1) [DRS 2002]MDR-TB cases among incident total TB casesin 2008

13 000 (10 000–16 000)


5 200 (4 300–6 600)


4 400 (3 600–5 300)


ment TotalConfirmed cases of MDR-TB 9 070MDR-TB patients started treatment 4 143





Mortality (excluding HIV/AIDS) 26 (14–42) 52 (29–85)Prevalence (incl HIV/AIDS) 400 (180–650) 808 (362–1 288)Incidence (incl HIV/AIDS) 490 (400–590) 971 (791–1 169)Case detection, all forms (%) 74 (61–91)


National reference laboratory in 2009 YesLink to supra-national laboratory Pretoria, South Africa



2009 2011 2013 20150

2000

4000

6000

800010000

GLC-approved

Non-GLC

GLC-approved plan

National plan



Yes


No



Peripherallevel

First-line drugs Yes NoSecond-line drugs Yes No




Yes


No


Yes


YesElectronic


Class B routinesurveillance data (2008);nationwide survey (2002);second nationwide surveyplanned for 2011



South Africa  TB   HIV  MDR-TBGenerated: February 23, 2011  



Name





Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects)

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health Yes includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisons MoHPrison care coordinated with NTP


2007 2008 2010 2011 2012 2013 2014 20150

100

200

300

MDR-TB Management

Second-line drugs

National plan **





2007 2010 2012 20140

100

200


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

10000

20000

30000

4000050000

Budget required

National plan


Issues in case-finding or enrolment for treatment: gap betweenpatient diagnosis and enrolment for treatment.

Programme management: centralized model; poor patienttracking mechanism.

Recording and reporting: system not keeping pace withdecentralization of MDR-TB services.

TB infection control: inadequate implementation of medicalsurveillance of health-care workers.

Other: there are no GLC-approved projects in South Africa.







South Africa (continued)

Tajikistan




200

400

600

800

10001200



4 000 (2 900–5 100)


690 (470–990)


330 (280–370)








Number of laboratories 2008 2009 2010Sputum smear (per 100 000 population) 1.5 1.4 1.4Culture (per 5 million population) 1.5 0.7 2.1DST (per 10 million population) 2.9 1.4 2.8LPA (per 10 million population) 0 2.8Number of DST units for which externalquality assurance was carried out 0 2




2009 2011 2013 20150

500

1000

1500

2000

GLC-approved

Non-GLC

GLC-approved plan

National plan



No


No





Peripherallevel





Yes


Yes (2009)


Under preparation


16.8


YesPaper-based


Routine surveillance datanot representative; surveyin the city of Dushanbe andRudaki district (2009);nationwide survey underway



Tajikistan  MDR-TBModel of care for MDR-TB treatment 2010MDR-TB patients hospitalized during intensivephase

Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects)

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health Yes includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisons MoHPrison care coordinated with NTP


2007 2008 2010 2011 2012 2013 2014 20150

100

200

300

MDR-TB Management

Second-line drugs

National plan **





2007 2010 2012 20140

100

200


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

10000

20000

30000

4000050000

Budget required

National plan


Issues in case-finding or enrolment for treatment: gap betweenpatient diagnosis and enrolment for treatment.

Programme management: centralized model; poor patienttracking mechanism.

Recording and reporting: system not keeping pace withdecentralization of MDR-TB services.

TB infection control: inadequate implementation of medicalsurveillance of health-care workers.

Other: there are no GLC-approved projects in South Africa.






Name





Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages, transport vouchers/reimbursement

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health Yes includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisons MOH, MOJ, International

Organization,NGO-Caritas Luxemburg,UNDP PIU GFATM,Quality Health CareProject USAID



2007 2010 2011 2012 2013 2014 20150

10

20

30

40

50

60

MDR-TB Management

Second-line drugs

National plan **

Financing (US$ millions) 2010 2011Total NTP budget 0MDR-TB financing component: second-line drugs budget total MDR-TB budget available funding 2 2 funding gap <1 <1




200720102011201220132014-10

0102030405060


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

10000

20000

30000

40000

Budget required

National plan


Issues in case-finding or enrolment for treatment: weakintegration with primary health-care providers.

Programme management: weak health systems andintegration with the health system; no electronic-based datamanagement system.

Recording and reporting: logistics management informationsystem for second-line drugs is under development.

Laboratory capacity and quality assurance: no electronic-baseddata management system.

Qualified MDR/XDR-TB treatment (human resources,facilities): limited human resource capacity for MDR-TBmanagement; weak infection control measures; low adherenceto treatment of MDR-TB patients; work overloading and lowmotivation of primary health-care personnel.

TB infection control: weak infection control in TB facilities.

Financing: weak domestic financing.







Tajikistan (continued)

Ukraine

| High HIV burden | High MDR-TB burden | Multidrug-resistant tuberculosis profile



2000

4000

6000

8000



8 700 (6 800–11 000)


4 700 (4 100–5 400)


2 400 (2 200–2 700)


ment TotalConfirmed cases of MDR-TB 1 437 2 045 3 482MDR-TB patients started treatment 3 186

% of MDR-TB patients living with HIV/AIDS 23.8 [2006 survey Donetsk oblast]Odds of HIV-positive TB patient havingMDR-TB over odds of HIV-negative TBpatient having MDR-TB

1.5 (1.1-2.0) [2006 survey Donetskoblast]



Mortality (excluding HIV/AIDS) 12 (7.9–18) 26 (17–39)Prevalence (incl HIV/AIDS) 59 (23–100) 130 (49–222)Incidence (incl HIV/AIDS) 46 (38–56) 101 (83–122)Case detection, all forms (%) 78 (65–95)

Number of laboratories 2008 2009 2010Sputum smear (per 100 000 population) 4.1 2.2 1.8Culture (per 5 million population) 11.6 11.3 11.3DST (per 10 million population) 10.2 10.1 6.8LPA (per 10 million population) 0Number of DST units for which externalquality assurance was carried out

National reference laboratory in 2009 YesLink to supra-national laboratory Riga, Latvia



2009 2011 2013 20150

2000

4000

6000

8000

GLC-approved

Non-GLC

GLC-approved plan

National plan



Yes


No





Peripherallevel

First-line drugs No NoSecond-line drugs Yes Yes




No


Yes (2009)


Under preparation


1.1


YesElectronic


Class B routinesurveillance data (2009);survey in Donetsk oblast(2006)



Ukraine   HIV  MDR-TBModel of care for MDR-TB treatment 2010MDR-TB patients hospitalized during intensivephase

Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages, transport vouchers/reimbursement

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health Yes includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisons MOH, MOJ, International

Organization,NGO-Caritas Luxemburg,UNDP PIU GFATM,Quality Health CareProject USAID



2007 2010 2011 2012 2013 2014 20150

10

20

30

40

50

60

MDR-TB Management

Second-line drugs

National plan **

Financing (US$ millions) 2010 2011Total NTP budget 0MDR-TB financing component: second-line drugs budget total MDR-TB budget available funding 2 2 funding gap <1 <1




200720102011201220132014-10

0102030405060


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

10000

20000

30000

40000

Budget required

National plan


Issues in case-finding or enrolment for treatment: weakintegration with primary health-care providers.

Programme management: weak health systems andintegration with the health system; no electronic-based datamanagement system.

Recording and reporting: logistics management informationsystem for second-line drugs is under development.

Laboratory capacity and quality assurance: no electronic-baseddata management system.

Qualified MDR/XDR-TB treatment (human resources,facilities): limited human resource capacity for MDR-TBmanagement; weak infection control measures; low adherenceto treatment of MDR-TB patients; work overloading and lowmotivation of primary health-care personnel.

TB infection control: weak infection control in TB facilities.

Financing: weak domestic financing.






Name





Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: limited support



2007 2009 2010 2011 2012 2013 2014 20150

20

40

60

80

100

MDR-TB Management

Second-line drugs

National plan **

Financing (US$ millions) 2010 2011Total NTP budget 203 211MDR-TB financing component: second-line drugs budget 29 35 total MDR-TB budget 79 85 available funding 18 funding gap 62 85

% of budget funded 22 % available funding from domestic sources 100 % available funding from Global Fund



2007 2010 2012 2014-20

0

20

40

60

80100


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

10000

20000

30000

40000

Budget required

National plan


Programme management: frequent changes of management inthe Ministry of Health.

Recording and reporting: technical assistance needed fortraining in MDR-TB data management.

Laboratory capacity and quality assurance: low laboratorycapacity; quality assurance is partially implemented.

Qualified M/XMDR-TB treatment (human resources,facilities): patient-oriented approach is not implemented.

Access to quality-assured second-line drugs: there islegislation on drug registration.

TB infection control: poor infection control.

Financing: lack of financing.







Ukraine (continued)

Uzbekistan




1000

2000

3000



8 700 (6 500–11 000)


1 700 (1 200–2 200)


1 200 (880–1 600)










First-line DST routinely performed for: new cases, all retreatment cases, casesfailing a retreatment regimen, cases failing one or more retreatment regimens


2009 2011 2013 20150

2000

4000

6000

8000

GLC-approved

Non-GLC

GLC-approved plan

National plan



Yes


Yes



Peripherallevel





Yes

TB infection control national situationassessment carried out in the scope of MDR-TBNational infection control planavailableTertiary hospitals with person incharge of TB infection controlTB notification rate (all forms) inhealth care workers (all staff) overrate in general population

0.2


YesElectronic


Routine surveillance datanot representative; surveysin the city of Tashkent(2005) and Republic ofKarakalpakstan (2002);nationwide survey underway



Uzbekistan  MDR-TBModel of care for MDR-TB treatment 2010MDR-TB patients hospitalized during intensivephase

Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: limited support



2007 2009 2010 2011 2012 2013 2014 20150

20

40

60

80

100

MDR-TB Management

Second-line drugs

National plan **

Financing (US$ millions) 2010 2011Total NTP budget 203 211MDR-TB financing component: second-line drugs budget 29 35 total MDR-TB budget 79 85 available funding 18 funding gap 62 85

% of budget funded 22 % available funding from domestic sources 100 % available funding from Global Fund



2007 2010 2012 2014-20

0

20

40

60

80100


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

10000

20000

30000

40000

Budget required

National plan


Programme management: frequent changes of management inthe Ministry of Health.

Recording and reporting: technical assistance needed fortraining in MDR-TB data management.

Laboratory capacity and quality assurance: low laboratorycapacity; quality assurance is partially implemented.

Qualified M/XMDR-TB treatment (human resources,facilities): patient-oriented approach is not implemented.

Access to quality-assured second-line drugs: there islegislation on drug registration.

TB infection control: poor infection control.

Financing: lack of financing.






Name





Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: food packages, transport vouchers/reimbursement,counselling/psychosocial support



2007200820092010201120122013201420150

5

10

15

20

25

MDR-TB Management

Second-line drugs

National plan **

Financing (US$ millions) 2010 2011Total NTP budget 13 19MDR-TB financing component: second-line drugs budget <1 2 total MDR-TB budget <1 3 available funding <1 3 funding gap 0 0




2007 2009 2011 2013 201505

10

15

2025


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

2000

4000

6000

800010000

Budget required

National plan


Programme management: weak health systems andintegration with the health system.

Qualified MDR/XDR-TB treatment (human resources,facilities): limited human resource capacity for MDR-TB.







Uzbekistan (continued)

Viet Nam




1000

2000

3000

4000



5 900 (3 800–8 100)


1 900 (1 400–2 500)


1 600 (1 200–2 000)


ment TotalConfirmed cases of MDR-TB 217MDR-TB patients started treatment 307







National reference laboratory in 2009 YesLink to supra-national laboratory Adelaide, Australia



2009 2011 2013 20150

500

1000

1500

GLC-approved

Non-GLC

GLC-approved plan

National plan



Yes


Yes





Peripherallevel





Yes


Yes (2009-2010)


Yes


YesPaper-based


Routine surveillance datanot representative;representative nationwidesurveys (1997 and 2006)



Viet Nam  TB   HIV  MDR-TBGenerated: February 23, 2011  



Name





Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: counselling/psychosocial support; EUR 500 (equiv. USD 700)per year available to patient and DOT supporter for provision of supportivemeasures

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health Yes includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisons None currently. Planned

to be provided by NTP viaagreement between MoHand MoJ

Prison care coordinated with NTP No


2007 2008 2009 2010 2011 2012 2013 2014 20150

1

2

3

4

5

6

MDR-TB Management

Second-line drugs

National plan **





2007 2009 2011 2013 201501

2

3

4

56


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

2000

4000

6000

800010000

Budget required

National plan


Laboratory capacity and quality assurance: almost sufficient.


Recording and reporting: "e-TB Manager" (etbmanager.org)has not yet been implemented.

Qualified M/XMDR-TB treatment (human resources,facilities): limited human resources capacity for MDR-TB.

Access to quality-assured second-line drugs: delays in drugdelivery; weak drug management capacity.

Financing: plan approved for Global Fund Round 9 andNational Strategic Plan calling for further funding from otherdonors.







Viet Nam (continued)


Yes

Treatment (drugs and care) free of charge YesPatient support available (GLC projects) YesType of support: counselling/psychosocial support; EUR 500 (equiv. USD 700)per year available to patient and DOT supporter for provision of supportivemeasures

MDR-TB programme 2010MDR-TB expansion plan: approved by NTP/Ministry of Health Yes includes a budget Yes part of NTP YesMDR-TB management programme part of NTP YesProvider of MDR-TB care in prisons None currently. Planned

to be provided by NTP viaagreement between MoHand MoJ

Prison care coordinated with NTP No


2007 2008 2009 2010 2011 2012 2013 2014 20150

1

2

3

4

5

6

MDR-TB Management

Second-line drugs

National plan **





2007 2009 2011 2013 201501

2

3

4

56


Loans

Global Fund


Gap

National plan ***


2008 2010 2012 20140

2000

4000

6000

800010000

Budget required

National plan


Laboratory capacity and quality assurance: almost sufficient.


Recording and reporting: "e-TB Manager" (etbmanager.org)has not yet been implemented.

Qualified M/XMDR-TB treatment (human resources,facilities): limited human resources capacity for MDR-TB.

Access to quality-assured second-line drugs: delays in drugdelivery; weak drug management capacity.

Financing: plan approved for Global Fund Round 9 andNational Strategic Plan calling for further funding from otherdonors.




ANNEX 3:

Update on drug resistance surveillance data

3.1 MDR estimates and indicators by country ..................................................................................... 98

3.2 Continuous drug resistance surveillance data quality indicators.......................................106

3.3 Continuous drug resistance surveillance ......................................................................................108

3.4 (a) XDR-TB and resistance to fluoroquinolones: continuous surveillance data ............112

3.4 (b) XDR-TB and resistance to fluoroquinolones: survey data ...............................................114

3.5 Countries and settings reporting data from drug resistance surveys since 2008 .......115


Coun

try

WHO

re

gion

Sour

ce of

es

timat

es

Estim

ated

% of

all

new

TB ca

ses w

ith

MDR

-TB

(200

8)

Estim

ated

% of

all

retre

ated

TB ca

ses w

ith

MDR

-TB

(200

8)N

Per 1

00 00

0 pop

ulat

ion

Estim

ated

case

s of

MDR

-TB

amon

g no

tifie

d ca

ses o

f pul

mon

ary T

B in

20

09 (A

)

Prop

ortio

n of

TB

case

s rep

orte

d in

2009

with

DST

re

sults

b

Notif

ied

case

s of

MDR

-TB

in 20

09

(B)

Notif

ied

case

s of

MDR

-TB

as %

of

estim

ated

case

s of

MDR

-TB

amon

g al

l not

ified

case

s of

pul

mon

ary T

B (B

/A)c

Case

s of

MDR

-TB

enro

lled

on

treat

men

t in

2009

Avai

labi

lity

of Cl

ass A

or

B d

rug

resis

tanc

e su

rvei

llanc

e da

taBe

stLo

wHi

ghBe

stLo

wHi

ghBe

stLo

wHi

ghBe

stLo

wHi

ghBe

stLo

wHi

ghNe

wRe

treat

ed

Alge

riaAF

RDR

S, 20

011.

20.

52.

514

.40

38.1

270

6947

00.

80.

21.

421

088

390

––

––

93–

Ango

laAF

Rm

odel

0.9

02.

414

.40

38.1

790

110

1500

4.4

0.6

8.3

1100

290

2400

––

––

0–

Beni

nAF

RDR

S, 19

970.

30

1.7

14.4

038

.158

012

00.

70.

01.

449

912

0–

35%

1429

7–

Botsw

ana

AFR

DRS,

2008

3.4

2.4

4.8

13.1

8.6

19.6

520

330

710

27.1

17.2

37.0

370

280

470

3%22

%10

127

111

–

Burk

ina F

aso

AFR

mod

el0.

90

2.4

14.4

038

.172

010

013

004.

70.

78.

512

031

270

0%9%

1916

19–

Buru

ndi

AFR

mod

el1.

80

4.3

7.7

018

.160

013

1200

7.4

0.2

14.9

110

2925

00%

0%0

032

–

Cam

eroo

nAF

Rm

odel

1.8

04.

37.

70

18.1

780

4615

004.

10.

27.

949

014

010

000%

14%

265

8–

Cape

Verd

eAF

Rm

odel

0.9

02.

414

.40

38.1

122

232.

40.

44.

67

216

0%0%

00

0–

Cent

ral A

frica

n Rep

ublic

AFR

DRSa , 1

998

1.1

0.5

2.5

18.2

8.6

34.4

220

6938

05.

11.

68.

819

010

031

03%

3%7

40

–

Chad

AFR

mod

el0.

90

2.4

14.4

038

.153

080

970

4.9

0.7

8.9

160

4534

0–

––

–0

–

Com

oros

AFR

mod

el0.

90

2.4

14.4

038

.13

06

0.5

0.0

0.9

21

40%

0%0

00

–

Cong

oAF

Rm

odel

1.8

04.

37.

70

18.1

310

1760

08.

60.

516

.616

045

340

––

––

0–

Côte

d’Ivo

ireAF

RDR

S, 20

062.

51.

34.

97.

70

18.1

2500

820

4100

12.1

4.0

19.9

530

260

890

0%22

%43

80

–

Dem

ocra

tic R

epub

lic of

th

e Con

goAF

Rm

odel

1.8

04.

37.

70

18.1

5600

530

1100

08.

70.

817

.122

0070

046

00–

1%91

417

6–

Equa

toria

l Gui

nea

AFR

mod

el2.

20

10.7

10.8

034

.538

083

5.8

0.0

12.6

181

61–

––

–0

–

Eritr

eaAF

Rm

odel

0.9

02.

414

.40

38.1

573

110

1.2

0.1

2.2

4713

100

––

––

––

Ethi

opia

AFR

DRS,

2005

1.6

0.9

2.7

11.8

6.4

2152

0024

0080

006.

43.

09.

920

0012

0029

000%

8%23

312

88–

Gabo

nAF

Rm

odel

1.8

04.

37.

70

18.1

150

1128

010

.40.

819

.398

3519

0–

––

––

–

Gam

bia

AFR

DRS,

2000

0.5

02.

60

020

.442

090

2.5

0.0

5.4

151

510%

0%0

00

–

Ghan

aAF

Rm

odel

0.9

02.

414

.40

38.1

640

8212

002.

70.

45.

124

072

510

––

––

0–

Guin

eaAF

RDR

S, 19

980.

60.

21.

628

.115

.645

.446

020

071

04.

72.

07.

220

012

031

00%

11%

6934

54–

Estim

ated

case

s of M

DR-T

B em

ergi

ng in

2008

a Es

timat

es ba

sed o

n sub

natio

nal d

rug r

esist

ance

data

b Th

e pro

porti

on m

ay be

over

estim

ated

or ex

ceed

100%

if TB

notifi

catio

n dat

a are

inco

mpl

ete,

espe

cially

in sy

stem

s whe

re re

porti

ng of

TB an

d DST

are n

ot

linke

d. D

enom

inat

or in

clude

s all n

ew or

retre

ated

case

s reg

ardl

ess o

f cul

ture

resu

lt; ca

ses w

ith pr

eviou

s hist

ory u

nkno

wn no

t inc

lude

d.c

The p

erce

ntag

e is c

alcul

ated

on th

e poin

t esti

mat

e of e

xpec

ted M

DR-T

B ca

ses a

nd m

ay th

eref

ore e

xcee

d 100

% (p

lease

refe

r to u

ncer

tain

ty bo

unds

of

estim

ate)

. The

ratio

of no

tified

MDR

-TB

case

s to e

xpec

ted c

ases

may

also

exce

ed 10

0% as

a re

sult

of co

nser

vativ

e esti

mat

es of

% M

DR-T

B am

ong n

otifi

ed TB

pa

tient

s, no

tifica

tion o

f MDR

-TB

case

s fro

m a

prev

ious y

ear, a

nd in

com

plet

e not

ifica

tion o

f TB

in sy

stem

s whe

re re

porti

ng of

TB an

d MDR

-TB

are n

ot lin

ked.

NA =

not a

pplic

able

DRS =

drug

resis

tanc

e sur

vey/

surv

eillan

ce–

= da

ta no

t ava

ilabl

e

3.1

MD

R es

tim

ates

and

indi

cato

rs b

y co

untr

y


Coun

try

WHO

re

gion

Sour

ce of

es

timat

es

Estim

ated

% of

all

new

TB ca

ses w

ith

MDR

-TB

(200

8)

Estim

ated

% of

all

retre

ated

TB ca

ses w

ith

MDR

-TB

(200

8)N

Per 1

00 00

0 pop

ulat

ion

Estim

ated

case

s of

MDR

-TB

amon

g no

tifie

d ca

ses o

f pul

mon

ary T

B in

20

09 (A

)

Prop

ortio

n of

TB

case

s rep

orte

d in

2009

with

DST

re

sults

b

Notif

ied

case

s of

MDR

-TB

in 20

09

(B)

Notif

ied

case

s of

MDR

-TB

as %

of

estim

ated

case

s of

MDR

-TB

amon

g al

l not

ified

case

s of

pul

mon

ary T

B (B

/A)c

Case

s of

MDR

-TB

enro

lled

on

treat

men

t in

2009

Avai

labi

lity

of Cl

ass A

or

B d

rug

resis

tanc

e su

rvei

llanc

e da

taBe

stLo

wHi

ghBe

stLo

wHi

ghBe

stLo

wHi

ghBe

stLo

wHi

ghBe

stLo

wHi

ghNe

wRe

treat

ed

Guin

ea-B

issau

AFR

mod

el0.

90

2.4

14.4

038

.138

077

2.4

0.0

4.9

308

64–

––

–0

–

Keny

aAF

RDR

S, 19

950

00.

90

07.

733

0058

060

008.

51.

515

.539

047

1100

0%18

%15

038

140

–

Leso

tho

AFR

DRS,

1995

0.9

0.3

2.6

5.7

1.9

15.4

200

3735

09.

81.

817

.119

065

390

––

––

429

–

Liber

iaAF

Rm

odel

0.9

02.

414

.40

38.1

120

824

03.

20.

26.

361

1614

0–

––

–5

–

Mad

agas

car

AFR

DRS,

2007

0.5

0.2

1.3

3.9

1.1

13.2

330

6560

01.

70.

33.

117

050

350

0%1%

32

0–

Mala

wiAF

Rm

odel

1.8

04.

37.

70

18.1

1200

180

2200

8.1

1.2

14.8

490

170

990

0%1%

00

6–

Mali

AFR

mod

el0.

90

2.4

14.4

038

.164

011

012

005.

00.

99.

411

033

240

0%3%

2220

0–

Mau

ritan

iaAF

Rm

odel

0.9

02.

414

.40

38.1

130

025

04.

00.

07.

844

1394

––

––

0–

Mau

ritiu

sAF

Rm

odel

0.9

02.

414

.40

38.1

30

60.

20.

00.

52

14

88%

100%

160

1Cla

ss B

(200

9)

Moz

ambi

que

AFR

DRS,

2006

3.5

2.5

4.7

11.2

4.2

3036

0023

0048

0016

.110

.321

.417

0011

0023

000%

6%14

08

103

–

Nam

ibia

AFR

mod

el1.

80

4.3

7.7

018

.137

023

720

17.4

1.1

33.8

350

120

680

0%–

301

8729

2–

Nige

rAF

Rm

odel

0.9

02.

414

.40

38.1

350

3367

02.

40.

24.

617

050

360

0%5%

2414

34–

Nige

riaAF

Rm

odel

1.8

04.

37.

70

18.1

1100

013

0020

000

7.3

0.9

13.2

2100

660

4400

0%0%

281

0–

Rwan

daAF

RDR

S, 20

053.

92.

65.

79.

44.

817

.516

0095

022

0016

.59.

822

.626

018

035

01%

29%

7830

77–

Sao T

ome a

nd Pr

incip

eAF

Rm

odel

0.9

02.

414

.40

38.1

20

51.

20.

03.

11

02

––

––

0–

Sene

gal

AFR

DRS,

2006

2.1

0.9

4.8

16.7

8.3

30.6

1100

360

1800

9.0

2.9

14.7

380

200

630

1%3%

113

0–

Seyc

helle

sAF

Rm

odel

0.9

02.

414

.40

38.1

00

00.

00.

00.

00

00

––

–NA

0–

Sierra

Leon

eAF

RDR

S, 19

970.

90

4.7

23.1

8.2

50.3

470

010

008.

50.

018

.020

030

540

––

––

––

Sout

h Afri

caAF

RDR

S, 20

021.

81.

52.

36.

75.

58.

113

000

1000

016

000

26.2

20.1

32.2

9600

8200

1100

0–

–90

7094

4143

Class

B (2

008)

Swaz

iland

AFR

DRS,

1995

0.9

0.3

2.6

9.1

3.6

21.2

270

6747

023

.15.

740

.220

079

380

23%

–19

094

166

–

Togo

AFR

mod

el0.

90

2.4

14.4

038

.143

070

790

6.7

1.1

12.2

5316

110

0%2%

47

0–

Ugan

daAF

RDR

Sa , 199

70.

50.

11.

94.

41.

214

.873

00

1500

2.3

0.0

4.7

350

6887

01%

6%57

162

–

Unite

d Rep

ublic

of

Tanz

ania

AFR

DRS,

2007

1.1

0.4

2.8

00

7.3

1200

250

2100

2.8

0.6

4.9

590

160

1300

1%4%

244

16–

Zam

bia

AFR

DRS,

2000

1.8

0.9

3.5

2.3

0.1

11.8

1100

400

1900

8.7

3.2

15.1

670

290

1200

0%1%

294

0–

Zimba

bwe

AFR

DRS,

1995

1.9

1.1

3.3

8.3

2.9

21.8

2400

1200

3600

19.3

9.6

28.9

1000

550

1700

––

––

0–

Antig

ua an

d Bar

buda

AMR

mod

el2.

20

10.7

10.8

034

.50

00

0.0

0.0

0.0

00

1–

50%

00

0–

Arge

ntin

aAM

RDR

S, 20

052.

21.

33.

615

.410

.322

.549

031

067

01.

20.

81.

727

019

036

0–

––

–0

–

Baha

mas

AMR

mod

el2.

20

10.7

10.8

034

.52

05

0.6

0.0

1.5

10

493

%80

%0

00

Class

B (2

009)

Estim

ated

case

s of M

DR-T

B em

ergi

ng in

2008


Coun

try

WHO

re

gion

Sour

ce of

es

timat

es

Estim

ated

% of

all

new

TB ca

ses w

ith

MDR

-TB

(200

8)

Estim

ated

% of

all

retre

ated

TB ca

ses w

ith

MDR

-TB

(200

8)N

Per 1

00 00

0 pop

ulat

ion

Estim

ated

case

s of

MDR

-TB

amon

g no

tifie

d ca

ses o

f pul

mon

ary T

B in

20

09 (A

)

Prop

ortio

n of

TB

case

s rep

orte

d in

2009

with

DST

re

sults

b

Notif

ied

case

s of

MDR

-TB

in 20

09

(B)

Notif

ied

case

s of

MDR

-TB

as %

of

estim

ated

case

s of

MDR

-TB

amon

g al

l not

ified

case

s of

pul

mon

ary T

B (B

/A)c

Case

s of

MDR

-TB

enro

lled

on

treat

men

t in

2009

Avai

labi

lity

of Cl

ass A

or

B d

rug

resis

tanc

e su

rvei

llanc

e da

taBe

stLo

wHi

ghBe

stLo

wHi

ghBe

stLo

wHi

ghBe

stLo

wHi

ghBe

stLo

wHi

ghNe

wRe

treat

ed

Barb

ados

AMR

mod

el2.

20

10.7

10.8

034

.50

00

0.0

0.0

0.0

00

00%

–0

NA0

–

Beliz

eAM

Rm

odel

20

612

.10

28.3

30

71.

00.

02.

33

17

1%0%

132

1–

Boliv

ia (P

lurin

atio

nal

Stat

e of)

AMR

DRS,

1996

1.2

0.6

2.6

4.7

210

.519

054

330

2.0

0.6

3.4

110

5420

0–

92%

6053

37Cla

ss A

, pr

evio

usly

treat

ed ca

ses

only

(200

9)

Braz

ilAM

RDR

S, 19

960.

90.

61.

45.

44.

17.

214

0090

018

000.

70.

50.

911

0082

014

00–

–44

941

398

–

Cana

daAM

RDR

S, 20

080.

80.

41.

64.

41.

710

.817

727

0.1

0.0

0.1

126

2091

%–

18>

100

18Cla

ss A

(200

9)

Chile

AMR

DRS,

2001

0.7

0.3

1.5

3.8

2.1

6.6

175

280.

10.

00.

223

1337

3%72

%23

9911

Class

A,

prev

ious

ly tre

ated

case

s on

ly (2

009)

Colo

mbi

aAM

RDR

S, 20

001.

50.

92.

412

.10

28.3

320

170

470

0.7

0.4

1.0

210

110

330

4%79

%11

053

90Cla

ss A

, pr

evio

usly

treat

ed ca

ses

only

(200

9)

Costa

Rica

AMR

DRS,

2006

1.5

0.6

3.8

4.8

0.2

22.7

70

150.

20.

00.

37

214

––

––

0–

Cuba

AMR

DRS,

2005

00

2.2

5.3

0.3

24.6

190

390.

20.

00.

36

117

26%

37%

351

––

Dom

inica

AMR

mod

el2

06

12.1

028

.30

00

0.0

0.0

0.0

00

0–

––

–0

–

Dom

inica

n Rep

ublic

AMR

DRS,

1995

6.6

4.3

1019

.713

.527

.859

037

081

05.

93.

78.

131

022

042

00%

0%0

093

–

Ecua

dor

AMR

DRS,

2002

4.9

3.6

6.6

24.3

18.7

3173

052

095

05.

43.

97.

036

030

044

0–

–15

643

452

–

El Sa

lvado

rAM

RDR

S, 20

010.

30.

11.

27

3.4

13.7

90

180.

10.

00.

312

522

4%75

%2

172

Class

A,

prev

ious

ly tre

ated

case

s on

ly (2

009)

Gren

ada

AMR

mod

el2

06

12.1

028

.30

00

0.0

0.0

0.0

00

0–

––

NA0

–

Guat

emala

AMR

DRS,

2002

31.

94.

626

.520

.133

.933

020

047

02.

41.

53.

411

079

150

5%>

100%

230

>10

028

–

Guya

naAM

Rm

odel

20

612

.10

28.3

355

654.

60.

78.

537

1178

0%–

00

––

Haiti

AMR

mod

el2

06

12.1

028

.364

00

1300

6.5

0.0

13.2

00

0–

––

NA–

–

Hond

uras

AMR

DRS,

2004

1.8

0.9

3.4

12.3

6.6

21.8

100

3517

01.

40.

52.

371

4111

01%

19%

46

5–

Jam

aica

AMR

mod

el2

06

12.1

028

.35

010

0.2

0.0

0.4

51

1052

%–

00

0Cla

ss B

(200

9)

Mex

icoAM

RDR

Sa , 199

72.

41.

24.

722

.415

.631

.267

031

010

000.

60.

30.

970

045

010

000%

1%11

218

–

Nica

ragu

aAM

RDR

S, 20

060.

60.

22.

27.

84

14.6

261

510.

50.

00.

933

1460

––

––

0–

Pana

ma

AMR

mod

el2

06

12.1

028

.358

711

01.

70.

23.

253

1611

0–

–8

15–

–

Estim

ated

case

s of M

DR-T

B em

ergi

ng in

2008


Coun

try

WHO

re

gion

Sour

ce of

es

timat

es

Estim

ated

% of

all

new

TB ca

ses w

ith

MDR

-TB

(200

8)

Estim

ated

% of

all

retre

ated

TB ca

ses w

ith

MDR

-TB

(200

8)N

Per 1

00 00

0 pop

ulat

ion

Estim

ated

case

s of

MDR

-TB

amon

g no

tifie

d ca

ses o

f pul

mon

ary T

B in

20

09 (A

)

Prop

ortio

n of

TB

case

s rep

orte

d in

2009

with

DST

re

sults

b

Notif

ied

case

s of

MDR

-TB

in 20

09

(B)

Notif

ied

case

s of

MDR

-TB

as %

of

estim

ated

case

s of

MDR

-TB

amon

g al

l not

ified

case

s of

pul

mon

ary T

B (B

/A)c

Case

s of

MDR

-TB

enro

lled

on

treat

men

t in

2009

Avai

labi

lity

of Cl

ass A

or

B d

rug

resis

tanc

e su

rvei

llanc

e da

taBe

stLo

wHi

ghBe

stLo

wHi

ghBe

stLo

wHi

ghBe

stLo

wHi

ghBe

stLo

wHi

ghNe

wRe

treat

ed

Para

guay

AMR

DRS,

2001

2.1

0.9

4.9

3.9

1.1

13.2

6713

120

1.1

0.2

1.9

4817

953%

26%

612

7–

Peru

AMR

DRS,

2006

5.3

4.3

6.4

23.6

19.5

28.3

2600

2000

3100

9.0

6.9

10.8

2300

2000

2600

3%19

%15

7870

1856

–

Sain

t Kitt

s and

Nev

isAM

Rm

odel

20

612

.10

28.3

00

00.

00.

00.

00

00

––

–NA

0–

Sain

t Luc

iaAM

Rm

odel

20

612

.10

28.3

00

10.

00.

00.

61

01

0%0%

00

0–

Sain

t Vin

cent

and t

he

Gren

adin

esAM

Rm

odel

20

612

.10

28.3

10

20.

90.

01.

80

01

––

–0

0–

Surin

ame

AMR

mod

el2

06

12.1

028

.319

038

3.7

0.0

7.4

51

111%

0%1

201

–

Trini

dad a

nd To

bago

AMR

mod

el2.

20

10.7

10.8

034

.518

037

1.3

0.0

2.8

121

330%

0%0

00

–

Unite

d Sta

tes o

f Am

erica

AMR

DRS,

2007

1.1

0.9

1.3

3.8

2.5

5.9

190

150

230

0.1

0.0

0.1

9174

110

70%

>10

0%11

5>

100

115

Class

A (2

009)

Urug

uay

AMR

DRS,

2005

00

1.1

6.1

1.7

19.6

220

440.

70.

01.

34

110

––

––

1–

Vene

zuela

(Bol

ivaria

n Re

publ

ic of

)AM

RDR

S, 19

990.

50.

21.

313

.58.

221

.393

3715

00.

30.

10.

583

4913

00%

37%

2125

21–

Afgh

anist

anEM

Rm

odel

2.8

08

35.4

075

.124

0042

043

008.

81.

515

.898

030

020

00–

–0

0–

–

Bahr

ainEM

Rm

odel

2.2

010

.710

.80

34.5

160

352.

10.

04.

54

020

13%

–0

00

–

Djib

outi

EMR

mod

el0.

90

2.4

14.4

038

.161

112

07.

20.

114

.147

1310

0–

––

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–

Egyp

tEM

RDR

S, 20

022.

21.

33.

738

.232

44.9

590

370

800

0.7

0.5

1.0

430

340

520

1%>

100%

204

4873

–

Iran (

Islam

ic Re

publ

ic of

)EM

RDR

S, 19

985

3.5

6.9

48.2

35.7

6187

057

012

001.

20.

81.

673

058

089

0–

––

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–

Iraq

EMR

mod

el2.

80

835

.40

75.1

820

9515

002.

70.

35.

043

015

086

00%

22%

7217

72–

Jord

anEM

RDR

S, 20

045.

42.

511

.340

24.6

57.7

249

400.

40.

10.

717

1026

26%

35%

846

9Cla

ss A

(200

9)

Kuwa

itEM

Rm

odel

2.2

010

.710

.80

34.5

460

991.

60.

03.

412

052

46%

100%

975

9Cla

ss A

(200

9)

Leba

non

EMR

DRS,

2003

1.1

0.3

3.8

62.5

38.6

81.5

189

270.

40.

20.

69

515

3%10

0%4

436

Class

A,

prev

ious

ly tre

ated

case

s on

ly (2

009)

Libya

n Ara

b Jam

ahiri

yaEM

Rm

odel

2.8

08

35.4

075

.112

020

210

1.9

0.3

3.3

479

120

––

––

3–

Mor

occo

EMR

DRS,

2006

0.5

0.2

1.1

12.2

8.2

17.7

200

5933

00.

60.

21.

027

018

037

0–

––

–0

–

Oman

EMR

DRS,

2008

2.2

0.7

6.2

8.3

0.4

35.4

80

160.

30.

00.

65

112

76%

100%

510

05

Class

A (2

009)

Pakis

tan

EMR

mod

el2.

80

835

.40

75.1

1500

012

0029

000

8.5

0.7

16.4

9300

2500

2000

00%

1%49

136

8–

Qata

rEM

Rm

odel

2.2

010

.710

.80

34.5

40

90.

30.

00.

76

031

52%

–3

473

Class

A (2

009)

Saud

i Ara

bia

EMR

mod

el2.

20

10.7

10.8

034

.521

00

460

0.8

0.0

1.8

772

280

––

––

0–

Som

alia

EMR

mod

el0.

90

2.4

14.4

038

.139

055

730

4.4

0.6

8.2

170

5136

0–

––

–0

–

Suda

nEM

Rm

odel

0.9

02.

414

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38.1

850

140

1600

2.1

0.3

3.9

460

130

990

0%10

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2094

–

Estim

ated

case

s of M

DR-T

B em

ergi

ng in

2008


Coun

try

WHO

re

gion

Sour

ce of

es

timat

es

Estim

ated

% of

all

new

TB ca

ses w

ith

MDR

-TB

(200

8)

Estim

ated

% of

all

retre

ated

TB ca

ses w

ith

MDR

-TB

(200

8)N

Per 1

00 00

0 pop

ulat

ion

Estim

ated

case

s of

MDR

-TB

amon

g no

tifie

d ca

ses o

f pul

mon

ary T

B in

20

09 (A

)

Prop

ortio

n of

TB

case

s rep

orte

d in

2009

with

DST

re

sults

b

Notif

ied

case

s of

MDR

-TB

in 20

09

(B)

Notif

ied

case

s of

MDR

-TB

as %

of

estim

ated

case

s of

MDR

-TB

amon

g al

l not

ified

case

s of

pul

mon

ary T

B (B

/A)c

Case

s of

MDR

-TB

enro

lled

on

treat

men

t in

2009

Avai

labi

lity

of Cl

ass A

or

B d

rug

resis

tanc

e su

rvei

llanc

e da

taBe

stLo

wHi

ghBe

stLo

wHi

ghBe

stLo

wHi

ghBe

stLo

wHi

ghBe

stLo

wHi

ghNe

wRe

treat

ed

Syria

n Ara

b Rep

ublic

EMR

mod

el2.

80

835

.40

75.1

250

5744

01.

20.

32.

112

038

230

–8%

1412

15–

Tuni

siaEM

Rm

odel

2.8

08

35.4

075

.111

020

190

1.1

0.2

1.9

4712

110

18%

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1110

–

Unite

d Ara

b Em

irate

sEM

Rm

odel

2.2

010

.710

.80

34.5

80

180.

20.

00.

42

08

––

––

2–

Yem

enEM

RDR

S, 20

042.

91.

84.

811

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322

.649

026

072

02.

11.

13.

120

012

030

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10%

136

––

Alba

nia

EUR

mod

el0.

40

1.3

5.6

013

.12

05

0.1

0.0

0.2

21

529

%43

%0

00

Class

B (2

009)

Ando

rraEU

RDR

S, 20

080

056

.110

.80

34.5

00

00.

00.

00.

01

03

29%

50%

00

0Cla

ss B

(200

9)

Arm

enia

EUR

DRS,

2007

9.4

7.3

12.1

43.2

38.1

48.5

480

380

580

15.6

12.3

18.8

180

160

210

33%

>10

0%15

685

134

Class

B (2

009)

Austr

iaEU

RDR

S, 20

051.

91.

13.

412

.53.

536

––

––

––

116

1861

%53

%22

>10

0–

Class

A (2

009)

Azer

baija

nEU

RDR

Sa , 200

722

.319

2655

.851

.659

.940

0033

0047

0045

.837

.853

.824

0022

0025

00–

––

––

–

Belar

usEU

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odel

12.5

025

.342

.111

.972

.280

026

013

008.

32.

713

.490

039

015

0045

%>

100%

1342

>10

0–

Class

B (2

009)

Belg

ium

EUR

DRS,

2008

2.4

1.4

3.9

12.5

5.9

24.7

3016

430.

30.

20.

415

925

77%

71%

1066

–Cla

ss A

(200

9)

Bosn

ia an

d Her

zego

vina

EUR

DRS,

2005

0.4

0.2

16.

63.

213

91

160.

20.

00.

413

722

51%

58%

215

0Cla

ss B

(200

8)

Bulg

aria

EUR

mod

el12

.50

25.3

42.1

11.9

72.2

460

9881

06.

11.

310

.742

018

073

028

%33

%43

1043

Class

B (2

009)

Croa

tiaEU

RDR

S, 20

050.

50.

21.

54.

91.

713

.58

114

0.2

0.0

0.3

72

1460

%66

%7

>10

0–

–

Cypr

usEU

RDR

S, 20

080

011

.733

.31.

779

.22

04

0.2

0.0

0.5

20

566

%67

%4

>10

0–

Class

A (2

009)

Czec

h Rep

ublic

EUR

DRS,

2008

2.1

1.1

3.8

2.7

0.1

13.8

208

320.

20.

10.

311

620

65%

61%

872

–Cla

ss A

(200

9)

Denm

ark

EUR

DRS,

2008

00

1.5

00

12.1

200

410.

40.

00.

81

04

73%

80%

2>

100

–Cla

ss A

(200

9)

Esto

nia

EUR

DRS,

2008

15.4

11.6

20.1

42.7

32.1

53.9

9371

120

6.9

5.3

8.9

8267

9874

%78

%86

>10

086

Class

A (2

009)

Finlan

dEU

RDR

S, 20

080.

40

2.3

00

29.9

30

70.

10.

00.

12

08

73%

50%

6>

100

–Cla

ss A

(200

9)

Fran

ceEU

RDR

S, 20

071

0.5

1.7

6.9

3.4

13.5

6232

930.

10.

10.

122

1138

100%

30%

30>

100

30Cla

ss B

(200

9)

Geor

gia

EUR

DRS,

2006

6.8

5.2

8.7

27.4

23.7

31.4

670

550

780

15.6

12.8

18.1

370

310

430

40%

>10

0%36

999

266

Class

A (2

009)

Germ

any

EUR

DRS,

2008

0.7

0.4

1.1

117.

515

.855

3773

0.1

0.0

0.1

5036

6666

%47

%61

>10

0–

Class

A (2

009)

Gree

ceEU

RDR

S, 20

082.

71.

64.

550

2.6

97.4

5815

100

0.5

0.1

0.9

137

2030

%31

%14

>10

0–

Class

B (2

009)

Hung

ary

EUR

mod

el2.

20

10.7

10.8

034

.578

017

00.

80.

01.

749

514

040

%26

%20

41–

Class

A (2

009)

Icelan

dEU

RDR

S, 20

0820

162

.410

.80

34.5

10

30.

30.

01.

02

05

86%

100%

00

–Cla

ss A

(200

9)

Irelan

dEU

RDR

S, 20

050.

50

2.8

100.

540

.45

012

0.1

0.0

0.3

30

948

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A (2

009)

Israe

lEU

RDR

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053.

61.

86.

933

.31.

779

.216

526

0.2

0.1

0.4

116

1976

%75

%7

627

Class

A (2

009)

Italy

EUR

DRSa , 2

005

1.6

0.8

3.2

17.7

10.9

27.6

120

6617

00.

20.

10.

331

1561

39%

75%

82>

100

–Cla

ss B

(200

9)

Kaza

khsta

nEU

RDR

S, 20

0114

.211

18.2

56.4

50.9

61.8

8100

6400

9700

52.2

41.2

62.5

7300

6600

8100

25%

47%

3644

5032

09Cla

ss B

(200

9)

Estim

ated

case

s of M

DR-T

B em

ergi

ng in

2008


Coun

try

WHO

re

gion

Sour

ce of

es

timat

es

Estim

ated

% of

all

new

TB ca

ses w

ith

MDR

-TB

(200

8)

Estim

ated

% of

all

retre

ated

TB ca

ses w

ith

MDR

-TB

(200

8)N

Per 1

00 00

0 pop

ulat

ion

Estim

ated

case

s of

MDR

-TB

amon

g no

tifie

d ca

ses o

f pul

mon

ary T

B in

20

09 (A

)

Prop

ortio

n of

TB

case

s rep

orte

d in

2009

with

DST

re

sults

b

Notif

ied

case

s of

MDR

-TB

in 20

09

(B)

Notif

ied

case

s of

MDR

-TB

as %

of

estim

ated

case

s of

MDR

-TB

amon

g al

l not

ified

case

s of

pul

mon

ary T

B (B

/A)c

Case

s of

MDR

-TB

enro

lled

on

treat

men

t in

2009

Avai

labi

lity

of Cl

ass A

or

B d

rug

resis

tanc

e su

rvei

llanc

e da

taBe

stLo

wHi

ghBe

stLo

wHi

ghBe

stLo

wHi

ghBe

stLo

wHi

ghBe

stLo

wHi

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treat

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Kyrg

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nEU

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odel

12.5

025

.342

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.972

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0035

024

0025

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544

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035

014

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598

545

Thre

e su

bnat

iona

l re

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s: Cla

ss

B (2

009)

Latv

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RDR

S, 20

0812

.19.

914

.831

.924

.939

.917

014

020

07.

56.

28.

914

012

016

074

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%13

192

124

Class

A (2

009)

Lithu

ania

EUR

DRS,

2008

97.

510

.747

.542

.952

.233

027

039

09.

98.

111

.733

030

036

064

%10

0%32

298

322

Class

A (2

009)

Luxe

mbo

urg

EUR

DRS,

2005

00

9.6

10.8

034

.5–

––

––

––

––

––

0NA

0Cla

ss A

(200

9)

Malt

aEU

RDR

S, 20

050

025

.910

.80

34.5

20

50.

50.

01.

23

09

41%

–0

00

Class

A (2

009)

Mon

aco

EUR

mod

el2.

20

10.7

10.8

034

.5–

––

––

––

––

––

–NA

––

Mon

tene

gro

EUR

DRS,

2008

00

4.9

00

29.9

00

10.

00.

00.

20

00

74%

82%

1NA

1Cla

ss A

(200

9)

Neth

erlan

dsEU

RDR

S, 20

081.

60.

92.

86.

31.

720

.119

829

0.1

0.0

0.2

127

2066

%60

%20

>10

0–

Class

A (2

009)

Norw

ayEU

RDR

S, 20

080.

60

3.1

14.3

439

.95

012

0.1

0.0

0.3

10

681

%65

%8

>10

0–

Class

A (2

009)

Polan

dEU

RDR

S, 20

040.

30.

10.

68.

26.

210

.973

4710

00.

20.

10.

377

5610

0–

–0

00

–

Portu

gal

EUR

DRS,

2008

1.3

0.8

26.

23.

311

.448

2868

0.4

0.3

0.6

4530

6454

%55

%22

49–

Class

A (2

009)

Repu

blic

of M

oldo

vaEU

RDR

S, 20

0619

.416

.822

.250

.848

.753

2100

1700

2400

57.8

46.8

66.1

1500

1400

1600

34%

68%

1069

7233

4Cla

ss B

(200

9)

Rom

ania

EUR

DRS,

2004

2.8

1.9

4.2

118.

214

.513

0084

017

006.

13.

98.

010

0080

013

0012

%30

%43

542

––

Russ

ian Fe

dera

tion

EUR

DRSa , 2

008

15.8

11.9

19.7

42.4

38.1

46.7

3800

030

000

4500

026

.921

.231

.831

000

2600

035

000

31%

21%

1468

648

8143

Natio

nal:

Class

B (2

009)

; Tw

elve

subn

atio

nal

regi

ons:

Class

A

(200

8)

San M

arin

oEU

Rm

odel

2.2

010

.710

.80

34.5

––

––

––

––

––

––

NA–

–

Serb

iaEU

RDR

S, 20

080.

70.

31.

47.

74.

213

.618

730

0.2

0.1

0.3

2615

40–

––

––

Class

A (2

008)

Slova

kiaEU

RDR

S, 20

080.

30

1.9

3.2

0.9

112

07

0.0

0.0

0.1

40

1047

%46

%1

28–

Class

A (2

009)

Slove

nia

EUR

DRS,

2008

0.5

03

7.7

0.4

33.3

10

40.

00.

00.

22

05

93%

100%

169

–Cla

ss A

(200

9)

Spain

EUR

DRSa , 2

005

0.1

00.

45.

10

13.7

120

031

00.

30.

00.

75

018

17%

96%

56>

100

––

Swed

enEU

RDR

S, 20

082

14.

113

.35.

329

.715

624

0.2

0.1

0.3

53

1182

%76

%13

>10

0–

Class

A (2

009)

Switz

erlan

dEU

RDR

S, 20

081.

20.

43.

42.

90.

214

.95

011

0.1

0.0

0.1

31

781

%>

100%

5>

100

–Cla

ss A

(200

9)

Tajik

istan

EUR

DRSa , 2

008

16.5

11.3

23.6

61.6

52.8

69.7

4000

2900

5100

58.5

42.4

74.6

1000

770

1300

14%

>10

0%31

931

52–

The F

orm

er Yu

gosla

v Re

publ

ic of

Mac

edon

iaEU

Rm

odel

0.4

01.

35.

60

13.1

20

50.

10.

00.

24

18

46%

58%

126

1Cla

ss A

(200

9)

Turk

eyEU

Rm

odel

0.4

01.

35.

60

13.1

150

2327

00.

20.

00.

412

036

260

23%

41%

222

>10

022

2Cla

ss B

(200

9)

Estim

ated

case

s of M

DR-T

B em

ergi

ng in

2008


Coun

try

WHO

re

gion

Sour

ce of

es

timat

es

Estim

ated

% of

all

new

TB ca

ses w

ith

MDR

-TB

(200

8)

Estim

ated

% of

all

retre

ated

TB ca

ses w

ith

MDR

-TB

(200

8)N

Per 1

00 00

0 pop

ulat

ion

Estim

ated

case

s of

MDR

-TB

amon

g no

tifie

d ca

ses o

f pul

mon

ary T

B in

20

09 (A

)

Prop

ortio

n of

TB

case

s rep

orte

d in

2009

with

DST

re

sults

b

Notif

ied

case

s of

MDR

-TB

in 20

09

(B)

Notif

ied

case

s of

MDR

-TB

as %

of

estim

ated

case

s of

MDR

-TB

amon

g al

l not

ified

case

s of

pul

mon

ary T

B (B

/A)c

Case

s of

MDR

-TB

enro

lled

on

treat

men

t in

2009

Avai

labi

lity

of Cl

ass A

or

B d

rug

resis

tanc

e su

rvei

llanc

e da

taBe

stLo

wHi

ghBe

stLo

wHi

ghBe

stLo

wHi

ghBe

stLo

wHi

ghBe

stLo

wHi

ghNe

wRe

treat

ed

Turk

men

istan

EUR

DRSa , 2

002

3.8

1.5

9.4

18.4

11.9

27.2

160

3429

03.

20.

75.

789

3522

05%

>10

0%39

44–

–

Ukra

ine

EUR

DRSa , 2

002

1613

.818

.344

.340

48.7

8700

6800

1100

018

.914

.823

.972

0065

0079

0036

%>

100%

3482

4931

86Cla

ss B

(200

9)

Unite

d Kin

gdom

of G

reat

Br

itain

and N

orth

ern

Irelan

d

EUR

DRS,

2007

10.

71.

36.

43.

312

.198

6513

00.

20.

10.

234

2444

56%

45%

58>

100

–Cla

ss A

(200

9)

Uzbe

kista

nEU

RDR

Sa , 200

514

.210

.418

.149

.835

.863

.887

0065

0011

000

32.0

23.9

40.5

2900

2400

3500

3%30

%65

422

464

–

Bang

lades

hSE

Am

odel

2.2

05.

614

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39.6

9800

1000

1900

06.

10.

611

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082

00–

––

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2Cla

ss A

, pr

evio

usly

treat

ed ca

ses

only

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8)

Bhut

anSE

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odel

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614

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70.

48.

927

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tic Pe

ople’

s Re

publ

ic of

Kore

aSE

Am

odel

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05.

614

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39.6

3900

660

7200

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2.8

30.2

3500

990

7500

––

––

0–

Indi

aSE

ADR

Sa , 200

52.

31.

82.

817

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000

7900

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0000

8.4

6.7

10.2

7300

065

000

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602

1136

–

Indo

nesia

SEA

DRSa , 2

004

20.

56.

914

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39.6

9300

021

000

4.1

0.0

9.2

6400

770

1800

0–

––

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–

Mald

ives

SEA

mod

el2.

20

5.6

14.7

039

.63

06

1.0

0.0

2.0

21

4–

––

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–

Mya

nmar

SEA

DRS,

2007

4.2

3.2

5.6

107.

114

9300

6400

1200

018

.812

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0038

0060

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10%

815

1764

–

Nepa

lSE

ADR

S, 20

072.

91.

94.

311

.77.

617

.617

0099

023

005.

93.

48.

011

0079

015

000%

7%58

515

6–

Sri L

anka

SEA

DRS,

2006

0.2

01

00

10.2

630

130

0.3

0.0

0.6

242

769%

>10

0%4

174

–

Thail

and

SEA

DRS,

2006

1.7

1.1

2.6

34.5

28.2

41.5

2900

2100

3800

4.3

3.1

5.6

2300

1800

2700

––

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-Les

teSE

Am

odel

2.2

05.

614

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011

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523

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250

0%12

%4

41

–

Austr

alia

WPR

mod

el2.

20

10.7

10.8

034

.520

832

0.1

0.0

0.2

211

70–

–31

>10

026

Class

A (2

009)

Brun

ei Da

russ

alam

WPR

mod

el2.

20

10.7

10.8

034

.512

026

3.1

0.0

6.6

30

1677

%>

100%

00

0Cla

ss A

(200

9)

Cam

bodi

aW

PRDR

S, 20

010

00.

63.

11.

18.

822

000

4600

15.1

0.0

31.6

8417

200

––

––

––

Chin

aW

PRDR

S, 20

075.

75

6.6

25.6

22.6

28.3

1000

0079

000

1200

007.

55.

99.

066

000

5900

073

000

––

474

145

8–

Cook

Islan

dsW

PRm

odel

1.9

07.

513

.80

36.2

00

00.

00.

00.

0–

––

0%–

0NA

0–

Fiji

WPR

mod

el1.

90

7.5

13.8

036

.25

011

0.6

0.0

1.3

20

7–

100%

00

0Cla

ss A

, pr

evio

usly

treat

ed ca

ses

only

(200

9)

Japa

nW

PRDR

S, 20

020.

70.

51.

19.

87.

313

.129

018

039

00.

20.

10.

329

023

037

0–

––

––

–

Kirib

ati

WPR

mod

el1.

90

7.5

13.8

036

.210

022

10.4

0.0

22.8

50

15–

––

–0

–

Estim

ated

case

s of M

DR-T

B em

ergi

ng in

2008


Coun

try

WHO

re

gion

Sour

ce of

es

timat

es

Estim

ated

% of

all

new

TB ca

ses w

ith

MDR

-TB

(200

8)

Estim

ated

% of

all

retre

ated

TB ca

ses w

ith

MDR

-TB

(200

8)N

Per 1

00 00

0 pop

ulat

ion

Estim

ated

case

s of

MDR

-TB

amon

g no

tifie

d ca

ses o

f pul

mon

ary T

B in

20

09 (A

)

Prop

ortio

n of

TB

case

s rep

orte

d in

2009

with

DST

re

sults

b

Notif

ied

case

s of

MDR

-TB

in 20

09

(B)

Notif

ied

case

s of

MDR

-TB

as %

of

estim

ated

case

s of

MDR

-TB

amon

g al

l not

ified

case

s of

pul

mon

ary T

B (B

/A)c

Case

s of

MDR

-TB

enro

lled

on

treat

men

t in

2009

Avai

labi

lity

of Cl

ass A

or

B d

rug

resis

tanc

e su

rvei

llanc

e da

taBe

stLo

wHi

ghBe

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treat

ed

Lao P

eopl

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emoc

ratic

Re

publ

icW

PRm

odel

1.9

07.

513

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36.2

280

059

04.

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09.

590

926

0–

––

––

–

Mala

ysia

WPR

DRSa , 1

997

0.1

00.

60

019

.410

00

220

0.4

0.0

0.8

724

230

––

5577

0–

Mar

shall

Islan

dsW

PRm

odel

1.9

07.

513

.80

36.2

30

84.

90.

013

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09

30%

50%

138

1Cla

ss B

(200

9)

Micr

ones

ia (F

eder

ated

St

ates

of)

WPR

mod

el1.

90

7.5

13.8

036

.23

06

2.7

0.0

5.4

31

933

%22

%3

913

Class

B (2

009)

Mon

golia

WPR

DRS,

1999

10.

42.

513

.80

36.2

110

2019

04.

20.

87.

210

027

230

3%89

%16

8>

100

88Cla

ss A

, pr

evio

usly

treat

ed ca

ses

only

(200

9)

Naur

uW

PRm

odel

1.9

07.

513

.80

36.2

00

00.

00.

00.

00

00

––

0NA

––

New

Zeala

ndW

PRDR

S, 20

080

01.

60

039

150

330.

40.

00.

80

00

81%

89%

7NA

–Cla

ss A

(200

9)

Niue

WPR

mod

el1.

90

7.5

13.8

036

.2–

––

––

––

––

––

–NA

––

Palau

WPR

mod

el1.

90

7.5

13.8

036

.20

00

0.0

0.0

0.0

00

1–

–0

NA0

–

Papu

a New

Gui

nea

WPR

mod

el1.

90

7.5

13.8

036

.260

00

1200

9.1

0.0

18.2

320

6976

0–

––

––

–

Phili

ppin

esW

PRDR

S, 20

044

35.

520

.914

.828

.713

000

8900

1700

014

.49.

918

.876

0059

0096

001%

0%10

7314

491

–

Repu

blic

of Ko

rea

WPR

DRS,

2004

2.7

2.1

3.4

1410

.418

.619

0014

0023

003.

92.

94.

817

0014

0021

00–

––

––

–

Sam

oaW

PRm

odel

1.9

07.

513

.80

36.2

10

20.

60.

01.

10

01

––

–NA

––

Singa

pore

WPR

DRS,

2008

0.1

00.

62.

91

8.2

30

80.

10.

00.

25

112

63%

64%

360

3Cla

ss A

(200

9)

Solo

mon

Islan

dsW

PRm

odel

1.9

07.

513

.80

36.2

200

413.

90.

08.

05

016

1%>

100%

00

0–

Tong

aW

PRm

odel

1.9

07.

513

.80

36.2

00

10.

00.

01.

00

00

––

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0–

Tuva

luW

PRm

odel

1.9

07.

513

.80

36.2

00

10.

00.

010

.10

00

0%0%

0NA

0–

Vanu

atu

WPR

DRS,

2006

00

11.7

13.8

036

.24

010

1.7

0.0

4.3

30

80%

0%0

00

–

Viet

Nam

WPR

DRS,

2006

2.7

23.

619

.314

.525

.259

0038

0081

006.

84.

49.

335

0028

0042

00–

–21

76

307

–

Estim

ated

case

s of M

DR-T

B em

ergi

ng in

2008

3.2 Continuous drug resistance surveillance data quality indicators

Class A surveillance data

Country or areaWHO

region Year

Case detection rate (%)

Culture positivity ratea

(%)DST coverage

(%)

Satisfactory External Quality

Assurance (Yes/No)

Australia WPR 2009 89 132 100 Yes

Austria EUR 2009 87 66 98 Yes

Belgium EUR 2009 88 89 95 Yes

Bosnia and Herzegovina EUR 2009 91 58 100 Yes

Brunei Darussalam WPR 2009 89 108 100 Yes

Canada AMR 2009 93 117 100 Yes

China, Hong Kong SAR WPR 2009 89 65 76 Yes

China, Macao SAR WPR 2009 89 70 100 Yes

Cyprus EUR 2009 91 79 76 Yes

Czech Republic EUR 2009 70 74 95 Yes

Denmark EUR 2009 79 77 100 Yes

Estonia EUR 2009 89 79 99 Yes

Finland EUR 2009 110 73 98 Yes

French Polynesia WPR 2009 89 118 100 Yes

Georgia EUR 2009 100 55 92 Yes

Germany EUR 2009 91 74 90 Yes

Guam WPR 2009 89 57 98 Yes

Hungary EUR 2009 82 51 76 Yes

Iceland EUR 2009 110 80 100 Yes

Ireland EUR 2009 89 57 85 Yes

Israel EUR 2009 89 107 100 Yes

Italy EUR 2009 66 90 100 Yes

Jordan EMR 2009 100 60 86 Yes

Kuwait EMR 2009 89 79 100 Yes

Latvia EUR 2009 94 83 97 Yes

Lithuania EUR 2009 81 77 100 Yes

Luxembourg EUR 2009 NA 100 100 Yes

Malta EUR 2009 89 53 85 Yes

Montenegro EUR 2009 85 82 100 Yes

Netherlands EUR 2009 89 115 100 Yes

New Zealand WPR 2009 89 123 100 Yes

Northern Mariana Islands WPR 2009 89 66 100 Yes

Norway EUR 2009 91 87 99 Yes

Oman EMR 2009 89 123 100 Yes

Portugal EUR 2009 86 77 81 Yes

Puerto Rico AMR 2009 89 104 96 Yes

Qatar EMR 2009 89 100 100 Yes

Serbia EUR 2008 95 72 80 Yes

Singapore WPR 2009 89 75 100 Yes

Slovakia EUR 2009 89 53 100 Yes

Slovenia EUR 2009 80 102 98 Yes


Country or areaWHO

region Year

Case detection rate (%)

Culture positivity ratea

(%)DST coverage

(%)


Assurance (Yes/No)

Sweden EUR 2009 89 129 100 Yes

Switzerland EUR 2008 87 81 99 Yes

The Former Yugoslav Republic of Macedonia

EUR 2009 98 67 92 Yes

United Kingdom of Great Britain and Northern Ireland

EUR 2009 94 88 98 Yes

United States of America AMR 2009 89 97 95 Yes

For previously treated cases only

Bangladesh SEAR 2008 NA 59 100 Yes

Bolivia (Plurinational State of ) AMR 2009 NA 92 100 Yes

Chile AMR 2009 NA 72 100 Yes

Colombia         AMR 2009 NA 100 79 Yes

Fiji WPR 2009 NA 100 100 Yes

Lebanon EMR 2009 NA 100 100 Yes

Mongolia WPR 2009 NA 89 100 Yes

El Salvador AMR 2009 NA 80 94 Yes

Class B surveillance data

Country or areaWHO

region Year

Case detection rate

(%)Culture positivity

ratea (%) DST coverage (%)


Assurance (Yes/No)

Albania EUR 2009 94 67 61 Yes

Andorra EUR 2009 89 38 100 Yes

Armenia EUR 2009 70 40 100 Yes

Bahamas AMR 2009 89 102 100 No

Belarus EUR 2009 140 43 100 No

Bulgaria EUR 2009 86 52 66 Yes

France EUR 2009 77 66 64 Yes

Greece EUR 2009 92 56 57 Yes

Jamaica AMR 2009 78 46 100 Yes

Kazakhstan EUR 2009 80 35 98 Yes

Marshall Islands WPR 2009 110 37 84 Yes

Mauritius AFR 2009 41 94 100 Yes

Micronesia (Federated States of ) WPR 2009 150 43 100 Yes

New Caledonia WPR 2009 89 88 100 No

Republic of Moldova EUR 2009 68 47 100 Yes

Russian Federation EUR 2009 84 47 85 No

South Africa AFR 2008 72 40 55 NR

Turkey EUR 2009 77 51 74 No

Ukraine EUR 2009 78 54 96 No

a Culture positivity rate: the number of culture positive cases divided by the number of notified pulmonary casesNA = not applicable; NR = not reported


3.3

Con

tinu

ous

drug

resi

stan

ce s

urve

illan

ce

CLA

SS A

New

cas

esPr

evio

usly

trea

ted

case

sA

ll ca

ses

Case

s w

ith

DST

re

sult

s (H

+R)

Mul

tidr

ug

resi

stan

tA

ny is

onia

zid

resi

stan

ceCa

ses

wit

h D

ST re

sult

s (H

+R)

Mul

tidr

ug

resi

stan

tA

ny is

onia

zid

resi

stan

ceCa

ses

wit

h D

ST

resu

lts

(H+

R)

Mul

tidr

ug

resi

stan

tA

ny is

onia

zid

resi

stan

ce

Num

ber

(%)

Num

ber

(%)

Num

ber

(%)

Num

ber

(%)

Num

ber

(%)

Num

ber

(%)

Aust

ralia

WPR

2009

––

––

––

––

––

1056

312.

915

014

.2

Aust

riaEU

R20

0926

55

1.9

134.

923

834

.810

43.5

439

225.

042

9.6

Belg

ium

EUR

2009

621

40.

624

3.9

563

5.4

610

.777

410

1.3

374.

8

Bosn

ia a

nd H

erze

govi

naEU

R20

0985

40

0.0

50.

666

23.

08

12.1

920

20.

213

1.4

Brun

ei D

arus

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2009

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2009

245

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2009

295

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2009

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2009

1777

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2009

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2009

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2009

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2009

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2009

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2009

210

83.

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0924

84

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2009

1391

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2009

191

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2009

167

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2009

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EUR

2009

3957

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f Am

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MR

2009

8071

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670

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415

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R20

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120

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MR

2009

487

102

20.9

147

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Fiji

WPR

2009

20

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103

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440

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2009

119

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2009

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2009

480

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2009

2071

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2009

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2009

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2009

369

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2009

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2009

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2009

5840

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2.4

9.0

Aze

rbai

jan,

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u20

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143

112

529

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12.8

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8.3

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27.0

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00.

014

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Chin

a20

0840

140

111

027

.423

.132

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7.2

4.9

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ujar

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tate

2006

216

216

5224

.118

.530

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3.2

1.2

6.6

Nam

ibia

2008

100

100

22.

00.

27.

00

0.0

0.0

3.6

Para

guay

2008

88

00.

00.

036

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0.0

0.0

36.9

Repu

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2004

110

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1311

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119

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Spai

n, A

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054

41

25.0

0.6

80.6

125

.00.

680

.6

Swaz

iland

2009

122

122

108.

24.

014

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0.8

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Tajik

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0910

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2121

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379

203

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315

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66

00.

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39.3

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XD

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: sur

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data


3.5

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g da

ta fr

om d

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 % (9

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 CI) 

 % (9

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Bots

wan

aAf

rican

2008

924

2.5%

      

      

   (1

.5–3

.5)

7.6%

            

       

(6.0

–9.5

)13

76.

6%   

      

      

 (2.4

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7)10

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(5.7

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6)

Chin

aW

este

rn P

acifi

c20

073 

037

5.7%

      

      

    (4

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16.0

%      

            

(14.

7–17

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892

25.6

%   

      

      

  (21

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38.6

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(35.

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Indo

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2006

1 12

61.

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(1.0

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      (9

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3.4)

7017

.1%

      

      

    (8

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6.2)

24.3

%     

          

 (1

4.8–

36.0

)

Mex

ico

Am

eric

as20

0915

842.

4%   

      

   (2

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6.1%

        

    (5

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.6)

191

6.5%

      

      

(5.1

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9.0%

        

    (7

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Mon

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tern

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ific

2007

650

1.4%

      

      

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10.2

–15.

4)20

027

.5%

      

      

    (2

1.8–

34.1

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(29.

8–43

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Moz

ambi

que

Afric

an20

071 

102

3.5%

      

      

      

 (2.2

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8%      

            

 (6

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2511

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   (0

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2008

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    (3

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(4.0

–6.7

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910

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(6.9

–14.

0)11

.7%

          

       

(8.3

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9)

Nam

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Afric

an20

081 

054

3.8%

      

      

   (2

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13.5

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(11.

5–15

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354

16.4

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 (12.

7–20

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38.4

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43.7

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Para

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as20

0831

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4814

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    (6

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Swaz

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133

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    (2

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39.3

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Tajik

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139

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23.8

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     (1

9.5–

34.8

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561

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     (

52.5

–70.

2)74

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    (6

5.8–

81.8

)

Uga

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pala

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rican

2008

473

1.1%

      

      

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(3.8

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11.7

%   

      

      

 (4.8

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6)20

.0%

          

      

(10.

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CI =

confi

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% fl

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entin

a20

0536

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1.8

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60.

718

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Arm

enia

2007

199

199

2512

.68.

318

.010

5.0

2.4

9.0

Aze

rbai

jan,

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u20

0743

143

112

529

.024

.833

.555

12.8

9.8

16.3

Bots

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a20

0832

242

8.3

1.0

27.0

00.

00.

014

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Chin

a20

0840

140

111

027

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7.2

4.9

10.2

Indi

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ujar

at S

tate

2006

216

216

5224

.118

.530

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3.2

1.2

6.6

Nam

ibia

2008

100

100

22.

00.

27.

00

0.0

0.0

3.6

Para

guay

2008

88

00.

00.

036

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0.0

0.0

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Repu

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2004

110

110

1311

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119

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1.8

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va20

0620

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6.4

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2.0

25.0

00.

00.

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Spai

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054

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25.0

0.6

80.6

125

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680

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Swaz

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2009

122

122

108.

24.

014

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0.8

0.0

4.5

Tajik

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16.9

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2006

379

203

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37.9

315

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Uni

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nia

2007

66

00.

00.

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0.0

0.0

39.3


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2 The global plan to stop TB 2011–2015: transforming the fight towards elimination of tuberculosis._Geneva,_World_Health_Organization,_2010_(also_available_at:_http://www.stoptb.org/assets/documents/global/plan/TB_GlobalPlanToStopTB2011-2015.pdf).

3 Global tuberculosis control: WHO report 2010._Geneva,_World_Health_Organization,_2010_(WHO/HTM/TB/2010.7;_also_available_at:_http://www.who.int/tb/publications/2010/en/index.html).

4 Multidrug and extensively drug-resistant TB (M/XDR-TB): 2010 global report on surveillance and response._Geneva,_World_Health_Organization,_2010_(WHO/HTM/TB/2010.3;_also_available_at:_http://www.who.int/tb/publications/2010/en/index.html).

5 62nd_World_Health_Assembly._Prevention and control of multidrug-resistant tuberculosis and extensively drug-resistant tuberculosis._WHA62.15._Eighth_plenary_meeting,_22_May_2009_.A62/VR/8.

6 Beijing “Call for Action” on tuberculosis control and patient care: Together addressing the global M/XDR-TB epidemic._Beijing,_2009._Available_at:_http://www.who.int/tb_beijingmeeting/media/en_call_for_action.pdf_

7 Global tuberculosis control: WHO report 2010._Geneva,_World_Health_Organization,_2010_(WHO/HTM/TB/2010.7)_and_TB_data_available_at:_http://www.who.int/tb/country/en/index.html.

8 Policy recommendations on the use of liquid culture (2007), second-line drug susceptibility testing (2008), and the use of line probe assays for rapid MDR-TB screening._Geneva,_World_Health_Organization,_2008._Available_at:_http://www.who.int/tb/laboratory/policy_statements/en/index.html.

9 Lienhardt_C_et_al._New_drugs_and_new_regimens_for_the_treatment_of_tuberculosis:_review_of_the_drug_development_pipeline_and_implications_for_national_programmes._Current Opinion in Pulmonary Medicine,_2010,_16(3):186–193.

10 62nd_World_Health_Assembly._Prevention and control of multidrug-resistant tuberculosis and extensively drug-resistant tuberculosis._WHA62.15._Eighth_plenary_meeting,_22_May_2009,_A62/VR/8.

11 Bloss_E_et_al._Adverse_events_related_to_multidrug-resistant_tuberculosis_treatment,_Latvia,_2000–2004._International Journal of Tuberculosis and Lung Disease,_2010,_14(3):275–281

12 Guidance on ethics of tuberculosis prevention, care and control._Geneva,_World_Health_Organization,_2010_(WHO/HTM/TB/2010.16)._Available_at:_http://www.who.int/tb/publications/2010/en/index.html.

13 Uplekar_M_et_al. Private_practitioners_and_public_health:_weak_links_in_tuberculosis_control._Lancet,_2001,_358(9285):912–916.

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15 Global tuberculosis control: WHO report 2010._Geneva,_World_Health_Organization,_2010_(WHO/HTM/TB/2010.7)_p.15._Available_at:_http://www.who.int/tb/publications/2010/en/index.html.

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17 Wells_W_et_al._Size_and_usage_patterns_of_private_TB_markets_in_the_high_burden_countries._2011_(in_press).

18 Guidelines for surveillance of drug resistance in tuberculosis,_4th_ed._Geneva,_World_Health_Organization,_2009._Available_at:_http://whqlibdoc.who.int/publications/2009/9789241598675_eng.pdf.

19 Guidelines for intensified tuberculosis case-finding and isoniazid preventive therapy for people living with HIV in resource-constrained settings._Geneva,_World_Health_Organization,_2010._Available_at:_http://whqlibdoc.who.int/publications/2011/9789241500708_eng.pdf.

20 Antiretroviral therapy for HIV infection in adults and adolescents. Recommendations for a public health

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21 Priority research questions for TB/HIV in HIV-prevalent and resource-limited settings._Geneva,_World_Health_Organization,_2010._Available_at:_http://whqlibdoc.who.int/publications/2010/9789241500302_eng.pdf.

22 Accelerating the implementation of collaborative TB/HIV activities in the WHO European Region,_Vienna._Austria,_2010._Available_at:_http://www.stoptb.org/wg/tb_hiv/assets/documents/euro_meeting%20report.pdf.

23 Policy on TB infection control in health-care facilities, Congregate Settings and Households._Geneva,_World_Health_Organization,_2009_(WHO/HTM/TB/2009.419)._Available_at:_http://www.who.int/tb/publications/2009/en/index.html.

24 An advocacy strategy for adoption and dissemination of the WHO policy on TB-IC in health-care facilities, Congregate Settings and Households._USAID/Stop_and_Stop_TB_Partnership,_2010._Available_at:_http://www.stoptb.org/wg/tb_hiv/assets/documents/TB%20IC%20Advocacy%20Strategy%20Final%20April%202010.pdf.

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26 62nd_World_Health_Assembly._Prevention and control of multidrug-resistant tuberculosis and extensively drug-resistant tuberculosis._A62/20_and_A62/20_Add.1._Geneva,_World_Health_Organization,_2009._Available_at:_http://apps.who.int/gb/ebwha/pdf_files/A62/A62_20-en.pdf_and_http://apps.who.int/gb/ebwha/pdf_files/A62/A62_20Add1-en.pdf.

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28 62nd_World_Health_Assembly._Prevention and control of multidrug-resistant tuberculosis and extensively drug-resistant tuberculosis._A62/20_Add.1_Annex._Geneva,_World_Health_Organization,_2009._Available_at:_http://apps.who.int/gb/ebwha/pdf_files/A62/A62_20Add1-en.pdf.

118

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