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Tuberculosis control in the South-East Asia Region: Annual Report 2016

April 1, 2016 World Health Organization

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Tuberculosis control in the South-East Asia Region

Annual report 2016

Tuberculosis control in the South-East Asia Region Annual report 2016

WHO Library Cataloguing-in-Publication data World Health Organization, Regional Office for South-East Asia. Tuberculosis control in the South-East Asia Region: annual report 2016. 1. Tuberculosis – prevention and control – statistics and numerical data 2. Tuberculosis, Multidrug-Resistant 3. HIV 4. Health Resources 5. Data Collection. ISBN 978-92-9022-504-1 (NLM classification: WF 200)

Requests for publications, or for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – can be obtained from Publishing and Sales, World Health Organization, Regional Office for South- East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 002, India (fax: +91 11 23370197; e-mail: publications@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Maps disclaimer The boundaries and names shown and the designations used on the maps contained in this document do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. Printed in India

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Contents Abbreviations........................................................................................................... v Foreword.................................................................................................................. ix 1. Global and Regional burden of Tuberculosis................................................... 1 TB burden ............................................................................................................................ 2 Drug-resistant TB ................................................................................................................. 4 Co-epidemics of TB and HIV ................................................................................................ 5 TB financing.......................................................................................................................... 6

Global and Regional progress in Tuberculosis care and management............. 8 TB care and control ............................................................................................................. 9 Drug-resistant TB ............................................................................................................... 10 Co-epidemic of TB and HIV................................................................................................ 11 New diagnostics rollout ..................................................................................................... 13 New drugs rollout............................................................................................................... 13 Research and development ............................................................................................... 13

3. 4. 5.

Regional challenges....................................................................................... 15 Over reliance on donor funding......................................................................................... 16

The End-TB Strategy...................................................................................... 20 Regional Strategic Plan – Overview............................................................... 25 Vision and goal .................................................................................................................. 26 Objectives........................................................................................................................... 26 Regional targets and milestones........................................................................................ 26 Strategic directions and interventions............................................................................... 28

WHO support in the Region........................................................................... 32 Transitioning to the End TB Strategy.................................................................................. 33 Diagnostic capacity-building .............................................................................................. 34 Expansion of DR-TB services.............................................................................................. 35 Strengthening TB/HIV collaboration.................................................................................. 37 Capacity-building and information exchange..................................................................... 37 Drug supply and management........................................................................................... 38

Tuberculosis control in the South-East Asia Region

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Routine surveillance........................................................................................................... 38 Operational research.......................................................................................................... 39 Resource mobilization........................................................................................................ 40

Major SEA Regional partnerships.................................................................. 41 Axshya project supported by The Global Fund .................................................................. 42 EXPAND-TB project ............................................................................................................ 43 Global TB Drug Facility (GDF)............................................................................................. 45 Paediatric TB project.......................................................................................................... 47 TB REACH project............................................................................................................... 47 UNITAID support in SEAR countries ................................................................................... 49 United States Agency for International Development (USAID) in SEAR countries............. 51

Country profiles............................................................................................. 57 Bangladesh......................................................................................................................... 59 Bhutan................................................................................................................................ 77 Democratic People’s Republic of Korea.............................................................................. 90 India .............................................................................................................................. 103 Indonesia.......................................................................................................................... 118 Maldives........................................................................................................................... 134 Myanmar.......................................................................................................................... 146 Nepal .............................................................................................................................. 157 Sri Lanka........................................................................................................................... 170 Thailand............................................................................................................................ 182 Timor-Leste...................................................................................................................... 194

Tuberculosis control in the South-East Asia Region

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Abbreviations ACSM AFB AIDS ART ARV CBO CCM CDC CHW CSMBS CN CPT CV DOT DOTS DRS DR-TB DST EQA FDC FHI FLD GDF GDI GF GLC advocacy, communication and social mobilization acid-fast bacilli acquired immunodeficiency syndrome antiretroviral therapy antiretrovirals community-based organizations country coordination mechanism Centers for Disease Control, Atlanta, USA community health worker Civil Servant Medical Benefit Scheme (Thailand) concept note(s) co-trimoxazole preventive therapy community volunteer directly observed therapy the internationally recommended strategy for TB control and the foundation of the Stop TB Strategy introduced in 2006 drug resistance surveillance drug-resistant tuberculosis drug susceptibility testing external quality assurance fixed-dose combination Family Health International First-line anti-TB drugs Global (TB) Drug Facility Global Drug-resistant TB Initiative Global Fund Global Fund to Fight AIDS, Tuberculosis and Malaria Green Light Committee

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rGLC GLI HBC HRD HRH HSS IC IPT IQC ISTC IC JICA KNCH LED LTBI MCH MDG MDR-TB M&E MSH NGO NRL NSP NSP NTP OTC PAL PHC PLHIV

regional Green Light Committee Global Laboratory Initiative high-burden (TB) country human resource development human resources for health health system strengthening infection control isoniazid preventive therapy internal quality control International Standards for TB Care infection control Japan International Cooperation Agency Royal Dutch Foundation light-emitting diode microscopes latent TB infection maternal and child health Millennium Development Goals TB multidrug-resistant tuberculosis monitoring and evaluation NFM New Funding Model Management Sciences for Health nongovernmental organization national reference laboratory national strategic plan new smear positive national TB control programme over-the-counter (sale of medicines) practical approach to lung health primary health care persons living with HIV/AIDS

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PMDT PMTCT PPM PTB PWID PR QA RNTCP RR-TB SCC SDG SEA SEAR SLD SOPs SR SSF SSS TA TB TWG-TB USAID UCS VR WHA WHO XDR-RB

programmatic management of drug-resistant tuberculosis prevention of mother to child transmission public-private mix pulmonary TB people who inject drugs principal recipient (under Global Fund grants) quality assurance Revised National TB Control Programme (of India) rifampicin-resistant TB short coerce chemotherapy Sustainable Development Goals South-East Asia South-East Asia Region (of WHO) Second-line anti-TB drugs standard operating procedures subrecipient (under Global Fund grants) single stream funding (GF) Social Security Scheme (Thailand) technical assistance Tuberculosis Technical Working Group on TB United States Agency for International Development Universal Coverage Scheme (Thailand) vital registration World Health Assembly World Health Organization extensively drug-resistant TB

The Union International Union against Tuberculosis and Lung Disease

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Tuberculosis control in the South-East Asia Region

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Foreword The start of 2016 heralds the beginning of a new era in global health and development. The United Nations has adopted the Sustainable Development Goals (SDGs), providing a new development framework for 2016−2030, replacing the 2000−2015 Millennium Development Goal (MDG) framework. Under Goal 3 of the SDGs specifically pertaining to health, target 3.3 states - By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, waterborne diseases and other communicable diseases. The year 2016 also marks the beginning of implementation of the WHO End TB strategy based on the principles and targets enshrined in the World Health Assembly resolution WHA67.1. The three pillars of the End TB strategy include integrated, patient-centred care and prevention; bold policies and supportive systems; and intensified research and innovation. Thus there is a reinvigorated emphasis on ending the global TB epidemic, and 2016 will be the year to lay the foundation for TB control globally as well as in the South-East Asia (SEA) Region. Thus, we need to acknowledge the massive challenge before us. Tuberculosis remains a major global health problem. Worldwide, 9.6 million people are estimated to have fallen ill with TB in 2014 of which 1.5 million people died comprising of 890 000 men, 480 000 women and 140 000 children. The WHO SEA Region accounts for 41% of the global burden in terms of TB incidence. In 2014, there were an estimated 5.4 million prevalence and 4 million incidence of TB and about 460 000 people died due to TB in SEAR. An estimated 340 000 children in the Region developed TB in 2014. TB notifications in the Region were about 2.6 million in 2014 whereas in 2013, they were 2.3 million. This was mostly due to a 29% increase in notifications in India, which followed the introduction of a policy of mandatory notification in May 2012, creation of a national web-based reporting system in June 2012 and intensified efforts to engage the private health sector. TB treatment success rate in the Region continues to be more than 88% since 2009. The Region also faces the challenge of treating an estimated 99 000 multidrug-resistant (MDR) cases among the notified pulmonary cases and about 210 000 cases coinfected with HIV.

Tuberculosis control in the South-East Asia Region

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The Regional Strategic Plan towards Ending TB in the SEAR 2016–2020 describes the future directions and focus of the work towards TB elimination aiming to support Member States in the reduction in tuberculosis mortality and incidence in line with the global targets as set in World Health Assembly resolution WHA67.1, guiding the countries in addressing the persisting and emerging epidemiological and demographic challenges and advancing universal health coverage and robust health systems. The plan builds on and expands the existing updated Regional Strategic Plan for TB Care and Control 2012–2015 and focuses on the implementation of the End TB Strategy in the coming 5 years within the overall scope of the 20-year strategy covering the period 2015 to 2035. Ending the TB epidemic is not mere biomedical but a developmental challenge. The global, regional, national and local level response to ending the TB epidemic must therefore be a part of an inclusive response designed to meet the overall development goals. The progress towards ending the TB epidemic will depend as much on achieving overall health improvement as it will on optimizing current strategies, developing new tools and technologies to diagnose, treat and prevent TB, and reaching them to all who need them. I urge all Member States to work at all levels along with partners for renewed commitment towards ending the TB epidemic. Additional resources would need to be mobilized. Ending the TB epidemic will require an expansion of the scope and reach of interventions for TB prevention, care and control: the institution of systems and policies to promote an enabling environment, shared responsibilities with universal coverage; and an aggressive pursuit of research and innovation to promote development and use of new tools for TB care and prevention.

Dr Poonam Khetrapal Singh Regional Director

Tuberculosis control in the South-East Asia Region

Annual Report 2016

Global and Regional burden of Tuberculosis

Source: World Health Organization. Global tuberculosis report 2015. Geneva: WHO, 2015

Tuberculosis control in the South-East Asia Region

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Tuberculosis (TB) is contagious and airborne. It ranks alongside HIV/AIDS as a leading cause of death worldwide.

TB burden Globally, 9.6 million people fell ill with TB in 2014, including 1.2 million people living with HIV. In the same year 1.5 million people died from TB, including 0.4 million among people who were HIV-positive. TB is one of the top five killers of women among adult women aged 20–59 years. 480 000 women died from TB in 2014, including 140 000 deaths among women who were HIV-positive. 890 000 men died from TB and 5.4 million fell ill with the disease. An estimated 1 million children became ill with TB and 140 000 children died of TB in 2014. The SEA Region of WHO is home to 26% of the world’s population; however the Region accounts for 41% of the global burden in terms of TB incidence. In 2014, there were an estimated 5.4 million prevalence and 4 million incidence of TB, and about 460 000 people died due to TB in SEAR. India and Indonesia have among the largest numbers of cases (23% and 10% of the global total respectively). An estimated 340 000 children in the Region developed TB in 2014. Table 1.1: Estimates of TB burden in SEAR countries in terms of incidence, prevalence and mortality, 2014 Incidence rate of all forms of TB (uncertainty intervals) 227 (200–256) 164 (148–181) 442 (412–473) 167 (156–179) 399 (274–546) 41 (36–47) 369 (334–406) 158 (139–178) 66 (57–73) 171 (90–276) 498 (411–594) 211 (192–232) Prevalence rate of all forms of TB (uncertainty intervals) 404 (211 – 659) 190 (75–359) 552 (150 1 210) 195 (131–271) 647 (513–797) 56 (25–98) 457 (352–575) 215 (102–369) 99 (51–164) 236 (161–326) 802 (426–1 340) 286 (233–343) Death rate for all forms of TB, excluding HIV (uncertainty intervals) 51 (37–68) 9.5 (5.1–15) 20 (7.9–37) 17 (12–27) 41 (26–59) 2.3 (1.9–2.8) 53 (38–70) 17 (12–24) 6.1 (4.8–7.6) 11 (5.7–18) 94 (66–126) 24 (19–30)

Country Bangladesh Bhutan Democratic People’s Republic of Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste SEAR

Source: World Health Organization. Global tuberculosis report 2015. Geneva: WHO, 2015. Tuberculosis control in the South-East Asia Region Annual Report 2016

The trends of TB burden in SEA Region in terms of estimated disease incidence, prevalence and mortality are shown in Graph 1.1, Graph 1.2 and Graph 1.3 respectively Graph 1.1: Estimated TB incidence rates (green) and estimated incidence rates of HIV-positive TB (red) in SEAR. Shaded areas represent uncertainty bands

200

100

0 1990 1995 2000 2005 2010 2015

Source: World Health Organization. Global tuberculosis report 2015. Geneva: WHO, 2015.

Graph 1.2: Estimated TB prevalence in SEAR (1990–2015). Shaded areas represent uncertainty bands. The horizontal dashed lines represent the Stop TB Partnership target of a 50% reduction in the prevalence rate by 2015 compared with 1990 600

400

200

0 1990 1995 2000 2005 2010 2015

Source: World Health Organization. Global tuberculosis report 2015. Geneva: WHO, 2015.

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Graph 1.3: Estimated TB mortality rates in SEAR (1990–2015). Estimated TB mortality excludes TB deaths among HIV-positive people. Shaded areas represent uncertainty bands. The horizontal dashed lines represent the Stop TB Partnership target of a 50% reduction in the mortality rate by 2015 compared with 1990 60

0 1990 1995 2000 2005 2010 2015

Source: World Health Organization. Global tuberculosis report 2015. Geneva: WHO, 2015.

Drug-resistant TB An estimated 480 000 people developed multidrug-resistant TB (MDR-TB) and an estimated 190 000 deaths from MDR-TB occurred globally in 2014. If all TB cases notified in 2014 had been tested for drug resistance, an estimated 300 000 would have been found to have MDR-TB. The SEA region has relatively low levels (2.2, range: 1.9–2.6%) of multidrugresistant (MDR) among newly detected cases. The estimated levels of MDR-TB among retreatment cases is 16% (range 14–18%). However, given the large number of TB cases in the SEA Region, this translates to a total of 99 000 estimated MDR-TB cases among notified pulmonary TB cases accounting for approximately 30% of the world’s MDR-TB cases among notified pulmonary TB cases in 2014. Six of the 30 high MDR-TB-burden countries are in the SEA Region: Bangladesh, Democratic People’s Republic of Korea, India, Indonesia, Myanmar and Thailand.

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Table 1.2: Estimates of proportion of MDR-TB among new and retreatment cases in SEAR countries, 2014 Country Bangladesh Bhutan Democratic People’s Republic of Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste Total New cases % 1.4 (0.7–2.5) 2.2 (1.9–2.6) 1.9 (0.8–3.9) 2.2 (1.9–2.6) 1.9 (1.4–2.5) 2.2 (1.9–2.6) 5 (3.1–6.8) 2.2 (1.3–3.8) 0.18 (0–0.99) 2 (1.4–2.8) 2.2 (1.9–2.6) Number 2 100 (1 000–3 700) 12 (10–14) % 29 (24–34) 35 (21–52) Retreatment cases Number 2 700 (2 200–3 200) 25 (15–37) 2 400 (1 400–3 800)

1 400 (610–3 000) 15 (8.8–24) 24 000 (21 000–29 000) 2 (2–2) 5 600 (3 500–7 700) 540 (320–930) 11 (0–62) 1 100 (780–1 600) 67 (58–80)

15 (11–19) 47 000 (35 000–59 000) 1 100 (770–1 600) 0 (0–0) 3 400 (1 900–4 900) 620 (410–920) 3 (0–10) 1 100 (800–1 500) 32 (28–35) 16 (14–18) 27 (15–39) 15 (10–23) 0.58 (0.07– 2.1) 19 (14–25) 16 (14–18)

5 600 (4 200–7 400) 12 (8.1–17)

2.2 (1.9–2.6) 40 432 (33 800– 53 488)

16 (14–18) 58 380 (42 523–75 002)

Source: World Health Organization. Global tuberculosis report 2015. Geneva: WHO, 2015.

Co-epidemics of TB and HIV In 2014, an estimated 1.2 million (12%) of the 9.6 million people who developed TB worldwide were HIV positive. In SEAR, an estimated 210 000 cases (5.2%) of the 4 million incident cases were HIV positive. This corresponds to 11 per 100 000 and 5% of all estimated TB incident cases. Globally, the number of people dying from HIV-associated TB peaked at 570 000 in 2004 and had fallen to 390 000 in 2014 (32% decrease). In SEAR, an estimated 62 000 cases died of HIV-associated TB in 2014.

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Table 1.3: Estimated HIV prevalence among adult populations and the number of people living with HIV infection in SEAR countries, 2013 Country Bangladesh Bhutan Democratic People’s Republic of Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste Total Estimated number of people newly infected with HIV 1 300 <200 Estimated adult (15–49 years) HIV prevalence (%) <0.1 0.1 Estimated number of people living with HIV 9 500 <1 000

No reported HIV-positive individual to date 130 000 80 000 N/A 6 700 1 300 <500 8 200 N/A 230 000 0.3 0.5 <0.1 0.6 0.2 <0.1 1.1 N/A 0.3 2 100 000 640 000 <100 190 000 39 000 2 900 440 000 N/A 3.4 million

Source: World Health Organization, Regional Office for South-East Asia. Health sector response to HIV in the South-East Asia Region 2013. New Delhi: WHO-SEARO, 2013.

TB financing The funding required for a full response to the global TB epidemic in low- and middle-income countries is estimated at US$ 8 billion per year in 2015, excluding research and development. Based on reporting by countries, US$ 6.6 billion was available for TB prevention, diagnosis and treatment in 2015, leaving a funding gap of US$ 1.4 billion. Overall, 87% (US$ 5.8 billion) of the US$ 6.6 billion available in 2015 is from domestic sources. International donor funding dominates in the group of 17 high-burden countries outside the BRICS (72% of the total funding available) and in low-income countries (81% of the total funding available). In 2015, US$ 0.8 billion in international donor funding was available to countries. Of this amount, 77% was from the Global Fund. For research and development, the most recent estimate of the annual funding gap is at about US$ 1.3 billion.

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Table 1.4: General government expenditure on health as a percentage of total government expenditure, and out-of-pocket expenditure on health as a percentage of total expenditure on health, 2013 General government expenditure on health as a percentage of total government expenditure 8–11 <8 Data not available <8 <8 12–14 <8 12–14 8–11 >15 <8 (<8; 8–11; 12–14; >15) Out-of-pocket expenditure on health as a percentage of total expenditure on health >45 16–29 Data not available >45 >45 30–44 >45 >45 >45 <15 16–29 (<15; 15;16–29; 30–44; >45)

Country Bangladesh Bhutan Democratic People’s Republic of Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste Cut of points used:

Source: World Health Organization, The World Bank. Tracking universal health coverage: first global monitoring report. Geneva: WHO, 2015. http://www.who.int/healthinfo/universal_health_coverage/ report/2015/en/ - accessed 15 February 2015.

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Global and Regional progress in Tuberculosis care and management

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The MDG target of halting and reversing TB incidence by 2015 was achieved globally in all six WHO Regions. The TB mortality rate in 2015 was 47% lower than in 1990: the target of a 50% reduction was almost met. The target was achieved in four WHO Regions including SEAR. Globally, the TB prevalence rate in 2015 was 42% lower than in 1990. The target of a 50% reduction was met in three WHO regions including SEAR. Overall, all three 2015 MDG targets for TB were met in the Region of the Americas, SEAR and WPR. Between 2000 and 2014, 43 million lives were saved through effective diagnosis and treatment.

TB care and control In 2014, 6 million newly diagnosed cases were notified to national TB programmes. This is about 63% of the 9.6 million people estimated to have fallen sick with the disease. In SEAR, TB notifications were about 2.6 million in 2014 whereas in 2013, they were about 2.3 million. This was mostly due to a 29% increase in notifications in India, which followed the introduction of a policy of mandatory notification in May 2012, creation of a national web-based reporting system in June 2012 and intensified efforts to engage the private health sector. Globally, the treatment success rate for people newly diagnosed with TB was 86% for the 2013 cohort. In SEAR, TB treatment success rate has continued to be more than 88% since 2009. Graph 2.1: Case notification and estimated TB incidence rates in SEAR (1990–2014). [Trends in case notification rates (new and relapse cases, all forms) (black) and estimated TB incidence rates (green). Shaded areas represent uncertainty bands]

200

100

0 1990 1995 2000 2005 2010 2015

Source: World Health Organization. Global tuberculosis report 2015. Geneva: WHO, 2015.

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Drug-resistant TB Globally 123 000 people were diagnosed with MDR-TB in 2014, about one fourth of the total 480 000 new cases of MDR-TB that occurred in 2014. A total of 111 000 people started MDR-TB treatment in 2014, an increase of 14% compared with 2013. 43 countries reported cure rates for MDR-TB patients of ≥75%. Nevertheless, globally, data show an average cure rate of only 50% for treated MDR-TB patients. Extensively drug-resistant TB (XDR-TB) has been reported by 105 countries by 2015. An estimated 9.7% of people with MDR-TB have XDR-TB. In SEAR, 33 264 cases were confirmed as Rifampicin resistant or multidrugresistant TB and 28 536 cases were started on MDR-TB treatment in 2014, which represented only 34% and 29 % respectively out of the estimated 99 000 MDR-TB cases among notified TB cases. Globally only 50% of MDR-TB patients were successfully treated and 49% in SEAR in 2014 (2012 cohort). Extensively drug-resistant TB had been reported by six countries in SEAR. Table 2.1: Treatment outcomes expressed as percentage among cases registered by type of cases in 2013 and 2012 (latter for RR/MDR-TB) and in Member States of the SEA Region Previously treated cases, excluding relapse, registered in 2013 (%) 86 60 83 66 64 75 71 HIV-positive TB cases, all types, registered in 2013 (%) 75 na na 76 49 na No data RR-/MDRTB cases started on second-line treatment in 2012 (%) 72 100 86 46 54 50 79 XDR-TB cases started on second-line treatment in 2012 (%) 25 Na Na 32 64 100 No data

Country

New and relapse cases registered in 2013 (%) 93 91 92 88 88 84 87

Bangladesh Bhutan Democratic People’s Republic of Korea India Indonesia Maldives Myanmar

Tuberculosis control in the South-East Asia Region

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Country

New and relapse cases registered in 2013 (%) 91 85 81 84 88

Previously treated cases, excluding relapse, registered in 2013 (%) 74 62 66 91 67

HIV-positive TB cases, all types, registered in 2013 (%) No data 24 67 No data 74

RR-/MDRTB cases started on second-line treatment in 2012 (%) 76 88 No data 75 49

XDR-TB cases started on second-line treatment in 2012 (%) No data Na No data No data 37

Nepal Sri Lanka Thailand Timor-Leste SEAR

Source: World Health Organization. Global tuberculosis report 2015. Geneva: WHO, 2015.

Treatment outcomes of MDR-TB patients initiated on treatment in yearly cohort since 2007 is provided in Graph 2.2 Graph 2.2: Treatment outcomes for patients diagnosed with MDR-TB in SEAR (2007–2012) cohorts. [The total number of cases with outcome data is shown beside each bar] 315 483 1597 3113 4305 11566

2007 2008 2009 2010 2011 2012

Source: World Health Organization. Global tuberculosis report 2015. Geneva: WHO, 2015.

Co-epidemic of TB and HIV In 2014, 51% of TB patients globally had a documented HIV test result. In the African Region, which has the highest TB/HIV burden, 79% of TB patients knew their HIV status. Globally, 77% of TB patients known to be living with HIV in 2013 were started on antiretroviral therapy (ART). Nevertheless, only one third of the 1.2 million people living with HIV estimated to have developed TB in 2014 had been placed on antiretroviral therapy. The number of people living with HIV who were treated with isoniazid preventive therapy reached 933 000 in 2014,

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an increase of about 60% compared with 2013. Over half of these people (59%) were in South Africa. Thirteen of the 41 high TB/HIV burden countries reported provision of IPT in 2014 and coverage among people living with HIV who were newly enrolled in care was 41%. In SEAR, 45% of notified TB patients had a documented HIV test result in 2014. Out of the TB patients known to be living with HIV, 85 % were on ART in the Region. SEAR maintained 85% CPT enrolment of all notified HIV positive TB patients from 2003. IPT uptake is still low with only 3049 cases reported in 2014. The achievement of Member States in strengthening TB/HIV collaborative activities are provided in Table 2.2 Table 2.2: Achievements in TB/HIV collaborative activities in Member States of the SEA Region, 2014 Incidence of HIV-positive TB cases (rate per 100 000, best estimate) 0.36 12 TB patients with known HIV status (%) <1 65 0 61 5 99 40 9 78 71 54 45 Number of HIV-positive TB patients identified 45 7

Country

HIV-positive TB patients on ART (%) 100 100 NA 90 26 0 36 No data 86 69 100 85

HIV-positive TB patients on CPT (%) 100 0

Bangladesh Bhutan Democratic People’s Republic of Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste SEAR

1.2 8.3 25 0.09 36 5.4 0.26 22 4.9 11

0 44 171 2355 0 6 412 369 21 6831 24 60 235

NA 93 41 0 73 74 86 64 100 85

Source: World Health Organization. Global tuberculosis report 2015. Geneva: WHO, 2015.

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New diagnostics rollout Globally, the use of the rapid test Xpert® MTB/RIF has expanded substantially since 2010, when WHO first recommended its use. In all, 4.8 million test cartridges were procured in 2014 by 116 low- and middle-income countries at concessional prices, up from 550 000 in 2011. By 2015, 69% of countries recommended using Xpert® MTB/RIF as the initial diagnostic test for people at risk of drug-resistant TB, and 60% recommended it as the initial diagnostic test for people living with HIV. GeneXpert has also been introduced and being rolled out in SEAR countries.

New drugs rollout In 2013 and 2014, WHO issued interim guidance on the use of bedaquiline and delamanid. By the end of 2014, 43 countries reported having used bedaquiline as part of treatment for MDR-TB. Indonesia is among the first countries in the Region and among four countries across the globe to systematically pilot bedaquiline introduction with WHO support. The process started in November 2013, and in June 2014, the first workshop of bedaquiline introduction was held followed by pharmacovigilance assessment and site selection. In October 2014, endorsement of technical guidelines and pharmacovigilance plan was done by the technical working group. In April 2015, a pharmacovigilance training workshop was held followed later by integration of bedaquiline Pv system in e-TB Manager software. Later, a Cohort Event Monitoring (CEM) Pv training was also held. The enrolment of patients started in September 2015, and by November 2015, seven patients were on treatment with a regimen inclusive of bedaquiline.

Research and development A diagnostic platform called the GeneXpert Omni® is in development. It is intended for point-of-care testing for TB and rifampicin-resistant TB using Xpert MTB/RIF cartridges. WHO expects to evaluate the platform in 2016. A nextgeneration cartridge called Xpert Ultra® is also in development. This technology could potentially replace conventional culture as the primary TB diagnostic tool. Eight new or repurposed anti-TB drugs are in advanced phases of clinical development. Fifteen vaccine candidates are in clinical trials. Their emphasis has shifted from children to adolescents and adults. New diagnostics, drugs and vaccines are necessary to achieve the ambitious targets set in the End TB Strategy.

Tuberculosis control in the South-East Asia Region

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Snapshot of TB burden and programme performance in WHO SEA Region:

Tuberculosis control in the South-East Asia Region

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Regional challenges

Source: World Health Organization, Regional Office for South-East Asia. Ending TB in South-East Asia – Regional Strategic Plan 2016–2020. New Delhi: WHO-SEARO, 2015. Tuberculosis control in the South-East Asia Region Annual Report 2016

TB care and control in the SEA Region has taken great strides in recent years with the expansion of programmes towards universal coverage, introduction of new tools and diagnostics, partnership building and resource mobilization. However additional concerted efforts are required to ensure the necessary progress towards the target of the elimination of TB by 2035. Analyses of constraints to regional TB control bring forward major persisting barriers. These include:

Over reliance on donor funding In most countries of the Region, insufficient domestic resources have been allocated for TB control programmes and for most countries, the funding is being supplemented considerable by international bilateral and multilateral funding agencies. National governments meet an average of 40% of current budgets for NTPs and variation between countries is considerable. For achieving the ambitious goals of the End TB strategy, it is expected that additional interventions may be needed specifically for introduction and roll-out of new tools, diagnostics and drugs that have not been included in the financing reported for 2015. Health financing data from national health accounts provide insights into the current status of progress towards universal health coverage (UHC). Two suggested benchmarks required to achieve UHC are that health spending reaches at least 6% of gross domestic product (GDP) and that out-of-pocket expenditures account for less than 15% of total health spending. Most countries, including all of the 22 HBCs (previous HBCs list) and all low-income countries, have not yet reached these benchmarks. Among SEAR Member States, Thailand is closest to doing so. The decreased domestic funding for TB control should also be seen in light of the out-of-pocket expenditures on health in the Region. With the exception of Thailand and East Timor (no data from Democratic People’s Republic of Korea) out-of-pocket expenditure as a percentage of total health expenditures in 2013 exceeded 45 % (Figure 3.1).

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Figure 3.1: Out-of-pocket expenditure as a percentage of total health expenditures, 2013

Source: World Health Organization. Global tuberculosis report 2015. Geneva: WHO, 2015.

Low notification rate of TB cases: More than 35% of the estimated incident cases in the region are not notified. These include cases that are either not being detected at all or being detected in sectors that do not notify the case to the national programme. There are also issues with the following. §§ §§ Delayed diagnosis and treatment of persons with TB, including children; Unregulated and growing private sector; many public and private health providers remain unlinked with national tuberculosis control efforts and there is insufficient involvement of big hospitals (public and private), lung clinics and other specialized facilities seeing people with respiratory symptoms; Insufficient progress in scaling up programmatic management of DR-TB (PMDT); Insufficient progress in scaling up TB-HIV collaborative activities; Inadequate laboratory capacity and outreach. This includes lack of efficient sputum transportation facilities specifically in difficult and hardto-reach areas that do not have a diagnostic facility in close vicinity; Insufficient strategies to address access issues for populations at risk, including targeted screening/active case finding.

§§ §§ §§

§§

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Persisting weaknesses in the health systems §§ Weak health systems: ww ww Limited access to quality health services;1 Overstretched and weak performance of health services, not only related to services for people with TB, but limiting access to highquality tuberculosis care; Poor governance and weak accountability mechanisms; Shortages of well-trained, motivated and supported health workers and unfair distribution of them within and across countries; and lack of knowledge or capability in many key areas such as quality assurance;

ww ww

§§ §§

Insufficient data collection, quality and use of data at all levels; Limited linkages required across social sectors to address poverty, undernutrition and risk factors that adversely influence people’s vulnerability to tuberculosis, and the health outcomes of people with tuberculosis; Limited programme management capacity with limited involvement of NTPs in decision-making related to the health sector reform processes while NTPs are affected by changes made.

§§

Insufficient management of comorbidities §§ Risk factors and comorbidities of tuberculosis such as diabetes, tobacco smoking, silicosis, alcohol and drug misuse, and undernutrition are often ignored and not addressed adequately, which hampers tuberculosis control, especially in low- and middle-income countries.

Insufficient regulatory systems and mechanisms §§ Absence of universal health coverage and access to free treatment aggravates the economic burden on the poor. This hardship is compounded by a lack of social protection mechanisms to address associated income loss and nonmedical costs.

Tracking universal health coverage: first global monitoring report. World Health Organization. World Bank. 2015. ISBN 978 92 4 156497 7.

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§§

Weak regulatory mechanisms essential to ensure effective infection control, rational use of tuberculosis diagnostics and medicines, mandatory disease notification, functioning vital registration systems, and protection of the legal rights of people with tuberculosis.

Absence of long-term strategies to address the underlying social determinants §§ Effective tuberculosis prevention will require actions resulting in poverty reduction, improved nutrition, and better living and working conditions as well as strategies to mitigate the impact of migration; focus on ageing populations that are at-risk factors for tuberculosis.

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The End-TB Strategy

Source: World Health Organization. The end TB strategy. http://www.who.int/tb/strategy/en/ - accessed 15 February 2015. Tuberculosis control in the South-East Asia Region Annual Report 2016

In May 2014, the World Health Assembly in its resolution WHA67.1 adopted the global strategy and targets for tuberculosis prevention, care and control after 2015 based on a bold vision of a world without tuberculosis and targets of ending the global tuberculosis epidemic, elimination of associated catastrophic costs for tuberculosis-affected households. The three pillars of the strategy include – integrated, patient-centred care and prevention; bold policies and supportive systems; and intensified research and innovation. The strategy is based on principles of government stewardship and accountability, with monitoring and evaluation; strong coalition with civil society organizations and community; protection and promotion of human rights, ethics, and equity; and adaptation of the strategy and targets at the country level, with global collaboration. Figure 4.1: Evolution of the End TB strategy

The DOTS Strategy 1. Government commitment 2. Case detecƟon through passive case ﬁnding 3. Standardized chemotherapy to all sputum smear posiƟve TB cases of under proper case management condiƟons 4. Establishment of a system of regular supply of anƟ -TB drugs 5. Establishment of a monitoring system, for programme supervision and evaluaƟon The Stop TB Strategy 1. Pursue high-quality DOTS expansion and enhancement 2. Address TB/HIV, MDR-TB and other challenges 3. Contribute to health system strengthening 4. Engage all care providers 5. Empower people with TB and communiƟes 6. Enable and promote research The End TB Strategy 1. Integrated, paƟent-centred TB care and prevenƟon 2. Bold policies and supporƟve systems 3. Intensiﬁed research and innovaƟon

Substantial additional efforts are required to reach the intended goals of the End-TB strategy. As explained in Graph 4.1, the current global trend of reduction in incidence rate of 1.5% has to be escalated to more than 10% by optimizing the use of current and new tools, universal health care, social protection and substantial investment in research. By 2025 there is a need to introduce new tools like a vaccine, new drug and shorter regimen and point of care test to further accelerate the decrease in incidence to at least 17%.

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Graph 4.1: The efforts required to reach the intended targets

Current global trend: -1.5%/year

OpƟmize use of current & new tools emerging from pipeline, pursue UHC and social protecƟon, substanƟal investments in research

-10%/year by 2025

-5%/year Introduce new tools: a vaccine, new drugs and shorter regimens for treatment of acƟve TB and latent infecƟon, a point-of-care test

-17%/year

Source: World Health Organization. The end TB strategy. Geneva: WHO, 2015. http://www.who.int/tb/ End_TB_brochure.pdf?ua=1 – accessed 15 February 2015.

The SEA Region as whole is on track to meet the MDG targets that were to be accomplished by 2015: §§ §§ §§ halving the TB mortality rate – achieved halving the 1990 level of TB prevalence – on track to meet the target by the end of 2015 halting and reversing TB incidence – achieved

This has been possible because of the high TB treatment success rate of more than 88% since 2009 and an increasing case notification: 2.58 million cases of TB notified in 2014. Table 4.1 provides an overview of country-wise progress in achievement of MDGs in the Region However, additional efforts and updating of strategies is required with renewed vigour to attain the End TB strategy goals. Action needed by Member States is as follows. 1. Reaffirm commitment to eliminate TB as a public health problem by adapting the End TB strategy; 2. Revise and implement the national tuberculosis strategic plans in line with the three pillars of the End TB Strategy: integrated, patient-centred care and prevention; bold policies and supportive systems and intensified research and innovation;

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3. Secure adequate financing for implementing and monitoring all tuberculosis specific, health sector-related and multisectoral actions proposed in the End TB Strategy, taking into consideration variations in the epidemiological, socioeconomic and health system contexts; 4. Engage a wide range of stakeholders in the implementation of the strategy, including local, national, regional and international partners, as well as stakeholders from within and beyond the health sector. Actions planned by WHO Regional and Country offices to support Member States: 5. Advocate from the highest level political commitment and increased funding from national and international sources to support TB elimination efforts in the Region; 6. Provide guidance to Member States on how to adapt and operationalize the End TB Strategy, including development of a Regional Strategic Plan for interventions in the period 2016–2020 towards TB elimination; 7. Assist Member States with implementation of the strategy, and evaluate the impact in terms of progress towards set milestones and targets; 8. Promote equitable access to new tools and medical products for the prevention, diagnosis and treatment of tuberculosis and multidrugresistant tuberculosis.

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Table 4.1: Progress towards MDGs in SEAR countries 24

Country 80 (53–106) 51 (37–68) 277 (191–326) 9.5 (5.1–15) 110 (105–224) 20 (7.9–37) 38 (25–54) 17 (12–27) 70 (47–89) 41 (26–59) 29 (27–31) 2.3 (1.9–2.8) 154 (106–193) 53 (38–70) 52 (32–70) 17 (12–24) 7.6 (4.5–12) 6.1 (4.8–7.6) 19 (6.3–40) 11 (5.7–18) 89 (48–145) 94 (66–126) 99 (51–164) 211 (110–346) 236 (161–326) 809 (381–1390) 820 (426–1 340) 215 (102–369) 111 (57–184) 348 (162–602) 457 (352–575) 894 (414–1550) 56 (25–98) 285 (140–480) 647 (513–797) 1 000 000 (700–1 400) 0.32 (0.250–0.400) 0.15 (0.13–0.17) 170 (140–200) 200 (180–220) 30 (24–38) 44 (39–50) 11 (9.4–15) 13 (12–15) 78 (70–87) 120 (61–190) 4.5 (3.6–5.4) 5.8 (4.8–6.9) 443 (211–760) 370 (320–440) 195 (131–271) 2 200 (2 000–2 300) 465 (415–518) 1 900 (1 700–2 100) 552 (150–1 210) 110 (100–120) 480 (130–1050) 78 (59–100) 384 (292–515) 442 (412–473) 217 (200–242) 167 (156–179) 206 (177–249) 399 (274 546) 146 (116–187) 41 (36–47) 395 (341–473) 369 (334–406) 164 (133–210) 158 (139–178) 66 (54–84) 65 (57–73) 138 (123–154) 171 (90–276) 498 (406–601) 498 (411–594) 190 (75–359) 1.3 (1.1–1.4) 164 (148–181) 1760 (827–3040) 4.2 (3.8–4.5) 770 (707–841) 404 (211–659) 360 (320 – 410) 227 (200–256) 504 (228–8879 240 (200–310) 226 (183–289) 48 673 191 166 1 154 1 066 No data 13 045 1 519 182 1 609 547 74 470 322 806 152 131 12 416 138 352 10 142 35 277 6 666 9 305 46 510 67 722 2 760 3 657

Year

Mortality (excluding HIV) rate (estimates) Prevalence rate (estimates)

Incidence (including HIV) all forms number (thousands)

Incidence (including HIV) rate

Notified new and relapse number (thousands)

Bangladesh

1990

2014

Bhutan

1990

2014

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Democratic People’s Republic of Korea

1990

2014

India

1990

2014

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Indonesia

1990

2014

Maldives

1990

2014

Myanmar

1990

2014

Nepal

1990

2014

Sri Lanka

1990

2014

Thailand

1990

2014

Timor-Leste

2002

2014

Regional Strategic Plan – Overview

Vision and goal The vision for TB control in the SEA Region is to have a Region free of TB with zero death, disease and suffering due to TB. All Member States can adopt this vision in national strategies and plans. The goal for TB control in the SEA is to End the TB epidemic in the Region by 2035, by adopting and adapting the vision, milestones and targets as outlined in the WHA67.1 resolution.

Objectives The overall objectives of the plan are to: §§ §§ §§ §§ §§ advance universal access to high-quality care for all people with TB as part of robust health systems reduce the human suffering and socioeconomic burden associated with TB protect vulnerable populations from TB, TB/HIV, and drug-resistant TB roll out new tools and enable their timely and effective use protect and promote human rights in TB prevention, care and control.

Regional targets and milestones With the goal of ending TB in the SEA Region by 2035, this Regional Strategic Plan provides guidance for the first 5 years, 2016–2020 towards this date. Ending the regional TB epidemic is defined as reducing the regional burden of TB disease to ≤10 cases per 100 000 population. For comparison, regionally there was an estimated 183 (175–192) cases per 100 000 population in 2013. The Regional Strategic Plan to End TB 2016–2020 includes three high-level, overarching indicators, and corresponding regional targets and milestones as detailed in Table 4 below. The long-term regional targets for 2030 reductions in TB cases and deaths correspond to the end date of the United Nations’ post-2015 Sustainable Development Goal framework, within which targets have been set for 2030.2 The SDG framework includes the End Strategy’s 2030 targets for reductions 2

The SDGs provide a new development framework for 2016−2030, replacing the 2000−2015 Millennium Development Goal (MDG) framework. For further details, see https://sustainabledevelopment.un.org/ topics/sustainabledevelopmentgoals

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in TB cases and deaths as part of a health-related subgoal. The corresponding regional milestones are for 2020 – the period covered by this strategic plan (Table 5.1). Table 5.1: The Regional Strategy to End TB – three high-level regional indicators and associated targets and milestones Indicators Percentage reduction in the absolute number of TB deaths (compared with 2015 baseline estimated at 460 000 thousand) Percentage reduction in the TB incidence rate (compared with 2015 baseline, estimated at around 211 cases per 100 000 population) Percentage of TB patients and their households experiencing catastrophic costs due to TB (level in 2015 unknown) Milestones 2020 35% 2025 75% Targets SDG 2030 90% End TB 2035 95%

20%

50%

80%

95%

Source: World Health Organization, Regional Office for South-East Asia. Ending TB in South-East Asia – Regional Strategic Plan 2016–2020. New Delhi: WHO-SEARO, 2015.

The third high-level indicator, the percentage of TB patients and their households experiencing catastrophic costs as a result of TB, is chosen because of its direct link to progress towards universal health coverage and universal social protection. UHC is defined as “all people who need health services (promotion, prevention, treatment, rehabilitation and palliation) receive them, without undue financial hardship. It has two interrelated components: the full spectrum of goodquality essential health services according to need, and protection from financial hardship, including possible impoverishment, due to out-of-pocket payments for health services.”3 Social protection includes replacement of income when this is lost due to ill health. Major regional progress towards UHC and social protection by 2025 are fundamental requirements for achievement of the regional targets for reductions in TB cases and deaths. The projected regional trajectory and the needed decline is provided in Graph 5.1. 3

Monitoring progress towards universal health coverage at country and global levels: Framework, measures and targets. WHO and World Bank Group, 2014. WHO/HIS/HIA/14.1.

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Graph 5.1: Projected regional trajectory of TB incidence and TB death 2015–2035 in the SouthEast Asia Region. Dotted line representing the current trend; continuous line representing needed decline to reach targets

Source: Ending TB in South-East Asia – Regional Strategic Plan 2016–2020. WHO-SEARO.

Strategic directions and interventions The strategic directions, areas of interventions and activities to reach the overall goal, vision, objectives and targets to End TB are grouped under the following 3 strategic directions: 1. Integrated patient-centred care and prevention 2. Bold policies and supportive systems 3. Intensified research and innovation. Implementation of strategies and interventions under the three strategic directions requires the combined efforts as well as close coordination and collaboration among and by NTP and multiple stakeholders within and outside the government. An overview is presented in Table 5.2 below.

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Table 5.2: Strategic directions, strategies and key interventions of the Regional Strategic Plan to End TB in SEAR, 2016–220 Strategic directions Strategic Direction 1: Integrated patientcentred care and prevention Strategies Strategy 1.1: Early diagnosis of TB, including universal drug susceptibility testing for all people with TB Key interventions Improve community awareness of and knowledge about TB Minimize barriers to health care Strengthen identification of people with presumptive TB including systematic screening for TB among selected high-risk groups Ensure universal access to quality-assured diagnosis, including universal drug susceptibility testing and the roll-out of new diagnostics Improve referral and notification practices Strategy 1.2: Ensure equitable access to quality treatment of people with TB including TB resistant to first-line antiTB medicines, and provide patient support Treat all forms of TB sensitive to first-line anti-TB medicines Treat all cases of TB resistant to first-line and secondline anti-TB medicines Treat all children with TB Ensure patient-centred mechanisms and systems for social and psychological support to patients in need to ensure effective ambulatory treatment adherence including follow-up after treatment Establish palliative care mechanisms for treatment of those M/XDR-TB patients in need Strategy 1.3: Scale up TB-HIV collaborative activities Scale up access to HIV testing among TB patients Scale up access to CPT for HIV-positive TB patients according to international guidelines Scale up access to ART for HIV-positive TB patients according to international guidelines Scale up screening for TB among people living with HIV according to international guidelines Scale up access to IPT among people living with HIV and do not have active TB according to international guidelines Scale up the implementation of measures for TB infection control in health-care facilities providing services to people living with HIV

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Strategic directions

Strategies Strategy 1.4:Ensure screening for and management of comorbidities Strategy 1.5:Ensure preventive treatment of people at high risk; and vaccination against TB

Key interventions Ensure integrated management at primary healthcare level of TB comorbidities and noncommunicable diseases of documented risk such as diabetes Routinely assess elderly people attending health services and other institutions Expand preventive treatment of people with high risk of tuberculosis, especially children below 5 years of age in close contact with adults affected with TB Ensure that WHO recommendations on BCG immunization are implemented through the EPI Update national strategic plans for TB prevention, care and control Mobilize adequate resources for the implementation of the national strategic plan Strengthen programme management capacity at all levels Strengthen government stewardship Strengthen human resource development Scale up implement comprehensive infection control measures in health-care facilities Strengthen management of anti-TB medicines Strengthen the TB surveillance systems including new standards and benchmarks Improve TB prevention, care and control in the penitentiary services and other non-MOH health services

Strategic Direction 2: Bold policies and supportive systems

Strategy 2.1:Ensure political commitment with adequate resources and effective management for TB prevention care and control Strategy 2.2: Contribute to strengthen health systems

Strategy 2.3: Improved regulatory frameworks including universal health coverage policy

Move with urgency to universal health coverage including equitable and full access to TB specific tests and treatment, minimizing geographical and financial barriers to services Enforce mandatory notification of tuberculosis cases Ensure recording of tuberculosis deaths within vital registration systems Regulate the production, quality and use of tuberculosis diagnostics and anti-TB medicines Develop legal frameworks for cross-border TB prevention, care and control through interministerial and intersectoral approaches

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Strategic directions

Strategies Strategy 2.4: Engage communities, civil society organizations and all public and private-care providers Strategy 2.5: Address social protection, poverty alleviation and actions on other determinants of tuberculosis

Key interventions Engage civil society organizations such as NGOs and CBOs in community-based TB prevention, care and control services Scale up public-private and public-public mix approaches and promote the International Standards for Tuberculosis Care Expand coverage of social protection schemes to cover needs associated with tuberculosis beyond free diagnosis and treatment Address poverty and related risk factors through “health–in–all policies” approaches Create a research-enabling environment Establish mechanisms for collaboration in planning and implementation of research activities between all stakeholders Ensure that results of operational research and other studies are included in the development of TB control policies on a continuous basis

Strategic Direction 3: Intensified research and innovation

Strategy 3.1: Implement research to optimize implementation and impact and promote innovation

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WHO support in the Region

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WHO supports global health promotion by providing leadership on matters critical to health and engaging in partnerships where joint action is needed; shaping the research agenda and stimulating the generation, translation and dissemination of valuable knowledge; setting norms and standards and promoting and monitoring their implementation; articulating ethical and evidence-based policy options; providing technical support, catalysing change, and building sustainable institutional capacity; and monitoring the health situation and assessing health trends. All 11 Member States in the Region continue to receive technical assistance through the WHO Regional Office for South-East Asia and respective WHO country offices, in coordination and collaboration with international technical partners, namely the Centers for Disease Control and prevention (CDC), USA; the Royal Foundation for Tuberculosis in the Netherlands (KNCV); U.S. Agency for International Development (USAID); USAID supported Challenge TB project, Foundation for Innovative New Diagnostics (FIND); PATH; the Institute of Tropical Medicine in Antwerp, Belgium; and The Union. There are five WHO Collaborating Centres in the Region, namely All India Institute of Medical Sciences (AIIMS), Delhi, India; National TB Institute (NTI), Bangalore, India; National Institute of Research in Tuberculosis (NIRT), Chennai, India; National Institute of TB and Respiratory Diseases (NITRD), Delhi, India; and the SAARC TB and HIV/ AIDS Centre in Kathmandu, Nepal. Technical missions were undertaken to all 11 Member States during 2015 to provide support to national programmes in various areas. These areas include laboratory assessments and laboratory capacity-building; strengthening laboratory quality control and assurance; culture and drug-sensitivity testing; introduction of rapid molecular tests; development and implementation of guidelines and/or national strategies for TB; human resource development for TB control; MDR-TB, TB-HIV, childhood TB, infection control, PPM; improvement of drug procurement and supply management, data management and use; and impact assessments.

Transitioning to the End TB Strategy Based on the goals and targets adopted by World Health Assembly resolution WHA67.1 for TB control beyond 2015, WHO has developed the End TB Strategy, transitioning from the earlier Stop TB Strategy. Most countries are in the process of adaption of this End TB Strategy. To provide overall guidance to countries, Regional Strategic Plan 2016–2020 has been developed. Salient features of the

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plan are discussed in an earlier section. The updated plan adopts key principles and strategies, pillars and components (integrated, patient-centred care and prevention, bold policies and supportive systems, intensified research and innovation) of the global “End TB Strategy: 2016–2035”. The updated Regional Strategic Plan aims to support member countries for reduction in TB mortality and incidence in line with the global goals in resolution WHA67.1, to guide countries in addressing the persisting and emerging epidemiological and demographic challenges, and to advance universal health coverage and robust health systems. The WHO Regional Office and Country Offices are providing support to countries to develop or revise National Strategic Plans (NSP) covering the post2015 period in alignment with the End TB Strategy. This year, the support was provided to Nepal and Thailand to develop a costed national strategic plan for TB control. All other countries were supported in implementation of the existing plans. WHO headquarters and organized an End TB summit for 30 high-burden countries in Cape Town, South Africa. The Regional office through country offices coordinated sufficient representation of national programme representatives to the summit from the Regional high-burden countries.

Diagnostic capacity-building Technical assistance, on laboratory issues such as upgrading and capacity building of national reference laboratories, quality assurance, certification and, introduction and roll-out of newer diagnostics is coordinated by WHO through the Supra National Reference Laboratory (SNRL) network. Such laboratories are based at the Institute of Medical and Veterinary Science (Australia), Institute of Tropical Medicine (Belgium), Central Reference Laboratory, Gauting (Germany), National Institute of Research in Tuberculosis (India), National Tuberculosis Institute (India), Bureau of TB (Thailand) and Department of Health, SAR (Hong Kong). All 11 countries have formally established linkages with SNRLs. Additionally, India receives support from the newly established SNRL-National Centre of Excellence (SNRL-CE) at the National Institute of TB and Respiratory Diseases in New Delhi, which belongs to the NRL network and has similar terms of reference to that of an SNRL but with an in-country focus. As a result, all 11 Member States have quality-assured smear microscopy, culture and first-line DST available (through in-country facilities or through linkage

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with SNRL) and four countries developed capacity for quality-assured second-line DST. The WHO Regional Office has been collaborating with the Global Laboratory Initiative (GLI), the Foundation for Innovative New Diagnostics (FIND) and GDF to ensure access to quality-assured new diagnostic technologies in various countries under the EXPAND-TB (Expanding Access to New Diagnostics for TB) Project financially supported by UNITAID. The project has been active in Bangladesh, India, Indonesia and Myanmar. In 2015, an additional technical support mission was undertaken for Bangladesh, Myanmar and Timor-Leste. A proposal to support diagnostic capacity expansion in Bhutan is under consideration. In 2015, representatives of the NTP of Democratic People’s Republic of Korea were supported for training in Culture and DST at the SRL Hong Kong.

Expansion of DR-TB services To provide coordinated and quality support for the implementation and expansion of programmatic management of drug-resistant TB (PMDT), the Regional Green Light Committee (rGLC) was established in 2012 with its secretariat housed in the WHO Regional Office. The rGLC acts as an advisory body performing in accordance with the memorandum of understanding between the GF and WHO. Its main objective is to provide decentralized monitoring and guidance on new policies and strategies for PMDT interventions in countries of the Region for rapid scaleup of DR-TB services. The rGLC in SEAR is supporting the implementation of the Regional Response Plan for MDR-TB, ensuring that country PMDT plans reflect programmatic recommendations on the response to DR-TB, including recording and reporting of the standard indicators selected for the SEA Region. The rGLC through its secretariat coordinates monitoring missions to countries to assess the progress in implementation of services, and undertakes peer review of monitoring missions’ reports. As a follow-up to these monitoring missions, the rGLC supports the organization of high-quality technical assistance and resource mobilization for countries in accordance with the PMDT expansion plan. The sixth and seventh meetings of the rGLC were held in February 2015 and October 2015, respectively. The meetings came out with key recommendations for the programmes for expansion of services as well as improving efficiency. Some of the programmatic recommendations of the rGLC are about the need to

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intensify case screening by prioritizing groups at risk of drug resistance and develop algorithms for increased use of WHO-approved rapid diagnostics; enhanced technical support for laboratory expansion through the SRLs; patient-centred care with increased involvement of patient groups and community members; strengthened infection control; and drug resistance surveys to estimate the burden of resistance to first-line TB drugs. The rGLC is also working towards identifying regional and national centres of excellence in MDR-TB management at the regional level to provide decentralized and sustained technical support for PMDT. With the assistance of the rGLC, monitoring missions were conducted in Bhutan, Democratic People’s Republic of Korea, Indonesia, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste to assess implementation status and identify any bottlenecks to expansion. Technical support to update PMDT guidelines and PMDT expansion plans were provided to Bhutan and Sri Lanka. A regional workshop to support PMDT expansion was organized in April 2015. Out of the 11 Member States, 10 participated (except Myanmar) along with country partners, technical and donor agencies that supported the national programmes in implementation of PMDT. The workshop was used as an opportunity to help countries assess existing status of services and to discuss planned expansion over the next two years. The major recommendations of the workshop pertained to strengthening of case-finding activities and development of clear diagnostic algorithm using recent recommendations by WHO; alignment of laboratory expansion plan and information systems with programme activities; advocacy for enhanced funding support through domestic sources, the GF and other donors; mainstreaming MDR-TB control programmes into TB control programmes for effective utilization of available resources; capacity strengthening for SL DST in most countries; sharing and replication of models of m-health and e-health within the Region such as the use of open MRS, patient adherence mechanism through mobile phones and software for drug management; intercountry collaboration for dealing with TB and MDR-TB among migrants; stronger coordination among partners for synergy and to avoid duplication of efforts; development of plans for introduction of new drugs or undertake operational research for shorter regimen where necessary; pharmacovigilance to be introduced and strengthened in all countries; strong data collection (recording and reporting) mechanisms in general and specifically for drug management including those from subnational storage facilities; strengthening of patient-centred initiatives in diagnosis, treatment, care and rehabilitation of MDR-TB patients; engagement of private sector

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through various approaches including capacity-building in the sector to ensure quality MDR-TB care; HR planning in alignment with PMDT expansion plan; and operational feasibility of universal insurance coverage for DR-TB.

Strengthening TB/HIV collaboration Considerable scale-up of collaborative TB/HIV activities has been reported in a majority of the countries in the Region. However, coverage needs to be expanded and the collaboration between TB and HIV control programmes needs further strengthening in all Member States to ensure universal HIV counselling and testing for all TB patients, the availability of co-trimoxazole preventive therapy and ART for all eligible TB patients coinfected with HIV as well as INH preventive therapy, and airborne infection control in health-care facilities. Mobilization of HIV groups and affected communities to advocate for the provision of TB prevention, treatment and care services to all people living with HIV is crucial for the successful implementation of the listed interventions. It is equally important to have epidemiological assessment of TB/HIV coinfection in countries to target activities and adequate resource mobilization. In 2015, assistance was provided for development of TB/HIV seroprevalence survey protocol in Bangladesh. As part of resource mobilization activities, Indonesia also developed a joint TB/HIV concept note for funding support through the GF.

Capacity-building and information exchange Training and exchange of information at the global and regional levels, as well as in-country capacity-building have been the key areas of work for the WHO Regional Office and country office during the past few years. WHO in the Region supported the facilitation of several national level trainings and workshops in all countries through Regional and country offices and where needed, with support from the HQ. Country staff also facilitate workshops and trainings organized by the NTP and partners. Some of the key Regional meetings and trainings held during the year include: §§ §§ 6th meeting of the SEA Regional Advisory Committee on MDR-TB (rGLC), Bangladesh, 14-16 February Regional workshop on combating drug-resistant TB, Thailand, April 2015

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§§ §§

Regional and country office staff participated in STAG meeting along with workshop on END TB strategy, Geneva, 15-20 June 2015 Regional representation was also made on the Global Drug-resistant TB Initiative (GDI) and Global Laboratory Initiative (GLI) combined meeting as well as the GDI core group meetings NTP Managers’ meeting held in Sri Lanka, 26-30 October 2015 7th Meeting of the SEA Regional Advisory Committee on MDR-TB (rGLC) in Myanmar, 10-12 August 2015 Childhood TB and PPM workshop, Nepal, November 2015 Regional and country office staff along with NTP representatives also participated in the first END TB summit for 30 high-burden countries, Child-TB subgroup and PPM subgroup meetings, South Africa, 2-6 December 2015

§§ §§ §§ §§

Drug supply and management All eleven countries in the Region use the Global TB Drug Facility (GDF) services and products for access to the low-cost and quality-assured fixed dosage combination drugs as well as second-line drugs (in part or completely). No stockouts were reported from any country at the point of treatment delivery. The rGLC secretariat continued to support the GDF by reviewing the applications for second-line drugs to check appropriateness of drugs used and the regimen, and quantification in accordance with planned expansion of MDRTB services. This ensured timely supply of quality-assured drugs in adequate amounts.

Routine surveillance Technical support was provided to several countries for strengthening routine surveillance systems. Efforts are being made to strengthen national TB surveillance systems, focussing on quality of data, with emphasis on completeness of case reporting, accurate compilation and implementing of new reporting framework. Over the last years interventions to support impact assessments were conducted in several Members states in the form of prevalence or annual risk of

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infection surveys, mortality surveys, in-depth analysis of several years’ programme data to determine trends, revision of burden estimates. In 2015 support to prevalence survey and analysis of results was provided to various countries. Thailand received support in dissemination of the results of the prevalence survey completed on 2014; Indonesia was supported in the review of results finalized earlier; Bangladesh and Democratic People’s Republic of Korea received support in initiation and implementation of the TB prevalence survey. Preparations for a prevalence survey in Nepal are under way and a field visit for observation was organized this year for the NTP. Assistance to India and Indonesia was provided this year in implementation of the National DRS after development of DRS protocol in 2014. Protocol for DRS developed by Sri Lanka NTP is currently under review. WHO also provided technical support to several countries for strengthening routine surveillance systems. Efforts are being made to strengthen national TB surveillance systems, focusing on quality of data, with main emphasis on completeness of case reporting, accurate compilation and reporting of data, and implementation of the new reporting framework.

Operational research Achievement of targets envisaged in the End TB strategy in 2035, require intensified, programme based research not only to develop new tools and drugs but also their adaption and roll-out in country context. These novel tools, as well as any innovation, must be linked with relevant epidemiological, health system, and operational research to ensure their adoption and implementation to scale. Programme-based operational research specifically aimed at developing interventions that result in improved policy-making, better design and implementation of health systems, as well as more efficient methods of service delivery is necessary to optimize TB control and determine the best ways of implementing and monitoring interventions. Member States in the Region were provided need based support in Operational Research. Bangladesh, Myanmar and Thailand received technical support in developing protocol for introduction and scale-up of shorter regimen for MDR-TB. Indonesia received support for piloting bedaquiline use in MDRTB regimen and, Democratic People’s Republic of Korea was supported for

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operational research on use of ambulatory care of MDR-TB treatment. Technical assistance is on-going to India and Indonesia to scale up implementation of PPM approach.

Resource mobilization Member States were also assisted in resource mobilization from development partners and donor agencies during the past year. Indonesia, Sri Lanka and TimorLeste were supported to develop a Concept Note for the Global Fund support under the New Funding Model (NFM). Indonesia developed a joint TB/HIV Concept Note. All countries (except Maldives) receive support for management of GF grants and funding. Maldives also intends to apply for funding under the NFM in 2016. In addition to the GF, the Region also receives support from USAID in the form of the Challenge TB project currently active in Bangladesh, India and Indonesia and the CAP-TB project in Myanmar. Commodity grants are available from the GDF and UNITAID. Other donors also have country-specific agreements. The activities undertaken and coordinated by the TB unit at the Regional Office were supported almost entirely through USAID regional funding. Some funding also continued through the Global TB Programme at WHO/HQ, for organizing regional workshops.

Tuberculosis control in the South-East Asia Region

Annual Report 2016

Major SEA Regional partnerships

Individual partners at the country level are also listed in respective country profiles. Tuberculosis control in the South-East Asia Region Annual Report 2016

Axshya project supported by The Global Fund Supported by the Global Fund and implemented by The Union in 300 districts across 21 States of India through eight civil society organization partners, Project Axshya continued its innovative interventions to intensify outreach to those with the greatest difficulty in accessing TB diagnosis and treatment. During January to December 2014, Axshya has facilitated identification and testing of over 300 000 TB symptomatics, including sputum collection and transportation of nearly 250 000 cases, resulting in diagnosis and treatment initiation of over 25 000 patients. The various interventions undertaken by the project during this period include: §§ Early diagnosis and treatment initiation through Axshya SAMVAD (Sensitization and Advocacy in Marginalized and Vulnerable areas of District). During January-December 2014, over 3.8 million households in vulnerable areas have been reached resulting in testing of nearly 140 000 TB symptomatics, and over 10 000 patients being diagnosed and put on treatment. Sputum collection and transportation services - Over 245 000 TB symptomatics benefited from the sputum collection and transportation services during this period. The project has trained and engaged 2500 Rural Health-Care Providers (RHCPs) and AYUSH providers who have identified nearly 51 000 TB symptomatics resulting in diagnosis of over 4200 TB patients. Nearly 25% of the trained RHCP and AYUSH are also serving as DOT providers. The project has so far identified 6100 such villages under Axshya Villages (TB-Free Village) reaching out to over 930 000 people through more than 65 000 community meetings. To empower the affected community, the project has facilitated creation of over 250 TB forums at the district level. To ensure early diagnosis and treatment of TB among the high-risk PLHIV, over 240 TIs, DLNs and CSCs have been sensitized on TB care and control. The project has sensitized nearly 3500 NGOs on RNTCP schemes of which 705 have submitted applications and 82 schemes have been successfully signed.

§§

§§ §§

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§§ §§ §§

A toll-free TB helpline has been initiated in the States of Punjab, Karnataka and Maharashtra. The project is providing services for regular preventive maintenance and addressing breakdown for over 5 000 BMs in nine States. Through Axshya, The Union is providing technical support to RNTCP in the areas of ACSM, PPM and M&E at the national level and nine identified States (Bihar, Jharkhand, Chhattisgarh, Punjab, Karnataka, Madhya Pradesh, Maharashtra, Uttarakhand and Uttar Pradesh) for ACSM. To address the high loss to follow up among drug-resistant TB (DR-TB) patients, Axshya has initiated a pilot offering counselling services to facilitate treatment adherence of DR-TB patients (MDR and XDR-TB) across 30 districts in the country. The Union through Axshya continues capacity-building on key thematic areas including TB epidemiology, operational research (OR), clinical management of DR-TB, and leadership and management. Over 125 personnel working with RNTCP have been trained in these courses during January–December 2014. The National Partnership for TB Care and Control, supported through Project Axshya, has networked with Civil Society Organizations across the country that are interested in TB control. The strength of the partnership has increased significantly in the last two years, and 180 partners have joined the partnership.

§§

EXPAND-TB project (in partnership with BMGF, FIND, GF, UNITAID and WHO)

Bangladesh In Bangladesh, FIND has supported establishment of one Liquid Culture & DST and one Line Probe Assay (LPA) laboratory at NRL Dhaka by providing equipment, consumables and essential supplies through the EXPAND-TB project. 558 MDR-TB cases were diagnosed between 2012 and 2014 in the country

Tuberculosis control in the South-East Asia Region

Annual Report 2016

India FIND in India is supporting use & policy development on newer TB diagnostics via demonstration & evaluation studies, building national capacity of newer rapid TB diagnostics and accelerating access to new TB diagnostics. FIND has supported the Central TB Division in establishing 40 Liquid Culture & DST, 46 Line Probe Assay and 38 GeneXpert sites in the country under projects supported by UNITAID, GFATM and BMGF. While the UNITAID funded EXPAND-TB project provisioned equipment, test kits and consumables; GFATM complemented this scale-up by supporting infrastructure up-gradation, lab capacity enhancement, additional lab HR and on-site trainings. Till end of 3rd quarter 2015, 42 LPA, 35 LC and 38 Xpert sites had been established and supported by FIND and a total of 742,264 TB tests had been conducted in these facilitie and 78,709 MDR-TB cases detected at these sites. In early 2011, FIND established the International Centre for Excellence in Laboratory Training (ICELT) at the National TB Institute in Bangalore with support from GLI, WHO, and UNITAID. This centre has played a pivotal role in scaling up of laboratory capacity in India. ICELT provides hands-on training courses on newer TB diagnostics, and on biosafety and infection control measures. ICELT also trains master trainers to build expertise required for scale-up and sustainability. FIND has supported training of close to 2500 laboratory personnel through the ICELT facility and on-site trainings

Indonesia In Indonesia FIND has helped establish two Liquid Culture & DST and two Line Probe Assay (LPA) laboratories by providing equipment, consumables and essential supplies through EXPAND-TB project. 797 MDR-TB cases were diagnosed between 2013 and 2014 in the country.

Myanmar FIND entered into an agreement with the Government of Myanmar in February 2009 and has successfully established two state-of-art LPA and two Liquid Culture laboratories under the UNITAID funded EXPAND-TB project. A total of 4070 patients have been MDR-TB diagnosed in these labs from 2010 to 3Q2015 under this project, and 21 lab personnel have also been trained on LPA, and Liquid Culture & DST.

Tuberculosis control in the South-East Asia Region

Annual Report 2016

Global TB Drug Facility (GDF) GDF, housed in the Stop TB Partnership, has been an important partner in the Region supporting supply of low-cost quality-assured first- and second-line drugs as well as providing technical support in strengthening the supply chain management systems within countries. Highlights of the GDF support in the Region for 2015 include: §§ Stop TB/UNOPS has approved the application from the Government of Democratic People’s Republic of Korea for the exceptional support for a 1-year adult and paediatric grant for the Jagang province where there is no support from the Global Fund, acknowledging the extenuating circumstances faced by the Ministry of Public Health of Democratic People’s Republic of Korea. The quantification exercise further to the monitoring mission conducted in Bhutan highlighted an early warning risk of stock-out for SLDs. Appropriate measures have since been taken and needed medicines have been made immediately available from the GDF Strategic Rotating Stockpile or different orders. The quantification exercise further to the monitoring mission conducted in Sri Lanka highlighted an early warning risk of stock-out for FLDs. Appropriate measures have since been taken and the best cost-effective price quotes proposed according to the programme’s requirement. Monitoring missions for review of the commodities supply chain and providing technical support for strengthening systems have also been undertaken in Bangladesh, Myanmar and Timor-Leste. There is ongoing support for the procurement of medicines and diagnostics commodities in the Region.

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An over view of the GDF support in the Region is provided in Graph 7.1 and 7.2

Tuberculosis control in the South-East Asia Region

Annual Report 2016

Graph 7.1: Overview of procurement support per product line: products (FLDs, SLDs and diagnostics) already delivered in each year and product expected to be delivered (orders already confirmed/placed with suppliers with shipments in pipeline and orders in draft status) USD 120 000 000

USD 100 000 000

USD 80 000 000

USD 60 000 000

USD 40 000 000

USD 20 000 000

USD 0

2013 FLD

2014 SLD

2015 Diagnostics

to be delivered

Graph 7.2: Overview of procurement support per country: breakdown per country/year USD 120 000 000

USD 100 000 000

USD 80 000 000

USD 60 000 000

USD 40 000 000

USD 20 000 000

USD 0

2013

2014

2015

to be delivered

Bangladesh Democratic Republic of Timor-Leste Maldives Sri Lanka

Bhutan India Myanmar Thailand

Democratic People’s Republic of Korea Indonesia Nepal

Tuberculosis control in the South-East Asia Region

Annual Report 2016

Paediatric TB project FIND, in consultation with the Revised National TB Control Programme of India (RNTCP) and with funding support from USAID and CDC, has been implementing a novel initiative from February 2014 aimed at the diagnosis of TB in children in Delhi, Kolkata, Chennai and Hyderabad. Under the project, Xpert MTB/Rif was offered as an upfront diagnostic test for paediatric TB diagnosis for the first time in India in both pulmonary and extrapulmonary samples. The project has been focusing on Public-Private Mix (PPM) activities targeting paediatric populations in key cities, in order to build the paediatric diagnostic capacity in both the public and private sector; for this purpose, one high throughput Xpert lab was established in each of the four cities at RNTCP sites. Upfront Xpert-based diagnosis was offered to all children showing symptoms of pulmonary and extrapulmonary TB from linked facilities free of cost through a hub-and-spoke model. Rapid specimen transportation and a reporting mechanism using email and SMS was also established for same-day transportation and reporting.

TB REACH project TB REACH was established in 2010 to provide grants to innovative, experimental or pilot projects that aim to find the 3 million missing TB cases. Over the past four years, US$ 92 million grant disbursements have been provided to 146 projects in 46 countries. There are several TB REACH-projects in the WHO South-East Asia Region, and here we highlight three past projects in India, Indonesia and Nepal to describe how TB REACH engaged partners to move beyond the “business as usual” approach to improve case detection.

Tuberculosis control in the South-East Asia Region

Annual Report 2016

Project Highlight: India Asha Kalp India’s tribal and indigenous people often have poor access to TB care services because they live in isolated and insular communities; the Saharia tribes of Madhya Pradesh province are no exception. Asha Kalp used community health workers to act as an extension of the India NTP in Saharia communities. These health workers verbally screened the tribes people for symptoms of TB, and specimens are collected in the community and transported to the nearest laboratory for testing. TB patients are then started on treatment in the community. Between July and December 2014, over 25 000 individuals were screened, resulting in the detection of more than 450 smear-positive TB patients. These activities resulted in a +89.4% increase in TB treatment compared with the previous year. This remote and tribal population has an extremely high TB burden. The rate of smearpositive TB alone in this community (1767 smear-positive TB cases per 100 000 population) is over 8 times that of India’s national all forms TB notification (-211 all forms TB cases per 100 000). The scale-up and replication of impactful community interventions, which alleviate the barriers in accessing care, will be essential to achieve the ambitious post-2015 targets. Project Highlight: Indonesia Yayasan Menara Agung Pengharapan Internasional South Nias Regency is one of the most underdeveloped areas in Indonesia. Due to the lack of human resources and the high transportation costs among more than 100 remote islands, many TB patients are not able to access care. Indigenous community volunteers were recruited and trained to screen for symptoms of TB as part of a comprehensive maternal child health and nutrition programme. Individuals presumed of having TB were then referred to a health facility to smear microscopy. Volunteers facilitated transportation to ensure testing. When a TB patient was detected, the volunteers helped to initiate and follow up treatment on the remote islands. In addition to these community-based activities, laboratory technicians were trained and monitored to improve the quality of diagnostic services offered through government health facilities. Over 50 000 people were screened for symptoms of TB in 112 villages in just 3 quarters. These activities resulted in the detection of over 225 smear-positive TB patients, including 44 smearpositive patients among children (an impressive feat given the paucibacillary presentation of disease in children). These active case-finding activities resulted in 86% increase in TB notifications compared with the previous year. In light of the significant upward revision of Indonesia’s prevalence estimate and subsequent decline in its case detection rate, initiatives that are able to expand services and demonstrate increases in anti-TB treatment uptake must be prioritized for replication and scale-up Tuberculosis control in the South-East Asia Region Annual Report 2016

Project Highlight: Nepal International Organization for Migration (IOM) IOM Nepal has been implementing a TB REACH Project in collaboration with the National Tuberculosis Programme (NTP) since October 2011, through the deployment of Xpert machines in primary to tertiary health-care centres in nine districts. The project covers the entire population of the Eastern Development Region and two districts of the Central Development Region. The project targets vulnerable, impoverished and hard-to-reach populations such as migrants, people living with HIV, people from mountainous regions and those served by periphery level primary health centres. Advocacy, communication and social mobilization activities were conducted to raise awareness about tuberculosis and Xpert technology, with a special focus on hard-to-reach groups. Active specimen referral through messengers is another intervention contributing to an increase in the number of tests conducted and cases detected. Xpert has been found to be a bridge tool, bringing the private health sector into collaboration with NTP for better TB care. Trainings and workshops on Xpert technology are regularly conducted at various levels of health facilities. As a result of regular advocacy and partnership with NTP at various levels, Xpert technology was endorsed as the TB diagnostic tool, and a national policy was developed in July 2014. As of 31 July 2015, a total of 39 806 Xpert tests had been performed, of which 7215 TB cases had been detected. Admittedly, these achievements come with continuing challenges. One of the main concerns is the high logistical and maintenance cost, raising the issue of the feasibility of sustaining operations in the long term for NTP policy-makers.

UNITAID support in SEAR countries UNITAID is a multilateral agency founded in 2006 by five founding countries and has its Secretariat based in the World Health Organization, Geneva (http://www. unitaid.eu/en/). Since 2000, UNITAID has contributed to major breakthroughs in the global disease response. It has helped to cut the cost of antiretroviral medicines to expand HIV treatment from 2 million people in 2006 to 13 million in 2014. UNITAID helped introduce recent new TB tests, the Hain Line Probe assay and the Xpert MTB Rif, which doubled detection rates for drug-resistant MDR-TB. UNITAID also has multiple projects that helped to expand access to new malaria diagnostics, drugs and preventatives. As of 2014, UNITAID has delivered health products worth US$ 243.5 million, and interventions have been delivered in about 94 countries (http://www.unitaid.eu/en/what/countries). In the area of tuberculosis, the following grants have been implemented or are underway:

Tuberculosis control in the South-East Asia Region

Annual Report 2016

§§

The Paediatric TB project, which provided access to paediatric TB drugs in about 56 countries during 2008–2012; the MDR-TB Scale up initiative, which provided more than 16 300 MDR-TB treatments in 17 countries are closed grants. The MDR-TB SRS Project of the Global Drug Facility is currently transitioning to another donor. The project helped create and maintain an emergency stockpile of MDR-TB medicines preventing treatment supply interruptions for all countries at risk. The EXPAND-TB project implemented by WHO and FIND introduced Line probe assay and expanded the use of liquid culture and Xpert MTB Rif in 27 countries, introduced TB technology in 103 referral labs in these countries and helped detect about 140 000 MDR-TB cases in those countries; the project will come to a close at the end of 2015 and has an outlay of US$ 87 million. In SEAR, this project was implemented in Bangladesh, India, Indonesia and Myanmar. The TBXpert Project, initiated in 2012 for an outlay of US$ 30 million, coupled a price buy-down of the new TB test, Xpert MTB Rif, along with a product roll-out and scale-up project implemented by the WHO Global TB programme and the TB-REACH of the Stop TB Partnership. It helped in scaling access to the new product in 21 countries, coupled with a 40% reduction in the product price in 145 countries. The SEAR countries covered by this project are Bangladesh, India, Indonesia, Myanmar and Nepal. Under the STEP-TB Project of the Global Alliance for TB Drug Development, UNITAID investments are being used to securing access to appropriately dosed and affordably priced child-friendly TB medicines. These new formulations are expected to be available by the end of 2015. The project also undertakes interventions in 16 high-burden countries to promote uptake of the new formulations for paediatrics. The End TB project, being implemented by Partners in Health (PIH) in 16 countries, focuses on improved access to the new MDR-TB medicines, delamanid and bedaquline, with an integral component of clinical and operational research. UNITAID also supports the WHO Pre-qualification of Medicines Programme, which has helped prequalify about 58 priority medicines in TB.

§§

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§§

In a recent approval granted by the UNITAID Board, the Medicines Patent Pool will look at improved IP access to the two new TB drugs bedaquline and delamanid.

United States Agency for International Development (USAID) in SEAR countries Challenge TB (CTB) is USAID’s flagship global project for implementing the United States Government (USG) TB strategy. KNCV Tuberculosis Foundation (KNCV) leads a unique and experienced coalition of nine partners implementing CTB. The other coalition partners (in addition to KNCV) are: American Thoracic Society (ATS), FHI 360, Interactive Research and Development (IRD), International Union Against Tuberculosis and Lung Disease (The Union), Japan Anti-Tuberculosis Association (JATA), Management Sciences for Health (MSH), PATH and the World Health Organization (WHO). Working closely with Ministries of Health, USAID, Global Fund, the Stop TB Partnership and other key stakeholders at global, regional, national and community levels, CTB contributes to the global End TB Strategy targets. Aligned with the USG strategy to prevent and control TB, CTB has three objectives including improved access to high-quality patient-centred TB, DR-TB and TB/HIV services, preventing transmission and disease progression, and strengthening TB service delivery platforms. CTB implements projects at the country, regional and international/global level, including projects in Bangladesh, India, Indonesia and Myanmar.

Bangladesh The lead partner for the CTB project in Bangladesh is Management Sciences for Health (MSH) while the technical support partner is KNCV. The project has prioritized the following areas: 1. Increased case finding, including community-based approaches, ACSM, active case finding among groups such as children, urban poor, prisoners, coinfected TB/HIV patients and TB/DM patients, engagement of private providers including the development of a mandatory notification system, and detection and enhanced quality of PMDT including social support. 2. Quality assurance of the laboratory network using internationally recommended tools.

Tuberculosis control in the South-East Asia Region

Annual Report 2016

3. Support for operational research and practical implementation of the surveillance system. 4. Strong political commitment. In year 1, the project CTB awarded case-finding grants to six NGOs, one professional body (Bangladesh Paediatric Association, BPA), and one trust organization (Centre for Woman and Child, CWCH), which together identified a total of 7356 TB cases in the most recent quarter. Social support was provided for 800 MDR patients, and technical assistance was provided to draft the laboratory strategic plan and a national plan for public-private mix. In addition to Challenge TB, USAID TB funds in Bangladesh also support a variety of other activities, including support for drug quantification and e-TB manager roll-out under SIAPS, TB case finding via urban NGOs in the NGO Health Service Delivery Project (NHSDP), social marketing under the Marketing Innovation for Health (MIH) project, and financial support for the Global Fund CCM restructuring, WHO country office operations, the TB prevalence survey, and some of the second-line drug supplies.

India The International Union Against Tuberculosis and Lung Disease (The Union) has been tasked to lead CTB in India and deliver a high-level Call to Action for a TB-Free India campaign to build political will and leadership and mobilize resources. The objectives of the Call to Action are to: a) mobilize a wide range of stakeholders to demand and sustain high-level domestic commitment to end TB in India and b) tap the energy and influence of key stakeholders to drive political, administrative and technical solutions to address specific barriers affecting TB prevention and care in India. The Call to Action for a TB-Free India was launched on 23 April

Shri J.P. Nadda, Honourable Union Minister of Health and Family Welfare (MoHFW), launching the Call to Action

Tuberculosis control in the South-East Asia Region

Annual Report 2016

2015 at New Delhi by Shri J.P. Nadda, Honourable Union Minister of Health and Family Welfare (MoHFW), Government of India. As a first, renowned superstar of Indian cinema, Mr Amitabh Bachchan came on board as a patient advocate along with Mr Richard Verma, US Ambassador to India. Mr Ratan Tata, Chairman Tata Trusts, joined as a corporate champion and Dr K. K. Aggarwal (Hon. Secretary Mr Ratan Tata, Mr Amitabh Bachchan and Ambassador Richard Verma (Left to right) signed the Pledge for a General, Indian Medical TB-Free India Association (IMA)), as private health sector champion lead IMA’s efforts to develop and disseminate ‘Guidelines for Private Health Sector on TB’ in line with Standards for TB Care in India (STCI). Dr Naresh Trehan, Founder of Medanta Medicity, is also supporting the campaign. In the first year, CTB has been successful in building visibility of TB and related issues with more than 150 articles in media (national and international). Other USAID-supported projects include accelerated access to quality TB diagnosis for paediatric cases in four major cities (Delhi, Hyderabad, Chennai and Kolkata) through FIND; a Grand Challenges for TB Control that seeks innovative projects through a crowdsourcing approach including innovations to improve treatment adherence and diagnosis of TB; and a successful pilot of innovative and intensified TB case finding and treatment at high-burden ART centres where daily FDC drugs have been introduced for the first time under RNTCP for management of TB cases.

Indonesia In Indonesia, CTB is led by KNCV with FHI360 and WHO as in-country partners, and supported by ATS and IRD through external short-term technical assistance (STTA). Based on lessons learned from TB CARE I and National Strategic Plan

Tuberculosis control in the South-East Asia Region

Annual Report 2016

Mapping C/DST Certified labs and 3 NRLs

2015–2019 gap analysis, CTB has prioritized technical intervention areas to work on: 1. Ensuring universal access by integrating TB in national health insurance (JKN/Jaminan Kesehatan Nasional) and securing increased local government funding for TB 2. Increasing case detection 3. Ensuring the quality of treatment and care for TB, DR-TB and TB-HIV 4. Expanding diagnostic services 5. Strengthening M&E, surveillance and operational research. Through collaborative intervention involving all relevant key players, CTB has achieved some key results during Year 1 of the programme (2015). §§ Four laboratories have successfully passed their EQA panel testing for FLDST, bringing the total of nation-wide laboratories with quality assurance of first-line DST to 13; out of these 13 laboratories, 5 have certified for SL-DST (as in map of C/DST labs and 3 NRLS) Joint TB-HIV Concept Note (CN) for the Global Fund NFM was submitted in April 2015 and is currently waiting for grant signing. The Global Fund has awarded the full requested allocation amount of US$ 132.2 million plus US$ 97.5 million in incentive funding.

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Provision of support and empowerment of patient group expansion through mentoring and capacity-building trainings. Up to now, six patient groups have been established (North Sumatra, Central Java, DKI Jakarta, East Java, West Java and South Sulawesi) with total membership of 102 persons. PETA (Jakarta) and REKAT (Surabaya, East Java) have officially registered as an incorporated foundation in the Ministry of Law and Human Rights. CTB also supported the adaptation of PCA (Patient-centred Approach) tools into the national TB programme. These tools will be used by CSOs including patient groups to provide feedback for service Budi Hermawan and Ulli Alawiyah (PETA Organization) improvement to health facilities. Mandatory notification has been included in the final draft Decree of the Minister of Health related to TB Control stating that TB is a notifiable disease and that all health providers delivering TB services are obliged to report cases to the National TB Programme (NTP). In an effort to intensify case finding, several interventions have been undertaken. One of the activities was focused on the TB-Diabetes Mellitus (DM) collaboration. The TB and Diabetes Mellitus Governance Consensus Charter was signed by seven professional The TB and Diabetes Mellitus Governance Consensus organizations, and Charter Communicable and Noncommunicable Disease Directorate of the MoH in August 2015 (picture showing the Consensus Charter). Provision of technical support to KPMAK-UGM (Centre for Health Insurance Management and Costing Policy, Gadjah Mada University) to

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Tuberculosis control in the South-East Asia Region

Annual Report 2016

finalize the TB-JKN (TB National Health Insurance) technical guideline. The Technical Guideline on TB National Health Insurance was already officially signed and launched by the Disease Control and Environmental Health (P2PL) Directorate General of the MoH. In addition to Challenge TB, the TB funding from USAID in Indonesia supports three community-based NGOs that provide patient support and community-based case finding, and the Promoting the Quality of Medicines (PQM) project, which is supporting local pharmaceutical companies to reach international standards.

Myanmar A new Challenge TB Project was approved mid-2015 with some initial achievements: §§ §§ Provided key support to develop the new National TB Strategic Plan. Established partnerships and started working in difficult ethnic areas to build capacity for TB services with local health staff – areas where NTP is unable to reach and provide quality diagnosis and treatment for TB. Conducted a PPM national situational analysis, national laboratory assessment and a national TB infection control assessment – all providing critical recommendations and direction for key future priorities for NTP, CTB and other partners.

§§

USAID is also supporting a CAP-TB project where FHI 360 is working with local partners to expand TB and MDR-TB services in Myanmar by developing a comprehensive prevention-to-care model in 22 townships in the Yangon and Mandalay regions. The project supports prevention, education and outreach services that identify and refer suspected TB cases; helps ensure more rapid diagnosis of MDR-TB (through Xpert); trains doctors on treatment and infection control; and establishes follow-up programmes to ensure MDR-TB patients finish their treatment. USAID is also supporting supply chain management via the SCMS project.

The information given in this section and pictures are as provided by the respective partners.

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Country profiles

Country profile

Bangladesh

Background information Population* - 159 077 513 Estimates of disease burden for 2014 Incidence of all forms of TB Incidence rate of all forms of TB (per 100 000 population per year) Incidence rate HIV+TB only (per 100 000 population per year) Prevalence of all forms of TB Prevalence rate of all forms of TB (per 100 000 population) TB death rate (of all forms of TB, excluding HIV per 100 000 population per year) % of MDR-TB cases among new TB cases % of MDR-TB cases among retreatment TB cases Number of MDR-TB cases among notified new TB cases Number of MDR-TB cases among notified retreatment TB cases 360 000 (320 000–410 000) 227 (200–256) 0.36 (0.28–0.45) 640 000 (340 000 –1 000 000) 404 (211–659) 51 (37–68) 1.4 (0.7–2.5) 29 (24–34) 2 100 (1 000–3 700) 2 700 (2 200–3 200)

*Source: United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects: The 2015 revision, DVD Edition. New York, 2015.

Tuberculosis control in the South-East Asia Region

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Programme performance and trends* Case notifications in 2014 Number of bacteriologically confirmed new pulmonary TB cases Number of bacteriologically confirmed relapse pulmonary TB cases Notification rate of new and relapse bacteriologically confirmed cases (per 100 000 population for the year 2014) Number of clinically diagnosed new pulmonary TB cases Number of clinically diagnosed relapse pulmonary TB cases Number of extra-pulmonary new TB cases Number of extra-pulmonary relapse TB cases Notification rate of all new and relapse TB cases (per 100 000 population for the year 2014) Number of previously treated cases, excluding relapses 106 767 2 989 67 42 832 863 37 406 309 120 5 631

Note: Among 187 005 new cases: 6 262 (3%) cases aged under 15 years; male:female ratio: 1.5

Case notifications by type of patients, 2014

Pulmonary TB cases, clinically diagnosed 21.8%

New extrapulmonary 19.0%

Relapse 2.1%

Pulmonary TB cases, bacteriologically conﬁrmed 54.3%

Previously treated paƟents, excluding relapse cases 2.9%

* All the data in this section is sourced from www.who.int/tb/data accessed 28 December 2015

Tuberculosis control in the South-East Asia Region

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Trends in TB case notifications, all forms (1995–2014) 250 000 200 000 150 000 100 000 50 000 0

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Pulmonary TB cases, bacteriologically conﬁrmed New extrapulmonary Previously treated paƟents, excluding relapse cases

Pulmonary TB cases, clinically diagnosed

Relapse Total new and relapse

RR/MDR-TB cases notification – 2104 New Cases tested for RR/MDR-TB Laboratory confirmed RR/MDR-TB cases Patients started on MDR-TB treatment** 12 753 (12%) Retreatment 4 959 (51%) Total 43 360* 994 (2.3%) 945 (95.1%)

* Includes patients with unknown previous TB treatment history. **Includes patients who were not laboratory confirmed and those diagnosed before 2014.

Tuberculosis control in the South-East Asia Region

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2014

Treatment success rate and cohort size New and relapse cases registered in 2013 Previously treated cases, excluding relapse, registered in 2013 HIV-positive TB cases, all types, registered in 2013 RR-/MDR-TB cases started on second-line treatment in 2012 XDR-TB cases started on second-line treatment in 2012

(%) (93) (86) (75) (72) (25)

Cohort 184 077 6 327 68 505 4

Treatment outcomes by type of cases, 2013 cohort (2012 cohort for RR/MRD-TB cases) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% All new and relapse Not evaluated Previously treated HIV-posiƟve TB, All conﬁrmed RR(excluding all types TB/MDR-TB relapse) Died Treatment failed Cured or treatment completed

Lost to follow-up

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Trends in treatment success rate by type of cases, 1995-2013 100 90 Treatment success rate (%) 80 70 60 50 40 30 20 10 0 1995 1997 1999 2001 2003 2005 Year All new cases and relapse HIV+ TB cases Retreatment cases (excluding relapse) MDR-TB cases 2007 2009 2011 2013

Highlights of programme performance •• Yearly notification of all forms of TB has increased to 196 797 mainly due to an increase in number of clinically diagnosed pulmonary TB cases and extra-pulmonary cases being notified A high treatment success rate of 93% achieved among all new and relapse cases MDR-TB treatment success rate is also high at 73% Detection of TB in children has increased from <2% (2005) to 3.35% (2014)

•• •• ••

Tuberculosis control in the South-East Asia Region

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Progress towards MDGs Trend in estimated TB prevalence rates, 1990–2014 (Shaded areas represent uncertainty bands. The horizontal dashed line represents the target of a 50% reduction by 2015 compared with 1990)

750

500

250

0 1990 1995 2000 2005 2010 2015

Tuberculosis control in the South-East Asia Region

Annual Report 2016

Trend in estimated TB mortality rates, 1990–2014 (Shaded areas represent uncertainty bands. The horizontal dashed line represents the target of a 50% reduction by 2015 compared with 1990)

0 1990 1995 2000 2005 2010 2015

Tuberculosis control in the South-East Asia Region

Annual Report 2016

Trend in case notification rates (new and relapse cases, all forms) and estimated TB incidence rates, 1990–2014 (Black line represents notification rate, green line represents estimated incidence, red line represents incidence of HIV positive TB cases only, shaded areas represent uncertainty bands) 300 200 100 0 1990

1994

1998

2002

2008

2010

NoƟﬁed (new and relapse) Incidence (HIV+TB only) 200

Incidence

100

0 1990 1995 2000 2005 Incidence 2010 Notified(newandrelapse) Incidence(HIV+TBonly)

Programmatic challenges Major challenges in achieving universal access to TB prevention, care and control services Even though the programme has achieved a steady increase in case notification drug-susceptible TB, the proportion of estimated missing cases for all forms of TB is still high at 47%. Similarly for RR/MDR-TB, only about 20% of estimated cases among notified pulmonary TB cases are being detected. This can mainly be attributed to: •• •• •• •• •• Inadequate access to quality diagnostic services Inadequate system for contact tracing and active screening in targeting key affected population Effective engagement of private sector through operationalization of mandatory notification is required Clinically diagnosed TB constitutes a high proportion of TB cases Childhood TB & Urban TB need to be addressed

Tuberculosis control in the South-East Asia Region

Annual Report 2016

••

Sustainability of funding is an issue specifically for: ‒‒ Human resources including capacity-building ‒‒ Social support targeting vulnerable population

••

Effective supervision and monitoring is lacking in many areas due to shortage of resources.

Major challenges in expansion of MDR-TB services •• Limited access to drug-sensitivity testing: ‒‒ Xpert MTB/RIF testing has been introduced but needs to expand for improved access. In certain places, the machines are out of order and need module replacement. Overall maintenance of GeneXpert machines remains an unaddressed area. ‒‒ Sputum/sample transport mechanism has not been effectively established specially in remote areas. •• Inadequate identification of presumptive DR-TB cases with specific inadequate detection of retreatment cases due to lack of proper historytaking. Mechanism to ensure uninterrupted supply of SLD and diagnostic logistics needs strengthening. Like DS-TB, monitoring and supervision need to be strengthened.

•• ••

National Strategic Plan for TB Control (2015–2020) Goal: Reduce the prevalence of TB (all forms) by at least 10% by 2020, and by 5% annually after 2020

PILLAR 1: INTEGRATED, PATIENT-CENTRED CARE AND PREVENTION Objective 1: To increase annual case detection of all forms of TB to 230 000 by 2020 (from baseline of 196 797 in 2014) Objective 2: To maintain treatment success rate of at least 90% in all forms of detected drug-sensitive TB cases and ensure quality-controlled treatment services at all implementation sites

Tuberculosis control in the South-East Asia Region

Annual Report 2016

PILLAR 2: BOLD POLICIES AND SUPPORTIVE SYSTEMS Objective 3: To ensure universal access to drug-susceptibility testing (DST) by 2020; treat 100% of detected MDR-TB cases and achieve a treatment success rate of at least 75% in detected MDR-TB cases Objective 4: To strengthen the engagement of all public and private-care providers Objective 5: To ensure that at least 90% of required staff positions identified in a revised national human resource development plan are filled, and 100% of all filled positions are trained, by 2020 Objective 6: To ensure that all TB service facilities will receive regular supervision and monitoring, and produce timely and accurate reports, by 2017 Objective 7: To ensure the long-term availability of 100% of required funding for activities at all programme levels through effective planning and partner coordination; increase GOB contribution to 10% of total TB budget by 2020

Pillar 3: INTENSIFIED RESEARCH AND INNOVATION Objective 8: To ensure adequate support for operational research to foster innovation

Laboratory expansion plan Xpert instruments (4 module) in districts Xpert instruments (4 module) in city corporations Total Xpert (4 module) instruments in country Xpert instruments (16 module) at NTRL Number of districts/City Corporations where specimen transportation systems for Xpert and for confirmation of culture and DST exist Number of solid culture and DST laboratories Liquid culture (MGIT) LPA molecular laboratory 2014 44 10 50 1 64/7 2015 64 11 75 1 64/7 2016 64 14 78 1 64/7 2017 64 16 80 1 64/7

6 1 1

6 2 2

Tuberculosis control in the South-East Asia Region

Annual Report 2016

Operational plan for 2016–2017 •• Completion of the field implementation of TB Prevalence Survey, data analysis and draft report, dissemination for finalization and publication of final survey report Recruitment of new staff / filling up of vacant positions Training /Refresher training Expansion of LED FM to all UHC and Gene Xpert to all districts Establish more RTRL (in Barisal, Sylhet and Rangpur division) Awareness-raising programme on TB with special attention to child TB Scale-up of contact tracing and IPT Improvement of drug storage facility Conduction of clinical research on 9-month regimen Expansion of e-TB manager Strengthening supervision and monitoring Operationalization of the Gazette on mandatory case notifications and involvement of private sector through systematic referral linkage Conduct Drug Resistance Survey (DRS) Piloting universal access to drug-susceptibility testing (DST) for all smearpositive TB cases Conduct joint monitoring mission in 2017

•• •• •• •• •• •• •• •• •• •• •• •• •• ••

Financing of NSP July 15–June 16 NSP budget GOB GF (NFM) USAID Gap 39 859 878 584 416 28 540 270 8 000 000 2 735 192 July 16–June 17 43 620 200 613 636 30 389 723 8 000 000 4 616 841 July–Dec 17 23 501 794 322 159 15 491 009 4 000 000 3 688 626 Total 106 981 872 1 520 211 74 421 002 20 000 000 11 040 659

Tuberculosis control in the South-East Asia Region

Annual Report 2016

••

Current situation of the GF grants: ‒‒ The grant was signed on 27 May 2015 with BRAC and 09 July 2015 with NTP ‒‒ Total NFM budget amount: US$ 71.77 million (NTP US$ 29.96 million including WHO part; BRAC US$ 41.81 million) ‒‒ Time period: 01 July 2015 to 31 December 2017 ‒‒ Implementation started from July 2015

••

Reprograming budget from savings of Round 10 Global Fund grant ‒‒ The budget amount: US$ 8.3 million (NTP 5.6 million and BRAC 2.7 million) ‒‒ Timeframe: July 2015 to December 2017

Partnerships BRAC - BRAC is the largest NGO partner of the National Tuberculosis Control Programme (NTP). Under the stewardship of NTP, currently BRAC covers 297 subdistricts (upazillas) of 42 districts with a population of 93 million, including Chittagong hill tracts, 41 prisons, 24 academic institutions, 392 peripheral laboratories, 2 port authority hospitals, Chittagong EPZ and 7 city corporations. It started its TB control activity in 1984 with its innovative community-based approach, which is operated by the Shasthya Shebikas (SS). Shasthya Shebikas plays the pivotal role of connecting individuals with TB control services during household visits and health forums. BRAC also conducts orientations with different stakeholders of the community to engage them in efforts to identify patients, ensure treatment adherence and reduce stigma. Damien Foundation Bangladesh – Damien Foundation covers 14 districts (111 upazillas) of which 13 districts (102 upazillas) are for combined TB and leprosy control. The organization has set up 151 centres including 5 in medical colleges and 1 in the workplace (DEPZ). The organization also runs three own hospitals with a total 255 beds to guarantee quality services for complicated TB (including MDR TB) and leprosy patients. Gonoshasthaya Kendra (GK) The Peoples Health centre is a pioneer nongovernmental organization (NGO) that provides innovative community health-

Tuberculosis control in the South-East Asia Region

Annual Report 2016

care services that is affordable and accessible to the rural people of Bangladesh. It is supporting TB control in the Savar upazilla as well as through its Dhaka Nagar Hospital. There are about 200 field paramedics employed by GK who provide door-to-door health-care services at the community level. HEED Bangladesh - HEED Bangladesh is committed to participate and promote national development through upgrading the socioeconomic condition of the disadvantaged and underprivileged people in the society. HEED Bangladesh is working at 120 upazillas (sub-district) under 32 districts with 132 offices. For TB, it is working at 24 upazillas under the Moulovibazar district. International Centre for Diarrheal Disease and health research institution, Bangladesh (ICDDR,B): ICDDR,B researchers are conducting a wide range of research in TB priority areas. For many years, it has been monitoring at the community level the disease burden, methods of transmission and care seeking behaviour on tuberculosis in its Matlab project area. ICDDR,B has also established enhanced case-finding activities in the private sector, which includes the extensive use of the Xpert MTB/RIF assay (GeneXpert), at private sector laboratories – an innovative public-private mix (PPM) initiative. Lutheran Aid to Medicine in Bangladesh (LAMB): LAMB works to improve the health of poor people in north-west Bangladesh. Services cover a population of well over 1 million people. The main site is 2 km west of the town of Parbatipur about 24 km east of the district city of Dinajpur. LAMB started treating TB patients in 1985. LAMB TB Control Programme is working in four upazillas – Parbatipur (one pourosova and one union); Chirirbandar and Khansama upazillas under the Dinajpur district; and Saidpur upazilla under the Nilphamari district covering approximately 842 627 people. The British Leprosy Relief Association (LEPRA) Bangladesh: LEPRA is a medical development charity based in the United Kingdom. The NGO is supporting TB control activities in three districts: Natore, Pabna and Sirajganj. The National Anti-tuberculosis Association of Bangladesh (NATAB): NATAB is one of the oldest TB organizations for TB control and a constituent member of The Union. At present, NATAB is working as a civil society advocacy agency to identify different groups by vocation, profession, religion, ethnicity and other possible classification and to turn the variations into strength. Each quarter, NATAB organizes a district-level advocacy programme in all 64 districts of the country

Tuberculosis control in the South-East Asia Region

Annual Report 2016

with civil society members. NATAB also organizes a subdistrict level advocacy programme in 64 subdistricts. PIME Sisters: In 2001, when NTP started DOTS implementation in Khulna City Corporation, the PIME Sisters’ leprosy network was made available for TB control activities also. The PIME Sisters run 12 DOT centres in Khulna city, including the jail. They have a small referral hospital for both TB and leprosy and in this hospital a there is a central laboratory. They conduct field activities in slum areas as well as other parts of Khulna city. SEED: The organization is actively collaborating with the government (DGHS and NTP) to develop innovative programmes to improve effectiveness of community-based health service delivery. SEED has been a pioneer in developing a sustainable Public-Private Partnership (PPP) model to engage Private Medical Practitioners (PMPs) into the TB control programme, in collaboration with the Bangladesh NTP and the Nuffield Centre for International Health and Development (NCIHD), University of Leeds, UK. The PPP in the TB control programme, which was piloted in Dhaka, has been scaled up in Chittagong and Sylhet, with plans to expand to other urban areas in Bangladesh. SEED has also forged successful partnership with the NTP, NGOs and the Bangladesh Garments Manufacturers and Exporters Association (BGMEA) in implementing a TB workplace project in the selected garments factories in the Dhaka and Gazipur areas. Rangpur-Dinajpur Rural Service: Rangpur-Dinajpur Rural Service (RDRS) Bangladesh has been working in the north-west region of Bangladesh for over three decades. From 1996, RDRS as a collaborating partner of the National Tuberculosis and Leprosy Control Programme took the responsibility for the care of TB patients in five upazillas of Lalmonirhat and nine upazillas of the Kurigram district through 47 clinics. Salvation Army: The Salvation Army Urban Health and Development Project is part of the organization’s integrated Community Health Development Project, Mirpur. The Salvation Army was signatory of the MoU between NTP and the Leprosy-TB Coordinating Committee and was made responsible for supporting TB control activities in Mirpur, Dhaka. The project area is mostly inhabited by Bihari (Urdu speaking) refugees living in unhygienic slum conditions with scarcity of water supply.

Tuberculosis control in the South-East Asia Region

Annual Report 2016

Smiling Sun Franchise Programme (SSFP): The SSFP is a project funded by the United States Agency for International Development (USAID). SSFP is contributing with the NTP to combat TB in Bangladesh through Smiling Sun Clinics (SSC). Eight SSFP NGOs/franchises are providing DOTS in four city corporations, namely Chittagong, Dhaka, Khulna and Rajshahi. There are about 4.1 million in catchment population receiving DOTS through 58 Smiling Sun Clinics; 33 of them have microscopy centres and one has an External Quality Assurance (EQA) centre. The Leprosy Mission Bangladesh (TLMB): TLMB started working in Bangladesh in June 1991 initially for leprosy and since 1994 also for TB. TLMB is supporting NTP in TB control implementation in 10 upazillas of Thakurgaon and Panchagarh districts. This international NGO is strengthening the health system by integrating its leprosy and TB control services in government health facilities. In addition, TLM fosters networking between government service providers and communitybased supporters including private practitioners, village doctors, local elite, NGO workers, nongraduated private practitioners and cured TB patients. Urban Primary Health Care Service Delivery Project (UPHCSDP), Bangladesh: UPHCSDP, a Public-Private Partnership, is an innovative initiative with the goal to improve the health status of the urban population, specially the poor, particularly focusing on women and children. UPHCSDP has been providing TB control services in city corporations area through 85 DOT centres. Systems for Improved Access to Pharmaceuticals and Services (SIAPS): the SIAPS programme implemented by Management Sciences for Health (MSH) is funded by USAID supports to the MOHFW, DGFP, DDGA and DGHS including other key entities. It strengthens the ability of policy-makers, health-care providers and institutions to improve commodity management, with an emphasis on governance, procurement, institutional capacity-building, management information system and other system strengthening initiatives, aimed at ensuring continuous availability of commodities required to support health-care delivery and the timely availability of reliable data to support evidence-based decisionmaking. SIAPS has been mandated by USAID under a cooperative agreement to work with NTP to strengthen pharmaceutical management systems for TB.

Tuberculosis control in the South-East Asia Region

Annual Report 2016

Figure: Map of Bangladesh indicating districts and working areas supported by NGOs

Map source: NTP, Bangladesh

Key achievements and success stories •• •• •• National guidelines and operational manual on childhood TB (2nd edition) finalized and endorsed by NTP National guidelines on TB/HIV management and programme collaboration and implementation manual (2nd edition) finalized Community-based DR-TB management is available in the whole country

Tuberculosis control in the South-East Asia Region

Annual Report 2016

•• •• •• •• ••

TB IC guidelines for field workers in local language (Bengla) published Number of microscopy labs increased from 1089 to 1104 Number of centres with Xpert MTB/RIF machines increased from 27 to 39 Electronic registration of TB data using e-TB manager software running in 240 out of 882 sites and 6 DR TB sites Government of Bangladesh has decided to conduct a TB prevalence survey with technical support from CDC Atlanta, RIT Japan, SNRL of Antwerp, Belgium and WHO. Major accomplishments so far: field testing was conducted from 15–17 January 2015, a total of 249 respondents participated; two pilot surveys were carried out prior to final kick-off of the survey to identify weaknesses and to assess overall capacity of the team. The pilot survey in urban setting was conducted from 4–11 February 2015 at Boro Moghbazar, Dhaka. A total of 742 respondents took part in the survey. The rural pilot survey was conducted from 20–26 February 2015 at Suapur Village, which is situated at Suapur Mouza at Suapur Union at Dhamrai Upazila of Dhaka district. A total of 772 respondents took part in the survey; until 17 December 2015, five teams completed the survey in 81 out of 125 clusters of urban and rural sites in the seven divisions; laboratory activities are ongoing with the support of NTRL. The Supra National Reference Lab (SNRL) is ensuring the quality of laboratory services. Four biosafety cabinets at NTRL were tested and certified by technical experts. RIT Japan and CDC Atlanta, as well as SRL Belgium provide technical support with continuing supervision from WHO, NTP, IEDCR, CDC, USAID and GFATM. As per the mission report of technical experts, overall progress of the survey is impressive.

••

Tuberculosis control in the South-East Asia Region

Annual Report 2016

Overseeing the pilot survey GFATM

Field visit by technical experts

Overseeing lab activities by experts from SRL

Overseeing field implementation of survey

Orientation for the Philippines Survey Team

The Philippines Survey Team visiting NTRL

Tuberculosis control in the South-East Asia Region

Annual Report 2016

Country profile

Bhutan

Background information Population* - 745 153 Estimates of disease burden for 2014 Incidence of all forms of TB Incidence rate of all forms of TB (per 100 000 population per year) Incidence rate HIV+TB only (per 100 000 population per year) Prevalence of all forms of TB Prevalence rate of all forms of TB (per 100 000 population) TB death rate (of all forms of TB, excluding HIV per 100 000 population per year) % of MDR-TB cases among new TB cases % of MDR-TB cases among retreatment TB cases Number of MDR-TB cases among notified new TB cases Number of MDR-TB cases among notified retreatment TB cases 1 300 (1100–1400) 164 (148–181) 12 (9.4–15) 1500 (570–2700) 190 (75–359) 72 (39–120) 2.2 (1.9–2.6) 35 (21–52) 12 (10–14) 25 (15–37)

*Source: As per the Projections of Population and Housing Census of Bhutan, 2005. These figures differ from those published by the United Nations, Department of Economic and Social Affairs, Population Division (2015). World Population Prospects: The 2015 Revision, DVD Edition.

Tuberculosis control in the South-East Asia Region

Annual Report 2016

Programme performance and trends* Programme performance in 2014 Number of bacteriologically confirmed new pulmonary TB cases Number of bacteriologically confirmed relapse pulmonary TB cases Notification rate of new and relapse bacteriologically confirmed cases (per 100 000 population for the year 2014) Number of clinically diagnosed new pulmonary TB cases Number of clinically diagnosed relapse pulmonary TB cases Number of extra-pulmonary new TB cases Number of extra-pulmonary relapse TB cases Notification rate of all new and relapse TB cases (per 100 000 population for the year 2014) b Number of previously treated cases, excluding relapses 454 55 59 91 0 466 0 139 16

Note: Among 1066 new and relapse cases: 56 (5%) cases aged under 15 years; male:female ratio: 1.0.

Case notifications by type of patients, 2014

New extrapulmonary 43.1%

Relapse 5.1%

Pulmonary TB cases, clinically diagnosed 8.4%

Pulmonary TB cases, bacteriologically conﬁrmed 42.0%

Previously treated paƟents, excludin g relapse cases 1.5%

* All the data in this section is sourced from www.who.int/tb/data accessed 28 December 2015

Tuberculosis control in the South-East Asia Region

Annual Report 2016

Trends in TB case notifications, all forms (1995 - 2014) 1400 1200 1000 800 600 400 200 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Pulmonary TB cases, bacteriologically conﬁrmed New extrapulmonary Previously treated paƟents, excluding relapse cases Pulmonary TB cases, clinically diagnosed Relapse Total new and relapse

RR/MDR-TB cases notification – 2014 New Cases tested for RR/MDR-TB Laboratory confirmed RR/MDR-TB cases Patients started on MDR-TB treatment* 380 (84%) Retreatment 44 (62%) Total 431 61 (14.2%) 61 (100%)

*Includes patients who were not laboratory confirmed and those diagnosed before 2014.

Tuberculosis control in the South-East Asia Region

Annual Report 2016

(%) (91) (60)

Cohort 1080 35

(100) 0

10 0

Treatment outcomes by type of cases, 2013 cohort (2012 cohort for RR/MRD-TB cases) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% All new and relapse Previously treated (excluding relapse) Died

HIV-posiƟve TB, All conﬁrmed all types RR-TB/MDR-TB

Not evaluated

Lost to follow-up

Treatment failed

Cured or treatment completed

Tuberculosis control in the South-East Asia Region

Annual Report 2016

Trends in treatment success rate by type of cases, 1995–2013 100 90 Treatment success rate (%) 80 70 60 50 40 30 20 10 0 1995 1997 1999 2001 2003 2005 Year All new cases and relapse HIV+ TB cases Retreatment cases (excluding relapse) MDR-TB cases

2007

2009

2011

2013

Highlights of programme performance •• •• •• •• •• Case detection rate for all forms of TB achieved at 87% TB incidence and mortality reduced by half – achieved MDGs Substantial increase in number of RR/MDR-TB cases diagnosed and initiated on treatment Treatment success rate among NSP sustained at 90% Treatment success rate of MDR-TB achieved at 100% (for a cohort of 10 cases)

Tuberculosis control in the South-East Asia Region

Annual Report 2016

3000

2000

1000

0 1990 1995 2000 2005 2010 2015

Tuberculosis control in the South-East Asia Region

Annual Report 2016

Trend in estimated TB mortality rates, 1990–2014 (Shaded areas represent uncertainty bands. The horizontal dashed line represents the target of a 50% reduction by 2015 compared with 1990)

300

200

100

0 1990 1995 2000 2005 2010 2015

Tuberculosis control in the South-East Asia Region

Annual Report 2016

1994

1998

2002

2006

2010 Incidence

NoƟﬁed (new and relapse) Incidence (HIV+TB only)

Programmatic challenges Major challenges in achieving universal access to TB prevention, care and control services •• •• •• •• •• •• •• •• •• DOT implementation and compliance with treatment Paediatric TB Lack of rapid diagnostic tool Limited knowledge and skills Shortage of human resources – multitasking Community participation Limited or no operational research on key priority areas Sustaining financial resources Geographical terrains

Tuberculosis control in the South-East Asia Region

Annual Report 2016

Major challenges in expansion of MDR-TB services •• •• •• •• •• •• •• Lack of newer WHO-recommended diagnostic tools as also a lack of DST facility for SLDs. Monitoring and supervision is suboptimal due to overburdened NTCP staff and difficult terrains. Infection control is still a challenge in the main MDR-TB hospital. Inadequate screening of high-risk group including family members of MDRTB patient and health workers working in MDR-TB hospital. Insufficient human resources at all levels of PMDT implementation, especially at the national level. Slow progress of decentralized MDR-TB care and treatment at the regional level. Sample shipment from the sites - Delayed transportation of sputum samples from areas not covered by influenza project and uncertainty of sputum transportation after influenza project ceases.

National Strategic Plan Goal: •• To reduce TB and MDR-TB burden until it no longer poses a public health problem in Bhutan.

Objectives: •• •• •• •• •• To sustain and increase case notification rate of ≥90% among prevalent cases; To sustain and increase treatment success rate of ≥90%; To improve MDR-TB case detection and achieve treatment success rate of 75% by 2016; To improve TB/HIV coinfection case detection to register at least 80% of estimated coinfected individuals by end of 2016; and To ensure adequate human resources at all levels to deliver services efficiently.

Tuberculosis control in the South-East Asia Region

Annual Report 2016

Laboratory expansion plan Activity Number of microscopy centres available Number of GeneXpert machines needed for DR screening Number of GeneXpert machines available for DR screening Number of labs certified to do FL C&DST Number of labs certified to do culture only Number of labs certified to do SL DST Baseline 35 0 0 1 0 0 2016 35 4 0 1 0 0 2017 35 2 1 1 0 0 2018 35 2 1 1 0 0 2019 37 1 1 1 0 0 2020 37 1 1 1 0 1

Operational plan for 2016–2017 •• •• •• •• •• Routine surveillance for DR-TB Capacity-building of health workers on PMDT Procurement of SLDs and XDR-TB drugs Procurement of reagents and supplies for solid, liquid culture and DST and LPA Refurbishment of MDR-TB wards

Financing of NSP NSP Budget NSP Budget RGoB Funding GF Support Total Gap 2014–2015 1 339 641 675 147 381 160 1 056 307 283 334 2015–2016 1 473 605 708 904 794 231 1 503 135 -29 530 2016–2017 1 547 285 744 349 588 396 1 332 745 -214 540 2017–2018 1 624 649 781 566 478 844 1 260 410 -364 239

Tuberculosis control in the South-East Asia Region

Annual Report 2016

The GF support The GF support to TB control programme started from April 2005. Since then, its support continued through Round 6 and TB TFM Grant until the end of June 2015. The NTCP submitted the proposal for TB NFM Grant, and NFM Grant has been approved for three years in 2015 with a total approved budget of US$ 2.083 million. The modules covered under the TB NFM Grant are: TB Care and Prevention, TB/HIV, MDR-TB, Procurement Supply Chain Management, Health Information Systems and M&E and Programme Management. Under each module, there are interventions and activities that need to be undertaken during this grant period. The TB NFM Grant was approved in March 2015 and was signed in May 2015. Implementation of this grant started from 1 July 2015. Through the GF support, steady progress has been made in terms of case detection and sustaining the treatment success rates.

Partnerships There are very few nongovernmental organizations (NGOs) and civil society organizations (CSOs) in the country. However, the engagement of NGOs and CSOs has been limited and they do not have any direct role in providing TBrelated services because of the free health-care services being provided by the government and good primary health-care coverage. There are no private hospitals in the country. However, few private diagnostic centres are being established and these centres do not diagnose and treat patients. The programme strives to involve cured TB patients, Village Health Workers (VHWs), multisectoral task force - MSTF (HIV/AIDS programme) and Community Action Group (Malaria programme) for support to TB and MDR-TB patients. Currently, under the NFM grant, NTCP have started involving Youth Development Fund (NGO) to target youth and Dratshang Lhentshog (FBO) to provide awareness on TB among monks in the monastic institutions. However, NTCP can explore the possibility of engaging more NGOs and CSOs for TB control in the near future. The programme plans to sensitize these groups (community action groups, MSTF, VHWs) specifically in high TB notification areas and where there are existing MDR-TB patients on treatment. District TB In-charge will seek the support of these groups for: •• •• Psychological support for patients Reintegration of patient into society after discharge from hospital

Tuberculosis control in the South-East Asia Region

Annual Report 2016

•• •• •• ••

Identification of a suitable DOT provider Ensuring DOT to the TB patients Observe and notify any adverse events/reactions of drugs to the physicians Patient follow-up is carried out to monitor the treatment adherence.

Key achievements and success stories For the programmatic management of MDR-TB, a greater number of bacteriologically confirmed RR/ MDR-TB cases are being diagnosed and enrolled on treatment. Their outcomes at the end of treatment is reported to be good enough as the treatment success rate for the 2012 cohort stands at 100%, which is far beyond regional and global achievements. However, there are much more that needs to be done as we move forward in adopting end-TB strategy to eliminate TB by 2035. The NTCP Bhutan has also achieved the Millennium Development Goals of halting and reversing TB prevalence, incidence and mortality rates by half compared with the 1990 targets. The credit towards achieving this goal goes to all categories of health-care professionals involved in TB prevention and control activities.

Introduction and expansion of new diagnostic tools or regimen for early detection and management of drug-resistant TB The NTCP is planning to introduce 4 GeneXpert machines in the country. The deployment of these machines shall be made in the strategic locations considering the regional access and high TB case notifications. With the introduction of Xpert machines, the programme is expected to enhance the case detection of TB and RR/MDR-TB cases in the coming years. The programme recently revised the PMDT guideline through the TA support from WHO. The NTCP had adopted the standard treatment regimen for MDR-TB as per WHO recommendations. The XDR-TB treatment regimen has also been included in this revised PMDT guideline.

Tuberculosis control in the South-East Asia Region

Annual Report 2016

Innovative approaches to find missing cases To find missing cases, symptomatic screening of the vulnerable populations are being conducted at various levels – such as in monastic institutions, mining sites, mega-hydro project sites and construction sites (to screen migrants and labourers). Contact tracing for those close contacts of NSP and MDR-TB cases are conducted to screen symptomatic and missing cases among the vulnerable groups of the population. The introduction of GeneXpert machines in four identified sites is aimed towards improving the diagnosis of more number of missing cases with a focus to high- and low-risk group populations.

Community work for improving access or promoting adherence The engagement of community groups, such as village health workers, MSTF members and community action group would be a good approach for TB control towards improving access and adherence to treatment. With the adoption End TB Strategy, their engagement is very crucial as they have direct link with TB or MDRTB patients in the communities. Going beyond the health sector in supporting patients will go a long way for the benefits of patients and their families and will help in controlling TB.

Advocacy work by NCTP/partners As a part of advocacy, sensitization and educational activities are being carried out in the monastic institutions including schools and colleges by all 20 districts across the country. Similar activities are planned to be conducted during this fiscal year to migrant/mine workers, monastic institutions and other vulnerable populations. The NTCP also airs TB messages through radio and TV programmes on a periodic basis. Every year, sensitization and educational programmes are being conducted during observation of world TB Day in all 20 districts focusing on reaching all population groups and the community at large.

Tuberculosis control in the South-East Asia Region

Annual Report 2016

Country profile

Democratic People’s Republic of Korea

Background information Population* - 25 026 772 Estimates of disease burden for 2014 Incidence of all forms of TB Incidence rate of all forms of TB (per 100 000 population per year) Incidence rate HIV+TB only (per 100 000 population per year) Prevalence of all forms of TB Prevalence rate of all forms of TB (per 100 000 population) TB death rate (of all forms of TB, excluding HIV per 100 000 population per year) % of MDR-TB cases among new TB cases % of MDR-TB cases among retreatment TB cases Number of MDR-TB cases among notified new TB cases Number of MDR-TB cases among notified retreatment TB cases 110 000 (100 000–120 000) 442 (412–473) 1.2 (0.99–1.5) 140 000 (38 000–300 000) 552 (150–1 210) 20 (7.9–37) 1.9 (0.8–3.9) 15 (8.8–24) 1 400 (610–3 000) 2 400 (1 400–3 800)

*Source: United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects: The 2015 revision, DVD Edition. New York, 2015.

Tuberculosis control in the South-East Asia Region

Annual Report 2016

Programme performance and trends* Programme performance in 2014 Number of bacteriologically confirmed new pulmonary TB cases Number of bacteriologically confirmed relapse pulmonary TB cases Notification rate of new and relapse bacteriologically confirmed cases (per 100 000 population for the year 2014) Number of clinically diagnosed new pulmonary TB cases Number of clinically diagnosed relapse pulmonary TB cases Number of extra-pulmonary new TB cases Number of extra-pulmonary relapse TB cases Notification rate of all new and relapse TB cases (per 100 000 population for the year 2014) Number of previously treated cases, excluding relapses 34 622 8 413 138 41 423 0 18 587 0 412 7 245

Note: Among 94 632 new cases: 5631 (6%) cases aged under 15 years; male:female ratio: 1.6

Case notifications by type of patients, 2014 Relapse 7.6% New extrapulmonary 16.9%

Pulmonary TB cases, clinically diagnosed 37.6%

Pulmonary TB cases, bacteriologically conﬁrmed 31.4%

Previously treated paƟents, excluding relapse cases 6.6%

* All the data in this section is sourced from www.who.int/tb/data accessed 28 December 2015

Tuberculosis control in the South-East Asia Region

Annual Report 2016

Trends in TB case notifications, all forms (1995 - 2014) 120000 100000 80000 60000 40000 20000 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Pulmonary TB cases, bacteriologically conﬁrmed New extrapulmonary Previously treated paƟents, excluding relapse cases Pulmonary TB cases, clinically diagnosed Relapse Total new and relapse

RR/MDR-TB cases notification – 2014 New Cases tested for RR/MDR-TB Laboratory confirmed RR/MDR-TB cases Patients started on MDR-TB treatment* 81 (<1%) Retreatment 364 (2%) Total 445 197 (44.3%) 212 (107.6%)

*Includes patients who were diagnosed in 2013 but were initiated on treatment in 2014.

Tuberculosis control in the South-East Asia Region

Annual Report 2016

(%) (92) (83)

Cohort 97 665 7 247 0

(86)

50 0

Treatment outcomes by type of cases, 2013 (2012 cohort for RR/MDR-TB cases) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

All new and relapse

Previously treated (excluding relapse) Died

HIV-posiƟve TB, All conﬁrmed all types RR-TB/MDR-TB

Not evaluated

Lost to follow-up

Treatment failed

Cured or treatment completed

Tuberculosis control in the South-East Asia Region

Annual Report 2016

2007

2009

2011

2013

Highlights of programme performance •• •• Consistent increase in case notification rates reaching 138/100 000 population in 2015 Consistently high treatment success rate of more than 90% among new and relapse cases and a treatment success rate of more than 80% among retreatment cases More than 4 times increase in number of RR/ MDR-TB cases being diagnosed and initiated on treatment since 2012 Achieved a treatment success rate of 86% in first cohort of 50 cases initiated on MDR-TB treatment

•• ••

Tuberculosis control in the South-East Asia Region

Annual Report 2016

1000

750

500

250

0 1990 1995 2000 2005 2010 2015

Tuberculosis control in the South-East Asia Region

Annual Report 2016

Trend in estimated TB mortality rates, 1990–2014 (Shaded areas represent uncertainty bands. The horizontal dashed line represents the target of a 50% reduction by 2015 compared with 1990) 150

100

0 1990 1995 2000 2005 2010 2015

Tuberculosis control in the South-East Asia Region

Annual Report 2016

1994

1998

2002

2006

2010 Incidence

NoƟﬁed (new and relapse) Incidence (HIV+TB only)

Programmatic challenges Major challenges in achieving universal access to TB prevention, care and control services •• •• •• •• •• Out-of-date facilities at TB facilities Limited diagnostic capacity at provincial and county level Limited drugs and health commodities for TB management Logistic management at all level should be improved immediately Technical capacity of health staff for TB management

Major challenges in expansion of MDR-TB services •• •• •• Limitation of diagnostic facilities for PMDT expansion Fund for second-line drugs supported entirely by donors and also limited Poor facility conditions in MDR-TB treatment sites

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Limited technical capacity for MDR-TB patient management at peripheral level Regular pharmacovigilance system not yet established in the country

National Strategic Plan 2015–2018 Based on the detailed country situation analysis and Joint Monitoring Mission results, NSP 2015–2018 was revised on October 2015 by Ministry of Public Health

Goal: •• To decrease the morbidity and mortality of TB through universal access to TB care and support

Objectives: (1) Scale up services for prevention, diagnosis and treatment of all forms of TB to achieve case notification rate of 444 per 100 000 population and to sustain 90 % success for notified new smear positive cases Achieve access to MDR TB diagnosis and treatment services (50% case detection and treatment with a 75% success rate) Engage all care providers, other health programmes, civil society, NGOs and key affected population in TB control Promote research and innovation in TB care programme performance

(2) (3) (4)

Laboratory expansion plan Indicator Culture and DST laboratories Functioning LPA Functioning Xpert MTB/RIF 1 NRL 2014 1 NRL 2015 1 NRL 1 RRL 1 NRL 1 NRL 1 RRL 2016 1 NRL 2 RRL 1 NRL 1 RRL 1 NRL 2 RRL

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Operational plan for 2016–2017 •• •• •• •• •• •• •• Complete the National TB Prevalence Survey in 2016 Ensure uninterrupted supply of quality-assured anti-TB drug Acquire accreditation for National TB Reference Laboratory Scale up the PMDT according to the expansion plan Initiate renovation of six provincial TB hospitals and one additional regional culture and DST laboratory Strengthen the diagnostic and patient management capacity for paediatric TB patients Review the current National Strategic Plan in line with the End TB Strategy and Implementation plan

Financing of NSP (Budget in millions of US$) 2015 NTP budget requirement Government Global Fund Gap 25.78 5.21 7.55 13.02 2016 28.83 5.35 10.61 12.87 2017 26.76 5.46 9.3 12 2018 30.98 5.59 1.32 24.07

Global Fund support: •• •• •• New Funding Model grant of US$ 28.4 million approved for TB programme covering 2015–2018 WHO supported the entire concept note submission and clarification process UNICEF is principal recipient while WHO is subrecipient

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Partnerships •• Activity Presumptive TB case detection and treatment support

Key civil society organizations collaborating with NTP: NGOs 1. Korean Federation of Red Cross 2. Korean federation for Protection of Disabled 3. Korean Family Planning and Maternal and Child Health association 1. Kim Il Sung Socialist Youth League 2. Trade Union of Democratic People’s Republic of Korea 3. Democratic People’s Republic of Korea Union of Agricultural Working People 4. Democratic People’s Republic of Korea Republic of women’s union

Support the advocacy and community engagement

Key achievements and success stories (1) Initiation of national TB prevalence survey after pilot survey After long preparation work for the national TB prevalence survey in Democratic People’s Republic of Korea from 2013, finally, a pilot survey was conducted at two clusters in Pyongyang city in June 2015. The Ministry of Public Health developed the protocol of national TB prevalence survey in consultation with WHO and partners. The Global Fund provided major financial support for the survey. Total of 70 000 individuals in 100 selected clusters across the country were expected to be surveyed under this NPS. Symptom screening, X-ray examination, sputum microscopy and culture were planned to be undertaken as per the protocol. The field operation will be finished middle of 2016, and survey results are expected to be announced after data analysis.

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Source: WCO, Democratic People’s Republic of Korea

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(2)

Completion of renovation of new regional TB culture and DST laboratory at South Hamgyong province The laboratory department in South Hamgyong Provincial TB Preventive Institute was fully renovated to function as a regional TB reference laboratory catering to northern and central parts of the country. Laboratory equipment and renovation materials were procured by UNICEF, Principle Recipient of the Global Fund grant, and the local government processed the renovation work of the laboratory. WHO provided the technical advice to establish the bio-safety level 3 laboratory for TB culture and Drug susceptibility testing and supported technical capacity-building of local laboratory staff. Renovation work including technical hands-on-training was completed by end of 2015.

(3)

High treatment success rate of MDR-TB patient cohort The first MDR-TB cohort consisting of 50 MDR-TB patients completed treatment in 2015. The results are encouraging, with 43 MDRTB patients declared cured after 24 months of full treatment. Unfortunately, 5 patients died during the treatment and 2 patients were recorded as lost follow-up. PMDT committees at peripheral levels are working actively, and based on their experience and recommendations, a national guideline for PMDT was revised by national experts, keeping it within international recommendations. An rGLC mission was conducted during 15–19 September 2015, and progress in current PMDT was evaluated by an international consultant, WHO country office and the Ministry of Public Health. Progress against recommendations made by the Joint Monitoring Mission 2014 was reviewed and the way forward discussed with the National TB Control Programme. The NTP is now inclined towards developing different models of ambulatory care for DR-TB patients with due consideration to the country context.

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Country profile

India

Background information Population* - 1 295 291 543 Estimates of disease burden for 2014 Incidence of all forms of TB Incidence rate of all forms of TB (per 100 000 population per year) Incidence rate HIV+TB only (per 100 000 population per year) Prevalence of all forms of TB Prevalence rate of all forms of TB (per 100 000 population) TB death rate (of all forms of TB, excluding HIV per 100 000 population per year) % of MDR-TB cases among new TB cases % of MDR-TB cases among retreatment TB cases Number of MDR-TB cases among notified new TB cases Number of MDR-TB cases among notified retreatment TB cases 2 200 000 (2 000 000–2 300 000) 167 (156–179) 8.3 (7.4–9.3) 2 500 000 (1 700 000–3 500 000) 195 (131–271) 17 (12–27) 2.2 (1.9–2.6) 15 (11–19) 24 000 (21 000–29 000) 47 000 (35 000–59 000)

*Source: United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects: The 2015 revision, DVD Edition. New York, 2015.

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Programme performance and trends* Programme performance in 2014 Number of bacteriologically confirmed new pulmonary TB cases Number of bacteriologically confirmed relapse pulmonary TB cases Notification rate of new and relapse bacteriologically confirmed cases (per 100 000 population for the year 2014) Number of clinically diagnosed new pulmonary TB cases Number of clinically diagnosed relapse pulmonary TB cases Number of extra-pulmonary new TB cases Number of extra-pulmonary relapse TB cases Notification rate of all new and relapse TB cases (per 100 000 population for the year 2014) Number of previously treated cases, excluding relapses Note: Among 1 609 547 new and relapse cases: 95 709 (6%) cases aged under 15 years; male:female ratio: 1.9 754 268 124 679 68 343 032 112 066 275 502 0 124 74 368

Case notifications by type of patients, 2014

New extrapulmonary 16.4% Pulmonary TB cases, clinically diagnosed 20.4% Pulmonary TB cases, bacteriologically conﬁrmed 44.8%

Relapse 14.1%

Previously treated paƟents, excluding relapse cases 4.4%

* All the data in this section is sourced from www.who.int/tb/data accessed 28 December 2015

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Trends in TB case notifications, all forms (1995 - 2014) 1800000 1600000 1400000 1200000 1000000 800000 600000 400000 200000 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Pulmonary TB cases, bacteriologically conﬁrmed New extrapulmonary Previously treated paƟents, excluding relapse cases Pulmonary TB cases, clinically diagnosed Relapse Total new and relapse

RR/MDR-TB cases notification – 2014 New Cases tested for RR/MDR-TB Laboratory confirmed RR/MDR-TB cases Patients started on MDR-TB treatment* 12 795 (2%) Retreatment 214 209 (69%) Total 255 897 25 748 (10.1%) 24 073 (93.5%)

*Includes patients who were not laboratory confirmed and those diagnosed before 2014.

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(%) (88) (66) (76) (46) (32)

Cohort 1 243 905 171 712 44 027 14 051 129

Treatment outcomes by type of cases, 2013 cohort (2012 cohort for RR/MRD-TB cases and XDR-TB cases) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% All new and relapse Previously treated HIV-posiƟve TB, All conﬁrmed RR(excluding all types TB/MDR-TB relapse) XDR-TB

Not evaluated

Lost to follow-up

Died

Treatment failed

Cured or treatment completed

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2007

2009

2011

2013

XDR-TB cases

Highlights of programme performance •• •• •• •• Case notification rate for new and relapse bacteriologically confirmed cases increased to 58/100 000 population Consistent treatment success rate of more than 85% among all new and relapse cases Number of laboratory confirmed RR/MDR-TB cases initiated on treatment increased to more than 24 000 Number of XDR-TB cases being diagnosed also consistently increasing with increasing accessibility to second-line DST

Key achievements in the last year India achieved complete geographical coverage for diagnostic and treatment services for multidrug-resistant TB (MDR-TB) in 2013, with a remarkable 66 000 persons with MDR-TB diagnosed and put on treatment in the last three years. The nation’s first national anti-TB drug resistance survey is being conducted by the National Tuberculosis Institute (NTI), Bangalore.

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500

400

300

200

100

0 1990 1995 2000 2005 2010 2015

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Trend in estimated TB mortality rates, 1990–2014 (Shaded areas represent uncertainty bands. The horizontal dashed line represents the target of a 50% reduction by 2015 compared with 1990)

0 1990 1995 2000 2005 2010 2015

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1994

1998

2002

2006

2010 Incidence

NoƟﬁed (new and relapse) Incidence (HIV+TB only)

Programmatic challenges Major challenges in achieving universal access to TB prevention, care and control services •• •• •• •• •• TB care in private sector Vulnerable and marginalized population Community participation/ownership/engagement and social support Implementation of airborne infection control Adequate resources

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Major challenges in expansion of MDR-TB services •• •• •• •• •• Laboratory capacity High cost of second-line anti-TB drugs Procurement of drugs: ‒‒ Limited WHO pre-qualified sources Lack of information about DR TB patients diagnosed and treated in the private sector Widespread irrational use of anti-TB drugs and inadequate implementation of Schedule H1 of Drugs and Cosmetics Act

National Strategic Plan The vision of the Government of India is for a ‘TB-free India’ with reduction of the burden of the disease until it is no longer a major public health problem. To achieve this vision, the programme has adopted the new objective of Universal Access for quality diagnosis and treatment for all TB patients in the community. This entails sustaining the achievements of the programme to date, and extending the reach and quality of services to all persons diagnosed with TB. With this vision as a long-term guide, the programme’s defined objectives for 2012–2017 are: (1) (2) (3) (4) (5) To ensure early and improved diagnosis of all TB patients including drugresistant and HIV-associated TB To provide access to high-quality treatment for all diagnosed cases of TB To scale up access to effective treatment for drug-resistant TB To decrease the morbidity and mortality of HIV-associated TB To extend RNTCP services to patients diagnosed and treated in the private sector.

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Laboratory expansion plan Technology CB-NAAT LPA Liquid culture Solid culture SL-DST 2014–2015 121 (421)* 46 40 55 16 2015–2016 200 0 20 25 6 2016–2017 200 0 20 20 10 2017–2018 200 0 20 20 8 Total 1021 46 100 120 40

*121 machines already available and 300 more procured in December 2015, taking the total to 421.

Operational plan for 2016–2017 •• •• •• •• •• •• •• •• •• •• •• Introduction of daily FDC for DS TB patients Lab expansion as per the plan DST guided treatment Expansion of PPM initiatives Expansion of TB surveillance through NIKSHAY and other ICT tools Expansion of paediatric TB services Transitioning towards daily regimen Strengthening laboratory capacity: 500 CB NAAT machines and 50 secondline DST laboratories Introduction of bedaquiline under RNTCP DST guided treatment AIC implementation

The Global Fund support •• •• Total allocation under NFM: US$ 233.2 million Allocation to CSO (Union and World Vision): US$ 30 million

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Partnerships Partners involved through various projects: •• •• •• •• •• •• •• The Union: with 8 subrecipients and 1200 NGOs under the GF support The World Vision: with 6 subrecipients and 40 NGOs under the GF support PATH- PPIA in Mumbai WHP- PPIA in Patna, Bihar CHAI Indian Medical Association- PPM CBCI-PPM

The partners support the programme through technical assistance on ACSM, PPM and M&E; conduct courses on OR, MDR-TB, TB epidemiology, IMDP; work with marginalized and vulnerable groups; intensified case finding; empowering TB patients; sputum collection and transport; sensitization of labs on ban on TB serology tests; annual maintenance contract for 5000 microscopes; maintain TB helpline; community meetings; training unqualified private health-care providers; and counselling MDR-TB patients. •• USAID, IKP Knowledge Park, and the Gates Foundation have funded a Grand Challenges for TB Control that seeks innovative projects through a crowdsourcing approach. The first call identified four innovations to improve treatment adherence through the use of information and communication technology. One of the innovations, 99DOTS, has already been taken up by the Government of India. The second call focuses on screening, detection and diagnosis of TB, which are specifically designed to work well in an Indian context. The Union Eli Lilly Collaborative Project – The Union in collaboration with the Lilly MDR-TB partnership is implementing a project to systematically involve private health-care providers in delivering effective and quality TB services in India. Interventions include engagement of rural health-care providers through m-Health (mobile app) to identify and track referrals of presumptive TB patients and ensure that they get tested and treated appropriately. The intervention is being piloted in the tribal district of Khunti (Jharkhand).

••

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••

The Union in partnership with Apollo Hospital Hyderabad has developed webbased software to facilitate notification and promote treatment adherence of patients treated in the private sector. The software links the private health facility with GoI’s TB notification portal Nikshay and simultaneously supports TB patients for treatment adherence through messages, interactive voice calls and counselling services. 141 TB patients were notified to the NTP through the software. Patients who missed doses or did not respond to IVRS were counselled telephonically by a trained counsellor.

Shri J.P. Nadda, Honourable Union Minister of Health and Family Welfare (MoHFW), launching the Call to Action

Key achievements and success stories Finding India’s missing TB cases using technology-enabled services for private providers and patients An innovative approach for engaging the private sector is being piloted in three diverse settings in – Patna in Bihar, Mumbai in Maharashtra and Mehsana in Gujarat State. These projects have been successfully eliciting TB notifications, enabling better surveillance and improved quality of care. Private provider notifications are attracted by offer of convenient, free TB drug vouchers for notified TB patients. When a TB case is diagnosed, the doctor or an assistant makes a toll-free call to a call centre, where operators collect

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TB notification information and generate e-vouchers for standard first-line TB medicines. Patients show the code received on their mobile phone through a short text message to an enrolled pharmacy, which validates and issues TB medicines without any charge. The call centre contacts the patient by phone and verifies the receipt of free TB medicines. The local TB officer signs off on payments every few days, and confirmation of each e-payment is sent to the pharmacy by a text message. Notification is the gateway to monitoring treatment adherence. The patient’s adherence is ensured via an escalating algorithm of reminders, alerts, self-reporting and if required, contacting family members and a visit by a programme staff. Until September 2015, the total TB case notification rate (annualized) doubled, relative to the same quarter one year earlier. Proportion of contribution to TB notification from the private sector was 46% in these three districts compared with 9% overall in the country; with stable TB notification from the public sector. This project also shows for the first time in India the feasibility of adherence monitoring and support to the large number of privately-treated TB patients. This model is showing that with innovation, India’s TB programme can tackle the problem of ‘missing TB cases’ in the private sector. Graph 8.1: TB Notification, Mehsana, Mumbai and Patna Annualized TB Notification rate Public (blue) and Private (red) sector 2013–15, Mehsana Annualized TB Case NoƟﬁcaiton rate (cases per 100 000 populaƟon per year) 400

300

200

100

0 1Q13 2Q13 3Q13 4Q13 1Q14 2Q14 3Q14 4Q14 1Q15 2Q15 3Q15 Quarter Year

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Annualized TB Notification rate Public (blue) and Private (red) sector 2013–15, Mumbai 400 Annualized TB Case NoƟﬁcaiton rate (cases per 100 000 populaƟon per year)

300

200

100

0 1Q13 2Q13 3Q13 4Q13 1Q14 2Q14 3Q14 4Q14 1Q15 2Q15 3Q15 Quarter Year

Annualized TB Notification rate Public (blue) and Private (red) sector 2013–15 , Patna Annualized TB Case NoƟﬁcaiton rate (cases per 100 000 populaƟon per year) 400

300

200

100

0 1Q13 2Q13 3Q13 4Q13 1Q14 2Q14 3Q14 4Q14 1Q15 2Q15 3Q15 Quarter Year

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Innovative intensified TB case finding and treatment at high-burden antiretroviral therapy (ART) centres An innovative project was started as a comprehensive strategy to reduce the burden of TB among people living with HIV AIDS (PLHA) for early diagnosis of TB and appropriate treatment. With technical support from the World Health Organization, RNTCP and NACP have joined hands for the implementation of this ‘Innovative, Intensified TB case finding and appropriate treatment at selected 30 high-burden ART centres in India’. This project was launch on 24 March 2015. The key features of the project are single window service delivery to HIV-positive individuals through provision of TB services at ART centres by intensified TB case finding (ICF) by deployment of GeneXpert. This rapid molecular diagnostic is used as a primary diagnostic tool in 30 identified ART centres. The diagnosed TB patients receive quality daily first-line anti-TB drugs in FDC. Treatment adherence support to patient includes use of information communication technology. In the last 6 months of implementation of the project, 21 523 PLHIVs were tested with Xpert MTB Rif for TB; 2620 (12%) TB, including 73 Rif resistant-TB cases, were diagnosed and placed on treatment.

Paediatric TB Project India started a project for better diagnosis of childhood TB in four urban sites with financial support from USAID and technical partnership with FIND. Under this project, upfront Xpert MTB/RIF testing in respiratory and extrapulmonary specimens, as recommended by WHO, was used. Xpert MTB/RIF testing was offered to all paediatric (0–14 years) presumptive TB cases (both pulmonary and extra-pulmonary) seeking care at public and private health facilities. Under this pilot project, 8370 paediatric presumptive TB and presumptive DR-TB cases have been tested so far. Overall, 9149 specimens were tested, of which 4445 (48.6%) were nonsputum specimens. Of the 8143 presumptive TB cases enrolled, 517 (6.3%) were bacteriologically confirmed. TB detection rates were twofold higher with Xpert MTB/ RIF compared with smear microscopy. Further, a total of 60 rifampicin-resistant TB cases were detected, of which 38 were detected among 512 presumptive TB cases while 22 were detected among 227 presumptive DR-TB cases tested under the project.** With the success demonstrated in this project, the programme is expanding the use of GeneXpert in diagnosing childhood TB in India. ** Raizada N, Sachdeva KS, Swaminathan S, Kulsange S, Khaparde SD, Nair SA, et al. (2015). Piloting Upfront Xpert MTB/RIF Testing on Various Specimens under Programmatic Conditions for Diagnosis of TB & DR-TB in Paediatric Population. PLoS ONE 10(10): e0140375. doi:10.1371/journal. Pone.0140375.

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Country profile

Indonesia

Background information Population* - 254 454 778 Estimates of disease burden for 2014 Incidence of all forms of TB Incidence rate of all forms of TB (per 100 000 population per year) Incidence rate HIV+TB only (per 100 000 population per year) Prevalence of all forms of TB Prevalence rate of all forms of TB (per 100 000 population) TB death rate (of all forms of TB, excluding HIV per 100 000 population per year) % of MDR-TB cases among new TB cases % of MDR-TB cases among retreatment TB cases Number of MDR-TB cases among notified retreatment TB cases 1 000 000 (700 000–1 400 000) 399 (274–546) 25 (16–36) 1 600 000 (1 300 000–2 000 000) 647 (513–797) 41 (26–59) 1.9 (1.4–2.5) 12 (8.1–17) 1 100 (770–1 600)

*Source: United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects: The 2015 revision, DVD Edition. New York, 2015.

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Programme performance and trends* Programme performance in 2014 Number of bacteriologically confirmed new pulmonary TB cases Number of bacteriologically confirmed relapse pulmonary TB cases Notification rate of new and relapse bacteriologically confirmed cases (per 100 000 population for the year 2014) Number of clinically diagnosed new pulmonary TB cases Number of clinically diagnosed relapse pulmonary TB cases Number of extra-pulmonary new TB cases Number of extra-pulmonary relapse TB cases Notification rate of all new and relapse TB cases (per 100 000 population for the year 2014) Number of previously treated cases, excluding relapses Note: Among 322 806 new and relapse cases: 23 170 (7%) cases aged under 15 years; male:female ratio: 1.4. 193 321 6 449 76 101 991 1 391 19 653 1 127 1 733

Case notifications by type of patients, 2014 New extrapulmonary 6.1% Relapse 2.4%

Pulmonary TB cases, clinically diagnosed 31.4%

Pulmonary TB cases, bacteriologically conﬁrmed 59.6%

Previously treated paƟents, excluding relapse cases 0.5%

* All the data in this section is sourced from www.who.int/tb/data accessed 28 December 2015

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Trends in TB case notifications, all forms (1995 - 2014) 350000 300000 250000 200000 150000 100000 50000 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Pulmonary TB cases, bacteriologically conﬁrmed New extrapulmonary Previously treated paƟents, excluding relapse cases Pulmonary TB cases, clinically diagnosed Relapse Total new and relapse

RR/MDR-TB cases notification – 2014 New Cases tested for RR/MDR-TB Laboratory confirmed RR/MDR-TB cases Patients started on MDR-TB treatment* 1 058 (<1%) Retreatment 8 445 (88%) Total 9 503 1 812 (19.1%) 1 284 (70.9%)

*Includes patients who were not laboratory confirmed and those diagnosed before 2014.

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(%) (88) (64) (49) (54) (64)

Cohort 325 582 1 521 2 438 432 11

Treatment outcomes by type of cases, 2013 cohort (2012 cohort for RR/MRD-TB cases and XDR-TB cases) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% All new and relapse Previously treated (excluding relapse) HIV-posiƟve TB, All conﬁrmed all types RR-TB/MDR-TB XDR-TB

Not evaluated

Lost to follow-up

Died

Treatment failed

Cured or treatment completed

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2007

2009

2011

2013

XDR-TB cases

Highlights of programme performance •• •• •• High treatment outcome for TB (>88% TSR in 2013) Increasing number of RR/MDR-TB cases being diagnosed and initiated on treatment reaching 1284 in 2014 Increasing number of XDR-TB cases being diagnosed and initiated on treatment

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1000

500

0 1990 1995 2000 2005 2010 2015

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124

Trend in estimated TB mortality rates, 1990–2014 (Shaded areas represent uncertainty bands. The horizontal dashed line represents the target of a 50% reduction by 2015 compared with 1990)

0 1990 1995 2000 2005 2010 2015

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600 400 200 0 1990 1994 1998 2002 2006 2010 Incidence

NoƟﬁed (new and relapse) Incidence (HIV+TB only)

Programmatic challenges Major challenges in achieving universal access to TB prevention, care and control services •• Number of TB cases treated by non-NTP providers still remain unknown; as a consequence, it is difficult to accurately estimate, review and monitor progress and properly plan effective TB control services ‒‒ TB mandatory notification yet to become a legal requirement and to be effectively implemented fully ‒‒ TB inventory study still in planning phase. •• Scientifically valid and evidence-based information about TB drug resistance burden is still lacking ‒‒ First nation drug resistance survey is under preparation. •• Access to diagnostic tools for DR TB, PLHIV, childhood, extrapulmonary and nonbacteriologically confirmed cases still limited.

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••

Insufficient human resources to support introduction and expansion of new strategies and much larger scale of disease burden: TB intensified case finding, LTBI management, TB prevention, etc. Financial gaps are wide to deal with more than double the disease burden and adopt new strategy and approaches and targets. An estimated 66% of the budget needed for TB control remains unfunded.

••

Major challenges in expansion of MDR-TB services •• •• •• •• •• Slow PMDT expansion and decentralization of services Focus on screening of re-treatment cases. The number of new pulmonary TB cases tested for resistance is very low Delays in GeneXpert expansion Sputum transport remains a bottleneck High loss to follow-up: ‒‒ Initial loss to follow-up is about 25% of diagnosed cases ‒‒ During treatment about 28% of drug-resistant cases are lost to followup, mainly in the first 3 months •• Limited local level support, including socioeconomic support required for treatment adherence in DR-TB cases

National Strategic Plan Goal: ‘End the tuberculosis epidemic in Indonesia’ Key objectives: •• •• •• •• Increase the case notification rate for all forms of TB from 131/100 000 in 2013 to 236/100 000 by 2019 Ensure treatment success in hospitals and the private sector, as well as the public sector, reaches 90% by 2019 Increase prevention, diagnosis and reporting of TB in children Increase coordination between TB and HIV AIDS programmes, crossprogrammes and cross-sectors, in all levels to reduce the TB and HIV burdens in the community

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•• ••

Ensure universal access to diagnosis and treatment for drug-resistant TB by 2018 Ensure political commitment at national, provincial and local levels for allocation of sufficient resources and enforcement of existing and new regulations that support TB control Expand and strengthen the infrastructure, human resources and management processes to implement the national strategy successfully Expand and strengthen the data collection and surveillance system to capture strategic information on TB cases diagnosed and treated in all sectors, and critically analyse that information for programme improvement.

•• ••

Laboratory expansion plan Numbers Microscopy laboratories NRLs GeneXpert Sites Districts with GeneXpert C/DST laboratory Culture laboratory 2014 6 143 3 41 37 11 0 2015 6 600 3 83 75 13 10 2016 7 000 3 183 142 15 20 2017 7 400 3 383 310 17 41

Operational plan 2016–2017 •• •• •• •• Scale up PPM to ensure universal access to quality TB care: accreditation, certification, quality assurance TB mandatory notification implementation Integration of TB into national health insurance system Accelerate PMDT expansion  comprehensive package including laboratory network strengthening, Xpert, E-TB manager, patient support

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••

TB-HIV comprehensive package  including expansion of IPT, CPT, expert, risk factor screening and opt out for HIV test and treat, strengthening TBHIV surveillance, and data validation system. Child TB and other risk groups: comprehensive package intensified contact screening, TB preventive therapy ‒‒ Step up community mobilization to increase demand for quality services ‒‒ Population-based surveys: NDRS and inventory study

••

Financing of NSP The total budget for the year 2015–2019 is US$ 925 556 871. Compared with the previous budget of the National Strategy for the period of 2010–2014–2015, there is an increase in the required budget for improving diagnosis (labs and supplies), contact screening, and second-line drugs for DR-TB. The budget estimation of the TB control national strategy 2015–2019 has been projected, by incorporating the national social health insurance (JKN) since 2014. The budget used the assumption that the national health insurance scheme will cover most of TB health-care treatment services, and gradually increases coverage from 50% of the population in 2014 to 100% of the population in 2019.

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Cost estimation for the national strategy, 2015–2019 (US$) 2015 23 934 085 29 727 971 34 035 814 36 937 958 45 970 540 2016 2017 2018 2019 TOTAL 5yrs 170 606 369

Objective 1. Increase the case notification rate for all forms of TB from 130/100,000 in 2013 to 236/100,000 by 2019. 47 034 293 56 515 522 65 839 348 81 108 873 101 605 898

Objective 2. Ensure treatment success in hospitals and the private sector, as well as the public sector, reaches 90% by 2019. 1 850 942 4 125 306 5 970 325 7 696 707 9 163 563 1 720 756 2 219 259 2 772 938 3 235 885 10 856 054

352 103 933

Objective 3: Increase prevention, diagnosis and reporting of TB in children.

11 799 779 37 811 955

Objective 4: Increase coordination between TB and HIV AIDS programmes, cross-programmes and cross-sectors, in all levels to reduce the TB and HIV burdens in the community. 15 636 429 5 056 330 6 203 001 5 212 787 23 352 649 30 555 678 40 167 316 5 832 724

Objective 5: Ensure universal access to diagnosis and treatment for drug-resistant TB by 2019.

49 647 445 6 473 310

159 359 517 28 778 152

Objective 6: Ensure political commitment at national, provincial and local levels for allocation of sufficient resources and enforcement of existing and new regulations that support TB control. 30 110 267 38 139 214

Tuberculosis control in the South-East Asia Region

Objective 7. Expand and strengthen the infrastructure, human resources and management processes to implement the NSP successfully 1 303 823

39 356 983

34 847 439

36 636 747

179 090 650

Objective 8: Expand and strengthen the data collection and surveillance system to capture strategic information on TB cases diagnosed and treated in all sectors, and critically analyse that information for programme improvement. 127 747 651 132 941 127 614 710

1 441 368

530 551

879 441

2 377 353

6 532 536

Annual Report 2016

Grand Total

161 629 437 1 373 115 160 256 323

184 916 576 3 513 272 181 403 304

210 830 812 4 453 049 206 377 763

254 425 879 4 521 108 249 904 771

939 550 355 13 993 485 925 556 871

129

Crosscutting programme with HIV

Grand Total TB

130

The central government budget is mainly allocated for programmatic purposes, including procurement of TB drugs, reagents and development and updating of norms, procedures and standard for health services. Funding sources are divided as follows: (1) Government source of funds: ‒‒ Central government budget (MoH and other central government ministries) ‒‒ Local (provincial/district municipality) government budget (APBD) (2) (3) (4) Social health insurance (jaminan Kesehatan Nasional) Private sector funding sources within the framework of Corporate Social Responsibility (CSR) Donor agencies (GlobalFund, WHO, DFAT, USAID, etc.)

A substantial funding gap remains even though funding can be mobilized from various sources noted above. Data suggest that the funding gap will increase significantly during the next 5 years. The existence of the national health insurance system will help close the gap, but the gap will remain significant if there is no increased commitment of government funding at all levels, particularly among districts with high fiscal capacity.

Analysis of funding gap for the national strategy 2015–2019 (US$) Source of Funds Total Budget Government Social Health Insurance Private Global Fund Other Donor Funding Gaps 2015 129 051 475 53 724 318 13 724 239 10 769 038 25 128 891 10 550 000 15 154 989 2016 163 070 805 61 669 746 15 553 449 12 130 059 29 015 838 10 550 000 34 151 713 2017 185 447 126 68 953 711 17 834 534 13 826 873 32 349 446 10 550 000 41 932 562 2018 211 710 253 72 854 021 18 466 711 14 684 139 0 0 105 705 382 2019 256 803 233 82 080 190 19 098 888 15 594 555 0 0 140 029 600

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The Global Fund support Current budget: SSF II PR AISYIAH •• •• PR MOH •• •• •• Grant No: IND-T-MOH Implementation period: 1/1/2014 – 30/6/2016 Grant Funds: US$ 56 544 111 Implementation period: 1/1/2014 – 30/6/2016 Grant Funds: US$ 10 457 223

Support under the NFM: •• Grant negotiation process for NFM is ongoing. The GAC II (Grant Approval Committee) had discussed final approval for a country Joint TB-HIV Concept Note on 25 November 2015. Implementation period: 1/1/2016 – 31/12/2017 Grant Funds: ‒‒ US$ 67 million (allocation) ‒‒ US$ 24 million (above allocation)

•• ••

Partnerships •• List of civil society organizations collaborating with NTP: ‒‒ PPTI Pusat (Central Board of Indonesian Tuberculosis Association) ‒‒ Majelis Kesehatan PP Aisyiyah (Health Council – Central Board of Aisyiah) ‒‒ Lembaga Kesehatan NU (Nahdatul Ulama Health Council) ‒‒ Pelkesi (All Indonesian Christian Health Services) ‒‒ Perdhaki (All Indonesian Catholic Health Association) ‒‒ Pamali TB ( TB Awareness Movement) ‒‒ Dompet Dhuafa Health Foundation

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‒‒ Kwarnas Pramuka (National Committee of Scout Movement) ‒‒ PKPU Foundation ‒‒ Kusuma Buana Foundation ‒‒ JAPETI ( TB Patient Network) ‒‒ Dewan Mesjid Indonesia ( Mosque Board Association) ‒‒ World Vision International, Indonesia ‒‒ Tim Penggerak Pusat PKK ( National Board of Women Welfare Movement) Activity/ role of CSO Advocacy Patient support Health promotion TB prevention All CSOs PPTI, Aisyiah, LKNU, Pelksi, Perdhaki, Pamali, Dompet Dhuafa, Pramuka All CSOs PPTI, Aisyiah, JAPETI, PAMALI CSO involved

Key achievements and success stories (1) New drugs introduction: Following the WHO interim guidelines for the introduction of bedaquiline, NTP is piloting a new drug treatment for 100 patients at three sites (Persahabatan, Soetomo and Hasan Sadikin Hospitals). Preparation process for the pilot started in June 2014 and finished by August 2015 with the close involvement of the national drugs and food agency (BPOM), donors (GF, USAID) and technical partners (WHO, KNCV). Included in the preparation process were manual and protocol development, active pharmacovigilance system development, monitoring evaluation system, dissemination workshops and trainings. By end of November 2015, a total of seven patients were put on treatment using bedaquiline.

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(2)

Adaptation of End TB Strategy into National Strategic Plan 2015–2019 The Government of Indonesia has recently developed the National Strategic Plan to control TB (NSP TB) for 2015–2019. The NSP uses the revised TB burden estimates as per final results of National TB Prevalence Survey 2013–2014.

As a first step to implement the End TB Strategy, the NSP TB has been created to respond to a rapidly changing landscape, align with new global and regional strategies, address new evidence that brings to light some gaps in TB control, and take advantage of new technologies that can improve programme performance. The national strategic plan 2015–2019 articulates the ambitious agenda set out by the National Tuberculosis Programme and all of its partners (other government bodies, community and civil society, professional society and health providers, media) to make significant progress towards the long-term goal of creating a TBfree Indonesia. The objectives and activities described in the NSP were developed by a wide range of stakeholders in Indonesia through an inclusive process. The NSP 2015–2019 has been proven as an important document for country programme resource mobilization. The approved Joint TB-HIV concept note for GF NFM proposal of Indonesia was written based on the NSP 2015–2019.

Patient on DR-TB treatment

Photo courtesy: NTP, Indonesia

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Country profile

Maldives

Background information Population* - 357 415 Estimates of disease burden for 2014 Incidence of all forms of TB Incidence rate of all forms of TB (per 100 000 population per year) Incidence rate HIV+TB only (per 100 000 population per year) Prevalence of all forms of TB Prevalence rate of all forms of TB (per 100 000 population) TB death rate (of all forms of TB, excluding HIV per 100 000 population per year) % of MDR-TB cases among new TB cases % of MDR-TB cases among retreatment TB cases Number of MDR-TB cases among notified new TB cases Number of MDR-TB cases among notified retreatment TB cases 150 (130–170) 41 (36–47) 0.09 (0.07–0.11) 200 (91–350) 56 (25–98) 2.3 (1.9–2.8) 2.2 (1.9–2.6) 16 (14–18) 2 (2–2) 0 (0–0)

*Source: United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects: The 2015 revision, DVD Edition. New York, 2015.

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Programme performance and trends* Programme performance in 2014 Number of bacteriologically confirmed new pulmonary TB cases Number of bacteriologically confirmed relapse pulmonary TB cases Notification rate of new and relapse bacteriologically confirmed cases (per 100 000 population for the year 2014) Number of clinically diagnosed new pulmonary TB cases Number of clinically diagnosed relapse pulmonary TB cases Number of extra-pulmonary new TB cases Number of extra-pulmonary relapse TB cases Notification rate of all new and relapse TB cases (per 100 000 population for the year 2014) Number of previously treated cases, excluding relapses 90 0 25 0 0 41 0 37 0

Note: Among 131 new and relapse cases: 14 (11%) cases aged under 15 years; male:female ratio: 1.2.

Case notifications by type of patients, 2014

New extrapulmonary 31.3%

Relapse 0.0%

Pulmonary TB cases, bacteriologically conﬁrmed 68.7%

* All the data in this section is sourced from www.who.int/tb/data accessed 28 December 2015

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Trends in TB case notifications, all forms (1995 - 2014) 250

200

150

100

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Pulmonary TB cases, bacteriologically conﬁrmed New extrapulmonary Previously treated paƟents, excluding relapse cases

Pulmonary TB cases, clinically diagnosed Relapse Total new and relapse

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RR/MDR-TB cases notification – 2014 New Cases tested for RR/MDR-TB Laboratory confirmed RR/MDR-TB cases Patients started on MDR-TB treatment *Includes patients from previous year. 3 (3%) 0 0 Retreatment 1 0 0 Total 5 0 (0%) 0 (0%)

TB/HIV collaboration Number TB patients with known HIV status HIV-positive TB patients HIV-positive TB patients on co-trimoxazole preventive therapy (CPT) HIV-positive TB patients on antiretroviral therapy (ART) HIV-positive people screened for TB HIV-positive people provided with IPT Treatment success rate and cohort size New and relapse cases registered in 2013 Previously treated cases, excluding relapse, registered in 2013 HIV-positive TB cases, all types, registered in 2013 RR-/MDR-TB cases started on second-line treatment in 2012 XDR-TB cases started on second-line treatment in 2012 (50) (100) 131 0 0 0 3 3 (%) (84) (75) Cohort 113 4 0 2 2 (%) (99) (0)

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Treatment outcomes by type of cases, 2013 cohort (2012 cohort for RR/MRD-TB cases and XDR-TB case) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% All new and relapse Previously treated (excluding relapse) HIV-posiƟve TB, All conﬁrmed all types RR-TB/MDR-TB XDR-TB

Not evaluated

Lost to follow-up

Died

Treatment failed

Cured or treatment completed

2007

2009

2011

2013

XDR-TB cases

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Highlights of programme performance •• •• •• •• Case notification rate of new and relapse cases has increased by ~150% in last two years reaching 25/100 000 population in 2014 Treatment success rate of all new and relapse cases close to 85% About 99% of TB cases with known HIV status The 2 XDR-TB cases initiated on treatment in 2012 successfully treated

400

300

200

100

0 1990 1995 2000 2005 2010 2015

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Trend in estimated TB mortality rates, 1990–2014 (Shaded areas represent uncertainty bands. The horizontal dashed line represents the target of a 50% reduction by 2015 compared with 1990) 50

0 1990 1995 2000 2005 2010 2015

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NoƟﬁed (new and relapse) Incidence (HIV+TB only)

Programmatic challenges Major challenges in achieving universal access to TB prevention, care and control services •• •• •• Lack of optimum human and financial capacity to implement, manage and coordinate all TB-related activities in the country No quality control has been carried out for smear microscopy In-country capacity for DST is not available. Further, a system of sputum transport with external TB laboratory to perform DST for diagnosis as well as for follow-up for X/MDR patients has not been fully established Large number of expatriate population from high-endemic countries

••

Major challenges in expansion of MDR-TB service •• •• Weak central level capacity to manage, monitor and supervise the programme Diagnosis of MDR and XDR-TB takes a long time

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•• •• ••

There is no specific MDR TB treatment facility Lack of trained staff for management of MDR TB The social stigma attached to the disease still lingers

National Strategic Plan Goal: Decrease the prevalence of TB by 25% by 2019 Objective 1: Ensure availability of quality-assured TB services, in line with current international standards and provided by qualified personnel, at 100% of all MOH facilities by 2016 Objective 2: Detect 80% of incident cases (based on a recalculation of incident cases to be performed in 2014) by 2016, and 90% by 2018; successfully treat 85% of detected cases by 2016 and 90% by 2018 Objective 3: Provide diagnostic services for MDR-TB for 50% of MDR-TB-suspects by 2016, and 100% of suspects by 2018; successfully treat 70% of detected MDR-TB cases by 2018 Objective 4: Provide effective ACSM activities to ensure that 50% of the population has adequate knowledge about TB and a positive attitude towards NTP services by 2016, and 100% of the population by 2018

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Laboratory expansion plan 2016 Microscopy centres Gene Xpert* 1 2 DR TB cases to be detected and treated 2017 1 2 DR TB cases to be detected and treated 2018 1 2 DR TB cases to be detected and treated

* All TB patients (Sputum negative and sputum pulmonary, extrapulmonary and children).

Operational plan for 2016–2017 •• •• •• Implementation of the revised and finalized National Strategic Plan for TB control in Maldives Finalization and implementation of the national guidelines for management of TB, programmatic management of DRTB and childhood TB Establishment of Gene Xpert facility at IGMH in 2016

Financing of NSP In US $ Domestic funding GF Other Sources Funding Gap 2015 400 977 375 898 – – 2016 462 577 345 326 – – 2017 500 650 383 986 – – 2018 536 200 382 586 – – 2019 577 997 383 764 – – 2020 581 863 212 708 – –

GF support: •• •• No GF support for TB control programme in the previous rounds Planning to apply for GF support in 2016

Partnerships •• Journey, SWAD (Society for women against drugs) and SHE (Society for Health Education) are CSOs collaborating with NTP.

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•• •• ••

Journey and SWAD collaborate with NTP in spreading awareness and symptomatic screening among drug users in the society. Their assistance is of valuable importance in tracing drug-using TB patients who default/stop or lose follow-up for TB treatment. Society for health education (SHE) collaborates with NTP to raise awareness among the expatriate population regarding TB. Their outreach peer educators (foreigners working in Maldives) are being trained for TB; and during their outreach programmes, they are given information about TB as well.

Key achievements and success stories Maldives achieved the targets of TB control by 1996. WHO listed Maldives among the five countries to achieved global targets; the achievement, announced at the 44th World Health Assembly, was for reaching the targets for TB control well ahead of 2005. Maldives was the first country in the SAARC region to reach the global target and receive the award from Stop TB Partner’s forum in 2004. The country continues to show excellent case detection and treatment success rates due to the quality of DOTS services provided at all health facilities in the country. DOTS are now extended to those who are in closed setting as well. These include prisons and homes for people with special needs.

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Health-care workers at central, atoll and island level home visit patients who are too weak to attend the DOTS clinic for their daily DOTS treatment.

Outdoor mass screening being conducted for expatriates.

Information on TB/HIV and NCD are being given to expatriates. Information on TB translated into regional languages and leaflets were given through a migrant fair that was held in 2013. Photo credits: National TB control programme

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Country profile

Myanmar

Background information Population* - 51 400 000 Estimates of disease burden for 2014 Incidence of all forms of TB Incidence rate of all forms of TB (per 100 000 population per year) Incidence rate HIV+TB only (per 100 000 population per year) Prevalence of all forms of TB Prevalence rate of all forms of TB (per 100 000 population) TB death rate (of all forms of TB, excluding HIV per 100 000 population per year) % of MDR-TB cases among new TB cases % of MDR-TB cases among retreatment TB cases Number of MDR-TB cases among notified new TB cases Number of MDR-TB cases among notified retreatment TB cases 190 000 (170 000–210 000) 369 (334–406) 37 (28–44) 235 000 (180 000–300 000) 457 (352–575) 53 (38–70) 5 (3.1–6.8) 27 (15–39) 5 600 (3 500–7 700) 3 400 (1 900–4 900)

*Source: Based on available National Census figure. These differ from those published by the United Nations, Department of Economic and Social Affairs, Population Division (2015). World Population Prospects: The 2015 Revision, DVD Edition.

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Programme performance and trends* Programme performance in 2014 Number of bacteriologically confirmed new pulmonary TB cases Number of bacteriologically confirmed relapse pulmonary TB cases Notification rate of new and relapse bacteriologically confirmed cases (per 100 000 population for the year 2014)** Number of clinically diagnosed new pulmonary TB cases Number of clinically diagnosed relapse pulmonary TB cases Number of extra-pulmonary new TB cases Number of extra-pulmonary relapse TB cases Notification rate of all new and relapse TB cases (per 100 000 population for the year 2014)** Number of previously treated cases, excluding relapses 42 608 5 276 93 70 305 3 650 16 108 405 269 3 605

Note: Among 138 352 new and relapse cases: 36 301 (26%) cases aged under 15 years; male:female ratio: 1.6. **The rates in previous regional reports used UN published population figures, which were higher. This year the country census figures are being used and therefore the rates may not be comparable.

Case notifications by type of patients, 2014 New extrapulmonary 11.3%

Relapse 6.6% Pulmonary TB cases, clinically diagnosed 49.5% Pulmonary TB cases, bacteriologically conﬁrmed 30.0%

Previously treated paƟents, excluding relapse cases 2.5%

* All the data in this section is sourced from www.who.int/tb/data accessed 28 December 2015

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Trends in TB case notifications, all forms (1995–2014) 160000 140000 120000 100000 80000 60000 40000 20000 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Pulmonary TB cases, bacteriologically conﬁrmed New extrapulmonary Previously treated paƟents, excluding relapse cases Pulmonary TB cases, clinically diagnosed Relapse Total new and relapse

RR/MDR-TB cases notification – 2104 New Cases tested for RR/MDR-TB* Laboratory confirmed RR/MDR-TB cases Patients started on MDR-TB treatment* 10 295 (24%) Retreatment 15 166 (117%) Total 26 240 3 495 (13.3%) 1 537 (44%)

*Testing of retreatment includes patients from previous year. Patients started on treatment also includes patients who were diagnosed before 2014.

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Treatment success rate and cohort size New cases registered in 2013 Previously treated cases registered in 2013 HIV-positive TB cases, all types, registered in 2013 RR-/MDR-TB cases started on second-line treatment in 2012 XDR-TB cases started on second-line treatment in 2012

(%) (87) (71) (79)

Cohort 135 614 7 147 443

Treatment outcomes by type of cases, 2013 cohort (2012 cohort for RR/MRD-TB cases)*

90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

All new cases

Previously HIV-posiƟve TB, All conﬁrmed treated including all types RR-TB/MDR-TB relapse Died Treatment failed Cured or treatment completed

Not evaluated

Lost to follow-up

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2007

2009

2011

2013

Highlights of programme performance •• •• •• •• A steady case notification of at least 80/ 100 000 population per year for new and relapse bacteriologically confirmed cases for past several years Nearly a fourfold increase in number of RR/MDR-TB cases being notified in the past two years Treatment success rate of more than 85% for drug-susceptible TB and 79% (up from 71% in last year) for RR/MDR-TB Treatment coverage sustained at about 70%

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1500

1000

500

0 1990 1995 2000 2005 2010 2015

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Trend in estimated TB mortality rates, 1990–2014 (Shaded areas represent uncertainty bands. The horizontal dashed line represents the target of a 50% reduction by 2015 compared with 1990)

200

150

100

0 1990 1995 2000 2005 2010 2015

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1994

1998

2002

2006

2010 Incidence

NoƟﬁed (new and relapse) Incidence (HIV+TB only)

Programmatic challenges Major challenges in achieving universal access to TB prevention, care and control services •• •• •• •• •• Human resources, capacity-building and staff motivation Funding sustainability beyond 2016 Missing cases in Myanmar especially in urban poor, rural and hard-to-reach areas Scale-up of TB/HIV and MDR-TB services Laboratory strengthening

Major challenges in expansion of MDR-TB services •• •• Human resources (vacant posts in TBH and NTP at all levels and need capacity-building ) Infection control measures at health facilities including the setup of isolation wards

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•• •• ••

Low Gene-Xpert coverage Geographical expansion of MDR-TB project sites to all township levels Ensure/sustain MDR-TB patient support, including nutritional support for achieving treatment adherence and outcome

National Strategic Plan 2016–2020 Strategic directions: (1) (2) (3) Accelerate the decline in the prevalence of drug-sensitive and drugresistant TB Fully integrate TB prevention and care in universal health coverage Enhance the prevention and early detection of TB through ACF and PPM, particularly for high-risk populations

Impact indicators: (1) Reduce the prevalence of all forms of TB by 40% by 2020, compared with the 2010 baseline (3% per year during 2010–2015, 5% per year during 2016–2020) ‒‒ Reduce the prevalence of MDR among new TB cases by 20% by 2020, compared with 2015 (4% per year) (2) (3) Reduce the mortality due to TB by 35% by 2020, compared with the 2015 baseline (7% per year) Reduce the proportion of affected households who are impoverished due to TB by 2020 (target to be determined after baseline study)

Laboratory expansion plan Indicator Microscopy centres Gene Xpert sites BSL-3 Laboratory 2015 458 49 3 2016 508 69 4 2017 558 79 5 2018 608 90 6

BSL-3 Lab includes facilities for culture and DST (both 1st and 2nd line) and line probe assay.

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Operational plan for 2016–2017: main activities Activity/ Area of work PMDT townships TB/HIV townships Percentage of HIV testing among registered TB cases TB/HIV received CPT during TB treatment Percentage of TB/HIV received ART during TB treatment Contribution to national notified TB cases by PPM GP Contribution to national notified TB cases by ACF 2016 148 319 70% 80% 70% 20.7% 15% 2017 188 330 75% 84% 75% 21.4% 17%

Financing of NSP Funding Source Government Global Fund 3DF 3MDG JICA USAID TBREACH WHO UNITAID GDF Others (DFAT, DFID, Chevron) TOTAL Funding gap 20 103 535 10 180 113 20 422 108 10 185 501 19 622 492 16 095 700 19 519 579 21 099 755 18 489 579 30 286 255 150 000 932 648 160 113 2 000 000 191 238 2 000 000 2 422 588 150 000 197 913 845 000 150 000 197 913 935 000 1 030 000 635 052 60 013 043 0 150 000 150 000 150 000 613 726 2011 1 250 000 13 010 774 2 600 000 2012 1 400 000 13 010 774 204 595 2 800 000 2 800 000 2 800 000 13 164 023 2013 1 400 000 14 139 579 2014 1 400 000 14 139 579 2015 1 400 000 14 139 579 2016* 4 715 294 40 869 948

*Funding for 2016 is based on operational plans received from donors and implementing partners. Funding gap was not computed.

GF NFM started from July 2013 •• •• •• •• •• US$ 88.6 million TB Grant for 2013–2016 under PR 1 (UNOPS) US$ 17.2 million TB Grant for 2013–2016 under PR 2 (SC) Will be extension of NFM for next grant Amount depends on costing of proposed activities in NSP (2016–2020) Costing plan to be conducted in December 2015

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Partnerships Name of CSO/CBO Pyi Gyi Khin (PGK) Sub Health Group (World Vision) Myanmar Mother and Child Welfare Association (MMCWA) Myanmar Women’s Affair Federation (MWAF) Myanmar Red Cross Society (MRCS) Myanmar Health Assistants Association (MHAA) MDR-TB patient support Health talk, Treatment adherence counselling, Referral of presumptive TB, DOT, Patient support, Income generation for their own funding Health talk, Treatment adherence counselling, Referral of presumptive TB, DOT, Patient support, Income generation for their own funding Health talk, Treatment adherence counselling, Referral of presumptive TB, DOT, Patient support, Income generation for their own funding Health talk, Treatment adherence counselling, Referral of presumptive TB, DOT, Patient support, Income generation for their own funding Health talk, Treatment adherence counselling, Referral of presumptive TB, DOT, Patient support, Income generation for their own funding Activities

Key achievements and success stories (1) (2) (3) (4) All townships (330) are covered by DOTS 108 PMDT townships and 236 TB/HIV townships Speedy roll-out of Gene Xpert (49 machines as of 2015) for rapid DST Prevalence and mortality are decreasing, and on track to achieve the MDG targets

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Country profile

Nepal

Background information Population* - 28 174 724 Estimates of disease burden for 2014 Incidence of all forms of TB Incidence rate of all forms of TB (per 100 000 population per year) Incidence rate HIV+TB only (per 100 000 population per year) Prevalence of all forms of TB Prevalence rate of all forms of TB (per 100 000 population) TB death rate (of all forms of TB, excluding HIV per 100 000 population per year) % of MDR-TB cases among new TB cases % of MDR-TB cases among retreatment TB cases Number of MDR-TB cases among notified new TB cases Number of MDR-TB cases among notified retreatment TB cases 44 000 (39 000–50 000) 158 (139 –178) 5.4 (4.2–6.7) 60 000 (29 000–100 000) 215 (102–369) 17 (12–24) 2.2 (1.3–3.8) 15 (10–23) 540 (320–930) 620 (410–920)

*Source: United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects: The 2015 revision, DVD Edition. New York, 2015.

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Programme performance and trends* Programme performance in 2014 Number of bacteriologically confirmed new pulmonary TB cases Number of bacteriologically confirmed relapse pulmonary TB cases Notification rate of new and relapse bacteriologically confirmed cases (per 100 000 population for the year 2014) Number of clinically diagnosed new pulmonary TB cases Number of clinically diagnosed relapse pulmonary TB cases Number of extra-pulmonary new TB cases Number of extra-pulmonary relapse TB cases Notification rate of all new and relapse TB cases (per 100 000 population for the year 2014) Number of previously treated cases, excluding relapses 15 947 2 302 57 8 445 0 8 583 0 125 1 748

Note: Among 35 277 new cases: 345 (<1%) cases aged under 15 years; male:female ratio: 1.8.

Case notifications by type of patients, 2014 Relapse 6.2%

New extrapulmonary 23.2% Pulmonary TB cases, clinically diagnosed 22.8% Pulmonary TB cases, bacteriologically conﬁrmed 43.1%

Previously treated paƟents, excluding relapse cases 4.7%

* All the data in this section is sourced from www.who.int/tb/data accessed 28 December 2015

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Trends in TB case notifications, all forms (1995 - 2014) 40000 35000 30000 25000 20000 15000 10000 5000 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Pulmonary TB cases, bacteriologically conﬁrmed New extrapulmonary Previously treated paƟents, excluding relapse cases Pulmonary TB cases, clinically diagnosed Relapse Total new and relapse

RR/MDR-TB cases notification – 2104 New Cases tested for RR/MDR-TB Laboratory confirmed RR/MDR-TB cases Patients started on MDR-TB treatment* 2 292 (14%) Retreatment 1078 (26%) Total 3 396 406 (11.9%) 349 (86%)

*Includes patients who were not laboratory confirmed and those diagnosed before 2014.

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(%) (91) (74)

Cohort 33 877 456

(76)

238

Treatment outcomes by type of cases, 2013 cohort (2012 cohort for RR/MRD-TB cases) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

All new and relapse

Previously treated (excluding relapse) Died

HIV-posiƟve TB, All conﬁrmed all types RR-TB/MDR-TB

Not evaluated

Lost to follow-up

Treatment failed

Cured or treatment completed

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2007

2009

2011

2013

Highlights of programme performance •• Case notification rate of new and relapse bacteriologically confirmed cases reached 57/100 000 population in 2014, up from 53/100 000 population in 2013 Steady increase in number of MDR-TB cases being diagnosed and being initiated on treatment Treatment success rate among new pulmonary bacteriologically confirmed cases steady, about 90% and among MDR-TB cases, more than 76%

•• ••

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400

200

0 1990 1995 2000 2005 2010 2015

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Trend in estimated TB mortality rates, 1990–2014 (Shaded areas represent uncertainty bands. The horizontal dashed line represents the target of a 50% reduction by 2015 compared with 1990)

0 1990 1995 2000 2005 2010 2015

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NoƟﬁed (new and relapse) Incidence (HIV+TB only)

Programmatic challenges Major challenges in achieving universal access to TB prevention, care and control services •• •• •• •• Low service coverage in hard-to-reach populations and TB contacts Hard to access and test all DR presumptive cases in the country because only two Culture and DST labs are available and functional in the country There is a low involvement of private sector in the national programme leading to low case notification from the private sector TB and HIV cross-referral services are still not functioning well leading to only 9% TB patients being tested for HIV

Major challenges in expansion of MDR-TB services •• •• High stigma and low commitment of health worker towards DR-TB management Insufficient HR in-health facilities including doctors to address the needs of patients

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••

Difficult to manage second-line TB drugs because of long treatment duration, short expiry date, no facility of proper storage system of drugs especially to maintain the temperature in the store Insufficient infection control measures in health facilities Insufficient expertise in the country for management of DR-TB

•• ••

National Strategic Plan 2016–2020 Goal: Decrease the Incidence of TB by 20% by 2020 based on reassessment of TB burden figures to be conducted in 2016

Objectives: •• •• •• Increase case detection by 15 000 cases (all forms of TB) by 2020 Maintain the treatment success rate at 90% patients (all forms of TB) Provide MDR diagnostic services for 50% of persons with likely MDR TB by 2017 and 100% by 2020; successfully treat at least 75% of the diagnosed MDR patients Engage at least 60% of all private health-care providers (hospitals and practitioners) in TB control by 2017, and 80% by 2020 Strengthen community systems for management, advocacy, support and rights for TB patients to create an enabling environment to detect and manage TB cases in 60% of all districts by 2017 and 100% by 2020 Ensure availability of quality TB services, in line with current international standards and provided by qualified personnel, at 70% of all facilities by 2017 and 90% of the facilities by 2020

•• ••

••

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Operational plan for 2016–2017 •• Expansion of TB diagnostic services ‒‒ Roll-out GeneXpert to all districts ‒‒ C/DST services to all regions ‒‒ Expansion of microscopy services in 198 public and private health sector health facilities ‒‒ Expansion of DR services up to all regional, zonal and district hospitals, expansion of DR subcentre up to PHC level •• Expansion of active case-finding activities to access hard-to-reach and vulnerable population through the following: ‒‒ Microscopic camp ‒‒ Contact tracing of TB patients’ families, neighbours, friends, schools and work place ‒‒ Mobilizing mobile van with GeneXpert and digital x-ray machines in strategic location •• Enhance TB diagnosis in children ‒‒ Strengthening the skills of doctors in child TB diagnosis and management through trainings ‒‒ Introduction of the newer technology and system for the confirmatory diagnosis in children ‒‒ Strengthening the R&R system to capture the referral, diagnosis and treatment of children ‒‒ Development and mobilization of TB volunteers in metro/ submetropolitan cities •• Establishment of sputum courier mechanism in all districts to ensure the screening of all DR presumptive TB cases, contacts of TB patients, access hard-to-reach and vulnerable populations

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•• •• •• ••

Strengthening the infection control measures in labs, DR centres and DOTS canters Promotion of psychosocial support to TB patients Meaningful engagement of patients and community in the diagnosis and treatment of TB patients – expansion of community/family DOTS Strengthen TB-HIV collaboration between NCASC and NTC at all levels ‒‒ Capacity development of HW ‒‒ Involvement of infected/affected people and community ‒‒ Strengthen and expand joint activities ‒‒ Establishment TB Referral Centres at the regional level for side-effect management, treatment, and rehabilitation

GF support: •• •• •• •• The Global Fund and MoHP, Nepal signed the NSA grant in two phases for the period 2010–2015 The grant for the period was US$ 54.4 million, which has almost 80% of total NTP needed during the period The grant was implemented beginning July 2010 and ended in July 2015 For the period 2015/2016, the NTP is being supported through no-cost extension grant of US$ 8.6 million through SCI (PR)

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Partnerships NGOs/ CSOs Save the Children International (SCI) Institute of Medicine (IoM) Type of collaboration PR of NTP for no-cost extension period (2015/2016) TB case diagnosis establishing GeneXpert machines in strategic location of districts in eastern and central regions of Nepal SR of NSA – majorly in the diagnosis and management of TB cases providing national reference laboratory for DR TB management in the collaboration of GENETUP and hospital services SR of NSA grant, diagnose TB cases running mobile vans and GeneXpert machines in 24 high-burden terai/hilly districts SR of NSA providing DOTS services, Diagnosis TB cases through TB Reach project SR of NSA , running QC services of lab in eastern region, Diagnosis TB cases through TB Reach project SR of NSA, partner for the development of CSS component for NSP 2016–2020, Diagnosis of TB cases through TB Reach project SSR of NSA grant, running DR referral centre in Mid-Western Region with laboratory, in-patient and out-patient services Partner for the development of CSS component for NSP 2015–2020

Nepal Anti-TB Association (NATA)

Health Research and Social Development Forum (HERD) Japan-Nepal Health & Tuberculosis Research Association (JANTRA) Britain Nepal Medical Trust (BNMT) FAITH

TB Nepal VFDN

Key achievements and success stories In this fiscal year, NTP has expanded 20 DOTS Centres and 25 Microscopic Centres in the public and private sectors of Nepal. Similarly one DR Centre and two Subcentres have been expanded in the districts for the management of DR TB cases. Along with this, NTC has procured all the necessary items for the establishment of a solid culture and DST facility in the three regions - Eastern Development Region, Western Development Region and Mid-Western Region of Nepal. Furthermore NTC has expanded three GeneXpert centres in the Accham, Okahaldhuna and Palpa districts respectively. In addition, NTC has strengthened the National Reference Laboratory with the facility of liquid C/DST and a LPA facility; as a result, its capacity has been strengthened in the management of DR TB cases.

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All preparatory work for the Prevalence Survey that is going to be conducted from July 2016 has been completed. Accordingly in 2015, NTP conducted an Epiappraisal with technical support from WHO and some of the recommendations of the appraisal have been addressed in the coming year’s FY budget and programme, which includes piloting of tracking referral childhood TB cases from the national child hospitals located in Kathmandu as well as tracking and enrolling the primary lost to follow up TB cases on treatment.

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Country profile

Sri Lanka

Background information Population* - 20 571 542 Estimates of disease burden for 2014 Incidence of all forms of TB Incidence rate of all forms of TB (per 100 000 population per year) Incidence rate HIV+TB only (per 100 000 population per year) Prevalence of all forms of TB Prevalence rate of all forms of TB (per 100 000 population) TB death rate (of all forms of TB, excluding HIV per 100 000 population per year) % of MDR-TB cases among new TB cases % of MDR-TB cases among retreatment TB cases Number of MDR-TB cases among notified new TB cases Number of MDR-TB cases among notified retreatment TB cases 13 000 (12 000–15 000) 65 (57–73) 0.26 (0.2–0.32) 20 000 (10 000–34 000) 99 (51–164) 6.1 (4.8–7.6) 0.18 (0–0.99) 0.58 (0.07–2.1) 11 (0–62) 3 (0–10)

*Source: United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects: The 2015 revision, DVD Edition. New York, 2015.

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Programme performance and trends* Programme performance in 2014 Number of bacteriologically confirmed new pulmonary TB cases Number of bacteriologically confirmed relapse pulmonary TB cases Notification rate of new and relapse bacteriologically confirmed cases (per 100 000 population for the year 2014) Number of clinically diagnosed new pulmonary TB cases Number of clinically diagnosed relapse pulmonary TB cases Number of extra-pulmonary new TB cases Number of extra-pulmonary relapse TB cases Notification rate of all new and relapse TB cases (per 100 000 population for the year 2014) Number of previously treated cases, excluding relapses 4 345 288 21 1 962 0 2710 0 45 168

Note: Among 8980 new and relapse cases: 313 (3%) cases aged under 15 years; male:female ratio: 1.9.

Case notifications by type of patients, 2014

Pulmonary TB cases, clinically diagnosed 20.7%

New extrapulmonary 28.6%

Relapse 3.0%

Pulmonary TB cases, bacteriologically conﬁrmed 45.9%

Previously treated paƟents, excluding relapse cases 1.8%

* All the data in this section is sourced from www.who.int/tb/data accessed 28 December 2015

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Trends in TB case notifications, all forms (1995 - 2014) 12000 10000 8000 6000 4000 2000 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Pulmonary TB cases, bacteriologically conﬁrmed New extrapulmonary Previously treated paƟents, excluding relapse cases Pulmonary TB cases, clinically diagnosed Relapse Total new and relapse

RR/MDR-TB cases notification – 2014 New Culture isolates for RR/MDR-TB* Isolates confirmed RR/MDR-TB* Patients started on MDR-TB treatment** *Not equal to number of patients. **Includes patients who were not laboratory confirmed and those diagnosed before 2014. 1 209 (28%) Retreatment 669 (147%) Total 1 816 42 (2.3%) 11 (26.2%)

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(%) (85) (62) (24) (88)

Cohort 9 010 167 37 8 0

Treatment outcomes by type of cases, 2013 cohort (2012 cohort for RR/MRD-TB cases) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

All new cases

HIV-posiƟve TB, All conﬁrmed Previously all types RR-TB/MDR-TB treated, including relapse Died Treatment failed Cured or treatment completed

Not evaluated

Lost to follow-up

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Trends in treatment success rate by type of cases, 1995–2013 100 90

Treatment success rate (%)

80 70 60 50 40 30 20 10 0 1995 1997 1999 2001 2003 2005 Year All new cases and relapse HIV+ TB cases Retreatment cases (excluding relapse) MDR-TB cases

2007

2009

2011

2013

Highlights of programme performance •• •• •• •• Case notification rate of new pulmonary bacteriologically confirmed cases stable at 21/ 100 000 population Treatment success rate of drug susceptible new cases above 85%, loss to follow-up rate at 5% and very low failure rate Increasing number of RR/MDR-TB cases being initiated on treatment and for 2012 cohort 7 out of 8 cases successfully completed treatment TB/ HIV collaborative activities were strengthened. In 2014, more than 75% TB patients screened for HIV

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150

100

0 1990 1995 2000 2005 2010 2015

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Trend in estimated TB mortality rates, 1990–2014 (Shaded areas represent uncertainty bands. The horizontal dashed line represents the target of a 50% reduction by 2015 compared with 1990)

0 1990 1995 2000 2005 2010 2015

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NoƟﬁed (new and relapse) Incidence (HIV+TB only)

Programmatic challenges Major challenges in achieving universal access to TB prevention, care and control services •• •• •• •• •• Difficulties in TB control among hard-to-reach populations Maldistribution of trained human resources Addressing stigma related to TB effectively Less priority for TB when compared with NCDs and other communicable diseases Multisector approach in TB control

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Major challenges in expansion of MDR-TB services •• •• •• •• •• •• Infrastructure for diagnosing and managing drug-resistant cases and trained human resources Funding (including drug supply and consumables) availability for expansion of services Centralized system of provision of care Problems in provision of ambulatory care Provision of social support Provision of palliative care and end of life support for needy patients

National Strategic Plan Goal: •• Decrease the prevalence of TB by 10% by 2020 based on TB burden figures of 2014 Objectives: •• •• •• Detect at least 80% of incident TB cases (all forms) by 2017 and 90% of incident cases by 2020 Increase the treatment success rate of the enrolled patients (all forms of non-MDR TB) to 90% by 2017; successfully treat 75% of MDR-TB cases Decentralize TB diagnostic- and treatment services to include 40% of all divisional hospitals (up to Type B) by 2017 and 80% of all divisional hospitals (up to Type B) by 2020 Engage 30% of all private health-care providers (hospitals and general practitioners) in TB control by 2017, and 50% by 2020 Ensure that quality TB services in line with current international standards are provided by qualified and regularly supervised personnel at 100% of all implementation sites by 2017.

•• ••

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Laboratory expansion plan 2015 Number of solid culture facilities central and regional Conventional DST facilities - at NTRL Liquid culture facility - central and regional Xpert MTB/Rif 4 module instruments - central and districts Line probe assay for first-line DST at NTRL Line probe assay for second-line DST at NTRL 3  2 1  2016 5  2 4   2017 7  2 6   2018 7  2 7   2019 7  2 7   2020 7  2 7  

Operational plan for 2016–2017 •• •• •• •• •• •• •• •• •• •• •• •• Enhance case detection among high-risk groups through estate and urban coordinators and involvement of non-NTP stakeholders Expand laboratory network and inclusion of WRDs in diagnosis Prepare guidelines and SOPs for community awareness and referral, screening of high-risk categories Continue supply of anti-TB drugs Conduct a DRS survey Introduce an E - PIMS System Strengthen monitoring through supervision of chest clinics / laboratories and programme reviews Build capacity of health staff Take evidence-based approaches in TB control through operational research Strengthen PPM through engaging private health-care providers in TB control in a phase-out manner Provide social support for needy TB patients and all MDR TB patients Prepare a ACSM plan following KAP survey and implementation

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Financing of your National Strategic Plan – 2014 Source of Funding GOSL Global Fund* World Bank WHO and other 2014 1 694 403 3 528 969 384 615 23 076 2015 1 859 093 733 690 566 923 23076.92 2016 NA NA NA 2017 NA NA NA

*Figures for 2014 and 2015 are part of no-cost and costed extension.

GF support: •• •• •• •• •• TFM Grant with NCE– completed on September 2015 Costed extension for October–December 2015 US$ 8.4 million approved at present for 3 years in NFM Signing of Performance agreement – Pending NFM – for 3 years October 2015–December 2018

Partnerships •• •• The involvement of CSOs is minimal in TB control During the process of preparation of the National Strategic plan, CNAPT, World Vision, HIV patient groups were involved

Roles: •• •• The role of CSO s and NGOs are limited to health education as of now Planned to get their involvement in organizing outreach programmes, DOT provision, provision of social/economic support for needy patients

Key achievements and success stories •• •• DOTs population coverage maintained at 100% with improving access to services Maintained quality-assured decentralized diagnostic services all over the country – more than 160 functioning microscopy centres and two more intermediate culture laboratories

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••

Case detection among high-risk categories (prisons and drug addicts) were strengthened and intersectoral collaboration between related agencies were strengthened. Able to strengthen PMDT activities by establishing central and site committees for PMDT Monitoring and evaluation of TB control activities at both central and regional levels were strengthened

•• ••

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Country profile

Thailand

Background information Population* - 67 725 979 Estimates of disease burden for 2014 Incidence of all forms of TB Incidence rate of all forms of TB (per 100 000 population per year) Incidence rate HIV+TB only (per 100 000 population per year) Prevalence of all forms of TB Prevalence rate of all forms of TB (per 100 000 population) TB death rate (of all forms of TB, excluding HIV per 100 000 population per year) % of MDR-TB cases among new TB cases % of MDR-TB cases among retreatment TB cases Number of MDR-TB cases among notified new TB cases Number of MDR-TB cases among notified retreatment TB cases 120 000 (61 000–190 000) 171 (90–276) 22 (12–36) 160 000 (110 000–220 000) 236 (161–326) 11 (5.7–18) 2(1.4–2.8) 19(14–25) 1 190 (780–1 600) 1 150 (800–1 500)

*Source: United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects: The 2015 revision, DVD Edition. New York, 2015.

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Programme performance and trends* Programme performance in 2014 Number of bacteriologically confirmed new pulmonary TB cases Number of bacteriologically confirmed relapse pulmonary TB cases Notification rate of new and relapse bacteriologically confirmed cases (per 100 000 population for the year 2014) Number of clinically diagnosed new pulmonary TB cases Number of clinically diagnosed relapse pulmonary TB cases Number of extra-pulmonary new TB cases Number of extra-pulmonary relapse TB cases Notification rate of all new and relapse TB cases (per 100 000 population for the year 2014) Number of previously treated cases, excluding relapses 34 394 1 969 51 21 115 0 10 244 0 100 3 896

Note: Among 34 394 new cases: 119 (<1%) cases aged under 15 years; male:female ratio: 2.5.

Case notifications by type of patients, 2014 New extrapulmonary 14.0% Pulmonary TB cases, clinically diagnosed 29.4% Relapse 2.7%

Pulmonary TB cases, bacteriologically conﬁrmed 49.5%

Previously treated paƟents, excluding relapse cases 4.3%

* All the data in this section is sourced from www.who.int/tb/data accessed 28 December 2015

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Trends in TB case notifications, all forms (1995 - 2014) 80000 70000 60000 50000 40000 30000 20000 10000 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Pulmonary TB cases, bacteriologically conﬁrmed New extrapulmonary Previously treated paƟents, excluding relapse cases

Pulmonary TB cases, clinically diagnosed Relapse Total new and relapse

RR/MDR-TB cases notification – 2014 New Cases tested for RR/MDR-TB Laboratory confirmed RR/MDR-TB cases Patients started on MDR-TB treatment** *Includes patients with unknown previous TB treatment history. **Includes patients who were not laboratory confirmed and those diagnosed before 2014. 4 370 (13%) Retreatment 2 209 (38%) Total 9 580* 506 (5.3%) NA

TB/HIV collaboration TB/HIV TB patients with known HIV status HIV-positive TB patients HIV-positive TB patients on co-trimoxazole preventive therapy (CPT) HIV-positive TB patients on antiretroviral therapy (ART) HIV-positive people screened for TB HIV-positive people provided with IPT Number 50 670 6 831 4 359 4 691 (%) (71) (13) (64) (69) NA NA

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(%) (81) (66) (67)

Cohort 65 867 1 812 7 665 NA NA

Treatment outcomes by type of cases, 2013 (2012 cohort for RR/MDR-TB cases) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

All new and relapse

Previously treated (excluding relapse) Died

HIV-posiƟve TB, All conﬁrmed RRall types TB/MDR-TB

Not evaluated

Lost to follow-up

Treatment failed

Cured or treatment completed

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Trends in treatment success rate by type of cases, 1995–2013 100 90

Treatment success rate (%)

80 70 60 50 40 30 20 10 0 1995 1997 1999 2001 2003 2005 Year All new cases and relapse HIV+ TB cases Retreatment cases (excluding relapse) MDR-TB cases

2007

2009

2011

2013

Highlights of programme performance •• •• •• Case notification rates of new and relapse bacteriologically confirmed cases improved to 51/100 000 population in 2014 Treatment success rate of all new and relapse cases steady above 80% More than 70% of TB patients tested for HIV status, and 69% of HIV positive TB patients are on ART

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400

300

200

100

0 1990 1995 2000 2005 2010 2015

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Trend in estimated TB mortality rates, 1990–2014 (Shaded areas represent uncertainty bands. The horizontal dashed line represents the target of a 50% reduction by 2015 compared with 1990)

0 1990 1995 2000 2005 2010 2015

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NoƟﬁed (new and relapse) Incidence (HIV+TB only)

Programmatic challenges Major challenges in achieving universal access to TB prevention, care and control services •• There is lack of formal collaboration with other major ministries such as the Ministry of Interior managing local administrative organizations where the local fund is available or the Ministry of Labour overseeing the Social Security Scheme for employees. Coverage of standard practice in non-MOPH hospitals and private hospitals is limited. Integrating TB services into the existing health system such as surveillance, infection control and pharmacovigilance has limited progress. The pharmacovigilance system is established to ensure the safety monitoring in new anti-TB drug use, and it needs the expansion plan. Capacity-building of clinical staff and programme staff at all levels is difficult because of no human resource development plan.

•• ••

••

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Major challenges in expansion of MDR-TB services •• •• •• •• •• •• •• The available capacity for diagnosing drug resistance is less utilized due to partial adherence to diagnostic flow charts. The degree of PMDT implementation differs between regions and provinces depending on expertise of TB coordinators of these levels. Staff supervision is challenged by shortage of personnel with appropriate authority/expertise. Missing PMDT reports remain unsolved, and it makes the programme improvement difficult. There is some evidence of MDR-TB outbreak in a few communities, and it needs continuous efforts in both in the field and technical support. Experience in the pharmacovigilance system for new TB drugs is limited. Few research activities are conducted to guide the practice.

National Strategic Plan Goal: To reduce the incidence of TB by 20% (4% per year) from 171/100 000 population in 2014 to 137/100 000 by the end of 2020. WHO-SEARO

Objectives: •• To ensure that all TB patients have access to standard TB diagnosis and effective treatment services, including special populations who are at higher risk of TB infection and those living in border areas – by 2020; To halve the TB mortality by 2020 compared with that of 2012; To strengthen the leadership and strategic management capacity for TB control; To sustain political commitment by mobilizing resources to support the system for TB prevention, care and control; To intensify research, to direct and optimize implementation and impact including innovation for improving programme performance consistent with the local situation.

•• •• •• ••

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Laboratory expansion plan 2015 Microscopy centre GeneXpert test Culture (solid and liquid) FL DST SL DST LPA 1 081 20 65 23 2 12 2016 1 081 44 65 23 2 12 2017 NA NA NA NA NA NA 2018 NA NA NA NA NA NA 2019 NA NA NA NA NA NA

Operational plan for 2016–2017 Main activities Active case finding among risk groups (elderly, prisoners, HIV+, DM) Strengthening TB laboratory capacity Integrating TB activities into hospital accreditation system to reduce diagnosis delay in the elderly to minimize the high death rate Human resource management through HRD plan, training curriculum 2016 X X X 2017 X X X 2018 X X X 2019 X X X

–

Financing the NSP Year Budget (in US$) Expected funding Government GF Others Gap 2015 38 274 292 18 247 332 5 243 060 – 11 633 777 2016 38 539 158 19 146 547 3 465 393 – 12 492 082 2017 41 983 518 20 090 777 – – 18 155 186 2018 43 494 464 21 068 974 – – 19 480 722 2019 51 456 544 22 123 176 – – 25 527 864

GF support: •• •• New Funding Model (NFM) is the current GF grant covering the period between 1 January 2015 and 31 December 2016. The funding in 2015 is US$ 5.24 million and in 2016, it is US$ 3.46 million.

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Partnerships NGO/CSO Raksthai Foundation World Vision Foundation International Committee of the Red Cross Activity/Role Providing background and working experience for migrant population Providing background and working experience for migrant population Providing background and working experience for prison population

Key achievements and success stories •• •• •• •• •• Funding from National Health Security Office now covers diagnosis, treatment and follow-up of drug-resistant TB among risk groups. Molecular testing for risk groups of DR-TB is expanded, and NHSO covers the use of GeneXPert for case finding for drug-resistant TB and treatment failure. Prisoners, elderly, migrants and PLHIV are targeted for active case finding and standard care nationwide. National expert committee for DR-TB is established to provide guidance on regimen and clinical management. Bedaquiline is being introduced (as a donation from Janssen), with appropriate systems in place for ADR monitoring instituted.

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The National TB Programme, Thailand has a continuous collaboration the Department of Corrections to conduct the TB programme in prison settings. With the financial support from the WHO Country Office, prison nurses had participated in a training to build their capacity to strengthen a patient-centred approach in the implementation of TB/HIV collaborative interventions.

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Country profile

Timor-Leste

Background information Population* - 1 157 360 Estimates of disease burden for 2014 Incidence of all forms of TB Incidence rate of all forms of TB (per 100 000 population per year) Incidence rate HIV+TB only (per 100 000 population per year) Prevalence of all forms of TB Prevalence rate of all forms of TB (per 100 000 population) TB death rate (of all forms of TB, excluding HIV per 100 000 population per year) % of MDR-TB cases among new TB cases % of MDR-TB cases among retreatment TB cases Number of MDR-TB cases among notified new TB cases Number of MDR-TB cases among notified retreatment TB cases 5 800 (4 800–6 900) 498 (411–594) 4.9 (3.7–6.3) 9 500 (4 900–16 000) 820 (426–1 340) 94 (66–126) 2.2 (1.9–2.6) 16 (14–18) 67 (58–80) 32 (28–35)

*Source: United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects: The 2015 revision, DVD Edition. New York, 2015.

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Programme performance and trends* Programme performance in 2014 Number of bacteriologically confirmed new pulmonary TB cases Number of bacteriologically confirmed relapse pulmonary TB cases Notification rate of new and relapse bacteriologically confirmed cases (per 100 000 population for the year 2014) Number of clinically diagnosed new pulmonary TB cases Number of clinically diagnosed relapse pulmonary TB cases Number of extra-pulmonary new TB cases Number of extra-pulmonary relapse TB cases Notification rate of all new and relapse TB cases (per 100 000 population for the year 2014) Number of previously treated cases, excluding relapses 1 838 78 159 1 222 0 519 0 316 121

Note: Among 3 579 new cases: 390 (11%) cases aged under 15 years; male:female ratio: 1.2.

Case notifications by type of patients, 2014 New extrapulmonary 14.2% Pulmonary TB cases, clinically diagnosed 33.4%

Relapse 2.1%

Pulmonary TB cases, bacteriologically conﬁrmed 50.3%

* All the data in this section is sourced from www.who.int/tb/data accessed 28 December 2015

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Trends in TB case notifications, all forms (2002 - 2014) 6000 5000 4000 3000 2000 1000 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Pulmonary TB cases, bacteriologically conﬁrmed New extrapulmonary Previously treated paƟents, excluding relapse cases

Pulmonary TB cases, clinically diagnosed Relapse Total new and relapse

RR/MDR-TB cases notification – 2014 New Cases tested for RR/MDR-TB Laboratory confirmed RR/MDR-TB cases Patients started on MDR-TB treatment* 0 0 Retreatment 198 (99%) 3 3 Total 198 3 (1.5%) 3 (100%)

*Includes patients who were not laboratory confirmed and those diagnosed before 2014.

TB/HIV Number TB patients with known HIV status HIV-positive TB patients HIV-positive TB patients on co-trimoxazole preventive therapy (CPT) HIV-positive TB patients on antiretroviral therapy (ART) HIV-positive people screened for TB New HIV-positive people provided with IPT 2 054 24 24 24 173 20 (%) (54) (1) (100) (100) (100) (26)

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(%) (84) (91) 69 (75) Nil

Cohort 3 718 11 13 4 Nil

Treatment outcomes by type of cases, 2013 (2012 cohort for RR/MDR-TB cases) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% All new and relapse Previously treated, HIV-posiƟve TB, all cases including relapse types All conﬁrmed RRTB/MDR-TB

Not evaluated

Lost to follow-up

Died

Treatment failed

Cured or treatment completed

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Trends in treatment success rate by type of cases, 2002–2013 100 90

Treatment success rate (%)

80 70 60 50 40 30 20 10 0 2002 2003 2004 2005 2006 2007 2008 Year All new cases and relapse HIV+ TB cases Retreatment cases (excluding relapse) MDR-TB cases

2009

2010

2011

2012

2013

Highlights of programme performance •• •• •• •• Case notification rate of new and relapse TB cases has increased from 138/100 000 population in 2013 to 159/100 000 population in 2014 Total number of all forms of TB cases initiated on treatment has also increased to 3 778 Nearly all retreatment cases screened for drug resistance Treatment success rate for drug susceptible TB is beyond 85% for the last 5 years

Key achievements in expansion of services •• •• Every village in Timor-Leste has a Health Post or SISCa post where TB diagnostic and treatment services can be accessed at these health centres All 18 Designated Microscopy Centres (DMCs) and Community Health Centre (CHC) laboratories are quality assured through implementation of a EQA

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system. A three-tier system of quality assurance is in place from the Supra National Reference Laboratory (SNRL) to the National Reference Laboratory; the National TB Reference Laboratory (NRL) to DMCs and DMCs to CHCs are established and fully operational. Currently all TB laboratories (100%) fully comply with the quality assurance system. •• Quality-assured drugs are available at all times and all diagnosed TB patients are put on appropriate TB treatment

1000

500

0 1990 1995 2000 2005 2010 2015

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Trend in estimated TB mortality rates, 1990–2014 (Shaded areas represent uncertainty bands. The horizontal dashed line represents the target of a 50% reduction by 2015 compared with 1990) 150

100

0 1990 1995 2000 2005 2010 2015

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2004

2006

2008

2010

2012 Incidence

NoƟﬁed (new and relapse) Incidence (HIV+TB only)

Programmatic challenges Major challenges in achieving universal access to TB prevention, care and control services •• •• •• •• There are several hard-to-reach areas where access to health services including TB services are difficult to reach, particularly during the rainy season Infection control in the health-care centres still needs to be strengthened Coverage of IPT in children is only 13% and needs rapid expansion For smear negative cases, access to X-ray services are limited in the districts

Major specific challenges in expansion of MDR-TB services •• •• •• •• There is no DRS done in the country, so the MDR burden is unknown Knowledge among doctors and health workers on PMDT is limited Culture and DST laboratory in the country is under construction and will take a year or so for full operationalization There is only one MDR centre in the country

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National Strategic Plan (2015–2020) (draft at the stage of compiling this report) Proposed goals: •• Long-term from WHO post-2015 strategy (Targets for 2035): ‒‒ 95% reduction in tuberculosis deaths (compared with 2015) ‒‒ 90% reduction in tuberculosis incidence rates (less than 10 tuberculosis cases per 100 000 population) •• For the NSP period: ‒‒ Decrease the prevalence of TB by 10% by 2020 based on reassessment of TB burden figures to be conducted in 2015 (and 2018 prevalence survey)

Objectives: •• •• •• Detect at least 75% of incident TB cases (all forms) by 2017 and 80% of incident cases by 2020 Ensure successful treatment for 85% of the enrolled patients (all forms) by 2017 and 90% patients by 2020 Provide drug susceptibility testing services for 50% of the estimated persons with suspected DR TB by 2017 and 100% by 2020; successfully treat at least 70% of the diagnosed RR/MDR patients Ensure timely and accurate recording and reporting from all (100%) reporting centres by 2017; and initiate impact measurement by 2018 Ensure availability of quality TB services, in line with current international standards and provided by qualified personnel at 70% of all facilities by 2017 and 90% of the facilities by 2020

•• ••

Operational plan for 2016–2017 •• •• Detect at least 75% of incident TB cases (all forms) by 2017 and 80% of incident cases by 2020 Ensure successful treatment for 85 % of the enrolled patients (all forms) by 2017 and 90% of patients by 2020

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•• ••

Ensure timely and accurate recording and reporting from all (100%) reporting centres by 2017; and initiate impact measurement by 2018 Ensure availability of quality TB services, in line with current international standards and provided by qualified personnel at 70% of all facilities by 2017 and 90% of the facilities by 2020

Financing of NSP 2016 Total NSP needs The Global Fund* Government Others GAP *The Global Fund support under NFM. 9 038 509 2 429 204 3 982 354 2 100 000 526 951 2017 6 317 544 2 316 319 3 620 819 65 000 315 406

Partnerships 1. Kilbur Domin (KD): This centre collaborates with the NTP in MDR management under a service contract currently and will be the new SR for the NFM. This arrangement is an excellent collaboration between an NGO and the National TB Programme in delivering quality TB services including MDR services for the people of TimorLeste through partnership.

2. Bairo Pite Clinic (BPC): This NGO clinic caters to one third of TB patients in the country and works in close collaboration with the NTP. Over the years, collaboration between BPC and NTP has improved significantly and now BPC delivers quality TB services to the population similar to government health facilities in Timor-Leste. BPC serves as one of the designated microscopy centres, DOTS centres and reporting centres for NTP. As a recognition to their work, NTP will enter into a service contract with BPC during the NFM period (2016–2017) to further improve the collaborative TB services in Timor-Leste.

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Stories from the field Over the past couple of years, Timor-Leste has significantly improved quality of TB services in the country. An excellent quality assurance system for smear microscopy was developed, and GeneXpert was introduced as an additional diagnostic services. Sputum sample transportation systems within and across districts were developed and improved. Robust regimen of anti-TB treatment as per WHO recommendation was introduced and all national guidelines were updated in line with recent WHO recommendations. Many doctors and health workers were trained on the updated guidelines and appropriate TB management. Recording and reporting tools were all updated and 100% of reporting centres are reporting to the NTP on time. An action-oriented supportive supervision system has been developed and implemented. Innovative ways of involving NGOs and civil societies in quality TB service delivery through constant partnership building and service contracts were developed and implemented. Photos 1 & 2: Engagement of NGO clinic (BPC) in delivering DOT.

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Photo 3: Evaluating drug management practices.

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Photo 4: Quality assurance of smear microscopy.

Photo 5: Strengthening recording and reporting.

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Photo 6: Training of doctors on TB services and appropriate TB case management.

Tuberculosis control in the South-East Asia Region

Annual Report 2016

The South-East Asia Region of WHO is home to 26% of the world's population; however, the Region accounts for 41% of the global burden of tuberculosis (TB) in terms of disease incidence. In 2014, there were an estimated 5.4 million prevalence and 4 million incidence of TB, and about 460 000 people died due to TB in the Region. India and Indonesia have among the largest numbers of cases (23% and 10% of the global total, respectively). An estimated 340 000 children in the South-East Asia Region developed TB in 2014. The Region has a total of 99 000 estimated MDR-TB cases among notified pulmonary TB cases, accounting for approximately 30% of the world's MDR-TB cases in 2014. Six of the 30 high MDR-TB-burden countries are in the South-East Asia Region: Bangladesh, Democratic People's Republic of Korea, India, Indonesia, Myanmar and Thailand. An estimated 210 000 cases (5.2%) of the 4 million TB-incident cases are HIV-positive. This corresponds to 11 per 100 000 and 5% of all estimated TB-incident cases. An estimated 62 000 cases died of HIV-associated TB in 2014. In alignment with the WHO End-TB Strategy, a new Regional Strategic Plan (2016–2020) has now been developed for TB control in the South-East Asia Region with the vision to have a Region free of TB with zero death, disease and suffering due to TB. All Member States can adopt this vision in their national strategies and plans. The goal for TB control is to End the TB epidemic in the Region by 2035, by adopting and adapting the vision, milestones and targets as outlined in the WHA67.1 resolution. The WHO Regional Office, in coordination with all country offices and international and national partners, continues to support all Member States in their efforts to achieve universal health coverage and to end the TB epidemic.

ISBN 978-92-9022-504-1

World Health House Indraprastha Estate, Mahatma Gandhi Marg, New Delhi-110002, India www.searo.who.int/topics/tuberculosis

9 789290 225041

Key facts

Organisation World Health Organization (WHO)

Document type Publications

Adoption date April 1, 2016

Source World Health Organization