Tuberculosis Control In the WHO Western Pacific Region 2004 Report
World Health Organization Regional Office for the Western Pacific
Tuberculosis Control in the WHO Western Pacific Region
2004 Report
World Health Organization Regional Office for the Western Pacific
Acknowledgements
We would like to thank all tuberculosis managers and statisticians from all the countries and areas of the Western Pacific Region for providing data for this publication.
WHO Library Cataloguing in Publication Data Tuberculosis Control in the WHO Western Pacific Region: 2004 Report
1. Infectious diseases — epidemiology I. Western Pacific ISBN 92 9061 090 5
2. Tuberculosis infections — epidemiology
(NLM Classification: WF 205)
© World Health Organization 2004 All rights reserved. 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. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: bookorders@who.int). Requests for permission to reproduce WHO publications, in part or in whole, or to translate them – whether for sale or for noncommercial distribution – should be addressed to Publications, at the above address (fax: +41 22 791 4806; email: permissions@who.int). For WHO Western Pacific Regional Publications, request for permission to reproduce should be addressed to Publications Office, World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000, Manila, Philippines, Fax. No. (632) 521-1036, email: publications@wpro.who.int
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Contents
Acknowledgements List of Abbreviations Map: Tuberculosis situation in the Western Pacific Region (all types), 2002 Summary Table 1: Key indicators of tuberculosis control in the Western Pacific Region, 2002 Part I: Commentary Chapter 1 Review of tuberculosis epidemiology Chapter 2 Review of DOTS implementation and treatment results Chapter 3 Grouping of countries Part II: Tables NOTIFICATION Table 6 Notification of tuberculosis cases by type, Western Pacific Region, 2002 Table 7 Age and sex distribution of new sputum smear-positive (SS+) cases in DOTS and non-DOTS areas, Western Pacific Region, 2002 Table 8 Trend of notified tuberculosis cases (all types) in DOTS and non-DOTS areas Table 9 Trend of notified tuberculosis cases (new smear-positives) in DOTS and non-DOTS areas Table 10 Trend of tuberculosis notification rates per 100 000 (all types) Table 11 Trend of tuberculosis notification rates per 100 000 (smear-positive cases) IMPACT Table 12 Input data used for estimation in the WHO Western Pacific Region Table 13 Summary of TB-HIV estimates for WHO Western Pacific Region, year 2001 Table 14 Summary of TB-HIV estimates for the WHO Western Pacific Region, 2001
ii v vi vii viii
2 7 10
18
19 20 21 22 23
24 25 26
iii
Commentary
TREATMENT RESULTS Table 15 Treatment outcome of new smear-positive cases registered in 2002 in DOTS areas Table 16 Treatment outcome of new smear-positive cases registered in 2001 in non-DOTS areas Table 17 Treatment outcome of re-treatment cases registered in 2001 in DOTS areas 27 28 29
Part III: Charts Chart 1 Notification of all cases by country, Western Pacific Region, 2002 Chart 2 Notification of new smear-positive cases by country, Western Pacific Region, 2002 Chart 3 Notification rate of new smear-positive cases by age and sex in DOTS areas, Western Pacific Region, 2002 Chart 4 DOTS case detection rate of new smear-positive cases, countries with a high burden, Western Pacific Region, 2002 Chart 5 Treatment success of new smear-positive cases under DOTS in countries with a high burden, Western Pacific Region, 2002 Chart 6 DOTS progress in countries with a high burden in the Western Pacific Region, 1998–2002 Annexes Annex 1 Definitions Annex 2 Formulas for estimating tuberculosis incidence, prevalence and deaths Annex 3 Statistical methods
32 33
34
34
35 35
38 41 42
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Abbreviations
AFB CFR DOT DOTS HIV IDU IRR MTB NTP PIC TB WHO WPR
Acid fast bacilli Case fatality rate Directly observed treatment Directly observed treatment short-course Human immunodeficiency virus Injecting drug use TB incidence rate ratio Mycobacterium tuberculosis National Tuberculosis Programme Pacific island country Tuberculosis World Health Organization Western Pacific Region (of WHO)
v
World Health Organization Regional Office for the Western Pacific Mongolia Japan
People's Republic of China
Republic of Korea
Western Pacific Region Marshall Islands
Tuberculosis Situation in the
(All Types), 2002
Lao Peoples Democratic Republic Cambodia
Hong Kong, China Macao, China Viet Nam Philippines
Northern Mariana Islands Guam Micronesia, FS Palau Papua New Guinea Solomon Islands Tuvalu Vanuatu New Caledonia Fiji Tokelau Wallis and Futuna Samoa American Samoa Niue Tonga New Zealand Cook Islands French Polynesia Nauru Kiribati
Brunei Darussalam Malaysia Singapore
vi
Australia
Cases / 100 000
> 100 25 - 100 < 25 The designations on this map do not imply the expression of any opinion on the part of the Regional Director concerning the legal status of any country or territory or the delimitation of its frontiers. Pacific islands not to scale.
NOTE: Clear areas are outside the WHO Region for the Western Pacific.
Summary
In 2002, 35 countries and areas notified 806 460 tuberculosis cases (all types) and 372 220 new smear-positive pulmonary cases
T
his 2004 report on tuberculosis control in the Western Pacific Region includes the cases notified during 2002 and the treatment results of the cohort of patients registered during 2001. Data were submitted by the National Tuberculosis Programmes of 35 countries and areas (accounting for a total population of 1.718 billion1 ). A standard form was used, based on common definitions and variables. The goal of this report is to provide an update on the epidemiological situation of tuberculosis in the Region and to show the progress of directly observed treatment short-course (DOTS) implementation. Key indicators in tuberculosis control are shown by country in Table 1. In 2002, 35 countries and areas notified 806 460 tuberculosis cases (all types) and 372 220 new smear-positive pulmonary cases. Notification rates were 47 per 100 000 and 22 per 100 000, respectively. The notification rates of all types showed no significant variation since 1993 while notification rates of smear-positive new cases increased significantly with a rate of change of +3.5%/year. Some 69% of the notified tuberculosis patients were aged 15-54, the most productive age group, while the group aged 25–34 had the highest tuberculosis burden at 19% (all cases) (Table 3). The DOTS case detection rate was 33% for all types and 36% for the smear-positive cases (31% and 37% the previous year, respectively), well short of the World Health Organization (WHO) target of 70%. It is expected that an acceleration of DOTS expansion should lead to an increase in case detection, especially of the most contagious cases – those that are pulmonary smear-positive. About 77% of the regional population had access to DOTS (68% the previous year) (Table 1). The treatment success rate was 92% for pulmonary new smear-positive patients registered in 2001. Out of these, 86% were cured, just over the WHO target of 85%. Among the group of seven countries with a high burden for tuberculosis in the Region (Cambodia, China, the Lao People’s Democratic Republic, Mongolia, Papua New Guinea, the Philippines, and Viet Nam) Mongolia and Viet Nam reached WHO targets of 70% DOTS case detection and 85% treatment success (for new smear-positive cases). Mongolia attained the WHO targets during 2001, two years after full DOTS coverage was reached in 1999. The Philippines, although not yet reaching the target for detection (58% in 2002) has achieved almost full DOTS coverage, five years after the introduction of DOTS. As a whole, the impact of HIV on the TB situation is low in the Region. The estimated percentage of incident cases attributable to HIV is highest in Cambodia (12%), but it is low in the other TB high-endemic countries of the Region, particularly in China (0.5%), the Philippines (0.3%) and Viet Nam (1.5%). To reach WHO 2005 targets in the Region, treatment success must be improved in some countries and case detection must be improved in almost all countries. 1
Population update 2002, Global Tuberculosis Control, WHO, Geneva.
vii
TABLE 1
Key indicators of tuberculosis control in the Western Pacific Region, 2002 Notification in DOTS and other areas *Pop. x 1000 Country American Samoa Australia Brunei Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong (China) Japan Kiribati Republic of Korea Lao People’s Democratic Republic Macao (China) Malaysia Mariana Islands Marshall Islands Micronesia Mongolia Nauru New Caledonia New Zealand Niue Palau Papua New Guinea Philippines Pitcairn Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis & Futuna Western Pacific a 60 19 544 350 13 810 1 294 867 18 831 241 160 6 981 127 478 87 47 430 5529 460 23 965 76 52 108 2559 13 224 3846 2 20 5586 78 580 0 176 4183 463 2 103 10 207 80 278 15 1 718 314 All cases Number Rate b c 4 7 1 013 5 221 63 24 610 178 462 609 36 1 6 150 18 66 27 51 32 6608 95 32 828 26 189 217 34 967 74 2621 47 388 84 14 389 60 53 70 51 98 127 118 3829 150 5 38 65 29 329 9 2 100 11 55 5324 95 118 408 151 30 1516 256 29 13 101 95 577 19 806 460 17 36 55 28 130 49 119 127 46.9 New Smr+ Number Rate e d 3 2 1 210 32 112 125 17 258 15 194 972 6 1 9 75 11 27 19 31 27 1890 8 10 807 94 82 24 11 345 33 1829 32 147 33 7958 28 21 35 18 20 22 65 1670 15 2 9 21 2 88 50 1 45 9 17 926 83 65 148 18 549 108 23 0 38 56 811 1 372 220 10 13 23 22 0 18 71 7 21.7 % f=d/b 50 21 51 70 42 100 50 41 61 29 33 43 32 70 38 55 40 35 17 44 40 32 27 0 100 17 55 60 36 42 79 0 38 59 5 46 *Number of estimated cases New All Smr+ cases g h 18 8 1126 505 206 93 75 788 33 450 1 459 103 656 017 6 3 253 114 73 33 145 65 6488 2918 41 990 18 885 78 35 42 950 19 325 9390 4224 393 176 22 708 10 190 69 31 47 21 98 44 5357 2411 4 2 203 91 408 183 1 0 18 8 14 202 6358 251 442 113 087 0 0 54 24 1785 798 420 189 0 0 31 14 3 1 187 84 154 513 69 365 4 2 2 089 562 938 756 Case detection rate All cases (%) i=b/g 22 90 107 32 32 18 59 90 35 102 78 241 81 28 99 63 77 108 129 71 128 32 81 333 61 37 47 56 85 61 93 407 54 62 425 39 New Smr+ (%) j=d/h 24 42 121 52 30 40 66 82 48 65 57 233 59 43 83 78 68 84 50 69 114 23 48 370 110 15 58 74 69 57 163 0 45 82 50 40 Pop. accessible to DOTS Pop. k 60 10 554 350 13 810 1 004 817 18 831 241 160 6981 78 654 87 0 4257 460 23 965 76 52 97 2559 13 224 3846 2 20 1341 77 008 176 4183 463 101 0 168 80 198 15 1 315 786 % l 100 54 100 100 78 100 100 100 100 100 62 100 0 77 100 100 100 100 90 100 100 100 100 100 100 24 98 100 100 100 98 0 81 100 100 77 Number of cases in DOTS areas All New cases Smr+ m n 2 1 603 127 221 112 24 610 17 258 388 195 180 239 1 1 150 75 66 27 51 31 5394 1501 19 301 6172 189 82 0 0 2621 1829 358 135 14 389 7958 53 21 51 18 127 22 3829 1670 5 2 65 21 329 88 2 1 11 9 5324 926 118 408 65 148 30 778 256 29 13 70 95 577 10 681 118 18 311 108 23 0 31 56 811 1 340 777 Number of cases in non-DOTS areas All New cases Smr+ p o 1 2 83 410 0 0 0 0 74 414 14 733 0 0 0 0 0 0 0 0 389 1214 4635 13 527 0 0 34 967 11 345 0 0 12 30 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 738 0 0 0 31 0 9 125 342 0 238 0 0 0 7 0 31 443 **DOTS case detection rate All cases (%) q=m/g 11 54 107 32 27 18 59 90 35 83 46 241 0 28 91 63 77 108 129 71 128 32 81 333 37 47 56 44 61 93 37 62 33 New Smr+ (%) r=n/h 12 25 121 52 27 40 66 82 48 51 33 233 0 43 77 78 68 84 50 69 114 23 48 370 15 58 74 39 57 163 37 82 36 DOTS cure and success rate Cure rate (%) s 18 44 89 94 100 85 80 53 72 51 79 67 86 0 0 36 100 83 100 84 0 100 45 74 41 0 66 67 65 89 100 86 Success rate (%) t 66 56 92 96 100 85 80 71 78 75 86 77 89 79 74 86 100 87 100 84 9 100 67 88 77 88 89 92 88 91 100 92 *TB deaths per 100 000 u 6.0 1.0 4.0 107.1 21.0 5.7 5.0 3.8 16.4 8.0 4.0 7.0 10.2 29.0 10.0 15.0 13.0 10.0 12.7 37.0 2.2 16.9 1.1 2.0 10.0 56.0 57.2 0.0 5.0 4.9 14.8 6.3 3.0 6.0 16.3 25.1 4.3 21.7
viii
*2003 update, WHO Geneva. **DOTS detection rate is the proportion of total estimated cases who are diagnosed and treated under DOTS.
PART I
Commentary Chapter 1 Review of tuberculosis epidemiology Chapter 2 Review of DOTS implementation and treatment results Chapter 3 Grouping of countries 2 7 10
1
Commentary
CHAPTER
1
Review of tuberculosis epidemiology The regional average notification rate for new smearpositive cases was 21.7 per 100 000 population, with the highest rate in Cambodia (125)
T
his report is based on case notification and treatment outcome data supplied by national control programmes to the World Health Organization (WHO) for 2002, using a standard data collection form, with common definitions and variables.
1.1 Notification of tuberculosis cases by type of tuberculosis in 2002 In 2003, 35 out of 37 countries and areas of the Western Pacific Region with a combined population of 1.718 billion sent tuberculosis data for 2002. Together, they notified 806 460 tuberculosis cases (all types) (46.9 per 100 000 population), of whom 372 220 were new smear-positive pulmonary cases (21.7 per 100 000) (Table 1, Charts 1 and 2). The two non-reporting areas – Tokelau and the Pitcairn Islands, have a combined population of only around 2000. Notification by country is given in Table 1.
All types Among the 806 460 tuberculosis cases (all types) in the Region (Figure 1), China notified 57%, the Philippines 15%, Viet Nam 12%, the Republic of Korea 4%, Japan 4% and Cambodia 3%. Together, the 29 other countries notified only 5%. Nine countries reported a notification rate (all types) greater than 100, and 10 countries reported a rate lower than 30. FIGURE 1
Distribution of notified tuberculosis (all types) by country, Western Pacific Region, 2002 Others 5%
Cambodia Japan 3% 4% Republic of Korea 4% Viet Nam 12%
China 57%
Philippines 15%
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TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2004
Pulmonary new smear-positive cases Among the 372 220 new smear-positive cases in the Region, China notified 194 972 cases (52%), the Philippines 65 148 (18%), Viet Nam 56 811 (15%), Cambodia 17 258 (5%), Korea 11 345 (3%) and Japan 10 807 (3%). The 29 other countries notified together 15 879 cases (4%) (Tables 1 and 6). The regional average notification rate for new smear-positive cases was 21.7 per 100 000 population, with the highest rate in Cambodia (125). The rate ranged between 25 and 100 in 20 countries. China notified 15 new smear-positive cases per 100 000 population. Four industrialized countries (Japan, Australia, New Zealand and Singapore) and 10 Pacific island countries (PICs) had lower rates (Table 1). The proportion of new smear-positive cases out of all notified cases was 46% for the Region (42% in China). Eleven countries, including four of the seven with the highest burden (Cambodia, the Lao People’s Democratic Republic, the Philippines, Viet Nam) notified proportions higher than 50% (Table 1). The 55 528 extra-pulmonary cases reported represented 7% of all notified cases (Table 6). FIGURE 2
Notified cases by type of tuberculosis in DOTS and non-DOTS areas, Western Pacific Region, 2002
New pulmonary smear-positive
New pulmonary smear-negative
New pulmonary: no smear or results unknown
New extra-pulmonary
Relapse smear-positive
0
100 000 DOTS
200 000
300 000 Non-DOTS
400 000
1.2 Notification of the new smear-positive pulmonary cases by age and gender in 2002 Some 68% of new smear-positive cases are aged between 15 and 54, the most productive age group, with the highest concentration in the group aged 25–34 (19%) (Table 7). Two male tuberculosis smear-positive cases are notified for every female one (sex ratio: 2.1) in the Region (Table 7). The sex ratio was 0.8 in the 0–14-year-old group (more females than males), 1.4 in the 15–24 year old group and then increased in the older age groups (Figure 3).
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TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2004
FIGURE 3
Notification of new smear-positive cases by age and gender, DOTS and non-DOTS areas, Western Pacific Region, 2002 (%) 20
15
10
5
0
0-14
15-24
DOTS areas reported 36% of all new estimated smear-positive cases (340 777 new smearpositive cases out of 938 756 estimated cases)
25-34 35-44 45-54 Age group (years) % female % male
55-64
65 or over
1.3 Case detection rate in 2002 The case detection rate (see Appendix 1 for definition) was 39% for all tuberculosis cases and 40% for new smear-positive cases (Table 1). In other words, in the Region, the 806 460 notified cases (all types) represented 39% of the 2 089 562 estimated cases (all types) and the 372 220 notified new smear-positive cases represented 40% of the 938 756 estimated new smear-positive cases. DOTS areas reported 36% of all new estimated smear-positive cases (340 777 new smearpositive cases out of 938 756 estimated cases) (Table 1). Figures of estimated cases (annual incidence) are WHO provisional estimates to appear in WHO Report 2004 Global Tuberculosis Control, with projections based on “Global Burden of Tuberculosis”,2 published in 1999, and “The Growing Burden of Tuberculosis”,3 published in 2003.
1.4 Trends in notification Trends in notification for all types and new smear-positive cases are given by country in four tables (8 to 11) in Part II. Overall notification rates from 1993 to 2002 both for all types and new smearpositive cases are presented in Figure 4. Trends in notification may reflect variations in performance in case finding as well as changes in the burden of the disease. Moreover, trends in case detection rates are also affected by changes in the estimated incidence. Regional trends are very influenced by trends in China. From 1993 to 2002, the rates of notified new tuberculosis cases (all types) have not increased significantly in the WPR. (p=0.3, See Annex 3 for details on statistical methods). However, there was a statistically significant increasing trend in case notification rates of smear-positive new cases (+3.2%/yr, p=0.034).
2 Dye
C., Scheele S., Dalin P. et al. Global Burden of Tuberculosis. Estimated Incidence, Prevalence, and Mortality by Country. JAMA 1999; 282: 677–686. 3 Corbett EL, Watt CJ, Walker N. et al. The Growing Burden of Tuberculosis. Global Trends and Interactions With the HIV Epidemic. Arch Int Med 2003; 163(9): 1009-1021.
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TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2004
The notification of new tuberculosis cases (all types) increased in Papua New Guinea since the previous year (+53%), Cambodia (+28%), the Philippines (+11%), the Lao People’s Democratic Republic (+10%), Mongolia (+9%) and slightly in Viet Nam (+5%). There was a statistically significant increase in new case notification rates in China from 1993 to 2002 of all types (+2.9%/yr, p=0.015) and smear-positive new cases (+8.6%/yr, p=0.006). FIGURE 4
Trend in notification rates of tuberculosis, Western Pacific Region, 1993–2002 (rate per 100 000) 60 50 40 30 20 10
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
All types
New smear-positive
FIGURE 5
Trend in notification of smear-positive cases in Cambodia, China, Viet Nam and the Philippines, Western Pacific Region, 1995-2002 (rate per 100 000)
150 125 100 75 50 25 0 1995 1996 1997 China
1998 Philippines
1999
2000
2001
2002
Cambodia
Viet Nam
Western Pacific Region
1.5 Trends in case detection Case detection makes slow progress in the Region, and only 36% of all estimated new smearpositive cases were notified by DOTS programs to WHO. Estimates of incidence were revised in a
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TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2004
substantial manner in several countries. There was no significant increase in case detection rates of smear-positive cases between 1998 and 2002, but estimates of prevalence and incidence were revised and improved during the period, leading to fluctuations of the case detection rates between years. In particular, data from China was revised for this report: re-treatment smear-positive cases are no longer included in the new smear-positive category, resulting in slightly lower case detections of smear-positive cases in China and as a result, in the Region. Although DOTS population coverage and case detection have been accelerating in some countries, particularly in the Philippines, the annual increment in case notifications under DOTS has been steady but slow in China where 22% of the population (around 290 million people) do not yet have access to DOTS. More data analysis is needed in China to investigate the reasons for low case detection and obstacles to DOTS expansion. If the current rate of progress is maintained, the global target of 70% case detection rate will be difficult to reach in the Region in 2005. In total, around 250 000 additional smear-positive new cases will need to be detected per year to reach the target.
1.6 HIV and tuberculosis The HIV epidemic has reached a generalized stage only in Cambodia where the prevalence of HIV infection among those aged 15 to 49 years was estimated to be 2.7% in 2002. In other countries affected by HIV in the Region,4 particularly in Viet Nam and China, the HIV epidemic is still at a concentrated stage. In China, HIV prevalence data indicated a focused, explosive spread of infections among injecting drug users (IDUs) and no significant spread in the non-IDU population. Although HIV/AIDS cases have been detected in all provinces, HIV transmission is focused primarily among IDUs in certain provinces. In Viet Nam, the prevalence is highest among IDUs (24% in 2000) but sexual transmission of HIV is increasing among female sex workers. Table 12 shows data used to compute estimates of TB morbidity and mortality. Tables 13 and 14 show estimates of tuberculosis and HIV co-infection numbers and rates, and the estimated impact of HIV on the tuberculosis situation. The percentage of HIV-attributable tuberculosis cases in the Region is 1% of all adult cases, the lowest percentage among all WHO Regions (the global percentage of tuberculosis cases attributable to HIV is 10%). The estimated percentage of incident cases attributable to HIV is highest in Cambodia (11.9%), but is low in the other countries with a high burden of tuberculosis in the Region (see Chapter 3 for details on the grouping of countries), particularly in China (0.5%), the Philippines (0.3%) and Viet Nam (1.5%). With the exception of Cambodia, the percentages of incident cases of tuberculosis attributable to HIV are lower in countries with a high burden of TB than in several countries with an intermediate burden (Singapore, 5,5%) and countries with low incidence of TB (Australia 2%).
1.7 Tuberculosis mortality It is estimated that 372 900 deaths from tuberculosis occurred in the Region in 2001, i.e. 21.7 deaths from tuberculosis per 100 000 population. The percentage of tuberculosis deaths attributable to HIV in the Region is 1.4%. The death rate from tuberculosis per 100 000 population is highest in Cambodia (107.1, of which 15.1% are attributable to HIV), as compared to 57.2 in the Philippines, 56 in Papua New Guinea, 25.1 in Viet Nam and 21 in China.
4
http://www.who.int/emc-hiv/fact_sheets/index.html, accessed 15 December 2003
6
CHAPTER
2
Review of DOTS implementation and treatment results Twenty-five countries reached 98% DOTS coverage or above
A
mong the 35 countries and areas in the Region that reported in 2002, 33 had at least part of their population served by DOTS units, compared to 18 in 1998. Thirty-one countries had a tuberculosis manual and have a special budget for tuberculosis control. Shortcourse chemotherapy is used in all DOTS areas by 31 countries. Thirty-two countries have implemented a mechanism for cohort analysis of treatment outcomes.
2.1 Population with access to DOTS The population in the Region with access to DOTS increased from 67% in 2000 to 77% in 2002 (Table 1). DOTS was applied in 94% of operational health units (6295 out of 6695) in the Region and in 56% of the health units in China (1551 out of 2754). Twenty-five countries reached 98% DOTS coverage or above (Table 1).
2.2 DOTS enrolment In 2002, 84% of all cases and 92% of new smear-positive cases in the Region were diagnosed and treated under DOTS. This is a rapid improvement compared to 1999, when the figures were 69% for all cases and 78% for new smear-positive cases. The increase was particularly marked in the Philippines (from 28% in 1999 to 100% in 2001) and Japan (from 37% in 1999 to 57% in 2002). The proportion of new cases notified in DOTS areas in China continued to increase: 84% in 2002, as compared to 75% in 2001.
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TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2004
FIGURE 6
Trends in population with access to DOTS and DOTS enrolment rate (all cases) in the Western Pacific Region, 1995–2002 (%)
90
75
60
45
30
15
In non-DOTS areas, the treatment success rate was 73% of 24 962 cases (59% of the 42 622 cases notified)
0 1995 1996 1997 1998 1999 2000 2001 2002
DOTS enrolment rate (all types)
Population with access to DOTS
2.3 Treatment results of new smear-positive cases In DOTS areas, the treatment cure and success rate were 86% and 92%, respectively, for the cohort of 322 220 new pulmonary smear-positive cases registered for treatment outcome evaluation in 2001 (they represented 85% of the 379 060 cases notified that year) (Table 15). The percentage of cases not evaluated was 1%. In China, 83% of new smear-positive cases were registered for treatment results (176 476 out of 212 766 notified in 2001) and the treatment cure rate was 94%. In non-DOTS areas, the treatment success rate was 73% of 24 962 cases (59% of the 42 622 cases notified) (Table 16). In China, 58% of the 24 286 notified cases in 2001 were evaluated and the treatment success was 86%.
2.4 Treatment results of re-treatment cases In DOTS areas, 44 652 re-treatment cases were registered for treatment outcomes evaluation (including relapses, failures and returns after treatment interruption). The treatment success rate was 90.7%, the cure rate was 84.9% and 1.3% of the cases were not evaluated (Table 17).
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TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2004
FIGURE 7
Treatment success for new smear-positive cases in DOTS and non-DOTS areas, 2001 cohort (%)
100
75
50
25
0
DOTS Non evaluated Others
Non-DOTS Treatment success
9
CHAPTER
3
Grouping of countries In 2002, the seven countries accounted for 86% of the Region’s population and 94% of all estimated cases
3.1 Tuberculosis in countries with a high burden even countries in the Region – Cambodia, China, the Lao People’s Democratic Republic, Mongolia, Papua New Guinea, the Philippines and Viet Nam – have been identified as countries with a high burden of tuberculosis. In 2002, these seven countries accounted for 86% of the Region’s population and 94% of all estimated cases. They notified 88% of all cases (712 978 out of 806 460) and 91% of the smearpositive cases in the Region (338 614 out of 372 220) (Table 1). The combined DOTS case detection was 36% for all types and 38% for the new smear-positive cases. DOTS expansion made the most progress in this group of countries. In 2002, 80% of the population had access to DOTS (71% the previous year). Treatment success exceeded 85% in five of these countries (including China). Mongolia and Viet Nam have reached the targets of 70% case detection and 85% treatment success for new smear-positive cases. Mongolia attained the WHO targets for the first time in 2001, two years after reaching full DOTS coverage in 1999. Viet Nam has been maintaining high case detection and treatment success for several years. Cambodia, China and the Philippines have all exceeded the 85% treatment success target.
S
3.1.1 TB control policies and DOTS components in countries with a high burden All countries with a high burden of TB are using WHO-recommended National TB guidelines and have central procurement and distribution systems for TB drugs and national reference laboratories. Five countries allot tuberculosis its own budget. DOTS is implemented in all public hospitals in Cambodia, Mongolia, the Philippines and Viet Nam, and in 71% of health centre units in China, 60% in the Lao People’s Democratic Republic and 22% in Papua New Guinea. All the countries use sputum smear microscopy for diagnosis (with the exception of Papua New Guinea, where it is used in some units only). DOT is applied in all public health units within DOTS areas. Treatment and smear microscopy examinations are free for the patients in six countries, while China has a patient fee system in non-DOTS areas. Reporting of treatment results is based on cohort analysis in all units in all countries with a high burden of tuberculosis. Screening and treatment of contact children is carried out in some units only.
3.1.2 Notification in countries with a high burden In 2002, the notification rate for all cases exceeded 100 per 100 000 population in four of the seven countries with a high burden of TB: 178 in Cambodia, 151 in the Philippines, 150 in Mongolia and 119 in Viet Nam. The estimated incidence5 of smear-positive cases was 24.3, reflecting largely the TB situation in China. The case detection rate was 32% in China, where around 70% of the 5
Based on the 2001 update of estimated cases from WHO, Geneva.
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TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2004
estimated cases of the Region reside. Therefore, DOTS expansion in China is a pre-condition for reaching the WHO target of 70% case finding in the Region. The notification rate of new smear-positive cases increased between 1995 and 2001 in Mongolia. It also increased slightly in Viet Nam, the Lao People’s Democratic Republic and China, and over the past year in Cambodia and the Philippines. Fluctuations in the Papua New Guinea results are mostly due to significant variations in the reporting system (Figure 8). FIGURE 8
Trend in notification rate of new smear-positive cases, countries with a high burden of TB, Western Pacific Region, 1995–2002 (rate per 100 000)
150 125 100 75 50 25 0 1995 1996 1997 China
1998 Philippines
1999
2000
2001
2002
Cambodia Papua New Guinea
Lao Peoples Democratic Republic Mongolia Viet Nam Western Pacific Region
3.1.3 DOTS implementation in countries with a high burden DOTS has made faster progress in countries with a high burden than in others. By the end of 2002, 79.9% of the population in the countries with a high burden had access to DOTS, compared to 63% in 1998. Nearly all of the populations of Viet Nam, Mongolia and Cambodia can access DOTS (Table 2). DOTS coverage also increased to 98% in the Philippines, 77% in the Lao People’s Democratic Republic, and 24% in Papua New Guinea. China’s population with access to DOTS increased to 78% (68% the previous year). TABLE 2
DOTS in countries with a high burden, Western Pacific Region, 1998–2001 (%) Pop. accessible to DOTS Country Cambodia China Lao People’s Democratic Republic Mongolia Papua New Guinea Philippines Viet Nam Countries with a high burden Other countries Western Pacific Region 1998 100 64 71 97 9 17 96 63 24 58 2002 100 78 77 100 24 98 100 80 56 77 Case detection rate* new S+ 1998* 54 33 39 57 41 70 83 43 66 44 2002 52 30 43 69 15 58 82 38 62 40 DOTS case detection rate* new S+ 1998 54 30 39 51 8 10 81 32 22 32 2002 52 27 43 69 15 58 82 37 31 36
* Case detection rates and DOTS case detection rates have been made available since the publication of estimated cases in Global Burden of Tuberculosis, in 1999. Data from China was revised in 2003: re-treatment smear-positive cases are no longer included in the smear-positive new category, resulting in slightly lower case detections of smear-positive cases in both China and the WPR as a whole.
11
TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2004
The population with access to DOTS increased the most in the Philippines – from 17% in 1998 to 98% in 2002. In China, an increase of 14 percentage points since 1998 translates as 176 million more population with access to DOTS (Figure 9). FIGURE 9
Comparison of population with access to DOTS in countries with a high burden, Western Pacific Region, 1998 and 2002 (%)
Cambodia China Lao Peoples Democratic Republic Mongolia Papua New Guinea Philippines Viet Nam
Patients treated under DOTS benefited from better management and follow-up
Western Pacific Region 0 20 40 1998
60 2002
80
100
3.1.4 Treatment results in countries with a high burden Better treatment outcomes were observed in the countries with a high burden, with the greatest DOTS enrolment. Treatment success in DOTS areas was 93% in countries with a high burden (new smear-positive cases registered in 2001), compared to 78% in other countries and the proportion of patients not evaluated6 was only 1% in countries with a high burden, compared to 5% in other countries (Table 3).
TABLE 3
Treatment outcomes of new smear-positive in seven high-burden countries, cohort 2001 in DOTS areas, Western Pacific Region Outcomes of treatment (%) Country Cambodia China Lao People’s Democratic Republic Mongolia Papua New Guinea Philippines Viet Nam Total Other countries Western Pacific Region Registered Non evaluated Completed Transferred Treatment number (% ) Cured treatment Defaulted Failed Died out success 14 277 176 476 1484 1631 469 55 402 55 236 304 975 17 245 322 220 0.0 0.7 3.8 0.1 3.8 0.0 1.9 0.8 5.2 1.0 89.3 94.0 66.8 83.4 45.4 74.5 89.2 89.1 27.2 85.8 2.5 2.1 9.8 3.3 21.5 13.1 1.6 4.1 50.2 6.6 2.9 0.7 8.4 3.9 22.8 6.0 1.5 2.0 4.8 2.2 0.4 0.7 0.7 4.5 0.4 1.3 0.9 0.9 2.4 1.0 4.0 1.1 8.0 2.3 3.4 2.3 3.0 1.9 9.3 2.3 0.9 0.6 2.6 2.6 2.6 2.7 1.9 1.3 0.7 1.2 91.8 96.1 76.6 86.7 67.0 87.6 90.8 93.2 77.5 92.4
6
Among the cohort of new smear-positive pulmonary patients registered for a treatment outcome in 2001.
12
TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2004
The cure rate was 89.1% in countries with a high burden (27% in others) (Table 3). Patients treated under DOTS benefited from better management and follow-up (including sputum examinations at the end of treatment to confirm that the patient had been “cured”). By country, the treatment success for pulmonary new smear-positive cases exceeded 85% in five countries, while it was 76.6% in the Lao People’s Democratic Republic (compared to 62% in 1997) and 67% in Papua New Guinea (Table 3). The Philippines’ figures improved from 83% in 1997 to 87.6% in 2001. Meanwhile Cambodia, China and Viet Nam have maintained high treatment success rates since 1997.
3.2 Tuberculosis in countries with an intermediate burden Countries with a intermediate burden of TB include Brunei Darussalam, Hong Kong (China), Japan, the Republic of Korea, Macao (China), Malaysia and Singapore. A stagnation of notification rates (defined as a slow-down or reversal of the annual decline of the crude notification rate) is observed in all countries with an intermediate burden over the last decade, with the exception of the Republic of Korea (mean annual change: -11%). However, the causes of this stagnation vary between countries. Although ageing of the population and the epidemic appears to be a major contributing factor, depending on the local situation, other factors, such as migration and HIV, do play an important role.
TABLE 4
Mean annual change in notification rate in countries with an intermediate burden (%) Mean annual change Brunei Darussalam Hong Kong (China) Japan Republic of Korea Macao (China) Malaysia Singapore 1960–70 -11 -4 1970–80 -3 -5 -10 1980–90 -6 -3 -4 -4 -12 -3 -7 1990–99/00 5 0 -2 -11 -1 1 -1
-6
-4
In Hong Kong (China) and Singapore, stagnation is mainly due to ageing of the tuberculosis epidemic and ageing of the population. Some risk groups seem to emerge, such as the urban poor, including the homeless. Population movements may have some importance, such as migrant workers in Singapore and travel in and out of mainland China into Hong Kong (China). In Malaysia, increasing tuberculosis notification rates in the 25-44 age group and the relatively high case fatality rates in this age group, suggest that tuberculosis is increasing at least in part due to the spread of HIV infection in this population. In Brunei Darussalam and Macao (China), changes in diagnostic practices and/or notifications, as well as ageing of the tuberculosis epidemic, appear most important, but transmission from migrant workers seems to play a role. The Republic of Korea shows a continuing decline. However, some stagnation due to ageing of the epidemic may be expected within the next 20 years, as the annual risk of infection has declined to approximately 0.5% and therefore has limited scope for further decline.
13
TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2004
3.3 Tuberculosis in Pacific island countries The Pacific island countries (PICs) include American Samoa, Cook Islands, Fiji, French Polynesia, Guam, Kiribati, Northern Mariana Islands, Marshall Islands, the Federated States of Micronesia, Nauru, New Caledonia, Niue, Palau, Pitcairn, Samoa, Solomon Islands, Tokelau, Tonga, Tuvalu, Vanuatu, Wallis and Futuna. Case notification rates vary widely among PICs. Rates also fluctuate with time due to the very small population size of many countries. However, higher rates are consistently observed north of the equator, with the exception of Guam, as compared to countries located south of the equator. Notification rates (all types) in Kiribati have been consistently higher than 200 per 100 000 since 1998, and are the highest rates recorded in the Western Pacific Region. The widely scattered populations in PICs create a great challenge to the organization of tuberculosis control.
14
TABLE 5
Key indicators of tuberculosis control in the Pacific island countries, 2002 *Number of estimated cases All cases g 18 5 246 71 132 71 63 43 89 4 185 1 17 52 382 32 8 170 5 1593 New Smr+ h 8 2 110 32 59 32 28 19 40 2 83 0 7 23 172 14 1 77 2 712 Pop. accessible to DOTS Pop. k 60 18 831 241 160 87 76 52 97 13 224 2 20 176 463 101 0 168 15 2804 % l 100 100 100 100 100 100 100 100 90 100 100 100 100 100 100 98 0 81 100 98 Number of cases in DOTS areas All cases m 2 1 150 66 51 189 53 51 127 5 65 2 11 30 256 29 13 70 10 1181 New Smr+ n 1 1 75 27 31 82 21 18 22 2 21 1 9 18 108 23 0 31 1 492 Number of cases in non-DOTS areas All cases o 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 31 9 42 New Smr+ p 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7 8 **DOTS case detection rate All cases (%) q=m/g 11 20 61 93 39 267 84 119 143 119 35 333 New Smr+ (%) r=n/h 13 50 68 84 53 257 75 95 55 106 25 333 DOTS cure and success rate Cure rate (%) s 100 85 80 53 79 0 36 100 100 84 100 58 67 91 41 74 78 63 164 40 69 41 66 67 65 100 86 Success rate (%) t 100 85 80 71 86 74 86 100 100 84 100 77 89 92 88 100 92 *TB deaths per 100 000 u 6.0 5.7 5.0 3.8 16.4 7.0 13.0 10.0 12.7 2.2 16.9 2.0 10.0 5.0 14.8 6.3 3.0 6.0 16.3 4.3 21.7
Notification in DOTS and other areas *Pop. x 1000 a 60 18 831 241 160 87 76 52 108 13 224 2 20 0 176 463 2 103 10 207 15 2868 All cases Number Rate b c 4 7 1 6 150 18 66 27 51 32 189 217 53 70 51 98 127 118 5 38 65 29 2 100 11 55 30 256 29 13 101 19 1223 17 55 28 130 49 127 42.6 New Smr+ Number Rate e d 3 2 6 1 9 75 11 27 19 31 94 82 28 21 35 18 20 22 15 2 9 21 50 1 45 9 18 108 23 0 38 1 500 10 23 22 0 18 7 17.4 % f=d/b 50 100 50 41 61 43 40 35 17 40 32 0 100 60 42 79 0 38 5 41
Case detection rate All cases (%) i=b/g 22 20 61 93 39 267 84 119 143 119 35 333 67 58 67 91 163 59 389 77 New Smr+ (%) j=d/h 25 50 68 84 53 257 75 95 55 106 25 333 121 78 63 164 0 50 45 70
Country American Samoa Cook Islands Fiji French Polynesia Guam Kiribati Mariana Islands Marshall Islands Micronesia Nauru New Caledonia Niue Palau Pitcairn Samoa Solomon Islands Tokelau Tonga Tuvalu Vanuatu Wallis & Futuna Western Pacific
15
*2003 update, WHO Geneva. **DOTS detection rate is the proportion of total estimated cases who are diagnosed and treated under DOTS.
PART II
Tables NOTIFICATION Table 6 Notification of tuberculosis cases by type, Western Pacific Region, 2002 Table 7 Age and sex distribution of new sputum smear-positive (SS+) cases in DOTS and non-DOTS areas, Western Pacific Region, 2002 Table 8 Trend of notified tuberculosis cases (all types) in DOTS and non-DOTS areas Table 9 Trend of notified tuberculosis cases (new smear-positives) in DOTS and non-DOTS areas Table 10 Trend of tuberculosis notification rates per 100 000 (all types) Table 11 Trend of tuberculosis notification rates per 100 000 (smear-positive cases) IMPACT Table 12 Input data used for estimation in the WHO Western Pacific Region Table 13 Summary of TB-HIV estimates for WHO Western Pacific Region, year 2001 Table 14 Summary of TB-HIV estimates for the WHO Western Pacific Region, 2001 TREATMENT RESULTS Table 15 Treatment outcome of new smear-positive cases registered in 2002 in DOTS areas Table 16 Treatment outcome of new smear-positive cases registered in 2001 in non-DOTS areas Table 17 Treatment outcome of re-treatment cases registered in 2001 in DOTS areas 27 28 29 24 25 26 18
19 20 21 22 23
17
Tables
TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2004
TABLE 6
Notification of tuberculosis cases by type, Western Pacific Region, 2002 Pulmonary Sputum positive % out of the total 50 21 % out % of all SS+ of new out of all pulmonary Relapse pulmonary 100 55 70 70 42 100 50 41 61 29 33 43 32 70 38 55 40 35 17 44 40 32 27 50 82 17 55 83 48 100 68 52 76 37 43 73 41 78 43 61 40 50 42 63 100 45 51 100 90 30 56 0 5 10 787 26 077 0 2 8 2 232 1126 3 2957 87 18 0 0 0 4 134 0 1 5 0 0 77 3628 100 56 76 86 54 100 69 67 80 42 47 76 52 82 48 61 40 50 49 68 100 47 53 100 90 33 59 Sputum negative % out of the total 0 17 18 12 40 0 23 26 16 44 41 14 37 16 46 35 60 35 21 22 0 38 25 0 9 38 40
Extrapulmonary % out of the Total total 2 50 472 47 47 21 3711 15 17 679 0 4 0 All types 4 1013 221 24610 462 609 1 150 66 51 6608 32 828 189 34 967 2621 388 14 389 53 51 127 3829 5 65 329 2 11 5324 118 408 0
Country American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong (China) Japan Kiribati Republic of Korea Lao People’s Democratic Republic Macao (China) Malaysia Mariana Islands Marshall Islands Micronesia Mongolia Nauru New Caledonia New Zealand Niue Palau Papua New Guinea Philippines Pitcairn Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis & Futuna Total
New 2 210 112 17 258 194 972 1 75 27 31 1890 10 807 82 11 345 1829 147 7958 21 18 22 1670 2 21 88 1 9 926 65 148
Total 0 168 39 2852 185 840 0 34 17 8 2919 13 361 27 13 057 418 178 5063 32 18 27 859 0 25 81 0 1 2040 47 520
39 26 14 21 5 10 804 12 6356 19 77 41 3971 287 41 11 11 11
1368 10 0 0
15 29 22 17 1166 30 3 60 18 28 105 32 1 50 0 0
2281 43 2112 2
18 549 108
60 36 42
72 57 51
0 91 2
72 67 52
7 320 101
23 21 39
5 17 154 10 45 18
30 1516 256
23 0 38 56 811 1 372 219
79 0 38 59 5 46
85
1 0
89
3 0
10 0 45 19 89 36
2
7
29 13 101 95 577 19 806 458
5 38 17 17 14 704 15 1 55 528 5 7
45 70 6 53
1 5469 0 40 727
46 77 6 58
45 18 593 17 293 670
18
TABLE 7
Age and sex distribution of new sputum smear-positive (SS+) cases in DOTS and non-DOTS areas, Western Pacific Region,* 2002 New SS+ males Country 0-14 15-24 25-34 35-44 45-54 55-64 >=65 New SS+ females Total 0-14 15-24 25-34 35-44 45-54 55-64 >=65 Total 0-14 15-24 New SS+ males and females 25-34 35-44 45-54 55-64 >=65 Total Sex ratio (M/F) 1.5 1.5 1.1 2.1 1.4 1.1 1.4 2.4 2.4 0.9 1.7 1.5 2.2 2.2 1.3 1.6 0.4 1.2 1.0 0.9 1.3 1.0 2.7 1.0
American Samoa 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 Australia 1 15 20 26 19 13 34 128 0 15 21 15 6 4 23 84 1 30 41 41 25 17 57 212 Brunei Darussalam 2 15 15 7 6 8 14 67 0 11 9 8 5 5 7 45 2 26 24 15 11 13 21 112 Cambodia 54 791 1449 1956 1799 1624 1432 9105 54 600 1114 1737 1898 1650 1100 8153 108 1391 2563 3693 3697 3274 2532 17 258 China 925 17 933 25 242 22 645 23 884 19 564 22 562 132 755 1152 13 250 15 188 10 505 8796 6586 6740 62 217 2077 31 183 40 430 33 150 32 680 26 150 29 302 194 972 Cook Islands 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 Fiji 0 13 9 8 5 7 2 44 0 8 6 8 2 5 2 31 0 21 15 16 7 12 4 75 French Polynesia 0 4 2 1 3 3 1 14 0 4 2 1 2 2 2 13 0 8 4 2 5 5 3 27 Guam 3 3 5 5 6 12 4 38 5 1 6 3 3 2 7 27 8 4 11 8 9 14 11 65 Hong Kong (China) 2 99 104 162 206 218 545 1336 8 97 115 89 56 35 154 554 10 196 219 251 262 253 699 1890 Japan 2 191 549 579 1192 1334 3747 7594 3 192 395 259 248 308 1808 3213 5 383 944 838 1440 1642 5555 10 807 Kiribati 5 11 1 7 7 7 0 38 5 15 8 8 3 4 1 44 10 26 9 15 10 11 1 82 Republic of Korea 20 806 1333 1374 1265 1029 1390 7217 19 759 854 456 334 377 1329 4128 39 1565 2187 1830 1599 1406 2719 11 345 Lao People’s Democratic Republic 4 86 159 220 223 227 185 1104 2 72 141 151 152 117 90 725 6 158 300 371 375 344 275 1829 Macao (China) 1 13 8 21 20 17 21 101 1 7 10 7 9 1 11 46 2 20 18 28 29 18 32 147 Malaysia 22 562 1106 1182 997 758 844 5471 30 421 524 415 485 319 293 2487 52 983 1630 1597 1482 1077 1137 7958 Northern Mariana Islands 1 2 3 7 10 5 2 30 0 9 10 3 1 0 0 23 1 11 13 10 11 5 2 53 Marshall Islands 0 1 2 1 3 2 2 11 0 2 0 0 3 1 1 7 0 3 2 1 6 3 3 18 Micronesia 2 0 1 1 1 1 0 6 3 5 1 1 2 0 2 14 5 5 2 2 3 1 2 20 Mongolia 9 242 272 184 94 57 47 905 16 263 253 133 55 22 23 765 25 505 525 317 149 79 70 1670 Nauru 0 0 1 0 0 0 0 1 0 0 0 1 0 0 0 1 0 0 1 1 0 0 0 2 New Caledonia 0 2 2 1 1 1 3 10 0 4 2 2 3 0 0 11 0 6 4 3 4 1 3 21 New Zealand 0 10 14 5 6 4 10 49 1 15 8 4 3 5 3 39 1 25 22 9 9 9 13 88 Niue 1 0 0 0 0 0 0 1 0 1 0 0 0 0 0 1 1 1 0 0 0 0 0 2 Palau 1 0 1 1 2 2 1 8 0 0 3 0 0 0 0 3 1 0 4 1 2 2 1 11 Papua New Guinea 18 139 133 74 62 37 6 469 22 160 149 60 47 18 1 457 40 299 282 134 109 55 7 926 Philippines 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Pitcairn Samoa 0 1 2 0 1 1 1 6 1 4 5 0 2 0 0 12 1 5 7 0 3 1 1 18 Singapore 0 14 28 73 88 65 130 398 2 10 15 30 32 24 38 151 2 24 43 103 120 89 168 549 Solomon Islands 3 16 12 9 9 7 4 60 0 16 15 4 2 7 4 48 3 32 27 13 11 14 8 108 Tokelau 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Tonga 0 1 0 0 4 0 10 15 0 1 1 1 0 1 4 8 0 2 1 1 4 1 14 23 Tuvalu 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Vanuatu 0 7 2 3 10 2 1 25 0 3 1 5 0 3 1 13 0 10 3 8 10 5 2 38 Vietnam 57 3250 6762 8855 8040 5162 8184 40 310 68 1571 2357 2508 2619 2409 4969 16 501 125 4821 9119 11 363 10659 7571 13 153 56 811 Wallis Futuna 0 1 0 1 1 0 1 4 0 0 0 0 3 2 0 5 0 1 0 1 4 2 1 9 WPR 1133 24 228 37 237 37 408 37 964 30 169 39 183 207 322 1392 17 516 21 213 16 414 14 771 11 907 16 613 99 826 2525 41 744 58 450 53 822 52 735 42 076 55 796 307 148 % 1 12 18 18 18 15 19 100 1 18 21 16 15 12 17 100 1 14 19 18 17 14 18 100 *Breakdown of cases by age and sex was not available for the Philippines.
19
0.5 2.6 1.3 1.9 1.9 2.4 0.8 2.1
TABLE 8
Trend of notified tuberculosis cases (all types) in DOTS and non-DOTS areas American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong (China) Japan Kiribati Republic of Korea Lao People’s Democratic Republic Macao (China) Malaysia Northern Mariana Islands Marshall Islands Micronesia Mongolia Nauru New Caledonia New Zealand Niue Palau Papua New Guinea Philippines Pitcairn Samoa Singapore Tokelau Solomon Islands Tonga Tuvalu Vanuatu Viet Nam Wallis & Futuna WPR
Year 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 7 8 2 2 6 6 8 12 5 8 9 13 5 15 2 4 6 0 6 0 4 3 3 2 1251 1292 1542 1457 1386 230 216 196 285 257 95 67 183 30 205 37 210 10 180 78 81 73 58 64 71 55 41 7191 89 245 6623 7903 8065 7729 80 76 70 65 97 81 910 89 803 98 532 91 572 85 669 87 88 87 74 169 789 419 460
10 264 442 1101 585 455 671 571 420 389 320 274 343 329 294 318 349 354 455 589 463 0 449 465 388 10 11 11 10 441 094 168 970 26
8 6 4 6 7
1075 1107 1123 1160 1094 1325 1514 1652 2994 2819 2433 2538 2233 1659 1611 1516 1418 1730 3010 3010 2987 2915 3348 3109 3526 3829
608 595 542 108 474 128 448 107 437 161 415 144 402 104 98 74 111 359 320 296 295
7 14 9 17 10 17 14 20 26 13 38 17 3 6 2 1 25 2 41 1 19 2 5 0 15 1
2212 107 108 2446 118 2232 108 2525 112 2418 116 587 813 307 821
36 2760 355 59 58 59 49 2964 2800 2710 2425 411 452 266 313
62
150
222 855 294 308 346 353 647 161 198 240
629 40 455 94 916 146 867 187
89 131 68 650 71 7 184 11 821 64 33 178 43 062 49 18 92 43 506
1270 245 8158 98 654 19 163 48 49 1219 276 7572 117 557 29 185 66 48 1299 256 10 241 151 564 20 165 73 54 1088 906 907 954 238 10 145 226 899 212 10 325 265 095 189 9106 313 604 126 10 691 362 114 36 17 16 15 230 199 173 162 75 79 63 64 37 49 34 41
7527 63 940 193 7301 62 021 127 7843 61 521 111 7545 7432 7269 7021 58 56 56 54 567 690 496 357 103 129 110 208
11 894 75 12 67 11 634 74 15 73 10 577 58 12 75 10 10 11 10 569 735 068 944 64 15 66 16 37 60 49 32 97 27 11 77 7 68
2742 104 715 2954 106 300 3505 151 863 3678 151 028 2877 153 129 3235 163 740 4261 183 113 3396 217 272 2497 317 008 3401 207 371 2540 236 172 5516 174 189 5335 180 044 8041 235 496 5087 276 295 7977 208 301
43 2179 324 0 45 12 173 51 206 41 2065 302 50 23 171 43 185 37 2143 337 0 54 9 188 43 875 1952 1760 29 1616 29 1666 377 2 49 32 124 292 35 27 131 334 9 24 22 90 372 1 14 24 118 46 47 55 52 941 557 505 463
355 645 457 427 534 450 611 650 714 766 088 256 475 627
20
952 128 7906 367 799 1016 143 6501 375 481 950 10 903 376 246
1 218 58 75 1 252 59 40 210 49
6704 53 112 121 6510 51 821 68 6283 50 612 6534 48 956 100 6537 47 437 6319 44 590 253 6212 43 078 0 6501 42 122 327 6983 42 190 32 7673 44 016 276 7087 40 800 253 7578 39 384 210 7262 35 489 189 6608 32 828 189
70 012 63 904 57 864 1 951 48 070 994 46 999 1 905 38 155 1 135 33 196 1 307 31 134 1 440 26 202 1 923 30 008 2 165 23 936 2 437 21 782 2 234 37 268 2 382 34 967 2 621
10 686 28 10 873 11 059
110 303 130 348 140 335 140 317 149 274 4 132 352 0 0 307 0 205 323 0 0 328 0 102 367 0 0 348 4 86 344 3 64 377 5 65 329
37 1617 488 35 25 144 52 270 44 1591 382 1 23 23 140 47 536 309 19 16 234 54 509
796 087 888 409 784 409
1011 16 148 12 240 83 991 160 13 270 344 218 6 82 70 15 112 363 804 4 225 89 94 1073 1073 1145 899 0 14 599 357 829 0 14 857 469 358 0 15 629 418 903 0 16 946 457 349 1 203 0 0 200 86 0 171 91 2 166 105 0 0 0 0
11 420 67 52 111 12 075 61 151 11 708 46 171 11 778 40 0 0 12 902 0 56 94 13 539 93 0 108 14 115 97 49 138 14 908 66 42 102 15 057 75 34 91 14 830 58 56 95 14 389 53 51 127
26 1512 364 1 23 30 147 56 594 4 433 480 49 1722 367 32 28 114 52 994 711 162 45 1677 332 0 23 19 152 51 763 11 723 716 0 51 1889 352 1 20 36 79 55 739 4 774 721 0 37 1889 289 1 22 0 0 74 711 0 942 481 0 32 1977 318 0 21 0 184 84 964 14 834 722 0 22 2120 295 0 30 18 178 87 449 0 839 121 0 31 1654 289 0 22 0 43 1728 303 0 24 0 22 1536 292 0 11 0 117 88 879 0 823 421 0 152 89 792 0 806 970 0 173 90 679 0 811 263
0 11 291 159 866
1073 272 19 266 460 169 1043 307 18 891 463 373 980 216 19 170 485 221 1013 221 24 610 462 609
3 192 93 0 1 144 59 54 2 183 45 63 1 150 66 51
2 32 12 189 145 807 0 0 12 121 128 495 0 2 0 11 3470 107 133 5324 118 408
0 30 1516 256 0 29 13 101 95 577 19 806 458
TABLE 9
Trend of notified tuberculosis cases (new smear-positives) in DOTS and non-DOTS areas American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong (China) Japan Kiribati Republic of Korea Lao People’s Democratic Republic Macao (China) Malaysia Northern Mariana Islands Marshall Islands Micronesia Mongolia Nauru New Caledonia New Zealand Niue Palau Papua New Guinea Philippines Pitcairn Samoa Singapore Tokelau Solomon Islands Tonga Tuvalu Vanuatu Viet Nam Wallis & Futuna WPR
Year 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 1 3 0 6 0 3 2 2 1 536 557 0 0 171 203 68 0 6 3 6 9 2 5 3 881 741 807 765 723 690 596 634 583 5801 5316 5507 5235 8715 7173 8246 5842 5132 8507 12 910 90 184 9560 84 898 11 058 104 729 19 236 25 628 38 367 53 078 60 949 145 41 101 32 114 41 111 52 97 39 98 32 79 48 82 52 99 48 86 49 75 45 65 44 76 43 83 63 34 4 75 40 4 39 53 1 60 38 40 0 68 0 0 0 0 0 0 69 37 0 66 41 1 74 34 13 373 13 198 12 806 12 291 12 214 12 649 13 010 13 277 4142 13 808 4110 13 745 4042 14 405 3918 14 592 3768 14 710 3670 15 498 3564 15 285 15 540 22 4 21 34 633 10 38 211 34 43 868 17 46 735 14 45 688 42 561 48 515 49 083 45 066 39 040 33 968 30 700 28 790 17 736
6050 6313 6622 6819 6766 7320 7251 6660 6682 6653 6924 6718 133 124 526 459 765 752 726 886 1234 1508 1719 1526 1533 1829 140 158 108 171 141 204 304 226 0 133 157 147 6711 6774 6752 6754 6954 6861 6688 7271 7596 7802 7960 8156 8309 7958 21 14 19 12 22 14 14 26 0 0 8 15 0 11 0 11 3 28 4 5 22 5 4 6 11 34 60 363 320 271 276 234 185 128 92 87 200 622 622 1171 1356 1513 1389 1631 1670 40 37 33 32 35 2 42 0 0 0 0 0 26 0 30 0 0 4 38 2 34 2 21 91 61 47 76 57 81 69 74 68 88 0 0 1 1 0 0 8 11 9 4 7 0 69 66 55 62 10 5 2 6 4 0 4
852 903 883 967 17 275 867 19 006 942 20 676 870 18 657 1061 21 291 870 39 571 606 50 624 839 72 150 1273 63 655 951 97 070 611 489 2 812 92 279 573 87 401 1652 94 768 652 86 695 1195 83 353 2107 71 663 1914 73 373 2267 67 056 462 59 341 926 65 148 21 18 0 15 0 10 0 14 0 7 0 17 0 13 0 12 0 18
1285 182 1375 174 1197 184 1266 153 32 1062 174 30 998 176 25 20 860 130 992 155 949 155 839 101 740 115 794 137 823 149 840 117 88
29 41 28 32 23 18 10 25 3 23 25 23 18 12 7 16 17 7 3 3 5 7 7 2 7 5 5 2 1 6 0 0 0 0 0 0 0
57 52 52 59 34 33 243 49 33 014 55 32 612 55 30 426 51 34 217 36 30 381 26 34 530 46 39 486 39 35 095 30 728 35 865 84 38 659
22 917 22 934 57 388 78 049 118 202 148 558 150 982 161 230 208 493 226 410 186 522 178 366 199 654 94 522 100 286 184 312
21
6 32 7 18 8 14 4 10 18
841 130 0 17 155 16 861 114 0 17 455 109 1 455 9 90 1 16
2429 15 210 99 16 630 14 777 184 18 375 0 14 367 1536 13 571 1869 11 935 1566 12 909 1940 11 853 1853 11 408 1890 10 807 0 11 754 11 59 54 9957 9 559 8 216 2116 12 867 144 11 420 50 10 359
41 36 534 267 476 62 35 613 2 282 061 30 37 550 0 314 624 0 48 911 0 352 935 66 53 647 1 375 801 38 54 873 0 393 244 43 53 805 0 393 801 63 53 169 0 385 434 56 54 202 0 379 060 38 56 811 1 372 219
0 11 101 134 488 0 12 065 173 034 0 12 686 195 396 0 13 865 202 817
0 17 10 11 28
432 113 0 12 480 140 0 16 465 93 0 10 248 109 0 15 357 118 0 8 549 108 0 23
285 102 15 744 201 775 251 84 14 822 204 765 228 95 14 361 204 591 210 112 17 258 194 972
0 65 33 0 0 62 29 42 2 73 24 47 1 75 27 31
15 17 16 27 11 15 19 15 8 21 18 22
1 20 0 0 0 1 0 9
64 11 805 82 11 345
TABLE 10
Trend of tuberculosis notification rates per 100 000 (all types) American Samoa Year 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 40 23 26 6 6 18 17 24 34 14 22 24 35 14 32 4 8 11 0 10 0 6 5 4 3 10 207 9 9 133 11 121 10 106 9 148 8 123 118 8 110 107 8 95 142 7 106 137 6 94 136 6 80 117 6 6 6 6 6 6 6 6 6 5 6 5 5 5 52 135 99 56 79 130 188 56 143 152 0 146 0 145 0 149 0 158 85 175 91 157 65 143 63 178 167 206 59 10 106 11 161 14 105 21 180 25 85 30 94 33 33 33 33 29 30 29 38 34 36 36 37 38 36 71 32 21 5 0 0 10 15 6 10 6 88 5 6 44 43 30 33 33 28 25 28 24 32 28 23 22 29 34 28 32 29 26 25 21 20 23 17 22 18 81 68 55 55 49 39 31 40 46 47 44 37 34 32 33 27 45 39 41 0 39 40 46 40 26 19 27 58 176 82 156 76 141 68 161 51 158 37 149 49 145 42 138 45 145 31 137 40 135 27 130 33 123 60 116 32 112 106 111 49 113 64 109 0 96 0 99 0 106 0 115 0 105 35 112 40 104 32 95 87 505 78 173 70 71 66 162 218 61 243 236 56 307 254 54 322 52 208 229 51 179 211 49 163 212 47 202 212 46 169 208 45 315 177 43 178 165 42 100 149 41 134 39 141 110 38 107 36 329 105 34 0 74 34 409 69 34 40 57 65 51 46 79 74 35 333 32 298 31 250 28 225 26 217 45 23 41 411 196 150 217 146 101 94 72 60 76 70 77 83
Australia
Brunei Darussalam
Cambodia
China
Cook Islands
Fiji
French Polynesia
Guam
Hong Kong (China)
Japan
Kiribati
Republic of Korea
Lao People’s Democratic Republic
Macao (China)
Malaysia 89 80 80
83 81 78 153 82 441 78 435 70 305
Northern Mariana Islands
Marshall Islands 65 30 21 14 19 22
38 93 45 100 34 85
Micronesia
Mongolia 76 71 71 70 71 65 77 86 91
Nauru
72 111 95 69 66 48 69 69 79 84 82 85 36 74 0 111 0 50 0 33 24 38 41 29 29
New Caledonia 78 90
New Zealand 20 20 19 17 15 14 14 13 12 11 10 9 9 9 10 10 9 8
Niue
38 50 100 64 113 67
142 83 204 100 84 204 154 106 284 217 108 276 93 85 274 271 90 279 121 25 50 118 308 87 362 67 516
Palau
Papua New Guinea
65 338 79 238 84 260 77 234 84 233 78 236
Philippines
Pitcairn
Samoa 37 37 31 27 25 23
52 123 154 23 119 172 38 126 192 117 205 112 118 99 134 88 130 83 117 84 125 0 0
Singapore
Solomon Islands
Tokelau
Tonga 74 68 95
75 100 163 69 471 155 52 225 77 45 150 140 48 288 134 56 113 145 49 400 36 338 25 275 15 300 29 313 23 288 95 97 62 79 90 96
Tuvalu
221 115 152 128 134 23 80 79 91 76 75 78 77 86 82 81 72 81 82 74 71 76 99 112 112 117 29 45.7 79 45.5 27 48.2 0 57.9 50.6 49.2 49.0
Vanuatu
Viet Nam
Wallis & Futuna
WPR
22
67 320 54 73 162 67 80 128 64 148 66 136 107 103 125 65 62 61 71 74 26 18 79 127 72 109 79 75 69 64
18 18 22 27 16 29 27 31 22 19 13 18 25 14 17
76 140 100 68 102 62 116 450 63 122 60 153 59 120 94 54 109 62 104 59 57 56 57 61 47 53 37 36 91 93 74 79 71 63 74 63 55 50 50 50 0 50 50
60 61 146 106 103 63 120 151 59 58 63 98 66 0
90 330 67 65 377 50 156 135 269
19 200 156 23 375 96 33 311 73 23 211 20 360 22 0 21 30 180 22 0 24 0 11 0 28 130 92 47 0 98 63 76 86 49
24 88 27 80 29 103 37 134 40 105 44 0 42 103 44 104 47 84
171 77 0 0 122 98 75 120 0 83 116 80 103 111 67 74 125 79 131 75 138 118 150
10 100 256 130 272 9 50 112 187 347 5 100 29 116 399 9 0 88 177 295 10 50 0 245 222 9 100 178 259 198 9 0 10 0 9 100 0 55 0 236 168 71 139 95 151
64 143 66 139 68 89 66 60
0 103
111 100 50.8
68 109 56 76 108 70 98
0
115 47.7 119 127 46.9
TABLE 11
Trend of tuberculosis notification rates per 100 000 (smear-positive cases) American Samoa Year 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2 6 0 10 0 5 4 3 2 3 3 0 0 1 1 2 1 1 1 7 6 5 6 5 5 5 4 4 4 84 75 76 71 115 92 104 73 63 101 150 24 103 111 0 111 0 117 0 121 0 32 25 28 32 129 143 123 107 125 8 7 9 11 14 15 17 17 17 17 15 24 21 5 0 0 0 5 0 0 10 6 2 3 4 5 6 21 24 17 18 18 15 15 12 12 14 12 10 9 10 11 8 10 8 9 9 8 9 8 7 9 9 31 30 23 28 35 26 21 29 33 30 27 26 23 24 19 22 19 18 0 17 18 15 14 13 10 11 37 27 0 0 0 0 0 27 30 19 12 12 11 11 11 10 11 11 11 11 11 12 12 12 13 12 12 12 129 12 239 11 0 10 180 11 14 9 10 9 9 8 60 69 64 76 94 42 39 7 36 92 17 100 56 28 23 113 119 114 105 118 117 107 93 80 72 67 41 38 41 26 25 22 22 21 17 25 24 29 27 30 41 28 43 32 46 69 51 0 30 35 32 0 18 9 18 26 6 14 8
Australia
Brunei Darussalam
Cambodia
China
Cook Islands
Fiji
French Polynesia
Guam
Hong Kong (China)
Japan
Kiribati
Republic of Korea
Lao People’s Democratic Republic
Macao (China)
Malaysia 53 47 48 49 50 48 50
Northern Mariana Islands 0 65
Marshall Islands 16 13 19 18 20 29 14
Micronesia
Mongolia
Nauru
New Caledonia
New Zealand
Niue
Palau 67 33 17 43
Papua New Guinea 30 31 30 32 28 29 25 32 26
Philippines 36 38 40 36 40 72
Pitcairn
Samoa 21 19 16 12
Singapore 59 55 58 50 52 43 40 34 39 37 32 28 30 31 31
Solomon Islands 94 88 81 83 68 75 70 50 58 57 35 40 45 47 37 27 39 44 31 29 23 28 34 20 27 25 23
Tokelau
Tonga
24 32 44 29 34 329 19 125 25 38 22 26 23 19 13 7 16 17 0 0 50 50 17 16 17 9 16 12 16 10 15 8 22 88 38 38 63 88 88 25 88 63 63 22 11 60 0 0 0 0 0 0 0
Tuvalu
Vanuatu 69 58 51 46 51 28 40 43 42 39 27 18 31 24
Viet Nam 61 59 57 52 57 49 53 62 54 47 53 56 51 49 51 65 70 70 68 69 68 71
Wallis & Futuna
WPR
23
15 44 20 15 11 19
23 41 20 17 14 14 11 9 6 25 23 20 19 20 24 0 14 0 15 0 18 15 9 3 2 1 1 2 2 2 2 2 2 0 0 50 50 0 0 50 0 0 50 2 2 2 2
75 75 72 69 65 63 60 42 0 32 23 28 23 29 27 27
49 18 44 147 42 20 41 41 40 39 38 37 36 37 35 33 35 36 36 36 37 37 33 46 47 23 0 22 37 20 39 25 28 25 61
33 0 29
18 90 23 123 35 107 24 162 17 13
12 10 17 16 15 18 24 28 31 29 28 33
29 24 0 30 0 18 27 18 29 35
18 8 15 0 8 8 21 12 13 6 20
4 4 9 25 25 46 52 56 58 64 65
18
50 69 53 24 41 0 111 0 0 45
20 142 14 132 38 140 15 125 27 118 46 99 41 100 44 88 9 77 17 83
1 13 11 9 6 8 4 10 8 8 10
30 31 14 13 13 14 13 8 9 13
55 26 38 18 0 37 21 23 32 28 18
16.6 14 17.5 0 19.6 0 21.7 7 22.9 23.7 23.5 23.4 22.3 7 21.7
33 16 15
0
TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2004
TABLE 12
Input data used for estimation in the WHO Western Pacific Region To be published in Global TB Control 2004. Visit www.who.int/gtb/tbestimates for 2001 estimates published in 2003 report, and for 2000 estimates published in Corbett et al. 2003. Arch Intern Med 163:1009-1021.
Proportion of TB cases treated SS+ Country American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong (China) Japan Kiribati Republic of Korea Leo People’s Democratic Republic Macao (China) Malaysia Northern Mariana Islands Marshall Islands Micronesia Mongolia Nauru New Caledonia New Zealand Niue Palau Papua New Guinea Philippines Pitcairn Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis & Futuna cfr = case fatality rate 0.7 0.4 0.6 0.0 1.0 0.0 0.4 0.8 0.5 0.1 0.5 0.2 0.8 0.0 0.8 0.4 0.1 0.3 0.4 0.5 0.6 0.0 0.3 0.0 0.4 0.5 1.0 0.3 0.5 0.1 0.7 0.4 1.0 0.3 0.3 0.0 0.10 0.12 0.10 0.10 0.10 0.10 0.10 0.1 0.1 0.20 0.12 0.20 0.20 0.20 0.20 0.20 0.20 0.20 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 2.0 1.0 2.0 2.0 2.0 2.0 2.0 2.0 2.0 DOTS non-DOTS 0.1 0.3 1.0 0.5 0.3 0.4 0.7 0.8 0.5 0.5 0.3 1.0 0.0 0.4 0.8 0.8 0.7 0.8 0.5 0.7 1.0 0.2 0.5 1.0 1.0 0.1 0.6 0.7 0.7 0.0 0.3 0.5 0.4 0.1 0.0 0.3 0.4 0.6 0.0 0.9 0.4 0.1 0.0 0.1 0.0 0.3 0.0 0.0 0.6 0.5 0.0 0.0 0.7 0.3 0.1 0.8 1.0 0.2 0.2 0.0 0.5 1.0 0.2 1.0 0.6 1.0 0.0 0.2 1.0 0.5 0.8 1.0 1.0 0.7 1.0 0.4 1.0 1.0 0.2 0.6 0.4 SSDOTS non-DOTS 0.6 0.2 0.0 0.5 0.5 0.7 0.2 0.0 0.5 0.0 0.4 0.0 1.0 0.6 0.0 0.3 0.0 0.0 0.0 0.0 0.0 0.3 0.0 0.0 0.5 0.1 0.4 cfr SS+ HIV-ve TB (%) Duration of HIV-ve TB (yr) DOTS 0.10 0.12 0.10 0.10 0.10 0.10 0.10 0.10 0.10 0.10 0.15 0.10 0.12 0.10 0.10 0.10 0.10 0.10 0.10 0.10 0.10 0.10 0.12 0.10 0.10 0.10 0.10 non-DOTS 0.20 0.12 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.10 0.15 0.20 0.12 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.12 0.20 0.20 0.30 0.30 DOTS 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.3 1.0 1.0 1.5 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.5 1.0 non-DOTS 2.0 1.0 1.5 1.5 2.5 2.0 2.0 2.0 2.0 1.0 1.3 2.0 1.5 2.5 1.5 1.5 2.0 2.0 2.0 2.5 2.0 2.0 1.0 2.0 2.0 3.0 2.5
24
TABLE 13
Summary of TB-HIV estimates for WHO Western Pacific Region, year 2001 (numbers in thousands) To be published in Global TB Control 2004. Visit www.who.int/gtb/tbestimates for 2001 estimates published in 2003 report, and for 2000 estimates published in Corbett et al. 2003. Arch Intern Med 163:1009-1021. Incident cases of TB All forms Country American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong (China) Japan Kiribati Republic of Korea Lao People’s Democratic Republic Macao (China) Malaysia Northern Mariana Islands Marshall Islands Micronesia Mongolia Nauru New Caledonia New Zealand Niue Palau Papua New Guinea Philippines Pitcairn Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis & Futuna Population millions 0.1 20.0 0.0 13.8 1294.9 0.0 0.8 0.0 0.2 7.0 127.5 0.0 47.4 5.5 0.5 24.0 0.1 0.1 0.1 2.6 0.0 0.2 3.8 0.0 0.0 6.0 78.6 0.0 0.2 4.2 0.5 0.0 0.1 0.0 0.2 80.3 0.0 All cases 0.0 1.0 0.0 75.8 1459.1 0.0 0.3 0.0 0.1 6.5 42.0 0.0 42.9 9.4 0.4 22.7 0.0 0.0 0.1 5.4 0.0 0.2 0.4 0.0 0.0 14.0 251.4 0.1 1.8 0.4 0.0 0.0 0.0 0.2 154.5 0.0 % incr -0.03 0.00 0.03 0.03 0.01 -0.05 -0.04 -0.03 0.02 0.02 -0.03 0.02 0.02 0.03 0.01 -0.01 0.05 0.02 0.01 0.02 -0.03 0.02 0.01 -0.06 0.03 0.03 0.02 -0.04 -0.01 0.03 -0.05 -0.04 -0.04 0.03 0.02 -0.04 In adults 0.0 1.0 0.0 45.9 882.9 0.0 0.2 0.0 0.1 3.9 19.5 0.0 26.0 5.7 0.2 13.7 0.0 0.0 0.1 3.2 0.0 0.1 0.2 0.0 0.0 9.0 152.1 0.0 0.8 0.3 0.0 0.0 0.0 0.1 93.5 0.0 In HIV+ve adults 0.0 0.0 0.0 6.5 5.8 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.3 0.6 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.7 0.0 Attr to HIV 0.0 0.0 0.0 5.5 4.8 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.3 0.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.4 0.0 SS+ 0.0 1.0 0.0 33.4 656.0 0.0 0.1 0.0 0.1 2.9 18.9 0.0 19.3 4.2 0.2 10.2 0.0 0.0 0.0 2.4 0.0 0.1 0.2 0.0 0.0 6.0 113.1 0.0 0.8 0.2 0.0 0.0 0.0 0.1 69.4 0.0 TB prevalence All forms 0.0 1.0 0.0 104.6 3240.9 0.0 0.4 0.0 0.2 6.6 56.0 0.0 65.4 19.8 0.4 28.9 0.0 0.1 0.1 6.9 0.0 0.3 0.4 0.0 0.0 30.0 424.4 0.1 1.9 0.6 0.0 0.0 0.0 0.3 211.9 0.0 SS+ 0.0 1.0 0.0 43.0 1384.6 0.0 0.2 0.0 0.1 3.1 25.0 0.0 29.9 8.4 0.2 12.3 0.0 0.0 0.1 3.2 0.0 0.2 0.2 0.0 0.0 16.0 176.3 0.0 0.9 0.3 0.0 0.0 0.0 0.1 81.5 0.0 TB deaths All cases in HIV+ve adults 0.0 0.0 0.0 14.8 272.4 0.0 0.0 0.0 0.0 0.6 5.2 0.0 4.9 1.6 0.0 3.5 0.0 0.0 0.0 0.9 0.0 0.0 0.0 0.0 0.0 3.1 45.0 0.0 0.2 0.1 0.0 0.0 0.0 0.0 20.2 0.0 0.0 0.0 0.0 2.4 2.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.4 0.0 Attr to HIV 0.0 0.0 0.0 2.2 2.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.4 0.0
25
TABLE 14
Summary of TB-HIV estimates for the WHO Western Pacific Region, 2001 (rates per 100 000 population) To be published in Global TB Control 2004. Visit www.who.int/gtb/tbestimates for 2001 estimates published in 2003 report, and for 2000 estimates published in Corbett et al. 2003. Arch Intern Med 163:1009-1021. Incident cases of TB All forms Country American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong (China) Japan Kiribati Republlic of Korea Lao People’s Democratic Republic Macao (China) Malaysia Northern Mariana Islands Marshall Islands Micronesia Mongolia Nauru New Caledonia New Zealand Niue Palau Papua New Guinea Philippines Pitcairn Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis & Futuna cfr = case fatality rate All cases 30 6 59 549 113 30 30 30 91 93 33 91 91 170 85 95 91 91 91 209 31 91 11 30 91 254 320 30 43 91 30 30 30 91 192 30 % incr -0.05 -0.01 0.00 0.00 0.00 -0.05 -0.05 -0.05 0.00 0.00 -0.04 0.00 0.01 0.00 0.00 -0.03 0.00 0.00 0.00 0.00 -0.05 0.00 0.00 -0.05 0.00 0.00 0.00 -0.05 -0.03 0.00 -0.05 -0.05 -0.05 0.00 0.00 -0.05 In adults 18 3 36 332 68 18 18 18 55 56 15 55 55 103 52 57 55 55 55 127 18 55 5 18 55 154 194 18 20 55 18 18 18 55 116 18 In HIV+ve adults 0.0 0.0 0.4 47.4 0.4 0.0 0.1 0.4 1.5 0.3 0.1 0.0 0.0 0.3 0.6 1.2 0.0 0.0 0.0 0.0 0.0 0.8 0.1 0.0 0.0 5.8 0.8 0.1 1.1 0.0 0.0 0.0 0.0 0.0 2.1 0.0 % attr to HIV 0.0 2.0 1.0 11.9 0.5 0.0 0.3 2.0 2.3 0.4 0.5 0.0 0.0 0.3 0.9 1.7 0.0 0.0 0.0 0.0 0.0 1.3 1.7 0.0 0.0 3.1 0.3 0.3 5.5 0.0 0.0 0.0 0.0 0.0 1.5 0.0 SS+ 14 3 26 242 51 14 14 14 41 42 15 41 41 76 38 43 41 41 41 94 14 41 5 14 41 114 144 14 19 41 14 14 14 41 86 14 TB prevalence All forms 58 6 59 758 250 56 43 33 148 95 44 91 138 359 92 121 112 97 111 270 30 151 11 30 130 545 540 44 44 125 61 41 61 147 264 37 SS+ 26 3 26 311 107 22 18 16 61 44 20 41 63 152 46 51 54 47 61 123 13.7 72 5 14 41 290 224 17 21 58 27 14 27 67 102 21 All cases 6.0 1.0 4.0 107.1 21.0 5.7 5.0 3.8 16.4 8.0 4.0 7.0 10.2 29.0 10.0 15.0 13.0 10.0 12.7 37.0 2.2 16.9 1.1 2.0 10.0 56.0 57.2 5.0 4.9 14.8 6.3 3.0 6.0 16.3 25.1 4.3 TB deaths In HIV+ve % attr adults to HIV 0.0 0.0 0.0 17.6 0.2 0.0 0.0 0.1 0.5 0.0 0.0 0.0 0.0 0.1 0.1 0.3 0.0 0.0 0.0 0.0 0.0 0.3 0.0 0.0 0.0 2.2 0.3 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.5 0.0 0.1 1.0 0.9 15.1 0.7 0.1 0.4 1.6 3.1 0.3 0.2 0.0 0.1 0.4 0.7 2.1 0.0 0.0 0.0 0.0 0.0 1.6 0.8 0.0 0.1 3.5 0.5 0.4 2.6 0.1 0.1 0.1 0.1 0.1 2.0 0.0 % AIDS deaths % TB deaths from TB in HIV+ves 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 TB cfr (%) HIV-ve HIV+ve 19.8 10.0 7.0 17.9 19.0 19.0 16.0 12.0 17.8 9.0 12.0 7.0 11.0 17.0 12.0 15.0 15.0 11.0 14.0 17.0 7.0 19.0 10.0 7.0 11.0 22.0 18.0 16.0 11.0 16.0 21.0 11.0 19.0 18.0 13.0 14.0 40.0 10.0 10.0 37.0 37.0 40.0 31.0 16.0 36.0 12.0 12.0 10.0 11.0 36.0 14.0 28.0 22.0 14.0 17.0 28.0 10.0 35.0 10.0 10.0 30.0 38.0 36.0 32.0 12.0 30.0 43.0 28.0 35.0 35.0 27.0 17.0 HIV int prev in new adult TB cases (%) 0.1 2.0 1.2 14.3 0.7 0.1 0.4 2.4 2.8 0.5 0.5 0.0 0.1 0.3 1.1 2.1 0.1 0.0 0.0 0.0 0.1 1.5 1.8 0.1 0.1 3.8 0.4 0.4 5.7 0.1 0.1 0.1 0.1 0.1 1.8 0.1
26
TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2004
TABLE 15
Treatment outcome of new smear-positive cases registered in 2002 in DOTS areas Outcomes of treatment (%) Country American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong (China) Japan Kiribati Republic of Korea Leo People’s Democratic Republic Macao (China) Malaysia Northern Mariana Islands Marshall Islands Micronesia Mongolia Nauru New Caledonia New Zealand Niue Palau Papua New Guinea Philippines Pitcairn Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis & Futuna Total 12 0 48 55 236 1 322 220 0.0 1.9 0.0 1.0 64.6 89.2 100.0 85.8 22.9 1.6 0.0 6.6 0.0 1.5 0.0 2.2 2.1 0.9 0.0 1.0 10.4 3.0 0.0 2.3 0.0 1.9 0.0 1.2 87.5 90.8 100.0 92.4 0.0 66.7 25.0 0.0 0.0 8.3 0.0 91.7 22 451 118 4.5 0.7 3.4 40.9 0.0 66.1 36.4 87.8 22.9 0.0 4.7 6.8 0.0 0.4 0.0 18.2 5.8 0.8 0.0 0.7 0.0 77.3 87.8 89.0 Non evaluated Completed Transferred Treatment Registered (% ) Cured treatment Defaulted Failed Died out success 0 133 147 14 277 176 476 1 73 45 62 1450 6026 71 0 1484 147 8277 19 22 8 1631 2 19 90 0 1 469 55 402 0.0 3.8 0.0 100.0 45.4 74.5 0.0 21.5 13.1 0.0 22.8 6.0 0.0 0.4 1.3 0.0 3.4 2.3 0.0 2.6 2.7 100.0 67.0 87.6 3.8 2.0 4.0 0.0 0.0 0.0 0.1 0.0 0.0 91.1 66.8 85.7 0.0 0.0 36.4 100.0 83.4 100.0 84.2 0.0 9.8 3.4 79.4 73.7 50.0 0.0 3.3 0.0 0.0 8.9 8.4 3.4 7.2 0.0 4.5 0.0 3.9 0.0 5.3 0.0 0.7 0.0 0.0 0.0 0.0 0.0 4.5 0.0 0.0 0.0 8.0 3.4 9.4 0.0 4.5 0.0 2.3 0.0 10.5 0.0 2.6 2.0 0.0 26.3 4.5 0.0 2.6 0.0 0.0 0.0 76.6 89.1 79.4 73.7 86.4 100.0 86.7 100.0 84.2 8.9 15.0 0.0 0.0 0.7 0.0 0.0 0.0 0.0 2.8 6.8 8.5 18.0 43.5 89.3 94.0 100.0 84.9 80.0 53.2 71.6 51.4 78.9 48.1 12.2 2.5 2.1 0.0 0.0 0.0 17.7 6.4 23.5 7.0 3.8 2.7 2.9 0.7 0.0 5.5 8.9 0.0 3.4 2.1 1.4 1.5 0.7 0.4 0.7 0.0 0.0 4.4 0.0 8.6 4.8 1.4 9.8 8.8 4.0 1.1 0.0 8.2 6.7 11.3 4.1 11.4 2.8 3.8 32.0 0.9 0.6 0.0 1.4 0.0 17.7 3.0 0.0 0.0 66.2 55.8 91.8 96.1 100.0 84.9 80.0 71.0 78.0 74.9 85.9
27
TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2004
TABLE 16
Treatment outcome of new smear-positive cases registered in 2001 in non-DOTS areas Outcomes of treatment (%) Country American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong (China) Japan Kiribati Republic of Korea Lao People’s Democratic Republic Macao (China) Malaysia Northern Mariana Islands Marshall Islands Micronesia Mongolia Nauru New Caledonia New Zealand Niue Palau Papua New Guinea Philippines Pitcairn Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis & Futuna Total 0 0 9 0 0 24 962 13.2 64.7 9.1 2.0 2.6 4.2 4.1 73.8 0.0 22.2 66.7 0.0 0.0 0.0 11.1 88.9 0 400 0 0.8 0.0 65.5 21.0 0.5 11.0 1.3 65.5 Non evaluated Completed Transferred Treatment Registered (% ) Cured treatment Defaulted Failed Died out success 2 70 0 0 14 024 0 0 0 0 407 4108 0 5863 79 0 0 0 0 0 0 0 0 0 0 0 0 0 4.0 0.0 77.2 36.7 1.3 21.5 1.4 10.1 1.2 2.5 3.3 25.3 11.5 3.8 78.5 58.2 58.2 60.5 4.4 18.4 4.2 15.6 25.8 1.2 1.2 3.8 0.5 0.4 5.7 0.0 8.6 34.0 2.4 77.1 8.6 1.3 3.0 5.4 2.2 85.8 0.0 15.7 0.0 20.0 100.0 58.6 0.0 1.4 0.0 0.0 0.0 0.0 0.0 4.3 100.0 78.6
28
TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2004
TABLE 17
Treatment outcome of re-treatment cases registered in 2001 in DOTS areas Outcomes of treatment (%) Country American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong (China) Japan Kiribati Republic of Korea Lao People’s Democratic Republic Macao (China) Malaysia Northern Mariana Islands Marshall Islands Micronesia Mongolia Nauru New Caledonia New Zealand Niue Palau Papua New Guinea Philippines Pitcairn Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis & Futuna Total 1 0 0 5895 0 44 652 1.1 84.9 5.8 1.8 2.8 2.6 1.0 90.7 0.0 80.0 5.5 0.0 0.0 0.0 1.9 85.5 0.0 100.0 0.0 0.0 0.0 0.0 0.0 100.0 1 0 0 0.0 Non evaluated Completed Transferred Treatment Registered (% ) Cured treatment Defaulted Failed Died out success 0 4 0 707 35 991 0 0 0 0 209 711 0 0 99 47 0 0 0 20 113 0 0 28 0 0 826 0 0.7 23.4 36.3 0.0 0.0 0.0 2.1 59.7 100.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 40.0 54.0 35.0 17.7 0.0 0.0 0.0 0.0 0.0 0.0 0.0 5.3 75.0 71.7 18.2 4.3 41.4 63.8 10.1 19.1 0.0 0.0 0.0 0.0 0.0 0.0 3.0 2.1 51.5 83.0 5.3 11.0 56.9 49.6 7.7 18.3 0.0 0.0 0.0 0.0 0.0 0.0 3.3 0.0 64.6 67.9 0.0 1.0 87.4 88.2 4.2 4.9 0.0 0.0 0.0 0.0 0.0 0.0 0.8 0.8 91.7 93.1
29
PART III
Charts Chart 1 Notification of all cases by country, Western Pacific Region, 2002 Chart 2 Notification of new smear-positive cases by country, Western Pacific Region, 2002 Chart 3 Notification rate of new smear-positive cases by age and sex in DOTS areas, Western Pacific Region, 2002 Chart 4 DOTS case detection rate of new smear-positive cases, countries with a high burden, Western Pacific Region, 2002 Chart 5 Treatment success of new smear-positive cases under DOTS in countries with a high burden, Western Pacific Region, 2002 Chart 6 DOTS progress in countries with a high burden in the Western Pacific Region, 1998–2002 32 33
34
34
35
35
31
Charts
TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2004
CHART 1
Notification of all cases by country, Western Pacific Region, 2002 (rate per 100 000) Kiribati Cambodia Philippines Mongolia Tuvalu Wallis & Futuna Viet Nam Micronesia Niue Marshall Islands Hong Kong (China) Papua New Guinea Macao (China) Republic of Korea Northern Mariana Islands Brunei Darussalam Malaysia Palau Solomon Islands Vanuatu Lao Peoples Democratic Republic Western Pacific Region Nauru Singapore China Guam New Caledonia Tonga French Polynesia Japan Fiji Samoa New Zealand Cook Islands Australia American Samoa 0 5 3 9 6 18 17 29 28 27 26 38 36 36 32 47 47 55 55 49 60 63 74 70 84 100 98 95 95 119 118 130 127 151 150 178 217
50
100
150
200
250
32
TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2004
CHART 2
Notification of new smear-positive cases by country, Western Pacific Region, 2002 (rate per 100 000) Cambodia Kiribati Philippines Viet Nam Mongolia Niue Palau Marshall Islands Lao Peoples Democratic Republic Malaysia Macao (China) Brunei Darussalam Northern Mariana Islands Hong Kong (China) Republic of Korea Solomon Islands Western Pacific Region Tonga Micronesia Guam Vanuatu Papua New Guinea China Nauru Singapore French Polynesia Samoa Fiji New Caledonia Japan Wallis & Futuna Cook Islands New Zealand Australia American Samoa 0 2 1 0 9 9 8 7 6 35 33 33 32 32 28 27 24 23 22 22 20 19 18 17 15 15 13 11 10 50 45 65 71 83 94 125
25
50
75
100
125
150
33
TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2004
CHART 3
Notification rate of new smear-positive cases by age and sex* in DOTS areas, Western Pacific Region, 2002 75 60 45 30 15 0
0-14
15-24
25-34 35-44 45-54 Age group (years) Female 2002
55-64
65 or over
Male 2002
Total 2002
*Excluding the Philippines.
CHART 4
DOTS case detection rate of new smear-positive cases, countries with a high burden, Western Pacific Region, 2002 (%) Cambodia China Lao Peoples Democratic Republic Mongolia Papua New Guinea Philippines Viet Nam Western Pacific Region 0 15 30 45 60 75 90
Detection by DOTS (DOTS detection rate)
Detection by non-DOTS
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TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2004
CHART 5
Treatment success of new smear-positive cases under DOTS in countries with a high burden, Western Pacific Region, 2002 (%) Cambodia China Lao Peoples Democratic Republic Mongolia Papua New Guinea Philippines Viet Nam Western Pacific Region 0 25 Successful
50 Others
75
100 Not evaluated
CHART 6
DOTS progress in countries with a high burden in the Western Pacific Region, 1998–2002 100 95 China Cambodia Philippines Mongolia Viet Nam Target zone
Treatment success new S+ (%)
90 85 80 75 70 65 60 55 50 0 10 20 30 40 50 Papua New Guinea (from 2000) Lao Peoples Democratic Republic
2002 1998
60
70
80
90
100
DOTS detection rate new S+ (%)
35
Annexes Annex 1 Definitions Annex 2 Formulas for estimating tuberculosis incidence, prevalence and deaths Annex 3 Statistical methods
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37
Annexes
ANNEX
1
Definitions
7
Definitions of tuberculosis cases A case of tuberculosis: A patient in whom tuberculosis has been bacteriologically confirmed, or has been diagnosed by a clinician. Any person given treatment for tuberculosis should be recorded. All types: The sum of new smear-positive pulmonary, relapse, new smear-negative pulmonary and extrapulmonary cases. New smear-positive pulmonary: A patient who has never received treatment for tuberculosis or has taken anti-tuberculosis drugs for less than four weeks and who has one of the following: • two or more initial sputum smear examinations positive for acid fast bacilli (AFB), • one sputum examination positive for AFB plus radiographic abnormalities consistent with active pulmonary tuberculosis as determined by a treating medical officer; or • one sputum specimen positive for AFB and at least one sputum that is culture positive for AFB. New smear-negative pulmonary: A case of pulmonary tuberculosis that does not meet the above definition for smear-positive tuberculosis: Extrapulmonary tuberculosis: Tuberculosis of organs other than the lungs, e.g. pleura, lymph nodes, abdomen, genito-urinary tract, skin, joints and bones, meninges. Diagnosis should be based on one culture-positive specimen, or histological or strong clinical evidence consistent with active extrapulmonary tuberculosis, followed by a decision by a clinician to treat with a full course of anti-tuberculosis chemotherapy. (A patient diagnosed with both pulmonary and extrapulmonary tuberculosis should be classified as a case of pulmonary tuberculosis.) Retreatment cases: Relapses, failures and defaulters. Relapse: A patient previously treated for tuberculosis and declared cured or treatment completed, who is later diagnosed with bacteriologically positive (culture smear) tuberculosis.
Definitions of treatment outcome Cured: A patient who is sputum smear-negative in the last month of treatment and on at least one previous occasion. Completed treatment: A patient who has completed treatment but who does not meet the criteria to be classified as a cure or a failure. Treatment success: The sum of patients who are cured and those who have completed treatment. Died: A patient who dies for any reason during the course of treatment. Failure: A patient who, while undergoing treatment, is sputum smear-positive at five months or later during the course of treatment. 7
WHO, IUATLD, KNCV. Revised international definitions in tuberculosis control. Int J Tuberc Lung Dis 2001; 5: 213-215.
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TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2004
Defaulted: A patient who has interrupted treatment for two consecutive months or more. Transferred out: A patient who has been transferred to another recording and reporting unit and for whom the treatment outcome is not known. Not evaluated: Patients who did not have the treatment outcome evaluated. Note: In countries where culture is current practice, patients can be classified as cured or failure on the basis of culture results.
Indicators to assess treatment outcome Cure rate: Proportion of cured cases out of all cases registered in a certain period (in 2001 in this report). Treatment success rates: The sum of the proportion of patients who were cured and patients who completed treatment out of all cases registered in a certain period. The global target is a 85% cure rate and a greater treatment success rate. The cure rate and treatment success rate are expressed as a percentage of registered cases. The number of new cases registered for treatment in 2001 (reported in 2003) is compared to the number of cases notified as smear-positive in 2001 (reported in 2002). Differences may arise because NTPs do not compile data at the end of each calendar year, diagnoses may be incorrect, patients are lost between diagnosis and the start of treatment, or records are lost. Second, the fraction of registered cases was evaluated for outcome. All registered cases should be evaluated. Third, data on the six standard, mutually exclusive outcomes of treatment are compiled. These figures are reported as percentages of all registered cases, so that the possible outcomes plus the fraction of cases not evaluated sum to 100%. When a country states the number of patients registered for treatment, but gives no outcomes, no result is reported rather than zero treatment success. Although treatment outcomes are expressed as percentages, they are referred to as rates. The six possible outcomes plus the fraction of cases not evaluated sum to 100%. If the number of registered cases is lower than the sum of the six outcomes or is missing, the denominator for treatment success will be the number evaluated or the number of smear-positive cases notified in the previous year, whichever is greater.
Case detection rate and DOTS detection rate DOTS: The recommended strategy for tuberculosis control. It comprises: • government commitment to ensuring sustained, comprehensive tuberculosis control activities; • case detection by sputum smear microscopy among symptomatic patients self-reporting to health services; • standardized short-course chemotherapy using regimens of six to eight months, for at least all confirmed smear-positive cases (Good case management includes DOT during the intensive phase for all new sputum smear-positive cases, the continuation phase of rifampicin-containing regimens and the whole re-treatment regimen); • a regular, uninterrupted drug supply of all essential anti-tuberculosis drugs; and • a standardized recording and reporting system that allows assessment of case-finding and treatment results for each patient and of the tuberculosis control programme performance overall. Targets for tuberculosis control established by the World Health Assembly: • to detect 70% of the estimated new sputum smear-positive tuberculosis cases; and • to cure 85% of the sputum smear-positive tuberculosis cases detected.
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TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2004
Case notifications represent only a fraction of the true number of cases in a country because the coverage by effective NTPs will be incomplete. The estimated case detection rate is defined as: Annual new smear-positive notifications (country) Case detection rate (%) = Estimated annual new smear-positive incidence (country) DOTS detection rate refers to case detection under DOTS: Annual new smear-positive notifications under DOTS DOTS detection rate (%) = Estimated annual new smear-positive incidence (country) The case detection rate and DOTS detection rate are identical when a country has a 100% DOTS enrolment rate. Updated estimated incidence for 2002 in this report was provided by WHO, Geneva. Population with access to DOTS: The country’s population that has access to units implementing DOTS. DOTS enrolment rate (%): This indicates a proportion of cases enrolled in DOTS out of notified cases. Annual notifications of all types under DOTS DOTS enrolment rate (all types) (%) = Total of annual notifications of all types Annual notification of new S+ under DOTS DOTS enrolment rate (New S+) (%) = Total of annual notifications of new S+
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ANNEX
2
Formulas for estimating tuberculosis incidence, prevalence and deaths Formulas 1. I = T/d and I s= Ts/ds 2. P = tl and P s= tsls 3. Is/N = λk 4. D = fl and D s= fls 5. I = I +I +In * a a
Definitions N = Population I = Incidence of TB (No. of New Cases of TB per year) P = Prevalence of TB T = TB Case Notifications (per year) D = Deaths from TB IRR = TB Incidence Rate Ratio (TB Incidence Rate in Human Immunodeficiency Virus [HIV]-Positive Persons/TB Incidence in HIV-Negative persons) d = Proportion of Cases Notified (Case Detection Rate) t = Average Duration of TB Disease (Years) λ = Rate of Infection With Mycobacterium tuberculosis (MTB) (Annual Rate of Infection per Person per year) k = Ratio of Incidence of Smear-Positive TB to Rate of MTB Infection
or I = m r N +m r N +maraNa + + + a a a - - a a a
6. IRR = ma ra /ma ra =(Ia /Na )/(Ia /Na ) + + + + -
f = Proportion of TB Patients Who Die From TB (Case Fatality Rate [CFR]) m = Prevalence of Infection with MTB r = Rate of Progression to TB disease in MTB-Infected Individuals (per Person per year) s = Sputum Smear-Positive TB (No Subscript Implies All Forms) a = Adult (15-49 Years Old)
7. I /I = IRR(N /Na)/[1+(N /Na)(IRR-1)] + a a + a a
8. I = I -I N /N * a + a a + + a * +
a
n = Other Age Groups (<15 or >49 Years Old), Assumed HIV-Uninfected + = HIV Positive - = HIV Negative * = Attributable to HIV Infection
9. Da = Da -f (I -I ) * a
Source: Corbett EL, Watt CJ, Walker N. et al. The Growing Burden of Tuberculosis. Global Trends and Interactions With the HIV Epidemic. Arch Int Med 2003; 163(9): 1009-1021.
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ANNEX
3
Statistical methods
Increasing or decreasing trends of times series were assessed using a non-parametric Spearman test between the observations and time.8 The series were re-sampled 1000 times for a bootstrap test. Rates of change per year were assessed by estimating the slope of the log-transformed rates against time. All p values found smaller than 0.05 were considered statistically significant. The statistical analysis was carried out using the R language,9 freely downloadable from the Internet.10
8 9
Siegel, S. & N.J. Castellan, 1988. Non-parametric statistics. McGraw-Hill, New York. 399 pp. Ross Ihaka and Robert Gentleman. R: A language for data analysis and graphics. Journal of Computational and Graphical Statistics, 5(3):299-314, 1996. 10 http://www.r-project.org
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WORLD HEALTH ORGANIZATION Regional Office for the Western Pacific Stop TB United Nations Avenue 1000 Manila, Philippines Tel No: +632 528 8001 Fax No: +632 521 1036 E-mail: stoptb@wpro.who.int Website: http://www.wpro.who.int ISBN: 92 9061 090 5