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Tuberculosis control in South-East Asia and Western Pacific Regions

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2005 Report

Tuberculosis Control in South-East Asia and Western Pacific Regions A Bi-Regional Report

World Health Organization South-East Asia Region Western Pacific Region

TUBERCULOSIS CONTROL in South-East Asia and Western Pacific Regions 2005 A Bi-Regional Report

World Health Organization South-East Asia Region Western Pacific Region

This publication was prepared by Stop TB Units in the WHO Regional Offices for South-East Asia (SEARO) and the Western Pacific (WPRO), in collaboration with Asheena Khalakdina, Erwin Cooreman and Nani Nair in SEARO, and Philippe Glaziou, Bernard Tomas, Pieter van Maaren and Dongil Ahn in WPRO.

Acknowledgements The contribution of NTP managers and statisticians from all countries and areas of the South-East Asia and Western Pacific Regions for providing data for this publication is gratefully acknowledged.

© World Health Organization 2005 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. 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 Secretariat 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. Designed in India and printed in the Philippines

Tuberculosis Control in South-East Asia and Western Pacific Regions

Contents Foreword....................................................................................................... v Executive Summary ..................................................................................... vii 1. Introduction .............................................................................................1 2. Epidemiology ........................................................................................... 3 2.1 Estimated Burden ...................................................................................................... 3 2.2 Case Notification ....................................................................................................... 4 Notifications ............................................................................................................................ 4 Notification rates ..................................................................................................................... 5 Age- and sex-specific notification rates ..................................................................................... 6

2.3 TB-HIV ..................................................................................................................... 6 2.4 Drug Resistance ........................................................................................................ 8

3. Progress in TB Control ............................................................................11 3.1 DOTS Coverage ...................................................................................................... 11 3.2 Case Detection ....................................................................................................... 11 3.3 DOTS Enrolment and Progress in Overall Case detection ......................................... 13 3.4 Treatment Outcomes .............................................................................................. 13 3.5 Treatment Results of Re-treatment Cases ................................................................. 15

4. Grouping of Countries ............................................................................ 17 4.1 High Burden Countries ........................................................................................... 17 4.2 Low and Intermediate Burden Countries ................................................................. 20 High income countries .......................................................................................................... 20 Countries with emerging economies ...................................................................................... 22 Island countries ..................................................................................................................... 24

5. WHO’S WORK ...................................................................................... 27 5.1 WHO’s Work in the Regions ................................................................................... 27 Providing timely and effective technical support .................................................................... Capacity strengthening .......................................................................................................... Effective coordination and information exchange ................................................................... Strengthening partnerships and mobilizing resources for TB Control ...................................... Monitoring and evaluation ..................................................................................................... Operational research ............................................................................................................. 28 28 29 29 30 30

Annexes 1. Definitions ................................................................................................................ 45 2. Formulas for estimating tuberculosis incidence, prevalence and deaths ...................... 48 3. Statistical Methods .................................................................................................... 49

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iii

List of Figures Figure 1: Figure 2: Figure 3: Figure 4: Figure 5: Figure 6: Figure 7: Figure 8: Figure 9: Trends in case notification rates (all forms), 1995 - 2003 ....................................... 6 Case-notification rates of smear-positive cases, 1995-2003 ................................... 7 Smear-positive notification rates, by age and sex ................................................... 7 DOTS coverage 1997-2003 in South-East Asia and Western Pacific Regions ........ 11 Trends in DOTS case detection rates in South-East Asia and Western Pacific Regions 1995-2003. ................................................................... 12 Trends in DOTS and non-DOTS case-detection rates (new smear-positive cases) in the South-East Asia and Western Pacific Regions ............................................. 13 Treatment outcomes for new smear-positive cases registered in 2002 in DOTS and non-DOTS areas in SEA and WP Regions ....................................... 14 Unfavourable outcomes among new smear-positive cases registered in 2002 in DOTS areas in South East Asia and Western Pacific Regions ............................ 14 Treatment outcomes for re-treatment cases registered in 2002 (DOTS areas) ....... 15

Figure 10: Trends in DOTS and non-DOTS case-detection rates (new smear-positive cases) in China, India, Indonesia and Viet Nam ............................................................ 18 Figure 11: Age-specific smear-positive notification rates per 100 000 population in China, India and Indonesia ............................................................................. 18 Figure 12: Age-specific smear-positive notification rates per 100 000 population in several high-burden countries in South-East Asia and Western Pacific Regions ...................................................................................... 19 Figure 13: Progress of DOTS towards targets in high-burden countries in South-East Asia and Western Pacific countries ................................................. 19 Figure 14: Age-specific case-notification rates per 100 000 population in Malaysia, Republic of Korea, Singapore and Japan .......................................... 21 Figure 15: Age-specific notification rates, 2003 ................................................................... 23

List of Tables Table 1: Estimated prevalence rates (all cases) and death rates per 100 000 from TB in the South-East Asia and Western Pacific Regions .................................... 4 Table 2: Notification rates and other indicators for the South-East Asia and Western Pacific Regions, 2003 (per 100 000 population) ......................................... 5 Table 3: Estimated prevalence of HIV in new TB cases and estimated incidence of TB in HIV-positive adults aged 15-49 years .......................................... 8 Table 4: Deaths due to TB in HIV-positive patients for countries with high TB/HIV burdens ....................................................................................... 9 Table 5: Anti-tuberculosis drug resistance, by country ......................................................... 10 Table 6: DOTS case detection rates of all forms and smear-positive (SS+) cases in 2003 ..... 12 Table 7: Annual rate of change in notification and case-detection rates (all cases) in middle to high-income countries ....................................................................... 21 Table 8: Case-notification rates, case-detection rates and rate of change, 1999-2003 .......... 23 Table 9: Progress with DOTS in 2003 ................................................................................. 24

Tuberculosis Control in South-East Asia and Western Pacific Regions

Foreword Tuberculosis (TB) remains to be one of the most serious health and development problems in the WHO South-East Asia and Western Pacific Regions, which together carry more than half of the global tuberculosis burden. Every year millions of people are newly infected with the TB bacillus, and thousands die of the disease in these two most populous regions of the world. The spread of the human immunodeficiency virus (HIV) during the last two decades and the emergence of multidrug-resistant forms of TB pose additional challenges to effective TB control. This year is a landmark for TB control. Five years ago, the World Health Assembly resolved to achieve the global targets of 70% case detection and 85% cure rate among all new infectious cases of TB by 2005. In addition, the Millennium Development Goals have set a new benchmark for further reversing the trends of TB and other major communicable diseases. Member States are accelerating their efforts to meet these goals. DOTS, the internationally recommended strategy to control tuberculosis, is proving to be successful in many countries. We are happy to note that nearly 90% of people in our regions have access to care under this highly effective strategy. Over 2.2 million cases are managed under DOTS in the two regions each year. Of these, 85% are being successfully treated, averting over 320 000 deaths. The growing number of patients cured of this debilitating and often fatal disease reflects the success of our interventions. This progress is largely an outcome of the sustained commitment on the part of governments, health workers and civil society. This publication is the first bi-regional report on tuberculosis control in the South-East Asia and the Western Pacific Regions. It presents data on TB epidemiology and gauges the enormous progress being made by national TB control programmes in both the regions. It presents the overall success with strategies adopted to control TB and highlights the similarities and differences between individual countries. This progress needs to be sustained and built upon to enable individual countries and the two regions to achieve the targets set under the Millennium Development Goals. This requires continued commitment and adequate support of national TB control programmes for several years to come.

Shigeru Omi, M.D., Ph.D. Regional Director WHO Western Pacific Region

Samlee Plianbangchang, M.D., Dr.P .H. Regional Director WHO South-East Asia Region

Tuberculosis Control in South-East Asia and Western Pacific Regions

Executive Summary This is the first bi-regional report on TB control for the WHO South-East Asia and Western Pacific Regions. It includes data on the estimates of disease burden, case notifications and treatment outcomes reported from 47 countries in the two regions of WHO in 2003. Tuberculosis is still a major public health problem in both the regions. In 2003, there were an estimated 9.7 million prevalent cases of TB (291 per 100 000 population) in the South-East Asia and Western Pacific Regions, of which almost 5 million were new cases (149 per 100 000 population). Six countries account for about 90% of the total estimated new cases in the two regions. China and India accounted for 63% of incident TB cases (all forms) in the two regions. The global HIV epidemic has had an impact in countries in Asia and the Pacific: the prevalence of HIV among TB cases was 12% in Cambodia and Thailand, 6.8% in Myanmar and 4% in Viet Nam. In addition, drug resistance was found in almost all settings surveyed in the South-East Asia and Western Pacific Regions; the prevalence of MDR-TB varied widely across settings ranging from 0.5% to 10.4%. The highest prevalence rates of MDR-TB in previously untreated cases were observed in Liaoning (10.4%) and Henan (7.8%) provinces in China. The case-detection rate in the two regions (see Annex 1 for definition) was 51% for all tuberculosis cases and 50% for new smear-positive cases. In other words, the 2.5 million notified cases (all types) represented 51% of the 5 million estimated cases (all types) and the 1.1 million notified new smear-positive cases represented 50% of the estimated new smear-positive cases. Case detection rates in DOTS areas have been steadily increasing in the South-East Asia Region since 1998 whereas progress in the Western Pacific Region was relatively slow until 2002. The rise in case detection in the South-East Asia Region is largely due to significant increments in the numbers of cases detected in India (+52%), particularly between 2002 and 2003. Similarly, the increase in case detection in the Western Pacific Region from 2002 to 2003 (+28%) is mostly due to a dramatic increase in case detection in China (+59%). Progress in these two countries with the highest burdens of tuberculosis globally will necessarily drive global progress in TB control. In DOTS areas, the treatment cure and success rates were 82% and 88% respectively for the cohort of 790 916 new pulmonary smear-positive cases registered for treatment in 2002 (85% and 81% respectively in the South-East Asia Region; 91% and 84%, respectively in the Western Pacific Region). In total, 23 countries out of 45 reported treatment outcomes below the 85%

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vii

WHO target (five in the South-East Asia Region, including three high burden countries1 (Bangladesh, Myanmar and Thailand) and 18 in Western Pacific Region, including two high burden countries2 (Lao PDR and Papua New Guinea). Several challenges need to be overcome to sustain the momentum towards reaching the global TB control targets set for end-2005. With DOTS expanding rapidly, ensuring high quality DOTS implementation has become an important concern. Also, TB associated with HIV coinfection and multidrug-resistant TB need to be addressed by implementing collaborative TBHIV activities and expanding DOTS-plus programmes designed to treat those with drug-resistant forms of TB. Given that tuberculosis has implications not only on health but also on the social and economic development the achievement of several other targets under MDGs will also depend on good TB control. This makes it all the more imperative that commitment and resources are sustained to ensure that well-managed DOTS programmes continue to effectively reach out to all those affected by TB.

1 Countries with a high burden of tuberculosis in the South-East Asia Region belong to the global list of 22 high burden countries: Bangladesh, India, Indonesia, Myanmar and Thailand. 2 Seven countries in the Western Pacific Region are considered to have a high burden of tuberculosis: Cambodia, China, Lao PDR, Mongolia, Papua New Guinea, the Philippines, Viet Nam.

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viii

1 Introduction The WHO South-East Asia and Western Pacific Regions cover a vast geographic area with over 60% of the world’s population in 48 countries and areas. Of these 47 reported data on TB to WHO in 2003. During 2004, a standard form for reporting surveillance data was sent to all 48 countries and areas in both regions. Information was collected about the number and types of TB cases notified in 2003, on the outcomes of treatment among smear-positive and smear-negative as well as retreatment smear-positive cases registered in 2002, and about policies and practices in use for TB control. Also, data from drug resistance and TB-HIV surveillance were compiled. Tuberculosis was declared a “global emergency” by WHO over a decade ago not only because of its toll on the health of individuals but also because of its wider social and economic impact on overall development. Targets were established to measure progress with implementation of the DOTS strategy to combat tuberculosis by 2005. These targets include 100% population coverage with DOTS, 70% case detection and 85% treatment success rate. Achieving these targets is an important intermediate step towards reaching the UN Millennium Development Goal (MDG) of halting and starting to reverse the incidence of TB by 2015. Since 2000, the WHO South-East Asia and Western Pacific Regions have achieved significant progress. A total of 45 of 48 countries in the regions are implementing DOTS, with the coverage reaching 84% at the end of 2003 (77% in the South-East Asia Region and 90% in the Western Pacific Region). The two regions have already achieved the treatment success rate target in DOTS areas and are now moving rapidly to achieve the 70% case-detection target. Every year, the WHO Regional Offices for South-East Asia and the Western Pacific have separately published an annual TB report to share current knowledge on the state of the TB epidemic in each region. This bi-regional report is the first combined report on tuberculosis in the two regions. Its primary aim is to present data on TB epidemiology and related information reported from national TB control programmes (NTPs) to WHO in the two regions. It highlights the similarities and contrasts between the countries in the two regions and the overall strategies that have been adopted to address TB.

Tuberculosis Control in South-East Asia and Western Pacific Regions

2 Epidemiology This report is based on case notifications for 2003 and treatment outcomes for patients registered in 2002 reported by national TB control programmes to the World Health Organization in 2004, using standard data collection forms, with common definitions and variables (Annexes).

2.1 Estimated burden Estimates of TB prevalence, incidence and mortality in countries are based on a consultative and analytical process that takes into account all available information on case notifications; prevalence of infection and disease; tuberculin surveys; duration of illness; proportion of smear-positive cases; numbers of cases treated and remaining untreated; HIV prevalence and incidence; mortality and demography. The estimates of disease burden are revised annually by WHO to reflect new information gathered through surveillance and from special studies such as prevalence and annual risk of tuberculosis infection (ARTI) studies conducted in countries. For instance, a national sample survey for ARTI, recently completed in India3, was used in these calculations. The estimates are also applied to previous years, retrospectively, when necessary. The estimated figures are WHO provisional estimates published in the WHO Report 2005–Global Tuberculosis Control. The methodology used for case estimates was that described in detail in the “Global Burden of Tuberculosis”4, published in 1999, and “The Growing Burden of Tuberculosis”5, published in 2003. Methods used to study the tuberculosis epidemic are also described in “Tuberculosis: Epidemiology and Control”6. In all measurements of TB indicators, population estimates provided by the UN Population Division7, are used, recognizing that these sometimes differ from population data in the countries themselves (many of which are based on more recent survey data). In 2003, there were an estimated 9.7 million prevalent cases of TB (291 per 100 000 population) in the South-East Asia and Western Pacific Regions, of which almost 5 million were

National Tuberculosis Institute, DGHS, India, Annual Risk of Tuberculosis Infection in Different Zones of India: A national sample survey 2000-2003. 3

Dye C, Scheele S, Dalin P et al. Global Burden of Tuberculosis. Estimated Incidence, Prevalence, and Mortality by Country. JAMA 1999; 282: 677–686. 4

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. 5

Kumaresan, J. Epidemiology in Tuberculosis: Epidemiology and Control (Jai P . Narain, ed), World Health Organization, Regional Office for South East Asia, 2002 (SEA/TB/248) 6 7

http://esa.un.org/unpp/, accessed January 2005.

Tuberculosis Control in South-East Asia and Western Pacific Regions

new cases (149 per 100 000 population). China and India accounted for 63% of all incident TB cases (all forms) in the two Regions. It was estimated that 944 073 deaths from tuberculosis occurred in both regions in 2003 (617 211 and 326 862 in the South-East Asia and Western Pacific Regions, respectively), i.e. 28 deaths from tuberculosis per 100 000 population (38 and 19 in the South-East Asia and Western Pacific Regions, respectively). The death rate from tuberculosis per 100 000 population was highest in Timor-Leste (96) and Cambodia (95) as compared to 33 in India and 18 in China. Table 1 shows the rates of change in the estimated prevalence and death rates from 1990 to 2003. Table 1: Estimated prevalence rates (all cases) and death rates per 100 000 from TB in the South-East Asia and Western Pacific Regions 1990 Prevalence South-East Asia Western Pacific Total Deaths South-East Asia Western Pacific Total 50 26 37 38 19 28 -24 -27 -24 -2 -2 -2 570 341 446 351 236 291 -38 -31 -35 -4 -3 -3 2003 Overall change (%) Yearly rate of change (%)

The estimated prevalence and death rates decreased in both regions at an overall yearly rate –3% and –2%, respectively in South-East Asia and the Western Pacific.

2.2 Case Notification Notifications The population coverage with DOTS was 77% in the South-East Asia Region and 90% in the Western Pacific Region in 2003, with a combined coverage of 84% in the two Regions8. The two regions together detected 58% of the total number of cases detected globally, 23% in the Western Pacific and 35% in South-East Asia. These two regions account for approximately 2.5 million cases of all forms of tuberculosis notified (1.5 million in South-East Asia and almost 1 million in the Western Pacific) and about 1.1 million notified cases of smear-positive tuberculosis (672 878 in the South-East Asia Region and 454 732 in the Western Pacific Region) in 2003. The largest number was from India with over 1 million cases (433 271 smear-positive cases) and China with 615 868 cases (267 414 smear-positive cases). Together, these two countries alone accounted for 40% of all reported tuberculosis cases and 37% of all smear-positive cases reported globally.

Population coverage at the end of 2004 in excess of 90% in both regions (unpublished data from NTP annual reports 2004) 8

Tuberculosis Control in South-East Asia and Western Pacific Regions

Of all TB case notifications, 86% of all TB cases and 92% of smear-positive tuberculosis cases were reported from DOTS areas. These proportions were slightly higher for the Western Pacific Region: 89% and 95%, for all and smear-positive cases respectively, compared to the South-East Asia Region where these were 85% and 91% respectively.

Notification rates The combined case notification rate per 100 000 population in the South-East Asia and Western Pacific Regions was 76 for 2003 (Table 2). In South-East Asia the notification rates were higher than for the Western Pacific with a total case rate of 96 (42 per 100 000 for smear-positive) compared to 57 in the Western Pacific (26 per 100 000 for smear-positive). The notification rate for all cases in both regions has been steady since 1995 with the SouthEast Asia Region having a higher rate (range: 86 and 102 per 100 000) than the Western Pacific Table 2: Notification rates and other indicators for the South-East Asia and Western Pacific Regions, 2003 (per 100 000 population) South-East Asia Population (thousands) All TB cases (number) All TB cases (rate) New TB cases Number smear positive(SS+) Rate (new SS+) Smear negative or unknown Extra pulmonary Re-treatment cases Relapse Treatment after failure Treatment after default Other retreatment Other All cases detection rate (%) New SS+ detection rate (%) Pop coverage (%) DOTS Detection Rate (%) Non-DOTS all cases Non-DOTS SS+ Includes both DOTS and Non-DOTS

Western Pacific 1 732 104 987 927 879 827 57 51 454 732 431 396 26 25 376 679 70 506 85 982 998 1 208 67 709 7 008 51 52 90 50 108 100 23 336

Total 3 346 752 2 543 312 2 194 810 76 78 1 127 610 1 041 475 34 37 1 013 385 251 371 150 918 15 647 65 425 109 997 17 436 51 50 84 47 348 502 86 135

1 614 648 Case Notifications Overall a DOTS Overall DOTS Overall DOTS Overall DOTS 1 555 385 1 314 983 96 81 672 878 610 079 42 38 636 706 180 865 64 936 14 649 64 217 42 288 10 428 Detection Rate 51 49 77 45 240 402 62 799

Tuberculosis Control in South-East Asia and Western Pacific Regions

Region (range: 47 and 57 per 100 000). After a slight but steady decline since 1996, the Western Pacific Region has experienced a more rapid increase in the notification rate from 47 to 57 per 100 000 between 2002 and 2003. The South-East Asia Region has shown a slow decline in notification rates, followed by a slow increase since 2001, from 90 to 94 per 100 000. (Figure 1) Figure 1: Trends in case notification rates (all forms), 1995 - 2003 120

100

80 per 100 000

0 1995 1996 1997 SEAR

1998

1999 WPR

2000

2001 TOTAL

2002

2003

Note: SEAR, South-East Asia Region; WPR, Western Pacific Region

Case-notification rates for smear-positive cases however, have been rising steadily in the South-East Asia Region since 1998, from 25 to 42 per 100 000, after being steady between 1995 and 1998 at around 25 per 100 000. In contrast, the smear-positive notification rate for the Western Pacific Region has been steady between 1997 and 2002 at 22 per 100 000. A comparative increase in the smear-positive notification rate has been made since then to 26 per 100 000. (Figure 2)

Age- and sex-specific notification rates The age- and sex-specific notification rates for the two regions for 2003 (Figure 3) show that the South-East Asia Region has higher rates for both men and women than the Western Pacific Region. Overall the highest rates are among men aged 15 to 64 years in the South-East Asia Region. In contrast, males in the Western Pacific Region have lower rates overall and display an upward trend in the higher age-groups indicating a shift in the epidemiology of tuberculosis. For females, the pattern is similar to that of males in the respective regions, albeit less dramatic than the trend seen in males. Females in the SEA Region have higher notification rates which are however lower in the higher age groups, compared to females in the Western Pacific Region who have lower rates overall and a slightly increasing rate in the 45+ age groups.

2.3 TB-HIV The HIV epidemic has reached a generalized stage at the national level in only three countries in the two regions: Cambodia, Myanmar and Thailand. In Cambodia the prevalence of HIV infection

Tuberculosis Control in South-East Asia and Western Pacific Regions

Figure 2: Case-notification rates of smear-positive cases, 1995-2003 45 40 35 30 per 100 000 25 20 15 10 5 0 1995 1996 1997 1998 1999 2000 2001 2002 2003

SEAR

WPR

TOTAL

Figure 3: Smear-positive notification rates, by age and sex 120 100

80 per 100 000 60 40

20 0 0-14 15-24 SEAR Male

25-34

35-44

45-54 WPR Male

55-64

65+ WPR Female

SEAR Female

among those aged 15 to 49 years was estimated to be 2.6% in 2003, in Myanmar the prevalence was 1.2% and in Thailand the prevalence was 1.5%. In addition, the epidemic is generalized in six states of India. In other countries affected by HIV9, particularly in China, Indonesia, Nepal and Viet Nam, the HIV epidemic is still at the concentrated stage. In China, HIV prevalence data 9

http://www.who.int/GlobalAtlas/PDFFactory/HIV/index.asp, accessed February 2005

Tuberculosis Control in South-East Asia and Western Pacific Regions

indicate a focused, explosive spread of infections among intravenous drug users (IDUs) and no significant spread to 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. Tuberculosis is the most important life-threatening opportunistic infection associated with HIV. In Thailand, 60% of AIDS patients have had pulmonary tuberculosis. This was 80% in Myanmar, 56% in India and 75% in Nepal10. Table 3 shows the estimated prevalence of HIV among TB cases and incidence of TB among HIV-positive adults in countries with a high TB/HIV burden in the two regions. The overall estimated HIV seropositivity among new adult TB cases is 3.5% in the South-East Asia Region and 1.2% in the Western Pacific Region. The three-fold higher proportion in South-East Asia could be attributed primarily to the high burden in India. Table 3: Estimated prevalence of HIV in new TB cases and estimated incidence of TB in HIV-positive adults aged 15-49 years a Prevalence of HIV in new adult TB cases Percentages b Cambodia China Myanmar Nepal India Indonesia Thailand Viet Nam a b

Incident cases of TB (all forms) in HIV+ adults (thousands) c 6.5 5.8 5.5 0.9 54.4 2.3 5.3 1.7

13 0.7 6.8 2.9 5.2 0.5 8.7 2.8

Detailed methodology and year 2000 estimates published in Corbett et. al. 2003. Arch Intern Med 163:1009-1021.

Global TB Report 2005, WHO (WHO/HTM/TB/2005.349) and http://www.who.int/GlobalAtlas/PDFFactory/TB/index.asp, accessed April 2005. c

2002 estimates accessed April 2005: http://www.who.int/docstore/gtb/tbestimates/2002tbestimates.xls

Table 4 shows the proportion of estimated TB deaths (numbers and rates) among those infected with HIV for some countries in the two regions. In the South-East Asia Region, 0.7% of prevalent TB cases are infected with HIV, but 4% of TB deaths occur among cases with HIV (11% in Thailand). In the Western Pacific Region, 0.2% of prevalent TB cases are infected with HIV and 3% of TB deaths occur in cases infected with HIV (1.5% in Cambodia). Surveillance of HIV in notified TB cases is not yet routinely done in all countries with concentrated or generalized HIV epidemics.

2.4 Drug Resistance Multidrug-resistant tuberculosis (MDR-TB) is posing a threat to tuberculosis control in several countries. 10

Jai P . Narain (ed). AIDS in Asia: The challenge ahead. WHO Regional Office for South East Asia 2004

Tuberculosis Control in South-East Asia and Western Pacific Regions

Table 4: Deaths due to TB in HIV-positive patients for countries with high TB/HIV burdens TB deaths among HIV+ Numbers (thousands) India Myanmar Thailand South-East Asia Cambodia China Malaysia Papua New Guinea Philippines Viet Nam Western Pacific Total a

Rates (per 100 000) a 2.1 2.9 2.1

22.2 1.4 1.3 26.0 2.4 2.2 0.1 0.1 0.2 0.4 5.5 31.5

17.6 0.2 0.3 2.2 0.3 0.5

Rates per 100 000 general population

In 1994, WHO, the International Union Against TB and Lung Disease (The Union) and several partners launched the Global Project on Anti-Tuberculosis Drug Resistance Surveillance. The Global Project methodology for surveillance of drug resistance was designed around and continues to operate on three main principles: (1) surveillance must be based on a sample of TB patients representative of all cases in the geographical setting under evaluation; (2) drug resistance must be clearly distinguished according to the treatment history of the patient in order to allow correct interpretation of resistance data; and (3) optimal laboratory performance must be attained through participation in a quality assurance programme including the international exchange of strains of Mycobacterium tuberculosis. Drug resistance was present in almost all settings surveyed in the South-East Asia and Western Pacific Regions. The prevalence of drug resistance varied widely across settings though (Table 5). Highest prevalence rates of MDR-TB were observed in Liaoning (24.4%) and Henan (36.6%) provinces in China. Three DOTS-plus pilot projects designed to treat MDR-TB cases under programme conditions were initiated in Bangladesh, India, Nepal and the Philippines in 2003. Continuous monitoring of trends in high prevalence MDR settings is essential in order to assess current interventions and their impact on the epidemic. To date, it is difficult to interpret trends in high MDR prevalence settings with any certainty. No area reaching MDR prevalence of >6.5% has dropped below that point in subsequent surveys suggesting that, when a critical threshold of transmission has been reached within a population, it may take a considerable amount of time to decrease the prevalence of MDR-TB. The results of improved TB control interventions under DOTS and targeted interventions such as DOTS-plus may not be as rapidly evident in these settings as they might in a population with a lower prevalence of resistance.

Tuberculosis Control in South-East Asia and Western Pacific Regions

Table 5: Anti-tuberculosis drug resistance, by country New cases Year South-East Asia Region India North Arcot Raichur District Wardha District Nepal Thailand Myanmar Western Pacific Region Australia Cambodia China, Hong Kong China Henan Hubei Liaoning Inner Mongolia Zhejiang Korea Japan Malaysia Mongolia New Zealand Singapore Viet Nam 2001 1999 1999 2003 1998 1998 1997 1996 1999 2001 2001 1996 1 222 859 818 806 802 2 370 1 374 1 001 405 272 823 640 3.3 3.7 5.4 5.0 2.7 4.9 2.0 1.0 4.4 4.4 1.6 6.7 29.8 17.5 42.1 35.0 14.8 10.6 10.3 4.2 29.4 11.4 5.0 32.5 7.8 2.1 10.4 7.3 4.5 2.2 0.9 0 1 0 0.5 2.3 22 126 0.0 8.0 140 283 264 16 35.0 7.0 19.7 0.0 265 238 86 36.6 21.8 24.4 2001 2001 2001 770 638 3 470 5.6 4.7 2.3 9.9 10.3 10.2 1.6 0 0.8 96 169 3.1 11.2 1999 1999 1999 2001 2001 2003 282 278 197 755 1 505 733 12.8 12.2 10.7 1.6 5.3 23.7 21.9 19.8 11 14.8 30.2 2.8 2.5 0.5 1.3 0.9 4 172 20.3 171 20.5 No. INH Any Resistance Resistance MDR Previously treated cases No. MDR

Tuberculosis Control in South-East Asia and Western Pacific Regions

3 Progress in TB Control 3.1 DOTS Coverage Among the 48 countries and areas in the South-East Asia and Western Pacific Regions, all but two had at least part of their population covered by DOTS units. Figure 4 shows the DOTS population coverage achieved between 1995 and 2003. Figure 4: DOTS coverage 1997-2003 in South-East Asia and Western Pacific Regions 100 90 80 % population covered 70 60 50 40 30 20 10 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 35 26 38 45 47 65 59 72 84

Much of the increase in population coverage in recent years is attributed to DOTS expansion in India, China and Myanmar.

3.2 Case Detection The DOTS case-detection rate in the two Regions (see Annex 1 for definition) was 78% for all tuberculosis and 47% for new smear-positive cases (Table 6). In other words, the 2.5 million notified cases (all forms) represented 51% of the 5 million estimated cases (all forms) and the 1.1

Tuberculosis Control in South-East Asia and Western Pacific Regions

Table 6: DOTS case detection rates of all forms and smear-positive (SS+) cases in 2003 DOTS case-detection rate (percentages) SS(+) cases Increase (2002–2003)

million notified new smear-positive cases represented 50% of the estimated new smear-positive cases.

The overall case-detection rate (DOTS and non-DOTS) was 51% for both Regions individually and South-East Asia 45 +36 combined. For smear-positive cases, this Western Pacific 50 +28 was 49% in South-East Asia and 52% in Overall 47 +34 the Western Pacific Region. DOTS areas reported 47% of all estimated new smear-positive cases (i.e. one million new smear-positive cases) in the two Regions. Case detection has increased 34% between 2002 and 2003 in the two regions. Figure 5: Trends in DOTS case detection rates in South-East Asia and Western Pacific Regions 1995-2003.

80 DOTS case detection rate (%) 70 60 50 40 30 20 10 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Note: The forecast lines for both the South-East Asia and Western Pacific Regions are based on the assumption that the annual rate of increase between 2003 and 2006 would remain similar to the annual rate of increase from 2002 to 2003. SEAR WPR World forecast SEAR forecast WPR

DOTS case detection has made steady progress in the South-East Asia Region since 1998 whereas progress in the Western Pacific Region was slow until 2002. The increase in case detection in the South-East Asia Region is largely due to the large increase in India (+52%) between 2002 and 2003. Similarly, the increase in case detection (+28%) in the Western Pacific Region between 2002 and 2003 is mostly due to a dramatic increase in case detection in China (+59%). If the rate of progress from 2002 to 2003 is maintained, the global target of 70% case detection rate may be reached in both Regions by the end of 2005 or during early 2006. In total, over 1.1 million additional new smear-positive cases will need to be detected per year to reach the target (760 000 in the South-East Asia Region and 437 000 in the Western Pacific Region).

Tuberculosis Control in South-East Asia and Western Pacific Regions

3.3 DOTS Enrolment and Progress in Overall Case Detection Figure 6 shows trends in new smear-positive case detection rates in DOTS and non-DOTS areas in both Regions during the period 1995 to 2003. In the South-East Asia Region, the DOTS casedetection rate increased initially at the expense of the non-DOTS case-detection rates. The total case-detection rate although increasing slightly, only made rapid gains after 1999. In the Western Pacific Region, the total case-detection rate was stable from 1997 to 2002 although there was a rapid DOTS expansion during this period.

Figure 6: Trends in DOTS and non-DOTS case-detection rates (new smear-positive cases) in the South-East Asia and Western Pacific Regions 100% 90% 80% % cases detected 70% 60% 50% 40% 30% 20% 10% 0% 1995 1996 1997 1998 1999 2000 2001 2002 2003

DOTS

non DOTS

Undetected

3.4 Treatment Outcomes In DOTS areas, the cure and treatment success rates were 82% and 88% respectively, for the cohort of 790 916 new pulmonary smear-positive cases registered for treatment in 2002 (85% and 81%, respectively in the South-East Asia Region, and 91% and 84%, respectively in the Western Pacific Region). With the minimal difference between cure and treatment success rates (6%), TB control programmes should not have difficulty in reaching 85% cure rates. It is notable that the failure rates in both DOTS (2%) and non-DOTS (1%) areas are very low (Figure 7). In total, 23 countries and areas out of the 45 that reported treatment outcomes below the 85% global target, five are in the South-East Asia Region, including three high burden countries11 (Bangladesh, Myanmar and Thailand), and 18 in the Western Pacific Region, including two high burden countries12 – (Lao PDR and Papua New Guinea). Non-DOTS areas reported a lower success rate for treatment completion than DOTS areas. Countries with a high burden of tuberculosis in South-East Asia Region belong to the global list of 22 high burden countries: Bangladesh, India, Indonesia, Myanmar and Thailand. 11

Seven countries in the Western Pacific Region are considered to have a high burden of tuberculosis: Cambodia, China, Lao PDR, Mongolia, Papua New Guinea, the Philippines, Viet Nam. 12

Tuberculosis Control in South-East Asia and Western Pacific Regions

Figure 7: Treatment outcomes for new smear-positive cases registered in 2002 in DOTS and non-DOTS areas in South East-Asia and Western Pacific Regions 100% 90% 80% Treatment outcomes (%) 70% 60% 50% 40% 30% 20% 10% 0% DOTS Success Death Failure Non DOTS Others

Figure 8 shows the distribution of unfavourable outcomes in both regions combined. Defaults (36%) followed by deaths (29%) together account for close to two-thirds of all unfavourable outcomes among new smear-positive TB cases registered under DOTS programmes in the Western Pacific and South-East Asia Regions in 2002.

Figure 8: Unfavourable outcomes among new smear-positive cases registered in 2002 in DOTS areas in South East Asia and Western Pacific Regions

100% 90% 80% 70% percentage 60% 50% 40% 30% 20% 10% 0% Not evaluated Transfer out Default Failure Death

Tuberculosis Control in South-East Asia and Western Pacific Regions

3.5 Treatment Results of Re-treatment Cases Figure 9 shows treatment outcomes for re-treatment cases in the South-East Asia and Western Pacific Regions. In 2003, the proportion of relapse cases among all smear-positive cases was 9.7% in the South-East Asia Region and 19% in the Western Pacific Region. The high proportion of relapses among all smear-positive cases in the Western Pacific Region was mainly due to the high proportion of relapses observed in China (26%). The high success rate among re-treatment cases in China accounted for the overall high treatment success rate (92%) among re-treatment cases in the Western Pacific Region. A larger proportion of deaths occurred among re-treatment cases in the South-East Asia Region (7%) than among those in the Western Pacific Region (3%). Thailand contributed to the large proportion of re-treatment deaths in the South East Asia Region (17%). This is partly due to the higher HIV prevalence and an ageing population in Thailand.

Figure 9: Treatment outcomes for re-treatment cases registered in 2002 (DOTS areas) 100% 90% Treatment outcomes (%) 80% 70% 60% 50% 40% 30% 20% 10% 0% SEAR Success Death Failure WPR Others

Tuberculosis Control in South-East Asia and Western Pacific Regions

4 Grouping of Countries 4.1 High Burden Countries High burden countries include Bangladesh, India, Indonesia, Myanmar and Thailand in the SouthEast Asia Region, and Cambodia, China, Lao PDR, Mongolia, Papua New Guinea, the Philippines and Viet Nam in the Western Pacific Region13. All high burden countries in the South-East Asia Region belong to the WHO list of 22 high burden countries14.

Epidemiology In 2003, the high burden countries accounted for 96% of the South-East Asia Region’s population and for 86% of the Western Pacific Region’s population; and for 95% of notified new cases in the South-East Asia Region and for 91% of the notified new cases in the Western Pacific Region. Overall case detection of new TB cases has made considerable progress in China and India from 2002 to 2003 (+59% and +52% respectively). The estimated prevalence rates (all cases) have decreased at a rate of –2%/yr in China and –4%/yr in India. The estimated incidence rate (all cases) has decreased at a rate of –1%/yr in China but remained stable in India. Figure 10 shows trends in DOTS and non-DOTS case-detection rates in China, India, Indonesia and Viet Nam. In China and India, most of the increase in the DOTS case-detection rate until 2002 has occurred at the expense of non-DOTS areas while early and extensive DOTS coverage in Indonesia and Viet Nam resulted in a regular increase in overall case-detection rates. Figure 11 shows the age distribution of cases in three of the highest burden countries in the two regions. A contrasting age pattern emerges between India and Indonesia, where a hump of higher notification rates is observed in the age group 15 to 64 years as opposed to China, where the pattern resembles that of middle to high-income countries with increasing rates with age. Figure 12 shows increasing notification rates with age, with the exception of the Philippines, which follows a pattern similar to India and Indonesia but with much higher rates overall.

Progress in TB control All countries with a high burden of TB are using WHO-recommended guidelines for national TB control programmes. Drug procurement is centralized in all countries. National reference 13 14

Based on incidence rates per 100 000 population. WHO. Global Tuberculosis Control 2005. Surveillance, Planning, Financing. WHO Geneva 2005.

Tuberculosis Control in South-East Asia and Western Pacific Regions

Figure 10: Trends in DOTS and non-DOTS case-detection rates (new smear-positive cases) in China, India, Indonesia and Vietnam 100% 90% Case-detection rate (%) Case-detection rate (%) 80% 70% 60% 50% 40% 30% 20% 10% 0% 1995 1996 1997 1998 1999 2000 2001 2002 2003 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 1995 1996 1997 1998 1999 2000 2001 2002 2003

China

India

100% 90% 80% Case-detection rate (%) 70% 60% 50% 40% 30% 20% 10% 0% 1995 1996 1997 1998 1999 2000 2001 2002 2003 Case-detection rate (%)

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 1995 1996 1997 1998 1999 2000 2001 2002 2003

Indonesia DOTS non DOTS Undetected

Vietnam

Figure 11: Age-specific smear-positive notification rates per 100 000 population in China, India and Indonesia 90 80 70 60 50 40 30 20 10 0 0-14 15-24 China 25-34 35-44 India 45-54 55-64 65+

Notification rates per 100 000 population

Indonesia

Tuberculosis Control in South-East Asia and Western Pacific Regions

Figure 12: Age-specific smear-positive notification rates per 100 000 population in several high-burden countries in South-East Asia and Western Pacific Regions. 700 Notification rates per 100 000 population 600 500 400 300 200 100 0 0-14 15-24 Cambodia Myanmar 25-34 35-44 Philippines Vietnam 45-54 55-64 Bangladesh Thailand 65+

laboratories have been designated. All the countries use sputum microscopy for diagnosis and directly observed treatment (DOT) is applied in most public health units within DOTS areas. Treatment and smear microscopy examinations are free of charge in all public health facilities in DOTS areas in these countries. Reporting of treatment results is based on cohort analysis in all countries with DOTS programmes. Screening and treatment of contacts is done in some units only. DOTS expansion made the most significant progress in the high burden countries. Figure 13 presents the progress of DOTS towards targets between 2002 and 2003. Figure 13: Progress of DOTS towards targets in high-burden countries in South-East Asia and Western Pacific countries 100% Cambodia China 90% Treatment success new SS+ (%) Indonesia Bangladesh Lao PDR Myanmar India Philippines Mongolia Target Zone Vietnam

80%

70%

Thailand

60% Papua New Guinea 50% 0% 10% 20% 30% 40% 50% 60% DOTS detection rate (new SS+ cases) 70% 80%

2002 2003

90%

100%

Tuberculosis Control in South-East Asia and Western Pacific Regions

The treatment success in Thailand remains below the WHO target because of high death rates, which are partly attributed to HIV and to a comparatively high proportion of older patients. The performance of the TB programme in Papua New Guinea remains unsatisfactory. Thailand has integrated TB and HIV programmes at the central and provincial levels, allowing streamlined TB-HIV activities. India has successfully expanded DOTS employing contracted national consultants who assist the state level NTP managers in implementing and monitoring the programme at the field level. China has recently made progress in case detection as a result of a strong political commitment at all levels and countrywide implementation of a public-public partnership linking general hospitals and TB dispensaries. Multidrug-resistant TB remains at high levels in several provinces, and there is a need to assess the magnitude of anti-TB drug resistance nationally. Myanmar has continued to make steady progress with case detection and treatment success along with phased expansion. Bangladesh and Indonesia are making slower advances in case detection while maintaining high treatment success rates. The transition to decentralized health care systems in countries such as Indonesia poses a great challenge to maintaining a successful TB programme because of the limited management capacity and insufficient human resources at provincial and district levels. Future actions in these countries to improve the TB programme will focus on human resource development (HRD) including capacity building through training of health staff, particularly for supervision and quality assurance15. Common issues and challenges include overstretched public health systems, the lack of adequate infrastructure and sufficient skilled staff. HIV-TB and MDR-TB create additional challenges in several countries with a high burden of TB. There is increasingly a need for greater involvement of other sectors, particularly the private sectors to ensure access to quality services and for attention to information, education and communication guidelines to improve community awareness and utilization of services.

4.2 Low and Intermediate Burden Countries High income countries Epidemiology Middle to high income countries include Australia, Brunei Darussalam; China, Hong Kong SAR; China, Macao SAR, Japan; the Republic of Korea; Malaysia, New Zealand and Singapore. A stagnation of notification rates (defined as a slowdown or reversal of the annual decline of the crude notification rate) is observed in several countries and areas (Table 7). Notification rates continue to decline in the Republic of Korea, Japan, Singapore and, to a lesser extent, in Hong Kong SAR. 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. With the exception of Malaysia, all countries have a high case-detection rate among all TB cases, well above the 70% global target.

Tuberculosis Control in the South-East Asia Region 2004, WHO Regional Office for South-East Asia (SE-TB-272)

Tuberculosis Control in South-East Asia and Western Pacific Regions

Table 7: Annual rate of change in notification and case-detection rates (all cases) in middle to high-income countries Yearly rate of change in notification rates (%) 1980-90 Australia Brunei Darussalam China, Hong Kong SAR China, Macao SAR Japan Republic of Korea Malaysia New Zealand Singapore -6.0 -10.0 -2.7 -13.0 -3.6 -4.2 -3.3 -6.6 -7.8 1990-2003 -1.7 +1.3 -1.5 +0.75 -3.7 -5.9 +0.19 +0.25 -3.4 Yearly rate of change in CDR (%) 1990-2003 0 -1 -3 -1 -4 0 -1 0 -3 Case detection rate (%) 2003 84 106 103 97 79 81 61 94 92

In Hong Kong SAR 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, and 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 SAR. 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 (Figure 14).

Figure 14: Age-specific case-notification rates per 100 000 population in Malaysia, Republic of Korea, Singapore and Japan

Notification rates per 100 000 population

250 200 150 100 50 0 0-14 15-24 25-34 35-44 45-54 55-64 65+ Age group (years) Malaysia Korea Singapore Japan

Tuberculosis Control in South-East Asia and Western Pacific Regions

In Brunei Darussalam and Macao SAR, 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 there is limited scope for further decline. Treatment success was below the 85% target in Australia, Brunei Darussalam, Hong Kong SAR, Japan, Korea, and Malaysia. This may be attributed partly to high death rates due to the age structure of the cases in countries such as Australia (10% death rate), to an increasing impact of HIV in countries such as Malaysia (8% death rate) where there is an increase in notification rates in the 25-44 years age group, or to high transfer rates such as in the Republic of Korea (10% transfer rate) where the information system does not easily capture treatment outcomes.

Progress in TB control With the exception of Japan, the Republic of Korea and Australia, all middle to high-income countries have 100% DOTS coverage. China and the Republic of Korea use an internet-based surveillance system, which in the Republic of Korea also covers the private sector. Japan passed a new legislation for tuberculosis control which will put emphasis on active case detection in highrisk groups. TB-HIV collaborative activities were progressively being implemented in Malaysia. Tuberculosis control has not been thoroughly assessed in vulnerable populations (migrants, elderly, homeless, intravenous drug users), where barriers to TB services exist. Population movements have some importance, such as migrant workers in Singapore and Brunei Darussalam, and travel in and out of mainland China into Hong Kong SAR. TB notification rates in Australia are much higher in the population of foreign origin and largely reflect notification rates in the country of origin.

Countries with emerging economies There are five countries in this category without a relatively high burden of TB, all in the SouthEast Asia Region16. These countries include both mountainous nations of Bhutan, the Democratic People’s Republic of Korea and Nepal, as well as Sri Lanka, and Timor-Leste.

Epidemiology The case-notification rates for 2003 among this group of countries are very heterogeneous, ranging from 16 per 100 000 in Bhutan to 132 per 100 000 in Timor-Leste. In DPR Korea’s the yearly rate of change for case detection is at +89% between 1999 and 2003 reflecting a huge increase in case detection from 2% to 96% in less than five years. The crude case-notification rate has also increased over 25% during the same period. The age-specific notification rates for Bhutan and Sri Lanka are the lowest in the group and also fairly constant across the age groups. DPR Korea and Nepal have a similar trend with increasing rates from 0-54 years followed by a strong decline in rates in the 55+ ages. The notification rates

Tuberculosis Control in the South-East Asia Region 2004, WHO Regional Office for South-East Asia (SE-TB-272)

Tuberculosis Control in South-East Asia and Western Pacific Regions

Table 8: Case-notification rates, case-detection rates and rate of change, 1999-2003 SS+ notification rate (per 100 000) 16 77 57 23 a

Countries

Overall SS+ case-detection rate 32% 96% 60% 83% 53%

CDR yearly rate of change 1999-2003 5.0% 89.4% 6.3% -0.8% -11%*

Notification rate yearly rate of change 1999-2003 -6.1% 25.5% 0.5% 4.3% -5.2%*

Bhutan DPR Korea Nepal Sri Lanka Timor-Leste a

132

rate of change is only for 2002-2003 period for Timor-Leste

in Timor-Leste are greater than in the other countries in this group and have the highest rates in the 45+ age groups. Figure 15: Age-specific notification rates, 2003

Notification rates per 100 000 population

350 300 250 200 150 100 50 0 0-14 15-24 25-34 35-44 45-54 55-64 65+ Age groups (years) Bhutan DPR Korea Nepal Sri Lanka Timor-Leste

Progress in TB control Case-detection rates for smear-positive tuberculosis in these countries range from a low of 32% in Bhutan to a high of 96% in DPR Korea. The highest population coverage (100%) in Bhutan is offset by the lowest case-detection rate (32%) in this group of countries. Nepal also demonstrates a similar paradox with high coverage (94%) but lower than optimal case detection (60%). DPR Korea shows a reversal of this relationship with the highest case-detection rate (96%). The case detection rate has remained fairly steady at a little over 70% in Sri Lanka during the same period. Treatment success rates are consistently high, above 81% in all countries in this group. A key challenge for expansion of DOTS implementation in this group of countries is the insufficient capacity to ensure quality laboratory diagnostic services, especially in Bhutan,

Tuberculosis Control in South-East Asia and Western Pacific Regions

Table 9: Progress with DOTS in 2003 Countries Bhutan DPR Korea Nepal Sri Lanka Timor-Leste DOTS population coverage (%) 100 80 94 74 78 Overall SS+ case-detection Rate (%) 32 96 60 83 53 Treatment success (2002 cohort) (%) 86 88 86 81 81 SS+ Case notification rate (per 100 000) 16 77 57 23 132

DPR Korea and Sri Lanka. Technical and managerial capacity requires strengthening with minimum staff turnover in Sri Lanka and Timor-Leste. For the hilly countries bordering India, namely Nepal and Bhutan, internal and cross-border migration of the population remain a problem as does population access to health care in remote regions. Plans for further strengthening DOTS programmes in all these countries include building managerial and human resource capacity at all levels, increasing community awareness, attention to improved supervision and monitoring including quality assurance for laboratory services. In addition, in Bhutan, DPR Korea and Timor-Leste’s plans are under way to improve infrastructure. Annual risk of TB infection (ARTI) surveys are being planned in DPR Korea and Nepal. In addition, the pilot DOTS Plus project has been initiated in Nepal.

Island Countries Epidemiology The island countries17 group includes Maldives in the South-East Asia Region and Pacific Island Countries (PICs) in the Western Pacific Region: 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 and Wallis and Futuna. Case-notification rates vary widely among island countries. Rates also fluctuate with time due to the very small population size of most countries or areas. In the Pacific, 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. A great deal of uncertainty is attached to estimates of incidence and prevalence in individual island countries and areas due to the limited amount of data and the small population size. Several countries show a case-detection rate well over 100% as a result of poor estimates of incidence and mopping up of prevalent cases. The prevalence of HIV is low in all island countries and none of them has reached the concentrated stage of the epidemic. HIV has therefore a very limited impact on the epidemiology of TB in these countries. 17

The term “Island Countries” refers to both countries and areas

Tuberculosis Control in South-East Asia and Western Pacific Regions

There is limited data on drug resistance in the Island countries; overall estimates indicate low rates of multidrug resistance.

Progress in TB control With the exception of the Federated States of Micronesia and Wallis and Futuna, all island countries have 100% DOTS coverage despite widely scattered populations where organization of tuberculosis control is complicated. Maldives was one of the first countries globally to achieve both cure rate and case-detection targets in 1997 and has surpassed these since 2000. Key challenges and constraints include weak supervisory capacity because of difficulties in travelling between islands, as well as in organizing decentralized treatment services, and inadequate laboratory capacity with limited capacity to implement national quality assurance programmes. Monitoring with precision progress towards the Millennium Development Goals in island countries will remain a challenge until better estimates of tuberculosis morbidity and mortality can be obtained. Future actions to improve TB control in Maldives will involve continued training of health staff and an improved communications strategy, particularly in the treatment of latent TB as the country moves towards elimination of TB entirely. Training efforts including training for TB laboratory staff are pursued in Pacific Island countries. The majority of islands in PICs are situated in remote locations and transport is infrequent and unreliable in some cases. Recognizing the unique situation of the Pacific, the Secretariat of the Pacific Community (SPC), the Member States and WHO endorsed a Pacific Strategic Plan to Stop TB in 2000.

Tuberculosis Control in South-East Asia and Western Pacific Regions

5 WHO’S WORK 5.1 WHO’s Work in the Regions WHO has continued to assist countries in both regions towards achieving the 2005 global targets and in reducing the burden of TB. Although there are separate regional strategic plans for South-East Asia Region (SEAR Strategic Plan for TB Control 2002-200618) and the Western Pacific Region (WPR Strategic Plan 2000200519), the two regions share common broad strategies to achieve the goals of TB control. The implementation of these strategies had been critical to achieving progress in both regions: • Expanding DOTS has been the key strategy to curb the TB epidemic in both regions. National TB programmes were assisted to build technical and managerial capacity to ensure quality while continuing to expand DOTS to cover the entire population in countries. • Improving case detection as the major focus of activities closely following on DOTS expansion. Countries were assisted to build and expand collaboration/partnerships with other sectors and providers, and to improve community awareness and use of DOTS services. • Strengthening advocacy, communications and social mobilization activities to increase political commitment and community participation in TB control. • Implementing a collaborative approach to addressing the emerging challenge of TB-HIV co-infection. In the Western Pacific Region, there was strong support for implementing activities to address the issue of multi-drug resistant-TB in several countries and enhancing country capacity for surveillance and programme monitoring. In the South-East Asia Region, implementation of operational research to identify replicable interventions to more effectively deliver DOTS in the diverse health settings has been a priority activity. WHO played a catalytic role in implementing these strategies in the countries through focused technical support, capacity strengthening, effective coordination, information exchange, 18 19

Regional Strategic Plan for TB Control 2002-2006. WHO Regional Office for South-East Asia, New Delhi (SE-TB-246).

Regional Strategic Plan to Stop TB in the Western Pacific Region 2000-2005. WHO Regional Office for the Western Pacific. Manila. 2000.

Tuberculosis Control in South-East Asia and Western Pacific Regions

advocacy, monitoring and supervision, and strengthening partnerships and mobilizing resources for TB control.

Providing timely and effective technical support The regional and country offices continued to assist countries in effectively undertaking TB control activities through sustained technical assistance, in-country missions, information exchange and consensus building on effective strategies and policies for TB control. Bringing technical assistance closer to the countries is one of the key approaches that have led to good progress. Long-term professional staff have been posted in five countries of the SEA Region (Bangladesh, India, Indonesia, Myanmar and Nepal) and six countries and areas in the Western Pacific Region (Cambodia, China, Pacific island countries, Papua New Guinea, the Philippines and Viet Nam). A network of national professional officers and national consultants is providing technical assistance at the field level in all countries with a high burden of TB. In both regions, WHO continues to provide targeted technical assistance for specific areas and to strengthen the operationalization of regional and country strategies. In recent years, technical assistance has been targeted at accelerating DOTS expansion and case detection, and in initiating response to emerging issues that included TB-HIV, MDR-TB and collaboration between public and private health providers for TB control.

Capacity strengthening WHO is continuing to strengthen technical and management capacity for TB control in both regions. One of the crucial areas is improving human resource capacity, which has been one of the persistent challenges of TB control. WHO continues to support regional, intercountry and national training courses on TB control in several areas, including surveillance and data management, laboratory methods for the diagnosis of TB including quality assurance, TB-HIV and drug resistance surveillance. WHO also supports fellows from countries for specific technical and management capacity strengthening objectives, which were found useful by many countries to promote exchange of information on lessons learnt with implementing DOTS and addressing specific challenges. In the SEA Region, the inter-country courses on comprehensive TB control and on leadership and strategic management for TB control programme managers have resulted in similar training being undertaken at the national level. In the WP Region, around 25 TB staff from different countries in the Region are supported to the International TB Course in Viet Nam organized in collaboration with the International Union of Tuberculosis and Lung Diseases (IUATLD). WHO is building capacity in the countries to respond to challenges by developing regional guidelines and plans and supporting countries to adapt these guidelines or plans to their specific settings. WHO has published the Quality Assurance Guidelines for Smear Microscopy in the Western Pacific Region, which had been the basis of the specific guidelines in some countries. To provide guidance on TB-HIV response, the SEA Region developed the Regional Strategic Plan on HIV-TB while the Western Pacific Region published the TB-HIV Framework for Collaborative Activities, which now serves as the basis for country TB-HIV frameworks. Moreover, a training course on operationalizing TB-HIV interventions, held in Thailand in January 2005 and the TB-HIV conference

Tuberculosis Control in South-East Asia and Western Pacific Regions

for the Mekong countries20 held in Viet Nam, will help improve country capacity for joint TB-HIV activities. With increasing emphasis on increasing good collaboration of health providers, especially private health providers, WHO is supporting countries to initiate and expand the private and public mix DOTS (PPMD) approach in some countries. Two countries in both regions, that is, India and the Philippines, have implemented PPMD projects that could be considered as models globally.

Effective coordination and information exchange Both regions continued to coordinate information exchange and technical discussions on strategies and policies for TB control at regional and country levels. In both regions, a number of meetings were organized that include the regional Technical Advisory Group meeting, the meeting of national TB programme managers (including laboratory managers in the case of WPR) and other technical meetings, that include special meetings on surveillance and monitoring, PPMD, TB-HIV and other technical areas, at the regional or at the country level. The technical advisory or working group meetings and the meeting of the national TB managers provided opportunities to review the programme, discuss issues and constraints, exchange lessons learned, and discuss strategies and new approaches to overcome the challenges for TB control. Sustaining political commitment for TB control has been part of the work. Both regions have implemented advocacy activities to maintain a good level of interest in TB control in the countries and also among donors. In 2004, WHO organized a China-WHO High Level Meeting to Accelerate TB Control in the 12 priority provinces of China. At this meeting, high-level officials, mostly vice-governors, affirmed their commitments to achieve the global TB control targets of 2005.

Strengthening partnerships and mobilizing resources for TB Control Stop TB partnerships were established in 1999 in the Western Pacific Region and in 2003 in the SEA Region. WHO plays a key role in strengthening partnerships for TB control by providing fora at regional and country levels for discussions on several aspects of TB control among technical partners and donors, including technical, strategy and policy development and implementation, the effective and efficient use of financial resources. WHO continues to work with international funding partners, including the Australian Agency for International Development, Canadian International Agency, United States Agency for International Development, Japan Government, World Bank and the Global Fund to close the gap for TB control in both regions. WHO assisted several countries with a high burden of TB to secure drug supplies from the Global Drug Facility and other donors, and for improving laboratory facilities through different donors. For the Global Fund, almost all countries which applied for funding support for their NTPs were assisted to develop proposals during Round 4. Proposals from six countries in the two regions (Bhutan, China, India, Laos, Mongolia and Nepal) amounting to a total of US $102

Mekong countries include Cambodia, China Yunnan Province, Laos, Thailand, Myanmar and Viet Nam.

Tuberculosis Control in South-East Asia and Western Pacific Regions

million over five years succeeded in getting Global Fund approvals during this round. Four years after the Global Fund was established, proposals approved by the Global Fund in both regions amount to a total of US $393 million over five years, substantially reducing the funding gap to achieve the 2005 process targets of TB control.

Monitoring and evaluation It is becoming increasingly important that countries be enabled to objectively measure and report on progress towards reaching the goals set by both regions. The Regional Offices continued to collect, compile, analyse and provide feedback to countries on routinely collected data on DOTS implementation. Information routinely collected from countries and analysed is published in the Global TB Control Report and the Bi-regional report on TB control in the Western Pacific and South-East Asia Regions. Monitoring missions were undertaken together with key partners and donors in most countries with a high burden of TB in 2004. These missions are useful for monitoring programme performance and assessing country capacity for surveillance and programme monitoring. A regional workshop on surveillance and epidemiology was conducted in each of the two regions. The workshops have contributed towards building capacity at the national level to compile, analyse and effectively use routinely collected data and to plan for improved surveillance for TB. In addition, several countries have initiated plans to better estimate incidence, prevalence and mortality of TB at national and sub-national levels.

Operational research Countries are being encouraged and supported in undertaking operational research projects that are contributing towards identifying mechanisms to improve access, make services more user-friendly and increase the involvement of other sectors, to further increase case detection and improve treatment outcomes. Projects to increase collaboration among a broad range of health providers are in place in Bangladesh, China, India, Indonesia, Republic of Korea, Myanmar and the Philippines, while other countires are being assisted to initiate similar collaborative activities. Communication for Behavioural Impact or COMBI, a new package for community information, education and communication, was piloted and evaluated by the Revised National Tuberculosis Control Programme (RNTCP) in India. Lessons learnt from these projects will be used to plan similar efforts in other countries in the Region.

Tuberculosis Control in South-East Asia and Western Pacific Regions

Tables

Country data for the Western Pacific and South East Asia Regions: estimated burden of TB, 1990 and 2003 Death, 1990 Incidence, 2003 All cases incl. HIV+ All cases excl. HIV+ All cases incl. HIV+ New ss+ incl. HIV+ Number Number Prevalence, 2003 All cases incl HIV+ All cases excl HIV+ Death, 2003 All cases incl HIV+ All cases excl HIV+

Incidence, 1990 All cases incl. HIV+ New ss+ incl. HIV+

Prevalence, 1990 All cases incl. HIV+ All cases excl. HIV+

Tuberculosis Control in South-East Asia and Western Pacific Regions

American Samoa Australia Brunei Darussalam Cambodia China China, Hong Kong SAR China, Macao SAR Cook Islands Fiji French Polynesia Guam Japan Kiribati Lao PDR Malaysia Marshall Islands Micronesia Mongolia Nauru New Caledonia New Zealand Niue Northern Mariana Is Palau Papua New Guinea Philippines Rep. Korea Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis & Futuna Is WP Region Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste SEA Region Total

Number 24 1,067 159 56,202 1,345,828 6,326 348 10 376 102 189 64,322 101 7,376 21,380 63 136 4,875 5 241 356 1 62 21 10,992 205,495 36,762 83 1,763 449 0.8 52 5 210 133,660 7 1,899,047 269,193 3,526 35,493 1,420,446 519,763 388 69,260 39,361 10,186 77,404 4,115 2,449,136 4 348 183 5 171 33 12,009 282,443 1,329 73 2 79 21 40 10,323 21 1,548 4,488 13 28 1,023 1 51 57 0.3 13 4 2,307 43,126 7,715 17 283 94 0.2 11 1.0 44 28,051 1 395,426 71,342 934 9,406 377,611 137,748 103 18,402 10,435 2,700 21,069 1,091 650,840 1 046 266 8 505 88 31,758 599,758 2,446 172 2 112 33 44 17,956 24 3,999 11,567 14 29 2,261 2 61 185 0.3 21 6 6,020 106,580 18,744 24 783 129 0.2 14 1 57 64,982 2 868,388 162,331 1,121 18,124 798,338 281,946 64 37,655 23,809 5,187 39,683 1,944 1,370,201 2 238 589

Rate 52 6 62 577 116 111 93 52 52 52 141 52 141 178 120 141 141 220 52 141 11 52 141 141 267 336 86 52 58 141 52 52 52 141 202 52 125 246 208 178 168 285 180 171 211 61 142 556 190 155

Number 11 478 72 24,848 605,046 2,845 156 4 169 46 85 28,927 45 3,318 9,591 28 61 2,194 2 108 160 0.5 28 10 4,925 92,457 16,539 37 789 202 0.4 23 2 95 59,924 3 853,229 121,126 1,586 15,972 634,211 233,706 175 30,847 17,636 4,582 34,377 1,850 1,096,068 1 949 297

Rate 23 3 28 255 52 50 42 23 23 23 63 23 63 80 54 63 63 99 23 63 5 23 63 63 120 151 39 23 26 63 23 23 23 63 91 23 56 111 94 80 75 128 81 76 95 27 63 250 85 69

Number 68 1,195 443 154,356 3,748,967 17,611 969 27 1,047 283 525 71,939 282 20,547 59,540 174 378 13,581 14 671 398 3 172 60 30,621 572,431 102,406 232 1,967 1,250 2 144 13 586 372,326 20 5,175,246 810,699 10,618 106,891 4,263,735 1,565,313 1,169 208,022 118,501 30,677 226,398 12,393 7,354,416 12 529 662

Rate 145 7 172 1,584 325 309 260 145 145 145 392 58 392 497 334 392 392 613 145 392 12 145 392 392 744 937 239 145 65 392 145 145 145 392 563 145 341 741 626 536 504 860 542 514 636 182 416 1,674 570 446

Number 68 1,195 443 153,874 3,748,967 17,608 969 27 1,047 283 525 71,895 282 20,547 59,536 174 378 13,581 14 671 398 3 172 60 30,621 572,431 102,406 232 1,963 1,250 2 144 13 586 372,326 20 5,174,709 810,699 10,618 106,891 4,260,935 1,565,313 1,169 207,910 118,493 30,677 225,061 12,393 7,350,160 12 524 869

Rate 145 7 172 1,579 325 309 260 145 145 145 392 58 392 497 334 392 392 613 145 392 12 145 392 392 744 937 239 145 65 392 145 145 145 392 563 145 341 741 626 536 503 860 542 513 636 182 414 1,674 569 446

Rate 11 1 13 123 24 23 20 11 11 11 30 8 30 37 25 30 30 46 11 30 2 11 30 30 56 71 18 11 9 30 11 11 11 30 42 11 26 65 55 47 45 76 48 45 56 16 39 147 50 37

Number 5 171 33 11,593 282,443 1,327 73 2 79 21 40 10,313 21 1,548 4,485 13 28 1,023 1 51 57 0.3 13 4 2,307 43,126 7,715 17 282 94 0.2 11 1.0 44 28,051 1 394,995 71,342 934 9,406 374,964 137,748 103 18,296 10,427 2,700 19,805 1,091 646,817 1 041 812

Rate 11 1 13 119 24 23 20 11 11 11 30 8 30 37 25 30 30 46 11 30 2 11 30 30 56 71 18 11 9 30 11 11 11 30 42 11 26 65 55 47 44 76 48 45 56 16 36 147 50 37

Number 18 1,128 195 71,830 1,334,066 5,439 382 5 249 73 98 39,927 53 8,891 25,785 32 66 5,025 4 137 413 0.6 48 12 13,437 236,885 41,664 53 1,749 286 0.5 31 3 127 144,942 4 1,933,054 360,767 2,492 40,277 1,788,043 627,047 142 84,546 53,139 11,530 89,351 4,323 3,061,657 4 994 711

Rate 30 6 54 508 102 77 82 30 30 30 60 31 60 157 106 60 60 194 30 60 11 30 60 60 235 296 87 30 41 60 30 30 30 60 178 30 112 246 110 178 168 285 45 171 211 60 142 556 190 149

Rate 13 3 25 225 46 35 37 13 13 13 27 14 27 71 47 27 27 87 13 27 5 13 27 27 105 133 39 13 18 27 13 13 13 27 80 13 50 111 50 80 75 128 20 76 95 27 63 250 85 67

Number 34 1,142 217 107,836 3,203,059 5,554 414 11 318 94 171 53,210 53 18,504 33,128 32 68 6,149 5 236 420 1 53 16 30,240 366,171 56,522 79 1,806 288 0.9 45 6 150 194,970 4 4,081,006 719,411 4,378 42,429 3,085,876 1,483,735 125 92,429 80,074 16,956 130,418 5,872 5,661,702 9 742 708

Rate 54 6 61 762 246 79 89 59 38 39 105 42 60 327 136 60 62 237 36 103 11 59 67 76 529 458 118 44 42 60 59 44 59 71 240 30 236 490 194 187 290 675 39 187 318 89 208 754 351 291

Number 34 1,132 217 105,008 3,200,204 5,548 413 11 317 94 170 53,154 53 18,494 32,945 32 68 6,147 5 235 418 1 53 16 30,108 366,079 56,409 78 1,786 288 0.9 45 6 150 193,762 4 4,073,485 719,339 4,377 42,428 3,054,470 1,482,607 125 90,475 79,556 16,948 127,792 5,863 5,623,979 9 697 464

Rate 54 6 61 742 245 79 89 59 38 38 105 42 60 327 135 60 62 237 36 103 11 59 67 76 527 458 118 44 42 60 59 44 59 71 238 30 235 490 194 187 287 674 39 183 316 89 203 753 348 290

Number 4 113 17 13,493 235,864 468 45 1 38 11 19 4,973 4 1,482 4,044 2 6 834 0.5 26 41 0.1 6 2 2,782 38,872 4,715 9 198 21 0.1 5 0.6 18 18,750 0.3 326,862 83,533 467 3,549 352,085 143,178 7 12,410 7,399 1,685 12,152 747 617,211 944 073

Rate 6 1 5 95 18 7 10 6 4 5 12 4 4 26 17 4 6 32 4 11 1 6 8 8 49 49 10 5 5 4 6 5 6 8 23 2 19 57 21 16 33 65 2 25 29 9 19 96 38 28

Number 4 111 17 11,469 233,918 467 44 1 37 11 19 4,960 4 1,475 3,942 2 6 833 0.5 26 41 0.1 6 2 2,700 38,811 4,690 9 193 21 0.1 5 0.6 18 18,116 0.3 321,957 83,467 466 3,549 329,915 142,168 7 11,748 7,138 1,680 10,853 742 591,734 913 691

Rate 6 1 5 81 18 7 10 6 4 5 12 4 4 26 16 4 6 32 4 11 1 6 8 8 47 49 10 5 5 4 6 5 6 8 22 2 19 57 21 16 31 65 2 24 28 9 17 95 37 27

Country data for the Western Pacific and South East Asia Regions: notification, detection and DOTS coverage, 2003 Whole Country New cases Pulm confirmed Extrapulmonary Relapse number – – 3 91 – 549 5 – – 1 – – – – 46 number number number number % % number rate number rate After failure Other All cases All cases New ss+ After default New ss+ number % of pop number number % Smearnegative or unknown DDR Re-treatment cases Other Detection rate Notifications DOTS Non-DOTS Notifications All cases number New ss+ number

Pop thousands

All Cases

Smear-positive.

number

rate

number

rate

Tuberculosis Control in South-East Asia and Western Pacific Regions 7 – – – 38 – – – 724 – 5,540 – – – – – 1 1 – 2 7,008 – – 7,532 – – – – 2,194 271 – 431 10,428 17,436

American Samoa Australia Brunei Darussalam Cambodia China China, Hong Kong SAR China, Macao SAR Cook Islands Fiji French Polynesia Guam Japan Kiribati Lao PDR Malaysia Marshall Islands Micronesia Mongolia Nauru New Caledonia New Zealand Niue Northern Mariana Is Palau Papua New Guinea Philippines Rep. Korea Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis & Futuna Is WPR Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste SEAR Total

62 19,731 358 14,144 1,304,196 7,049 464 18 839 244 163 127,654 88 5,657 24,425 53 109 2,594 13 228 3,875 2 79 20 5,711 79,999 47,700 178 4,253 477 2 104 11 212 81,377 15 1,732,104 146,736 2,257 22,664 1,065,462 219,883 318 49,485 25,164 19,065 62,833 778 1,614,648 3,346,752

3 949 206 28,216 615,868 5,624 371 0 179 50 22 31,638 284 2,780 15,671 60 99 3,918 3 36 386 0 45 9 18,405 134,375 33,888 27 1,616 293 0 16 30 104 92,741 15 987,927 88,156 1,026 41,810 1,073,065 178,260 137 75,744 30,925 8,998 54,504 2,760 1,555,385 2,543,312

5 5 58 199 47 80 80 0 21 20 14 25 324 49 64 113 91 151 23 16 10 0 57 44 322 168 71 15 38 61 0 15 283 49 114 102 57 60 45 184 101 81 43 153 123 47 87 355 96 76

2 113 121 18,923 267,414 1,779 138 0 70 21 0 10,843 99 1,882 7,989 20 27 1,541 1 14 106 0 16 5 3,231 72,670 10,976 12 586 138 0 11 0 40 55,937 7 454,732 53,618 360 17,392 433,271 92,566 68 27,448 14,348 4,321 28,459 1,027 672,878 1,127,610

3 1 34 134 21 25 30 0 8 9 0 8 113 33 33 38 25 59 8 6 3 0 20 24 57 91 23 7 14 29 0 11 0 19 69 48 26 37 16 77 41 42 21 55 57 23 45 132 42 34

0 38 136 18,923 267,414 3,399 224 0 – 36 39 17,316 – 2,277 – 20 41 1,541 1 19 181 0 30 – 3,231 72,670 13,062 20 947 138 0 11 0 40 0 11 401,765 56,123 443 – 419,668 – 0 – – 4,764 – – 480,998 882,763

0 316 41 4,307 248,805 2,932 154 0 49 19 15 13,621 71 495 5,811 22 51 812 1 9 125 0 19 2 7,038 55,942 18,399 8 645 107 0 3 17 45 16,791 7 376,679 24,913 284 18,112 459,424 77,561 26 26,006 8,894 2,650 17,596 1,240 636,706 1,013,385

1 497 40 4,232 30,768 594 47 0 55 5 7 6,160 110 317 1,465 18 21 1,419 1 12 136 0 10 2 6,769 1,693 1,312 7 173 43 0 2 8 18 14,564 0 70,506 7,120 344 4,606 132,253 4,047 40 17,796 5,619 1,811 6,756 473 180,865 251,371

– 23 4 754 68,881 319 32 0 5 5 0 1,014 4 86 406 0 0 146 0 1 19 0 0 0 1,367 4,070 3,201 0 184 5 0 0 5 1 5,449 1 85,982 2,505 38 1,700 48,117 4,086 3 4,494 2,064 216 1,693 20 64,936 150,918

– – 0 51 – 0 0 0 – – 0 – – 5 20 0 0 58 0 – – 0 0 0 – – 359 0 12 0 0 0 1 1 491 0 998 – 19 1,105 12,206 – 0 964 300 47 – 8 14,649 15,647

5 – 1 28 – 1 6 0 – – 0 – – 39 175 0 3 31 0 – – 0 0 0 – – 713 0 16 0 0 0 0 0 189 1 1,208 – 11 833 61,295 – 0 1,487 412 161 – 18 64,217 65,425

– – – – 67,709 – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – 67,709 – – – 42,288 – – – – – – – 42,288 109,997

16 84 106 39 46 103 97 0 72 69 23 79 540 31 61 189 151 78 77 26 94 0 95 73 137 57 81 51 92 103 0 52 954 82 64 343 51 24 41 104 60 28 96 90 58 78 61 64 51 51

24 22 138 60 45 73 80 0 63 65 0 60 419 47 69 140 92 68 57 23 57 0 75 90 54 68 59 51 75 107 0 80 0 70 86 356 52 33 32 96 54 33 106 73 60 83 72 53 49 50

100 63 100 100 91 100 100 100 100 100 100 64 100 85 100 100 90 100 100 100 100 90 100 100 46 100 100 100 100 100 0 100 0 100 100 90 90 99 100 80 67 98 100 95 94 74 100 78 77 84

3 590 206 28,216 553,677 4,461 350 0 179 50 22 21,350 284 2,780 15,671 60 99 3,918 3 36 386 0 45 9 5,607 134,375 13,463 27 791 293 0 16 – 104 92,741 15 879,827 88,156 1,026 39,396 836,768 178,260 137 75,744 30,925 7,307 54,504 2,760 1,314,983 2,194,810

5 3 58 199 42 63 75 0 21 20 14 17 324 49 64 113 91 151 23 16 10 0 57 44 98 168 28 15 19 61 0 15 – 49 114 102 51 60 45 174 79 81 43 153 123 38 87 355 81 78

2 48 121 18,923 257,287 1,426 130 0 70 21 0 7,212 99 1,882 7,989 20 27 1,541 1 14 106 0 16 5 921 72,670 4,379 12 341 138 0 11 – 40 55,937 7 431,396 53,618 360 16,445 372,088 92,566 68 27,448 14,348 3,652 28,459 1,027 610,079 1,041,475

3 0 34 134 20 20 28 0 8 9 0 6 113 33 33 38 25 59 8 6 3 0 20 24 16 91 9 7 8 29 0 11 – 19 69 48 25 37 16 73 35 42 21 55 57 19 45 132 38 37

24 9 138 60 43 58 76 – 63 65 – 40 419 47 69 140 92 68 57 23 57 – 75 90 15 68 23 51 44 107 – 80 – 70 86 356 50 33 32 91 47 33 106 73 60 70 72 53 45 47

– 359 – – 62,191 1,163 21 0 – – – 10,288 – – – – – – – – – – – – 12,798 – 20,425 – 825 – – – 30 – – – 108,100 – – 2,414 236,297 – – – – 1,691 – – 240,402 348,502

– 65 – – 10,127 353 8 0 – – – 3,631 – – – – – – – – – – – – 2,310 – 6,597 – 245 – – – 0 – – – 23,336 – – 947 61,183 – – – – 669 – – 62,799 86,135

Country data for the Western Pacific and South East Asia Regions: treatment outcomes for cases registered in 2002 New smear-positive cases – non-DOTS % transferred notified regist'd % of notif regist'd Number regist'd % not eval % success Number of cases % cured % completed % died % failed % default % transferred % not eval % success % cured % completed % died % failed % default

New smear-positive cases – DOTS % died % failed % default

Smear-positive re-treatment cases – DOTS % transferred % not eval % success

Number of cases

notified

regist'd

% of notif regist'd

% cured

% completed

100 57 25 3 3 8 2 – – 82

– 10 13 4 1 5 5

– 4 – – 3

– – – – 2 – – – – – –

Tuberculosis Control in South-East Asia and Western Pacific Regions 5 7 25 12 4 7 8 – – 3 50 5 5 – 5 25 3 3 1 11 7 4 – 17 – 11 3 – 2 5 3 2 4 2 3 5 5 4 11 6 4 4 3 – – 0 0 – – 1 1 – – – – – – – – – – – – 100 – – – – – – – 25 – – – 9 – – – – – – – 8 2 – – 0 3

1 127 112 17,258 180,239 1,501 135 1 75 28 31 6,172 82 1,829 7,958 18 22 1,670 2 21 88 1 21 9 926 65,148 – 19 311 108 – 23 – 31 56,698 1 340,666 45,741 364 14,290 245,135 76,230 60 24,162 13,307 3,643 25,593 1,090 449,615 790,281

1 180 77 17,396 180,239 1,529 138 1 73 28 28 6,602 82 1,738 7,424 20 22 1,671 2 20 93 2 21 8 930 59,453 4,743 19 449 108 – 24 – 38 56,590 5 339,754 46,811 390 14,290 244,859 76,230 60 23,922 13,307 3,643 26,559 1,091 451,162 790,916

100 142 69 101 100 102 102 100 97 100 90 107 100 95 93 111 100 100 100 95 106 200 100 89 100 91 – 100 144 100 – 104 – 123 100 500 100 102 107 100 100 100 100 99 100 100 104 100 100 100

21 60 89 90 71 87 100 85 – 68 52 87 67 – 90 91 83 50 45 – 50 71 38 39 77 81 84 – 71 – 75 – 63 90 100 84 81 76 85 86 72 95 71 84 79 69 71 81 82

24 7 11 76 10 – 4 – 40 60 50 – – 14 11 2 – 87 19 – 8 – 16 2 – 6 3 10 3 1 15 – 10 2 2 5 10 4 5

– – – 0 1 8 – – – – – 4 2 0 – – – 5 – – – – – – 1 1 2 – – – – – – 5 1 – 1 1 3 5 3 1 2 2 2 1 2 1 2 2

– 1 3 2 1 3 1 – 8 11 – 2 – 11 11 – – 3 – 10 – – – – 16 5 3 – 6 5 – – – 3 1 – 2 7 2 3 6 5 – 9 5 12 10 10 6 5

– 6 – 1 2 5 2 – 1 – 7 6 – 4 5 – 9 3 – – 3 – 24 – 5 3 10 5 0 2 – – – 3 2 – 2 3 5 2 0 3 – 2 2 2 4 2 1 2

100 78 84 92 93 79 89 100 85 82 68 76 94 78 76 100 91 87 50 85 60 100 71 38 53 88 83 84 87 90 – 83 – 79 92 100 91 84 86 88 87 86 95 81 86 81 74 81 85 88

– 83 – – 14,733 389 12 – – – – 4,635 – – – – – – – – – – – – – – 11,345 – 238 – – – – 7 – – 31,442 1,070 – 4,286 150,698 – – – 407 654 – – 157,115 188,557

– 139 – – 13,681 363 12 – – – – 2,985 – – – – – – – – – – – – 1,345 – – – 449 – – – 8 – – – 18,982 – – 1,355 41,368 – – – 407 654 – – 43,784 62,766

– 167 – – 93 93 100 – – – – 64 – – – – – – – – – – – – – – – – 189 – – – – – – – 60 – – 32 27 – – – 100 100 – – 28 38

– 9 – – 85 0 – – – – – 17 – – – – – – – – – – – – – – – – – – – – – – – – 64 – – 70 41 – – – 68 68 – – 42 49

– 68 – – 7 1 – – – – – 16 – – – – – – – – – – – – – – – – 65 – – – 25 – – – 10 – – 9 17 – – – 10 12 – – 17 15

– 11 – – 1 1 75 – – – – 2 – – – – – – – – – – – – – – – – 29 – – – 25 – – – 2 – – 4 2 – – – 4 4 – – 2 2

– – – – 1 0 – – – – – 4 – – – – – – – – – – – – – – – – – – – – – – – – 1 – – 5 1 – – – 1 – – – 2 1

– – – – 2 0 25 – – – – 0 – – – – – – – – – – – – – – – – 6 – – – 25 – – – 2 – – 5 30 – – – 9 12 – – 28 20

– 12 – – 1 98 – – – – – 60 – – – – – – – – – – – – – – – – 0 – – – – – – – 12 – – 7 9 – – – 1 2 – – 9 10

– 77 – – 92 1 – – – – – 34 – – – – – – – – – – – – – – – – 65 – – – 25 – – – 74 – – 79 58 – – – 78 80 – – 59 64

– 17 10 875 46,932 246 47 – 2 8 3 743 3 117 – – 3 226 – 1 3 – – – 82 – 1,576 – 87 2 – 1 – 2 6,079 6 57,071 4,360 85 1,097 84,078 3,731 4 8,036 2,663 379 1,990 – 106,423 163,494

– 24 50 86 83 59 62 – 100 – 100 47 33 54 – – – 55 – 100 – – – – 26 – 66 – – 100 – 100 – 100 79 83 81 66 40 75 68 60 75 65 80 54 55 – 68 73

– 47 20 3 5 9 26 – – 75 – 24 67 12 – – – 15 – – 67 – – – 26 – 2 – 70 – – – – – 6 – 6 3 15 6 3 17 – 10 2 6 6 – 4 5

– 18 20 6 3 7 4 – – 25 – 11 – 9 – – 33 8 – – – – – – 12 – 2 – 11 – – – – – 5 – 3 4 2 6 7 2 – 8 7 9 17 – 7 6

– – – 1 4 12 – – – – – 7 – 7 – – – 11 – – – – – – 9 – 2 – 1 – – – – – 5 – 4 2 7 6 6 3 25 4 4 2 7 – 6 5

– – 10 3 2 9 4 – – – – 3 – 9 – – 33 7 – – – – – – 16 – 5 – 17 – – – – – 2 – 2 10 2 4 14 5 – 10 4 26 9 – 13 9

– 12 – 1 1 4 4 – – – – 8 – 3 – – – 5 – – – – – – 12 – 20 – – – – – – – 2 – 2 3 2 3 1 3 – 4 3 2 6 – 1 1

– – – – 2 – – – – – – – – 6 – – 33 0 – – 33 – – – – – 2 – – – – – – – – 17 2 12 31 – 0 8 – 0 0 1 – – 1 1

– 71 70 89 88 68 87 – 100 75 100 71 100 66 – – – 69 – 100 67 – – – 51 – 68 – 70 100 – 100 – 100 85 83 87 69 55 81 72 78 75 75 82 60 62 – 72 77

Country data for the Western Pacific and South East Asia Regions: re-treatment outcomes for cases registered in 2002 After failure – DOTS % transferred % cured % completed % cured % completed % not eval % success Number regist'd % died % failed % default % transferred % not eval % succes s Number regist'd % died % failed % default After default – DOTS % transferred % not eval % success

Relapse – DOTS

Number regist'd

% cured

% completed

% died

% failed

% default

Tuberculosis Control in South-East Asia and Western Pacific Regions

– 17 10 807 – 239 45 – 2 8 3 743 3 117 – – – 134 – 1 3 – – – 82 – 1,415 – 65 2 – 1 – 1 5,446 5 9,149 2485 37 638 34,317 – 3 3,762 1,898 208 1,416 – 44,764 53,913

– 24 50 88 – 61 64 – 100 – 100 47 33 54 – – – 61 – 100 – – – – 26 – 67 – – 100 – 100 – 100 81 80 74 66 65 78 73 – 100 67 83 62 58 – 72 72

– 47 20 3 – 8 27 – – 75 – 24 67 12 – – – 12 – – 67 – – – 26 – 2 – 78 – – – – – 6 – 8 3 14 5 3 – – 9 2 5 7 – 3 4

– 18 20 5 – 7 2 – – 25 – 11 – 9 – – – 8 – – – – – – 12 – 2 – 12 – – – – – 5 – 5 4 5 5 7 – – 8 7 9 17 – 7 7

– – – 1 – 12 – – – – – 7 – 7 – – – 6 – – – – – – 9 – 2 – 2 – – – – – 4 – 4 1 11 6 6 – – 3 3 2 6 – 5 5

– – 10 2 – 9 2 – – – – 3 – 9 – – – 7 – – – – – – 16 – 4 – 8 – – – – – 2 – 3 7 – 4 12 – – 9 3 20 8 – 11 9

– 12 – 1 – 3 4 – – – – 8 – 3 – – – 5 – – – – – – 12 – 20 – – – – – – – 2 – 6 2 5 3 1 – – 3 3 2 5 – 1 2

– – – – – – – – – – – – – 6 – – – 1 – – 33 – – – – – 2 – – – – – – – – 20 0 16 – – – – – – – – – – 1 1

– 71 70 91 – 69 91 – 100 75 100 71 100 66 – – – 73 – 100 67 – – – 51 – 69 – 78 100 – 100 – 100 87 80 82 69 78 83 75 – 100 76 84 67 64 – 75 76

– – – – – – – – – – – – – – – – – 66 – – – – – – – – – – – – – – – – 472 – 538 365 19 268 8,727 – 1 – 300 30 574 – 10,284 10,822

– – – – – – – – – – – – – – – – – 50 – – – – – – – – – – – – – – – – 67 – 65 69 26 69 57 – – – 71 43 49 – 58 58

– – – – – – – – – – – – – – – – – 15 – – – – – – – – – – – – – – – – 1 – 3 2 21 6 3 – – – 1 10 6 – 3 3

– – – – – – – – – – – – – – – – – 5 – – – – – – – – – – – – – – – – 6 – 6 4 – 8 8 – – – 7 13 17 – 9 8

– – – – – – – – – – – – – – – – – 23 – – – – – – – – – – – – – – – – 18 – 18 3 5 8 15 – 100 – 14 13 9 – 14 14

– – – – – – – – – – – – – – – – – 6 – – – – – – – – – – – – – – – – 4 – 4 14 5 4 16 – – – 5 17 12 – 15 15

– – – – – – – – – – – – – – – – – 2 – – – – – – – – – – – – – – – – 4 – 4 4 – 4 1 – – – 2 – 7 – 1 2

– – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – 0 4 42 – – – – – – 3 – – 0 0

– – – – – – – – – – – – – – – – – 65 – – – – – – – – – – – – – – – – 68 – 67 72 47 76 60 – – – 71 53 55 – 61 61

– – – – – 7 2 – – – – – – – – – 3 26 – – – – – – – – 161 – 22 – – – – 1 161 1 384 1510 29 191 41,034 – – – 465 141 – – 43,370 43,754

– – – – – – – – – – – – – – – – – 35 – – – – – – – – 58 – – – – – – 100 71 100 57 67 17 76 67 – – – 75 45 – – 67 67

– – – – – 43 – – – – – – – – – – – 27 – – – – – – – – 4 – 45 – – – – – 7 – 10 2 14 7 4 – – – 3 6 – – 4 4

– – – – – – 50 – – – – – – – – – 33 12 – – – – – – – – – – 9 – – – – – 6 – 4 4 v 6 7 – – – 8 9 – – 7 7

– – – – – 14 – – – – – – – – – – – 4 – – – – – – – – 2 – – – – – – – 6 – 4 3 3 3 5 – – – 2 1 – – 5 5

– – – – – 14 50 – – – – – – – – – 33 12 – – – – – – – – 14 – 45 – – – – – 8 – 13 15 3 4 16 – – – 8 38 – – 16 16

– – – – – 29 – – – – – – – – – – – 12 – – – – – – – – 21 – – – – – – – 2 – 11 3 – 3 1 – – – 3 1 – – 1 1

– – – – – – – – – – – – – – – – 33 – – – – – – – – – 1 – – – – – – – – – 1 6 62 – – – – – – 1 – – 0 0

– – – – – 43 – – – – – – – – – – – 62 – – – – – – – – 62 – 45 – – – – 100 78 100 67 69 31 83 71 – – – 79 50 – – 71 71

Country data for the Western Pacific and South East Asia Regions: age and sex distribution of smear-positive cases in non-DOTS areas, 2003 (absolute numbers) Female 45-54 55-64 65+ 0-14 15-24 25-34 35-44 45-54 55-64 65+ 0-14 15-24 25-34 35-44 45-54 All 55-64 65+

Male

0-14

15-24

25-34

35-44

Tuberculosis Control in South-East Asia and Western Pacific Regions

American Samoa Australia Brunei Darussalam Cambodia China China, Hong Kong SAR China, Macao SAR Cook Islands Fiji French Polynesia Guam Japan Kiribati Lao PDR Malaysia Marshall Islands Micronesia Mongolia Nauru New Caledonia New Zealand Niue Northern Mariana Is Palau Papua New Guinea Philippines Rep. Korea Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis & Futuna Is WPR Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste SEAR Total

– 0 – – 74 5 0 – – – – 0 – – – – – – – – – – – – – – 12 – 1 – – – 4 – – – 96 – – 5 521 – – – – 1 – – 527 623

– 10 – – 926 10 1 – – – – 80 – – – – – – – – – – – – – – 331 – 7 – – – 2 – – – 1,367 – – 53 4,421 – – – – 25 – – 4,499 5,866

– 7 – – 1,289 12 1 – – – – 186 – – – – – – – – – – – – – – 644 – 13 – – – 0 – – – 2,152 – – 106 6,810 – – – – 68 – – 6,984 9,136

– 1 – – 1,394 21 0 – – – – 182 – – – – – – – – – – – – – – 708 – 24 – – – 1 – – – 2,331 – – 137 7,304 – – – – 85 – – 7,526 9,857

– 5 – – 1,215 28 1 – – – – 350 – – – – – – – – – – – – – – 714 – 27 – – – 6 – – – 2,346 – – 129 5,661 – – – – 126 – – 5,916 8,262

– 4 – – 913 27 0 – – – – 432 – – – – – – – – – – – – – – 615 – 24 – – – 0 – – – 2,015 – – 85 3,483 – – – – 74 – – 3,642 5,657

– 18 – – 817 136 4 – – – – 1,229 – – – – – – – – – – – – – – 991 – 69 – – – 0 – – – 3,264 – – 72 1,776 – – – – 74 – – 1,922 5,186

– 0 – – 57 2 0 – – – – 0 – – – – – – – – – – – – – – 19 – 0 – – – 0 – – – 78 – – 3 625 – – – – 2 – – 630 708

– 3 – – 668 9 0 – – – – 70 – – – – – – – – – – – – – – 396 – 2 – – – 3 – – – 1,151 – – 31 3,179 – – – – 55 – – 3,265 4,416

– 6 – – 834 20 0 – – – – 123 – – – – – – – – – – – – – – 502 – 13 – – – 0 – – – 1,498 – – 81 4,422 – – – – 37 – – 4,540 6,038

– 1 – – 636 15 1 – – – – 93 – – – – – – – – – – – – – – 327 – 17 – – – 1 – – – 1,091 – – 76 3,658 – – – – 38 – – 3,772 4,863

– 3 – – 523 8 0 – – – – 77 – – – – – – – – – – – – – – 232 – 7 – – – 0 – – – 850 – – 79 2,535 – – – – 38 – – 2,652 3,502

– 2 – – 327 4 0 – – – – 114 – – – – – – – – – – – – – – 231 – 13 – – – 0 – – – 691 – – 46 1,419 – – – – 29 – – 1,494 2,185

– 5 – – 320 56 0 – – – – 695 – – – – – – – – – – – – – – 875 – 28 – – – 0 – – – 1,979 – – 44 606 – – – – 17 – – 667 2,646

– 0 – – 131 7 0 – – – – 0 – – – – – – – – – – – – – – 31 – 1 – – – 4 – – – 174 – – 8 1,146 – – – – 3 – – 1,157 1,331

– 13 – – 1,594 19 1 – – – – 150 – – – – – – – – – – – – – – 727 – 9 – – – 5 – – – 2,518 – – 84 7,600 – – – – 80 – – 7,764 10,282

– 13 – – 2,123 32 1 – – – – 309 – – – – – – – – – – – – – – 1,146 – 26 – – – 0 – – – 3,650 – – 187 11,232 – – – – 105 – – 11,524 15,174

– 2 – – 2,030 36 1 – – – – 275 – – – – – – – – – – – – – – 1,035 – 41 – – – 2 – – – 3,422 – – 213 10,962 – – – – 123 – – 11,298 14,720

– 8 – – 1,738 36 1 – – – – 427 – – – – – – – – – – – – – – 946 – 34 – – – 6 – – – 3,196 – – 208 8,196 – – – – 164 – – 8,568 11,764

– 6 – – 1,240 31 0 – – – – 546 – – – – – – – – – – – – – – 846 – 37 – – – 0 – – – 2,706 – – 131 4,902 – – – – 103 – – 5,136 7,842

– 23 – – 1,137 192 4 – – – – 1,924 – – – – – – – – – – – – – – 1,866 – 97 – – – 0 – – – 5,243 – – 116 2,382 – – – – 91 – – 2,589 7,832

Country data for the Western Pacific and South East Asia Regions: trends in DOTS treatment success and detection rates, 1994–2003 DOTS new smear-positive case detection rate (%) 2001 2002 1995 1996 1997 1998 1999 2000 2001 2002 2003 1997 1998 1999 2000

DOTS new smear-positive treatment success (%)

1994

1995

1996

Tuberculosis Control in South-East Asia and Western Pacific Regions

– – – 84 94 – 75 – 90 – – – – – – – 64 59 – 62 – – – 64 – 80 71 50 88 – – 89 – – 91 – 90 73 71 – 83 94 95 – – 77 – – 80

100 – – 91 96 – – – 86 67 – – – 70 69 – 80 78 – 75 – – – 67 60 – 76 80 86 65 – 75 – – 91 – 91 71 97 – 79 91 97 66 – 79 – – 74

– – – 94 96 – – – – 95 – – – 55 – – – 78 – – – – – 75 – 82 71 100 – 73 – 82 – – 90 – 93 72 96 – 79 81 93 79 85 80 78 – 77

– 66 – 91 96 – 81 50 87 100 – – – 62 – – – 86 – – – – – – 93 83 82 – – 92 – 75 – – 85 – 93 78 85 – 82 54 94 82 87 76 62 – 72

50 75 85 95 97 85 – – 90 74 – – 83 75 – 83 – 84 – 70 – – – – 72 84 – 86 – 92 – 94 – – 93 – 95 80 90 91 84 58 94 82 89 76 68 – 72

100 84 76 93 96 78 78 80 92 85 94 76 88 84 90 82 95 86 50 77 – – 80 – 66 87 – 94 95 – – 80 – 88 92 – 94 81 85 94 82 50 94 81 87 84 77 – 73

100 74 63 91 95 76 89 – 85 97 93 70 91 82 78 91 93 87 25 89 30 – 81 – 63 88 – 92 85 81 – 93 – 88 92 – 92 83 90 91 84 87 97 82 86 77 69 – 83

100 66 56 92 96 78 86 100 85 80 71 75 86 77 79 86 100 87 100 84 9 – 74 100 67 88 – 77 88 89 – 92 – 88 93 100 93 84 93 91 85 86 97 81 88 80 75 73 84

100 78 84 92 93 79 89 100 85 82 68 76 94 78 76 100 91 87 50 85 60 100 71 38 53 88 83 84 87 90 – 83 – 79 92 100 91 84 86 88 87 86 95 81 86 81 74 81 85

– – – 40 15 – 86 – 47 – – – – – 64 – 18 7 – 24 – – – 115 – – 34 48 57 – – 48 – – 30 – 16 7 28 – – 1 96 – – 63 – – 2

– – – 34 28 – 155 – 49 94 – – – 24 69 – 30 31 – 31 – – – 53 4 – 65 30 26 55 – 78 – – 60 – 28 14 24 – 1 5 97 26 6 61 – – 4

64 – – 44 32 – 194 – 49 107 – – 34 33 – – – 31 – – – – – 97 1 3 56 48 – 71 – 64 – – 79 – 32 18 23 – 1 7 94 26 11 71 5 – 6

– 23 – 47 32 – 163 32 56 91 – – 170 40 – 59 – 54 – – – – – – 7 10 58 – – 91 – 97 – – 83 – 33 23 22 – 2 12 94 29 16 75 21 – 8

34 30 123 53 29 60 – – 51 91 – – 203 45 – 96 – 67 – 30 – – – – 4 20 – 63 – 63 – 63 – 36 84 – 31 23 26 2 7 18 101 32 44 75 39 – 14

23 24 100 49 31 59 93 – 50 82 85 22 196 40 73 66 43 62 216 28 41 – 117 – 7 48 – 49 13 76 – 98 – 40 83 – 37 23 29 26 12 19 81 48 56 68 46 – 18

23 20 111 47 31 57 91 75 61 – 97 29 244 40 73 94 24 73 110 28 37 – 85 – 8 57 – 43 22 85 – 54 – 77 84 – 38 25 31 53 24 20 79 56 56 73 73 – 27

12 25 129 55 30 60 79 39 65 84 67 33 329 46 69 119 71 74 112 33 48 364 96 156 16 62 – 77 39 81 – 161 – 52 88 49 39 29 32 79 31 27 87 65 57 71 65 59 33

24 9 138 60 43 58 76 – 63 65 – 40 419 47 69 140 92 68 57 23 57 – 75 90 15 68 23 51 44 107 – 80 – 70 86 356 50 33 32 91 47 33 106 73 60 70 72 53 45

Country data for the Western Pacific and South East Asia Regions: age and sex distribution of smear-positive cases in DOTS areas, 2003 (absolute numbers) MALE 35-44 – 0 0 46 1,350 8 0 – – 2 6 1,256 9,145 104 5 – 45-54 55-64 65+ 0-14 15-24 25-34 35-44 45-54 55-64 65+ 0-14 15-24 25-34 35-44 45-54 FEMALE ALL 55-64 65+

0-14

15-24

25-34

Tuberculosis Control in South-East Asia and Western Pacific Regions – 1 2 5 7 196 4 4 19 – 0 7 – 1 1 24 300 13 – 0 9 – 0 – 0 66 0 2,063 544 14 90 4,120 608 0 154 189 12 49 13 5,793 7,856 13 13 – 1 – 2 2,574 0 21,699 2,086 13 1,316 11,520 6,085 5 1,491 609 149 1,279 76 24,629 46,328 0 13 – 0 – 1 115 0 3,848 864 23 171 6,010 1,140 1 261 311 23 90 18 8,912 12,760 1 5 1,271 4 95 626 4 1 19 – 3 5 – 0 2 5 2,018 450 1 30 1 – 0 – 2 4,896 0 19,957 591 6 326 3,379 1,649 0 617 220 103 1,866 17 8,774 28,731

American Samoa Australia Brunei Darussalam Cambodia China China, Hong Kong SAR China, Macao SAR Cook Islands Fiji French Polynesia Guam Japan Kiribati Lao PDR Malaysia Marshall Islands Micronesia Mongolia Nauru New Caledonia New Zealand Niue Northern Mariana Is Palau Papua New Guinea Philippines Rep. Korea Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis & Futuna Is WPR Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste SEAR Total

– 0 0 37 1,059 3 0 – 2 – 0 1 5 6 216 6 0 10 0 0 5 – 0 0 15 356 10 – 0 4 – 0 – 1 49 0 1,785 320 9 81 1,890 532 1 107 122 11 41 5 3,119 4,904

– 4 5 805 24,199 94 8 – 9 2 2 130 13 94 1,211 4 3 206 0 1 9 – 2 0 164 6,360 401 2 10 14 – 1 – 2 3,475 0 37,230 5,166 62 1,101 42,830 9,570 14 2,536 2,039 286 1,636 130 65,370 102,600

– 3 25 1,514 31,471 78 8 – 7 2 1 335 5 186 2,010 2 2 217 0 1 10 – 2 1 132 9,302 564 – 15 9 – 1 – 4 7,036 2 52,945 7,275 50 2,173 54,948 12,647 7 4,408 1,658 399 4,615 135 88,315 141,260

– 1 17 2,183 30,210 119 16 – 6 1 3 368 9 240 2,073 7 2 171 0 1 6 – 2 1 83 11,458 557 – 44 12 – 1 – 7 8,486 2 56,086 8,058 20 2,541 56,283 10,925 4 4,427 1,619 609 4,259 107 88,852 144,938

– 6 8 1,848 31,370 167 26 – 9 2 4 713 6 233 1,798 7 0 93 1 1 6 – 1 1 56 10,713 493 – 70 14 – 1 – 5 7,965 2 55,619 6,947 25 2,340 47,204 9,558 9 3,269 1,769 665 3,497 98 75,381 131,000

– 1 8 1,729 26,330 150 9 – 5 4 7 956 6 202 1,438 2 2 55 0 1 8 – 0 1 28 6,445 377 1 56 8 – 0 – 2 5,066 0 42,897 5,501 20 1,327 30,256 6,720 9 1,974 1,639 421 2,740 66 50,673 93,570

– 12 9 1,487 31,210 337 23 – 6 3 5 2,502 0 200 1,601 2 1 39 0 3 9 – 2 0 6 3,648 481 – 65 0 – 2 – 3 7,793 0 49,449 4,142 13 562 16,242 3,615 4 1,296 735 315 3,241 41 30,206 79,655

– 6 9 691 18,143 75 7 – 5 3 3 133 20 78 969 9 4 254 – 0 18 – 3 0 167 3,218 285 2 4 14 – 1 – 4 1,659 0 25,784 4,298 57 792 31,332 8,734 8 1,781 1,283 250 944 98 49,577 75,361

– 7 14 1,287 18,414 113 7 – 6 1 1 272 4 105 1,044 2 4 233 – 2 8 – 0 0 148 4,551 291 2 13 14 – 0 – 4 2,262 1 28,810 4,282 39 1,542 31,895 10,127 5 2,442 1,107 181 1,678 116 53,414 82,224

– 2 11 1,975 14,147 86 10 – 4 1 4 153 12 160 857 4 1 148 – 2 1 – 2 1 51 4,761 174 2 13 16 – 1 – 3 2,327 0 24,929 3,258 17 1,531 19,662 7,889 1 2,003 873 148 1,350 76 36,808 61,737

– 2 4 2,208 11,578 55 7 – 4 1 2 177 7 161 669 6 1 45 – 0 10 – 1 0 25 4,000 133

– 2 5 1,857 8,661 37 4 – 7 0 1 199 3 115 584 1 2 32 – 0 4 – 0 1 17 2,858 150 2 8 10 – 2 – 1 2,283 0 16,846 1,150 15 723 6,903 3,907 1 943 486 103 1,264 43 15,538 32,384

– 0 0 83 2,409 11 0 – 2 – 1 3 10 13 412 10 4 29 0 0 12 – 1 1 39 656 23

– 10 14 1,496 42,342 169 15 – 14 5 5 263 33 172 2,180 13 7 460 0 1 27 – 5 0 331 9,578 686 4 14 28 – 2 – 6 5,134 0 63,014 9,464 119 1,893 74,162 18,304 22 4,317 3,322 536 2,580 228 114,947 177,961

– 10 39 2,801 49,885 191 15 – 13 3 2 607 9 291 3,054 4 6 450 0 3 18 – 2 1 280 13,853 855 2 28 23 – 1 – 8 9,298 3 81,755 11,557 89 3,715 86,843 22,774 12 6,850 2,765 580 6,293 251 141,729 223,484

– 3 28 4,158 44,357 205 26 – 10 2 7 521 21 400 2,930 11 3 319 0 3 7 – 4 2 134 16,219 731 2 57 28 – 2 – 10 10,813 2 81,015 11,316 37 4,072 75,945 18,814 5 6,430 2,492 757 5,609 183 125,660 206,675

– 8 12 4,056 42,948 222 33 – 13 3 6 890 13 394 2,467 13 1 138 1 1 16 – 2 1 81 14,713 626 83 27 – 2 – 7 10,539 2 77,318 9,033 38 3,656 58,724 15,643 14 4,760 2,378 814 4,776 174 100,010 177,328

– 3 13 3,586 34,991 187 13 – 12 4 8 1,155 9 317 2,022 3 4 87 0 1 12 – 0 2 45 9,303 527 3 64 18 – 2 – 3 7,349 0 59,743 6,651 35 2,050 37,159 10,627 10 2,917 2,125 524 4,004 109 66,211 125,954

– 14 15 2,743 40,355 441 28 – 6 4 10 3,773 4 295 2,227 6 2 58 0 6 14 – 2 2 11 5,666 931 1 95 1 – 2 – 5 12,689 0 69,406 4,733 19 888 19,621 5,264 4 1,913 955 418 5,107 58 38,980 108,386

Country data for the Western Pacific and South East Asia Regions: smear-positive notification rates (per 100 000 population) by age and sex, 2003 FEMALE 45-54 55-64 65+ 0-14 15-24 25-34 35-44 45-54 55-64 65+ 0-14 15-24 25-34 35-44 45-54 ALL 55-64 65+

MALE

0-14

15-24

25-34

35-44

Tuberculosis Control in South-East Asia and Western Pacific Regions 6 91 – 25 – 28 74 – 22 39 17 129 30 60 49 65 68 19 36 248 38 30

American Samoa Australia Brunei Darussalam Cambodia China China, Hong Kong SAR China, Macao SAR Cook Islands Fiji French Polynesia Guam Japan Kiribati Lao PDR Malaysia Marshall Islands Micronesia Mongolia Nauru New Caledonia New Zealand Niue Northern Mariana Is Palau Papua New Guinea Philippines Rep. Korea Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis & Futuna Is WPR Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste SEAR Total

– 0 0 1 1 – – – 1 – 0 0 – 1 5 – 0 2 – 0 1 – – – 1 2 0 – 0 4 – 0 – 2 0 – 1 1 2 3 1 2 1 1 2 1 1 3 1 1

– 1 15 50 23 – – – 11 8 15 3 – 16 53 – 25 72 – 5 3 – – – 28 77 19 10 6 28 – 9 – 9 41 – 27 34 27 64 45 44 41 52 80 17 29 131 44 32

– 1 72 185 28 – – – 11 10 8 5 – 47 105 – 28 96 – 5 4 – – – 30 147 28 – 9 24 – 13 – 28 103 – 36 62 33 115 71 67 32 106 90 30 83 265 72 51

– 0 64 321 29 – – – 11 5 22 7 – 87 126 – 35 99 – 6 2 – – – 25 250 30 – 17 55 – 19 – 63 158 – 43 93 19 148 91 74 25 147 122 47 93 224 91 67

– 1 39 425 39 – – – 22 15 39 12 – 128 147 – 0 102 – 8 2 – – – 27 339 39 – 28 97 – 29 – 65 236 – 55 123 33 227 106 94 90 151 198 68 107 300 109 83

– 0 96 706 56 – – – 21 50 120 16 – 190 209 – 102 106 – 12 4 – – – 25 344 50 29 43 84 – 0 – 44 297 – 68 183 38 135 108 108 152 149 276 63 137 331 117 106

– 3 165 1077 73 – – – 42 54 103 37 – 212 323 – 57 92 – 49 4 – – – 8 276 94 – 88 0 – 72 – 86 385 – 86 178 29 100 70 71 69 123 169 58 194 363 85 108

– 0 0 2 1 – – – – – 4 0 – 1 5 – 20 5 – 0 2 – – – 2 2 1 – 0 9 – 0 – 0 1 – 1 2 3 3 3 2 0 2 4 1 1 9 3 2

– 1 28 44 19 – – – 6 13 24 3 – 14 44 – 34 90 – 0 7 – – – 32 40 19 11 2 30 – 10 – 19 20 – 20 30 25 48 36 41 24 37 54 18 17 111 35 26

– 1 38 154 17 – – – 10 5 9 4 – 26 56 – 53 104 – 11 3 – – – 33 74 19 17 9 40 – 0 – 27 33 – 21 39 26 85 46 54 24 58 63 15 29 319 47 31

– 0 43 253 14 – – – 7 6 36 3 – 55 53 – 17 84 – 12 0 – – – 16 104 12 30 7 71 – 19 – 26 42 – 20 40 17 92 36 54 7 64 67 14 27 168 41 30

– 0 27 405 16 – – – 10 8 22 3 – 84 56 – 23 48 – 0 4 – – – 13 124 12

– 0 98 523 19 – – – 28 0 20 3 – 93 87 – 96 59 – 0 2 – – – 17 147 18 51 11 112 – 69 – 24 125 – 27 37 27 68 26 56 19 66 78 21 59 211 35 33

– 1 108 466 18 – – – – 17 101 14 – 87 109 – 46 35 – 44 2 – – – 8 121 57 22 32 16 – 0 – 60 207 – 29 24 12 43 14 26 0 49 44 18 89 142 22 28

– 0 0 1 1 – – – 1 – 2 0 – 1 5 – 9 3 – 0 1 – – – 2 2 1 – 0 6 – 0 – 1 0 – 1 2 2 3 2 2 1 2 3 1 1 6 2 1

– 1 21 47 21 – – – 8 11 20 3 – 15 49 – 29 81 – 3 5 – – – 30 59 19 11 4 29 – 9 – 14 31 – 23 32 26 56 41 43 33 45 67 17 23 121 40 29

– 1 55 170 22 – – – 10 8 9 5 – 36 81 – 41 100 – 8 4 – – – 32 111 24 7 9 32 – 7 – 27 68 – 29 51 30 100 59 60 28 82 77 22 56 287 60 41

– 0 54 285 22 – – – 9 6 28 5 – 71 90 – 26 91 – 9 1 – – – 21 177 21 13 12 63 – 19 – 44 99 – 31 68 18 120 65 64 17 105 95 31 59 197 67 49

– 1 34 414 28 – – – 16 12 31 7 – 105 102 – 11 75 – 4 3 – – – 21 230 26 – 17 94 – 27 – 47 153 – 39 82 25 178 69 77 69 107 133 46 70 275 75 58

– 0 96 598 38 – – – 25 26 73 10 – 138 149 – 99 82 – 6 3 – – – 21 243 34 41 27 98 – 37 – 34 208 – 48 109 32 100 67 80 89 106 174 44 96 270 76 70

– 1 136 673 44 – – – 19 35 102 24 – 145 208 – 51 59 – 46 3 – – – 8 190 72 13 57 8 – 34 – 73 289 – 55 100 19 67 40 46 36 83 102 38 135 250 51 66

Country data for the Western Pacific and South East Asia Regions: number of TB cases notified, 1980–2003 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

1980

1981

1982

1983

1984

Tuberculosis Control in South-East Asia and Western Pacific Regions

American Samoa 2 6 6 8 12 5 8 9 13 5 9 3 1 4 4 – 0 6 3 4 3 3 2 3 Australia 1,457 1,386 1,270 1,219 1,299 1,088 906 907 954 952 1,016 950 1,011 991 1,057 1,073 – 1,145 899 1,073 1,043 980 1,013 949 Brunei Darussalam 196 285 245 276 256 238 212 189 126 128 143 – 180 160 – – – 160 – 272 307 216 230 206 Cambodia 2,576 1,980 8,158 7,572 10,241 10,145 10,325 9,106 10,691 7,906 6,501 10,903 16,148 13,270 15,172 14,603 14,857 15,629 16,946 19,266 18,891 19,170 24,610 28,216 China 0 – 98,654 117,557 151,564 226,899 265,095 251,600 304,639 310,607 375,481 345,000 320,426 344,218 363,804 515,764 504,758 466,394 445,704 449,518 454,372 470,221 462,609 615,868 China, Hong Kong SAR 8,065 7,729 7,527 7,301 7,843 7,545 7,432 7,269 7,021 6,704 6,510 6,283 6,545 6,537 6,319 0 6,501 7,072 7,673 7,512 7,578 7,262 6,244 5,624 China, Macao SAR 1,101 585 233 455 671 571 420 389 320 274 343 329 294 285 – 402 570 575 465 – 449 465 388 371 Cook Islands 37 10 19 29 20 36 17 16 20 1 1 8 12 6 4 – 0 0 1 3 2 2 1 0 Fiji 210 180 163 185 165 230 199 173 162 218 226 247 240 183 280 203 200 171 166 192 144 183 150 179 French Polynesia 76 66 65 78 80 78 85 80 63 73 59 49 83 78 89 – 86 91 105 93 62 62 64 50 Guam 55 41 49 48 54 37 49 34 41 75 – – 60 70 94 – – – – – 54 63 51 22 Japan 70,916 65,867 63,940 62,021 61,521 58,567 56,690 56,496 54,357 53,112 51,821 50,612 48,956 48,461 44,425 43,078 42,122 42,190 44,016 40,800 39,384 35,489 32,828 31,638 Kiribati 146 187 193 127 111 103 129 110 208 121 68 91 100 99 253 – 327 464 276 255 252 189 196 284 Lao PDR 7,630 – 4,706 4,700 6,528 4,258 1,514 3,468 7,279 2,952 1,826 1,951 994 2,093 1,135 830 1,440 1,923 2,153 2,434 2,234 2,418 2,621 2,780 Malaysia 11,218 10,970 11,944 11,634 10,577 10,569 10,735 11,068 10,944 10,686 11,702 11,059 11,420 12,285 11,708 11,778 12,691 13,539 14,115 14,908 15,057 14,830 14,389 15,671 Marshall Islands 6 7 12 15 12 15 37 32 11 7 – 26 52 61 – – 59 – 49 41 34 56 51 60 Micronesia 0 – 67 73 75 66 60 98 77 68 367 350 111 151 173 172 126 107 123 91 104 127 99 Mongolia 1,161 1,094 1,340 1,512 1,651 2,992 2,818 2,432 2,541 2,237 1,577 1,611 1,502 1,433 1,730 2,780 3,457 2,987 2,915 3,348 3,109 3,526 3,829 3,918 Nauru 0 2 8 0 0 0 8 6 8 0 7 – – – 4 – – – – 2 4 3 5 3 New Caledonia 108 128 120 171 144 104 98 74 111 128 143 140 140 104 97 87 104 88 90 78 94 61 65 36 New Zealand 474 448 437 415 404 359 320 296 295 303 348 335 317 274 352 391 352 321 365 447 344 377 329 386 Niue 1 0 2 3 1 0 5 0 3 – 0 – 2 1 2 0 2 0 0 1 0 0 4 0 Northern Mariana Is 0 26 75 74 58 64 16 56 27 28 28 – 67 – 46 48 51 93 97 66 75 58 53 45 Palau 17 10 17 14 20 26 13 38 17 3 – 6 4 25 41 19 5 15 – 32 – – 11 9 Papua New Guinea 2,525 2,508 2,742 2,955 3,505 3,453 2,877 2,251 4,261 3,396 2,497 3,401 2,540 7,451 5,335 8,041 5,097 7,977 11,291 13,067 12,121 15,897 5,324 18,405 Philippines 112,307 116,821 104,715 106,300 151,863 151,028 153,129 163,740 183,113 217,272 317,008 207,371 236,172 178,134 180,044 119,186 165,453 195,767 162,360 145,807 119,914 107,133 118,408 134,375 Rep. Korea 89,803 98,532 100,878 91,572 85,669 87,169 88,789 87,419 74,460 70,012 63,904 57,864 48,070 46,999 38,155 42,117 39,315 33,215 34,661 32,075 21,782 37,268 34,967 33,888 Samoa 59 49 43 41 37 43 65 29 29 37 44 44 26 49 45 45 31 32 22 31 43 22 31 27 Singapore 2,710 2,425 2,179 2,065 2,143 1,952 1,760 1,616 1,666 1,617 1,591 1,841 1,778 1,830 1,677 1,889 1,951 1,977 2,120 1,805 1,728 1,536 1,516 1,616 Solomon Islands 266 313 324 302 337 377 292 334 372 488 382 309 364 367 332 352 299 318 295 289 302 292 256 293 Tokelau 0 1 0 0 0 2 0 9 1 0 1 1 1 – 0 2 0 – – 0 0 0 – 0 Tonga 64 49 45 50 54 49 35 24 14 36 23 20 29 33 23 20 22 21 30 22 24 12 29 16 Tuvalu 33 18 12 23 9 32 27 22 24 26 23 30 30 28 19 36 – – 18 14 16 16 13 30 Vanuatu 178 92 173 196 188 124 131 90 118 144 140 230 193 114 152 79 126 184 178 120 152 175 101 104 Viet Nam 43,062 43,506 51,206 43,185 43,875 46,941 47,557 55,505 52,463 52,270 50,203 59,784 56,594 52,994 51,763 55,739 74,711 77,838 87,468 88,879 89,792 90,728 95,044 92,741 Wallis & Futuna Is 23 24 5 17 14 14 – 34 1 30 22 4 11 11 6 8 14 – – – – 19 15 WPR 356,482 355,345 461,572 462,193 541,001 615,179 651,853 655,019 716,450 741,916 893,992 760,870 754,466 718,799 724,345 818,740 874,721 870,313 834,604 822,454 789,457 808,817 805,578 987,927 number reporting 36 33 36 36 36 36 36 36 36 35 33 31 35 33 33 28 31 31 31 33 35 35 35 36 percent reporting 100 92 100 100 100 100 100 100 100 97 92 86 97 92 92 78 86 86 86 92 97 97 97 100 Bangladesh 39,774 42,644 49,870 52,961 45,679 41,802 45,599 45,355 44,280 45,191 48,673 56,052 31,400 54,001 48,276 56,437 63,471 63,420 72,256 79,339 75,557 76,302 81,963 88,156 Bhutan 1,539 2,657 720 1,017 904 1,073 1,582 608 1,126 1,525 1,154 996 140 108 1,159 1,299 1,271 1,211 1,292 1,174 1,140 1,037 1,089 1,026 DPR Korea 0 – – – – – – – 0 – – – – – – – – 11,050 1,152 12,287 34,131 29,284 40,159 41,810 India 705,600 769,540 923,095 1,075,098 1,109,310 1,168,804 1,279,536 1,403,122 1,457,288 1,510,500 1,519,182 1,555,353 1,121,120 1,081,279 1,114,374 1,218,183 1,290,343 1,132,859 1,102,002 1,218,743 1,115,718 1,085,075 1,060,951 1,073,065 Indonesia 25,235 32,461 33,000 31,809 32,432 17,681 16,750 – 97,505 105,516 74,470 60,808 98,458 62,966 49,647 35,529 24,647 22,184 40,497 69,064 84,591 92,792 155,188 178,260 Maldives 73 112 111 143 123 91 111 115 85 203 152 123 92 175 249 231 212 173 176 153 132 139 125 137 Myanmar 12,744 12,461 12,069 11,012 11,045 10,506 10,840 11,986 9,348 10,940 12,416 14,905 17,000 19,009 15,583 18,229 22,201 17,122 14,756 19,626 30,840 42,838 57,012 75,744 Nepal 1,020 337 1,459 700 190 52 252 1,012 1,603 11,003 10,142 8,983 13,161 15,572 19,804 22,970 24,158 24,135 27,356 29,519 29,519 30,359 30,925 Sri Lanka 6,212 6,288 7,334 6,666 6,376 5,889 6,596 6,411 6,092 6,429 6,666 6,174 6,802 6,809 6,132 5,710 5,366 6,542 6,925 7,157 8,413 7,499 8,939 8,998 Thailand 45,704 49,452 48,553 65,413 69,240 77,611 52,152 51,835 50,021 44,553 46,510 43,858 47,697 49,668 47,767 45,428 39,871 30,262 15,850 29,413 34,187 49,656 49,581 54,504 Timor-Leste – – – – – – – – – – – – – – – – – – – – – – 2,760 2,760 SEAR 837,901 915,952 1,076,211 1,244,819 1,275,299 1,323,509 1,413,418 1,520,444 1,667,348 1,735,860 1,719,365 1,747,252 1,322,709 1,287,176 1,298,759 1,400,850 1,470,352 1,308,981 1,279,041 1,464,312 1,414,228 1,414,141 1,485,366 1,552,625 number reporting 9 8 8 8 8 8 8 7 9 8 8 8 7 8 8 8 8 9 9 9 9 9 10 11 percent reporting 82 89 89 89 89 89 89 78 100 89 89 89 78 89 89 89 89 100 100 100 100 100 100 100 TOTAL 1,194,383 1,271,297 1,537,783 1,707,012 1,816,300 1,938,688 2,065,271 2,175,463 2,383,798 2,477,776 2,613,357 2,508,122 2,077,175 2,005,975 2,023,104 2,219,590 2,345,073 2,179,294 2,113,645 2,286,766 2,203,685 2,222,958 2,290,944 2,540,552 number reporting 45 41 44 44 44 44 44 43 45 43 41 39 42 41 41 36 39 40 40 42 44 44 45 47 percent reporting 96 87 94 94 94 94 94 91 96 91 87 83 89 87 87 77 83 85 85 89 94 94 96 100

Country data for the Western Pacific and South East Asia Regions: case notification rates (per 100 000 population), 1980–2003 1985 19 6 56 67 33 114 92 5 31 30 42 95 44 66 8 6 – 136 30 104 – 6 – 127 42 0 98 7 6 83 150 36 112 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

1980

1981

1982

1983

1984

Tuberculosis Control in South-East Asia and Western Pacific Regions 381 71 74 84 10 0 64 61 519 149 27 53 120 62 23 260 94 76 46 46 104 – 164 10 59 29 1 42 101 – 119 79 59 31 6 40 99 – 125 81 59 44 68 – 179 41 70 31 54 40 86 – 133 93 21 37 42 66 36 330 25 59 – 164 73 38 51 10 92 87 245 117 269 86 27 50 92 0 23 202 91 72 78 45 40 65 – 122 26 102 36 76 35 84 – 93 67 26 – – 34 – 18 58 – 161 116 – 45 11 0 87 111 171 174 94 27 54 94 131 20 378 46 77 43 51 46 72 – 131 18 92 41 95 32 79 – 99 73

American Samoa Australia Brunei Darussalam Cambodia China China, Hong Kong SAR China, Macao SAR Cook Islands Fiji French Polynesia Guam Japan Kiribati Lao PDR Malaysia Marshall Islands Micronesia Mongolia Nauru New Caledonia New Zealand Niue Northern Mariana Is Palau Papua New Guinea Philippines Rep. Korea Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis & Futuna Is WPR Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste SEAR Total 16 24 41 – 32 308 47 66 81 – 135 17 37 12 49 99 170 251 196 69 18 46 68 0 22 139 63 115 – 49 59 59 56 122 33 54 42 119 39 49 – 96 71

6 10 102 39 – 160 437 207 33 50 52 61 252 238 82 20 – 70 0 76 15 29 – 140 78 234 236 38 112 116 0 66 441 152 81 208 27 47 117 – 102 17 46 38 7 43 99 – 80 50

18 9 143 29 – 150 226 56 28 42 38 56 317 – 78 22 – 64 26 88 14 0 140 81 76 237 255 32 98 132 64 50 235 77 80 209 27 49 197 – 109 21 69 36 2 43 105 – 85 53

17 8 120 116 10 144 87 108 24 41 44 54 321 141 82 36 86 76 104 81 14 64 370 135 81 207 257 28 86 132 0 46 154 141 93 42 34 56 52 – 129 21 66 34 9 49 101 – 98 63

22 8 131 103 11 137 163 165 27 47 42 52 207 137 78 43 90 84 0 114 13 101 331 108 85 205 230 26 80 119 0 51 291 156 76 139 34 58 72 – 147 20 83 31 4 44 134 – 111 69

32 8 118 132 14 145 229 114 24 47 46 51 177 185 69 33 90 89 0 94 13 35 233 151 98 287 212 24 81 128 0 56 112 146 76 112 39 48 62 – 148 20 69 30 1 41 139 – 111 72

13 7 107 125 21 138 186 204 32 45 31 48 161 118 67 40 77 157 0 67 11 0 232 191 94 278 214 27 72 139 121 50 393 94 79 109 44 43 72 – 153 11 50 28 0 38 153 – 113 75

20 6 92 122 24 135 131 96 28 48 40 47 197 41 67 94 68 143 96 62 10 192 52 93 77 276 215 41 64 104 0 36 327 97 79

21 6 80 104 23 131 117 90 24 44 27 46 164 91 67 79 109 120 70 46 9 0 164 266 59 288 210 18 57 115 546 25 262 65 90 256 45 45 39 – 176

29 6 52 118 27 125 92 111 23 34 32 44 303 186 65 26 84 121 90 68 9 123 72 117 109 314 177 18 58 124 61 14 281 83 83 7 49 43 70 – 179 55 42 24 9 37 95 – 134 88

11 6 51 84 27 119 76 6 30 38 57 43 172 73 61 16 72 103 0 76 9 – 69 20 85 364 165 23 55 158 0 36 299 99 81 220 50 42 92 – 182 59 97 27 60 39 83 – 137 90

6 6 – 108 29 109 86 43 34 25 – 41 125 46 60 57 354 71 – 80 10 – – 39 81 332 134 27 59 94 63 20 334 150 89 159 49 50 58 – 180 33 55 36 47 36 80 – 133 87

2 6 66 155 27 112 75 64 33 41 43 39 135 23 61 113 110 65 – 78 9 90 137 25 59 369 110 16 56 107 64 29 329 122 82 29 48 27 8 – 127 52 40 41 – 39 85 – 99 71

8 6 57 123 29 110 72 32 24 38 50 39 131 47 64 131 146 61 – 57 8 46 – 153 167 272 106 30 56 105 – 33 303 70 75 79 46 46 6 – 121 33 74 45 66 39 88 – 94 68

0 – – 126 41 103 136 0 26 39 – 33 414 30 61 122 117 143 – 53 10 95 88 28 106 237 87 19 54 77 0 22 – 71 101 57 54 50 69 – 136 12 82 50 107 30 68 – 102 77

11 6 51 129 38 110 134 0 22 41 – 33 578 39 63 – 99 123 – 44 9 0 153 83 161 274 72 19 53 80 – 21 – 101 104 98 53 49 64 51 117 11 65 38 110 36 51 – 89 70

5 5 – 136 36 117 107 5 21 46 – 35 339 43 64 98 115 119 – 44 10 0 152 – 222 223 75 13 56 72 – 30 181 95 115 – 50 55 66 5 112 20 64 32 107 38 27 – 86 67

5 5 92 144 36 111 100 11 18 27 35 31 300 42 65 67 85 124 33 44 9 0 107 – 227 158 47 25 43 69 0 24 157 77 115 – 47 55 55 153 110 40 45 65 126 45 56 – 92 69

5 5 63 142 37 105 102 11 22 26 40 28 222 45 63 108 97 139 24 28 10 0 79 – 291 139 79 13 37 65 0 12 155 87 115 – 47 54 49 131 105 43 46 89 123 40 81 – 90 68

3 5 66 178 36 89 84 5 18 27 32 26 227 47 60 97 117 150 39 29 9 203 70 55 95 151 74 18 36 55 – 28 124 49 118 130 47 57 50 178 101 71 40 117 123 47 80 374 94 70

5 5 58 199 47 80 80 0 21 20 14 25 324 49 64 113 91 151 23 16 10 0 57 44 322 168 71 15 38 61 0 15 283 49 114 102 57 60 45 184 101 81 43 153 123 47 87 355 96 76

Country data for the Western Pacific and South East Asia Regions: new smear-positive cases, 1993–2003 Number of cases 1997 6 226 0 12,686 236,021 1,943 325 0 66 41 – 13,571 50 1,234 7,496 – – 97 11 27 34 – 9 – – 11 3 285 102 15,744 201,775 2,020 – 0 65 33 – 12,909 59 1,719 8,207 17 2 3 24 1998 1999 2000 2001 2002 2003 1993 1994 1995 1996 1997 1998 1999 2000 Rate (per 100 000 population) 2001 2002 2003

1993

1994

1995

1996

1 557 68

Tuberculosis Control in South-East Asia and Western Pacific Regions 9 1,171 – 24 83 0 21 7 1,195 80,163 9,957 14 436 113 11 – 66 50,016 1 416,952 33,117 284 3,980 274,877 19,492 95 9,695 11,323 3,506 13,214 – 369,583 786,535 16 – 38 54,889 – 379,699 37,737 270 403 278,275 32,280 88 10,089 11,306 3,761 7,962 – 382,171 761,870 1,513 2 22 94 1 15 20 1,914 73,373 9,559 17 465 93 0 10 0 43 53,805 – 383,884 37,821 315 5,073 345,150 49,172 88 11,458 13,410 3,911 14,934 – 481,332 865,216 10 33 – 8 19 – 11 2 0 25 52 35 139 26 9 13 29 66 9 63 17 52 21 20 17 20 – 28 16 46 20 41 17 35 – 25 22 41 95 22 4 13 34 – 16 – 20 72 – 23 29 14 2 28 16 32 22 50 21 13 – 26 24

American Samoa Australia Brunei Darussalam Cambodia China China, Hong Kong SAR China, Macao SAR Cook Islands Fiji French Polynesia Guam Japan Kiribati Lao PDR Malaysia Marshall Islands Micronesia Mongolia Nauru New Caledonia New Zealand Niue Northern Mariana Is Palau Papua New Guinea Philippines Rep. Korea Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis & Futuna Is WPR Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste SEAR Total 7 41 27 21 8 – – 14 131 – 36 26 – 4 – 9 3 0 – 49 – 141 38 13 16 44 – 16 22 – – – 14 16 – – 25 33 53 – 33 19 – – 23 18

84,898 2,429 108 4 58 – – 17,890 99 – 6,954 12 – 86 – 16 91 0 – 8 – 92,279 16,630 21 513 155

2 203 – 13,865 202,817 2,091 276 1 74 34 – 11,935 52 1,494 7,802 11 14 1,356 – 26 106 0 26 – 2,107 69,476 10,359 7 482 140

4 1 – 111 16 32 63 5 9 15 – 9 64 30 36 22 13 55 – 13 3 0 41

16 2 – – – 222,895 18,993 – – 225,256 62,966 126 – 6,679 3,335 – – 317,355 540,250

4 – – 11,058 104,729 – – 1 60 38 40 16,770 184 – 6,861 – – 145 2 28 61 0 – 11 – 87,401 13,266 18 861 114 0 17 1 62 – – 241,732 1,710 352 – 226,543 49,647 125 – 10,442 3,405 20,260 – 312,484 554,216

– – – 11,101 134,488 1,677 141 – 68 – – 14,367 – 478 6,688 – 9 455 – 21 78 0 14 9 1,652 94,768 11,754 15 455 109 1 9 6 30 37,550 3 315,946 20,524 367 – 264,515 31,768 114 8,681 8,591 3,049 20,273 – 357,882 673,828

0 – – 12,065 203,670 1,774 258 0 69 37 – 12,867 144 886 7,271 12 14 769 – 26 90 1 26 4 652 86,695 11,420 9 519 90 0 14 – 50 48,911 3 388,346 29,674 308 – 290,953 11,790 106 9,716 10,365 2,958 16,997 – 372,867 761,213

2 251 84 14,822 204,765 1,940 160 0 62 29 43 11,853 54 1,526 8,156 11 15 1,389 4 20 74 0 27 – 2,267 67,056 8,216 13 248 109 0 15 0 63 53,169 – 376,443 38,484 347 16,440 349,374 52,338 65 17,254 13,683 4,314 17,754 – 510,053 886,496

2 228 95 14,361 204,591 1,857 157 2 73 0 47 11,408 64 1,563 8,309 15 8 1,631 2 19 68 0 19 – 1,122 59,341 11,805 11 357 118 0 8 0 57 54,238 1 371,577 40,777 359 14,429 384,827 53,965 59 21,161 13,683 4,316 28,363 – 561,939 933,516

1 210 112 17,258 194,972 1,890 147 1 75 28 31 10,807 82 1,829 7,958 18 22 1,670 2 21 88 1 21 9 926 65,148 11,345 19 549 108 – 23 0 38 56,811 1 372,221 46,811 364 18,576 395,833 76,230 60 24,162 13,714 4,297 25,593 1,090 606,730 978,951

8 – – 99 9 – – 5 8 18 28 13 240 – 35 – – 6 19 15 2 0 – 66 – 131 30 11 26 31 0 17 11 37 – – 15 1 20 – 25 26 51 – 51 19 35 – 22 18

0 – – 102 17 28 61 0 9 17 – 10 182 18 35 25 13 32 – 13 2 47 45 23 14 124 25 5 14 23 0 14 – 28 66 21 24 23 17 – 31 6 41 22 48 16 29 – 26 25

11 1 0 104 19 30 76 0 8 18 – 11 62 25 35 – 8 48 – 12 2 0 34 39 24 112 22 8 12 28 – 11 – 36 67 7 25 26 15 18 28 10 36 21 52 19 22 – 25 25

5 2 31 123 16 30 – 0 8 14 – 10 71 33 36 34 – 61 17 10 3 49 22 106 37 99 21 10 12 22 0 10 0 22 70 – 23 28 16 23 35 24 31 24 58 21 25 – 32 27

3 1 25 113 16 28 36 0 8 12 28 9 64 29 35 22 14 56 33 9 2 0 39 – 43 89 18 8 6 25 0 15 0 32 68 – 22 28 17 74 34 25 22 36 58 23 29 – 33 28

3 1 28 107 16 27 34 11 9 0 30 9 75 29 35 29 7 65 16 9 2 0 26 – 21 77 25 6 9 26 0 8 0 28 68 7 22 29 17 64 37 25 20 44 57 23 46 – 36 28

2 1 32 125 15 27 32 5 9 12 19 8 95 33 33 34 20 65 16 9 2 51 28 45 17 83 24 11 13 23 – 22 0 18 71 7 22 33 17 82 38 35 19 49 56 23 41 148 38 30

3 1 34 134 21 25 30 0 8 9 0 8 113 33 33 38 25 59 8 6 3 0 20 24 57 91 23 7 14 29 0 11 0 19 69 48 26 37 16 77 41 42 21 55 57 23 45 132 42 34

Country data for tuberculosis drug resistance New cases Year WPR Australia Cambodia China Hong Kong Henan Hubei Liaoning Inner Mongolia Zhejiang Korea Japan Malaysia Mongolia New Zealand Singapore Viet Nam SEAR India North Arcot Raichur District Wardha District Nepal Thailand Myanmar 1999 1999 1999 2001 2001 2003 282 278 197 755 1505 733 12.8 12.2 10.7 1.6 5.3 – 23.7 21.9 19.8 11 14.8 30.2 2.8 2.5 0.5 1.3 0.9 4 – – – 171 – 172 – – – 20.5 – 20.3 2001 2001 1999 1999 2003 1998 1998 1997 1996 1999 2001 2001 1996 3470 1222 859 818 806 802 2370 1374 1001 405 272 823 640 2.3 3.3 3.7 5.4 5 2.7 4.9 2 1 4.4 4.4 1.6 6.7 10.2 29.8 17.5 42.1 35 14.8 10.6 10.3 4.2 29.4 11.4 5 32.5 0.8 7.8 2.1 10.4 7.3 4.5 2.2 0.9 0 1 0 0.5 2.3 169 265 238 86 – 140 283 264 16 – 22 126 – 11.2 36.6 21.8 24.4 – 35 7 19.7 0 – 0 8 – 2001 2001 770 638 5.6 4.7 9.9 10.3 1.6 0 – 96 – 3.1 No INH Any MDR Previously treated cases No MDR

Tuberculosis Control in South-East Asia and Western Pacific Regions

Annexes

Annex 1

Definitions21 1. Definitions of Tuberculosis Cases A case of tuberculosis. A patient in whom tuberculosis has been bacteriologically confirmed, or 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 tuberculosis: A patient who has never received treatment for tuberculosis or has taken anti-tuberculosis drugs for less than 30 days and who has one of the following: • • • two or more initial sputum smear examinations positive for acid fast bacilli (AFB); or one sputum examination positive for AFB plus radiographic abnormalities consistent with active pulmonary tuberculosis as determined by a clinician; or one sputum specimen positive for AFB and at least one sputum that is culture positive for AFB.

New smear-negative pulmonary tuberculosis: 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, bones, meninges, etc. 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: Patient previously treated for tuberculosis, undergoing treatment for a new episode of bacteriologically-positive (sputum smear or culture) tuberculosis. Relapse: A patient previously treated for tuberculosis and declared cured or treatment completed, who is later diagnosed with bacteriologically-positive (culture smear) tuberculosis. WHO, IUATLD, KNCV. Revised international definitions in tuberculosis control. Int J Tuberc Lung Dis 2001; 5: 213215. 21

Tuberculosis Control in South-East Asia and Western Pacific Regions

2. Definitions of Treatment Outcome Cured: Initially smear-positive patient who was 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: Smear-positive patient who remained smear-positive at five months or later during treatment. 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: Patient 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.

3. Indicators to Assess Treatment Outcome Cure rate: Proportion of cured cases out of all cases registered in a certain period (in 2002 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 2003 (reported in 2004) is compared to the number of cases notified as smear-positive in 2002 (reported in 2003). 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 lost records. All registered cases should be evaluated. 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 up 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 up 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 smearpositive cases notified in the previous year, whichever is greater.

Tuberculosis Control in South-East Asia and Western Pacific Regions

4. 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. 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 cure 85% of the sputum smear-positive tuberculosis cases detected. To detect 70% of the estimated new sputum smear-positive tuberculosis cases.

Case notifications represent only a fraction of the true number of cases in a country because the coverage by effective NTPs may be incomplete. The estimated case detection rate is defined as: Case-detection rate (%) = Annual new smear-positive notifications (country) Estimated annual new smear-positive incidence (country) DOTS detection rate refers to case detection under DOTS: DOTS detection rate (%) = Annual new smear-positive notifications under DOTS 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 2003 used in this report was provided by WHO. Population with access to DOTS: The country’s population that lives in administrative areas where DOTS services are available.. DOTS enrolment rate (%): This indicates a proportion of cases enrolled in DOTS out of notified cases. DOTS enrolment rate (all types) (%) = Annual notifications of all types under DOTS Total of annual notifications of all types DOTS enrolment rate (New S+) (%) = Annual notification of new S+ under DOTS Total of annual notifications of new S+

Tuberculosis Control in South-East Asia and Western Pacific Regions

Annex 2

Formulas for Estimating Tuberculosis Incidence, Prevalence and Deaths 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. Formulas 1. I = T/d and I s= Ts/ds 2. P = tl and P s= tsls 3. Is/N = ?k 4. D = fl and D s= fls 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 [HIV]-Positive persons/TB incidence in HIV-Negative persons) d = Proportion of cases notified (Case detection rate) t = Average duration of TB disease (Years) + + a a + a -

Definitions

5. I = Ia*+Ia-+In or I = m r N +ma ra Na +maraNa

? = 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

6. IRR = ma+ra+/ma-ra-=(Ia+/Na+)/(Ia-/Na-)

t = 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. Ia /Ia = IRR(Na /Na)/[1+(Na /Na)(IRR-1)] + + -

8. Ia = Ia -Ia Na /Na * + +

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+-Ia*)

Tuberculosis Control in South-East Asia and Western Pacific Regions

Annex 3

Statistical Methods Rates of change per year in time series were assessed by estimating the slope of the log-transformed rates against time. The statistical analysis was carried out using the R language22, freely downloadable from the internet23.

Ross Ihaka and Robert Gentleman. R: A language for data analysis and graphics. Journal of Computational and Graphical Statistics, 5(3):299-314, 1996. 22 23

http://www.r-project.org

Tuberculosis Control in South-East Asia and Western Pacific Regions

World Health Organization South-East Asia Region Western Pacific Region

Informations clés

Organisation Organisation mondiale de la santé (OMS)

Type de document Publications

Date d'adoption 31 décembre 2005

Source Organisation mondiale de la santé