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Tuberculosis control in the WHO Western Pacific Region : 2003 report

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TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2000

Tuberculosis Control In the WHO Western Pacific Region 2003 Report

World Health Organization Office for the Western Pacific Region

iii

Tuberculosis Control in the WHO Western Pacific Region

2003 Report

World Health Organization Office for the Western Pacific Region

Acknowledgements

We would like to thank all tuberculosis managers and statisticians from all the countries and areas of the Western Pacific Region for providing data for this publication.

WHO Library Cataloguing in Publication Data

Tuberculosis Control in the WHO Western Pacific Region : 2003 report

1. Tuberculosis — epidemiology. 2. Western Pacific

ISBN 92 9061 043 3

(NLM Classification: WF 205)

The World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. Applications and enquiries should be addressed to the Office of Publications, World Health Organization, Geneva, Switzerland, or to the Regional Office for the Western Pacific, Manila, Philippines, which will be glad to provide the latest information on any changes made to the text, plans for new editions, and reprints and translations already available. © World Health Organization 2003 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.

Published in the Philippines

Contents

Acknowledgements Abbreviations Map: Tuberculosis situation in the Western Pacific Region (all types), 2001 Summary Table 1: Key indicators of tuberculosis control in the Western Pacific Region, 2001 Part I: Commentary Chapter 1 Review of tuberculosis epidemiology Chapter 2 Review of DOTS implementation and treatment results Chapter 3 Tuberculosis control in high-burden countries Part II: Tables Notification of tuberculosis cases by type, Western Pacific Region, 2001 Age and sex distribution of new sputum smear-positive cases in DOTS and non-DOTS areas, Western Pacific Region, 2001 Notification rate per 100 000 of new smear-positive cases by age and sex in DOTS and non-DOTS areas,Western Pacific Region, 2001 Trend in notified tuberculosis cases (all types) in DOTS and non-DOTS areas Trend in notified cases (new smear-positives) in DOTS and non-DOTS areas Trend in tuberculosis notification rates per 100 000 population (all types) Trend in tuberculosis notification rates per 100 000 population (smear-positives) Trend in tuberculosis notification (number of all types) in DOTS and non-DOTS areas, 1998–2001 Trend in tuberculosis notification (number of new smear-positives) in DOTS and non-DOTS areas, 1998–2001 Trend in tuberculosis notification (rate for all types) in DOTS and non-DOTS areas, 1998–2001 Trend in tuberculosis notification (rate for new smear-positives) in DOTS and non-DOTS areas, 1998–2001 Treatment outcome of new smear-positive cases registered in 2000 in DOTS areas

ii v vi vii viii 1 2 7 10 15 17 18 19 20 21 22 23 24

Table 5 Table 6 Table 7 Table 8 Table 9 Table 10 Table 11 Table 12 Table 13 Table 14 Table 15 Table 16

26 26 28

iii

Contents

Table 17 Treatment outcome of new smear-positive cases registered in 2000 in non-DOTS areas Table 18 Treatment outcome of re-treatment cases registered in 2000 in DOTS areas Table 19 Treatment outcome of re-treatment cases registered in 2000 in non-DOTS areas Part III: Charts Chart 1 Notification of all cases (rate per 100 000) by country, Western Pacific Region, 2001 Chart 2 Notification of new smear-positive cases (rate per 100 000) by country, Western Pacific Region, 2001 Chart 3 Notification rate of new smear-positive cases by age and sex in DOTS areas, Western Pacific Region, 2001 Chart 4 DOTS enrolment rate in high-burden countries, Western Pacific Region, 2001 Chart 5 DOTS enrolment rate of new smear-positive cases in high-burden countries, Western Pacific Region, 1997 and 2001 Chart 6 DOTS case detection rate of new smear-positive cases in high-burden countries, Western Pacific Region, 2001 Chart 7 Treatment success of new smear-positive cases under DOTS in highburden countries, Western Pacific Region, 2001 Chart 8 DOTS progress in high-burden countries in the Western Pacific Region, 1998–2001 Annexes Annex 1 Profiles of high-burden countries in the Western Pacific Region Annex 2 Definitions

29 30 31 33 34 35 36 36 37 37 38 38 39 40 48

Abbreviations

AFB DOT DOTS HIV NTP TB WHO WPR

Acid Fast Bacilli Directly Observed Treatment Directly Observed Treatment Short-Course Human Immunodeficiency Virus National Tuberculosis Programme Tuberculosis World Health Organization Western Pacific Region (of WHO)

World Health Organization Regional Office for the Western Pacific Mongolia Japan

People's Republic of China

Republic of Korea

Western Pacific Region Marshall Islands

Tuberculosis Situation in the

(All Types), 2001

Lao Peoples Democratic Republic Cambodia

Hong Kong, China Macao, China Viet Nam Philippines

Northern Mariana Islands Guam Micronesia, FS Palau Papua New Guinea Solomon Islands Tuvalu Vanuatu New Caledonia Fiji Tokelau Wallis and Futuna Samoa American Samoa Niue Tonga New Zealand Cook Islands French Polynesia Nauru Kiribati

Brunei Darussalam Malaysia Singapore

vi Cases / 100 000

Australia

> 100 25 - 100 < 25 The designations on this map do not imply the expression of any opinion on the part of the Regional Director concerning the legal status of any country or territory or the delimitation of its frontiers. Pacific islands not to scale.

NOTE: Clear areas are outside the WHO Region for the Western Pacific.

Summary

1 Population

update 2001, Global Tuberculosis Control, WHO, Geneva.

vii

Summary

his 2003 report is an update on the epidemiological situation of tuberculosis in the Western Pacific Region and shows the progress of Directly Observed Treatment Short-course (DOTS) programmes. National Tuberculosis Programmes of 33 countries and areas (accounting for a total population of 1.702 billion1) submitted data on cases notified during 2001 and the treatment results of the cohort of patients registered during 2000. A standard form was used, based on common definitions and variables. In 2001, the 33 countries and areas notified 811 263 tuberculosis cases (all types) and 379 060 new smear-positive pulmonary cases. Notification rates were 48 per 100 000 and 22 per 100 000, respectively, showing no significant variation from recent years (Table 1, page viii). About 69% of the notified tuberculosis patients were aged 15–54, which is the most productive age group, while the group aged 25–34 had the highest tuberculosis burden at 20% (all cases) (Table 6, page 18). Based on the estimated incidence for 2001, the case detection rate was 40% for all types and 41% for smear-positive cases (Table 1), well short of the World Health Organization (WHO) target of 70%. Higher case detection rates were observed in DOTS areas (31% for all types and 37% for new smear-positive cases) compared to non-DOTS areas (9% and 5%, respectively) (Table 1). Further DOTS expansion should lead to an increase in case detection, especially of the most contagious cases – those that are pulmonary smear-positive. About 68% of the regional population had access to DOTS. The DOTS enrolment rate for new smear-positive cases increased to 89%, from 78% in 2000 (Table 1). The treatment success rate was 92.3% (Table 16, page 28) for pulmonary new smear-positive patients registered in 2000. Out of these, 89% were cured, exceeding the WHO target of 85%. Among the seven countries with the highest burden of tuberculosis in the Region (Cambodia, the People’s Republic of China, the Lao People’s Democratic Republic, Mongolia, Papua New Guinea, the Philippines, and Viet Nam) Mongolia and Viet Nam passed WHO targets of 70% DOTS case detection and 85% treatment success (for new smear-positive cases). Mongolia passed the WHO targets during 2001, two years after full DOTS coverage was achieved in 1999. The Philippines, although not yet reaching the target for detection (57% in 2001), managed almost full DOTS coverage, five years after the introduction of DOTS. In some countries, an increase was seen in the number of human immunodeficiency virus (HIV) patients with tuberculosis. For instance, HIV prevalence among tuberculosis patients increased from 6% in 2000 to 8.4% in 2002 in Cambodia (see profiles of high-burden countries in Annex 1). The level of primary multidrug resistance in China is also a cause for concern.

In 2001, the 33 countries and areas notified 811 263 tuberculosis cases (all types) and 379 060 new smear-positive pulmonary cases.

TABLE 1

Key indicators of tuberculosis control in the Western Pacific Region, 2001 Notification in DOTS and non-DOTS areas *Pop. x 1000 Country American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong, China Japan Kiribati Republic of Korea Lao PDR Macao, China Malaysia N. Mariana Islands Marshall Islands Micronesia, FS Mongolia Nauru New Caledonia New Zealand Niue Palau Papua New Guinea Philippines Pitcairn Islands Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis and Futuna Western Pacific a 70 19 338 335 13 441 1 284 972 20 823 237 158 6961 127 335 84 47 069 5403 449 22 633 76 52 126 2559 13 220 3808 2 20 4920 77 131 0 159 4108 463 1 99 10 202 79 175 15 1 702 484 All cases Number Rate b c 3 4 980 5 216 65 19 170 143 485 221 38 2 10 183 22 45 19 63 40 7262 104 35 489 28 189 225 37 268 79 2382 44 465 104 14 830 66 58 76 56 108 95 75 3526 138 3 24 64 29 377 10 0 0 3470 107 133 22 1536 292 0 11 173 90 679 811 263 71 139 14 37 63 0 11 86 115 47.7 New S+ Number Rate e d 3 2 1 228 28 95 107 14 361 17 212 766 10 2 9 73 10 24 30 47 27 1853 9 11 408 76 64 25 11 805 28 1533 35 157 37 8309 25 19 29 15 6 8 64 1631 16 2 15 34 2 68 0 0 462 59 341 12 357 118 0 8 56 54 202 379 060 9 77 8 9 25 0 8 28 68 22.3 *No. of estimated cases New All S+ cases g h 23 11 1528 687 185 83 78 564 35 118 1 447 947 651 110 7 3 276 124 80 36 133 60 5755 2587 44 954 20 227 71 32 32 787 14 721 12 789 5755 371 167 27 119 12 149 64 29 44 20 106 48 5041 2268 4 2 185 83 409 184 1 0 17 7 11 771 5285 232 266 104 439 53 1874 390 0 33 3 170 143 412 5 2 048 439 24 842 176 0 15 2 77 64 535 2 920 908 Case detection rate All cases (%) i=b/g 13 64 116 24 34 30 66 56 47 126 79 267 114 19 125 55 91 128 90 70 71 35 92 0 29 46 41 82 75 0 33 102 63 40 New S+ (%) j=d/h 19 33 114 41 33 67 59 67 78 72 56 201 80 27 94 68 66 76 17 72 106 41 37 0 9 57 50 42 67 0 53 73 84 41 Pop. with access to DOTS No. of cases in DOTS areas All New cases S+ m n 0 0 485 99 216 95 19 170 14 361 362 172 188 480 2 2 183 73 45 24 63 47 5907 1425 17 809 5709 189 64 0 0 1618 1533 465 157 14 830 8309 58 19 56 15 95 8 3526 1631 3 2 0 0 89 21 0 0 3470 107 133 22 749 292 0 11 121 90 679 629 458 462 59 341 12 175 118 0 8 46 54 202 336 438 No. of cases in non-DOTS areas All New cases S+ p o 2 3 129 495 0 0 0 0 123 049 24 286 0 0 0 0 0 0 0 0 428 1355 5699 17 680 0 0 37 268 11 805 0 764 0 0 0 0 0 0 0 0 0 0 0 0 0 0 34 64 47 288 0 0 0 0 0 787 0 0 0 52 0 181 805 0 0 0 182 0 0 0 10 0 42 622 **DOTS enrolment rate All cases (%) q=m/b 0 49 100 100 75 100 100 100 100 81 50 100 0 68 100 100 100 100 100 100 100 0 24 0 100 100 100 49 100 0 100 70 100 78 New S+ (%) r=n/d 0 43 100 100 89 100 100 100 100 77 50 100 0 100 100 100 100 100 100 100 100 0 31 0 100 100 100 49 100 0 100 82 100 89 ***DOTS case detection rate All cases (%) s=m/g 0 32 116 24 25 30 66 56 47 103 40 267 0 13 125 55 91 128 90 70 71 0 22 0 29 46 41 40 75 0 33 71 63 31 New S+ (%) t=n/h 0 14 114 41 29 67 59 67 78 55 28 201 0 27 94 68 66 76 17 72 106 0 11 0 9 57 50 21 67 0 53 60 84 37 Non-DOTS case detection rate All cases (%) u=o/g 13 32 0 0 8 0 0 0 0 24 39 0 114 6 0 0 0 0 0 0 0 35 70 0 0 0 0 0 42 0 0 0 0 31 0 9 New S+ (%) v=p/h 19 19 0 0 4 0 0 0 0 17 28 0 80 0 0 0 0 0 0 0 0 41 26 0 0 0 0 0 22 0 0 0 0 13 0 5

% f=d/b 67 23 44 75 44 100 40 53 75 26 32 34 32 64 34 56 33 27 8 46 67 53 18 0 13 55 55 23 40 0 73 0 32 60 47

Pop. k 70 10 443 335 13 441 873 781 20 823 230 158 6961 58 574 84 0 4323 449 22 633 76 52 88 2559 13 0 3808 2 640 74 817 159 4108 417 0 97 131 79 016 1 158 305

% l 100 54 100 100 68 100 100 97 100 100 46 100 0 80 100 100 100 100 70 100 100 0 100 100 13 97 100 100 90 0 98 65 100 68

viii

* 2001 update, WHO Geneva. ** DOTS enrolment rate is the proportion of all detected cases that are diagnosed and treated in DOTS areas. *** DOTS detection rate is the proportion of total estimated cases that are diagnosed and treated under DOTS.

PART I

Commentary Chapter 1 Review of tuberculosis epidemiology Chapter 2 Review of DOTS implementation and treatment results Chapter 3 Tuberculosis control in high-burden countries 2

Commentary

CHAPTER

Review of tuberculosis epidemiology The regional average notification rate for new smear-positive cases was 22.3 per 100 000 population, with the highest rate in Cambodia (107).

his report is based on case notification and treatment outcome data supplied by National Tuberculosis Programmes (NTPs) to the World Health Organization (WHO) for 2001, using a standard data collection form, with common definitions and variables.

1.1 Notification of tuberculosis cases by type of tuberculosis In 2001, 33 out of 37 countries and areas of the Western Pacific Region with a combined population of 1.702 billion submitted tuberculosis data for 2001. Together, they notified 811 263 tuberculosis cases (all types2 ) (47.7 per 100 000 population), 379 060 new smear-positive pulmonary cases (22.3 per 100 000), 307 228 new pulmonary smear-negatives, 32 852 extrapulmonary cases and 36 178 relapses (Tables 1, page viii, and 5, page 17). The four non-reporting countries – Palau, the Pitcairn Islands, Tuvalu, and Wallis and Fortuna — have a combined population of only 45 000.

All types Among the 811 263 tuberculosis cases (all types) in the Region (Figure 1), the People’s Republic of China (China) notified 485 221 cases (61%), the Philippines 107 133 (13%), Viet Nam 90 679 (11%), the Republic of Korea 37 268 (5%), Japan 35 489 (4%) and Cambodia 19 170 (2%) (Table 1, Page viii). The 27 other countries together notified 36 303 cases (4%). Eight countries reported a notification rate (all types) greater than 100, and 13 countries reported a rate lower than 30 (Table 1).

Pulmonary new smear-positive cases Out of the 379 060 new smear-positive cases in the Region, China notified 212 766 cases (56%), the Philippines 59 341 (16%), Viet Nam 54 202 (14%), Cambodia 14 361 (4%), Korea 11 805 (3%) and Japan 11 408 (3%). The 27 other countries together notified 15 177 cases (4%) (Tables 1 and 5). The regional average notification rate for new smear-positive cases was 22.3 per 100 000 population, with the highest rate in Cambodia (107). The rate ranged between 25 and 100 in 15 countries: 77 in the Philippines; 76 in Kiribati; 68 in Viet Nam; 64 in Mongolia; 37 in

In 2001, 956 re-treatment after failure cases and 23 667 other re-treatment cases were not included in the notification.

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

FIGURE 1

Distribution of notified tuberculosis all types by country, Western Pacific Region, 2001 Cambodia Japan 2% 4% Republic of Korea 5% Viet Nam 11% China 61% Others 4%

Philippines 13%

Total: 811 263 tuberculosis cases, all types

Malaysia; 35 in Macao, China; 30 in Guam; 29 in the Marshall Islands; 28 in Brunei Darussalam, the Lao People’s Democratic Republic and Vanuatu; 27 in Hong Kong, China; and 25 in the Republic of Korea, the Northern Mariana Islands and Solomon Islands. China notified 17 new smear-positive cases per 100 000 population. Four industrialized countries (Japan, Australia, New Zealand and Singapore) and 12 Pacific island countries had lower rates (Table 1, page viii). The proportion of new smear-positive cases out of all notified cases was 47% for the Region. China’s rate was 44%. Thirteen countries, including five of the seven with the highest burden (Cambodia, the Lao People’s Democratic Republic, Mongolia, the Philippines and Viet Nam) notified proportions higher than 50% (Table 1). Directly Observed Treatment Short-course (DOTS) areas reported 53% of new smear-positive cases (336 438 new smear-positives out of 629 458 all cases) compared to only 23% in nonDOTS areas (42 622 new smear-positives out of 181 805 all cases) (Table 1 and Figure 2). Extrapulmonary tuberculosis cases were not reported in China. The 32 852 extrapulmonary cases reported in the 32 other countries represented 4% of all notified cases (Table 5, page 17). FIGURE 2

Notified cases by type of tuberculosis in DOTS and non-DOTS areas, Western Pacific Region, 2001

New pulmonary smear-positive New pulmonary smear-negative New pulmonary: no smear or results unknown New extrapulmonary Relapse smear-positive 0

336 438 42 622 223 918 83 310 8638 31 744 24 794 8058 29 328 6940

100 000 DOTS

200 000

300 000 Non-DOTS

400 000

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

1.2 Notification of new smear-positive pulmonary cases by age and gender About 69% of new smear-positive cases are aged between 15 and 54, the most productive age group, with the highest concentration (20%) in the group aged 25–34 (Table 6, page 18). On average, two male tuberculosis smear-positive cases are notified for every female one (a sex ratio of 2:1) in the Region (Table 7, page 19). By age group, the sex ratio was 0.8:1 in the 0–14 year old group (more females than males), 1.3:1 in the 15–24 year old group and then increased in the older age groups (Figure 3 below). FIGURE 3

Notification of new smear-positive cases by age and gender, DOTS and non-DOTS areas, Western Pacific Region, 2001 20

On average, two male tuberculosis smear-positive cases are notified for every female one (a sex ratio of 2:1) in the Region.

0-14

15-24

25-44 % male

45-54 % female

55-64

65 or over

1.3 Case detection rate The case detection rate (see Annex 2 for definition) was 40% for all tuberculosis cases and 41% for new smear-positive cases (Table 1, page viii). In other words, in the Region, the 811 263 notified cases (all types) represented 40% of the 2 048 439 estimated cases (all types) and the 379 060 notified new smear-positive cases represented 41% of the 920 908 estimated new smearpositive cases. Figures of estimated cases (annual incidence) are based on the 2001 update of estimated cases from WHO, Geneva, with projections based on Global Burden of Tuberculosis,3 1999.

1.4 Trends in notification Trends in notification for all types and new smear-positive cases are given by country in Tables 8 to 11 in Part II (pages 20–23). Overall notification rates both for all types and new smear-positive cases have not changed significantly in recent years (Figure 4 opposite). Trends in notification

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

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

may reflect variations in performance in case finding as well as changes in the burden of the disease. They may thus be misleading, with their interpretation biased by variations in the reporting system and/or the use of different denominators (estimates of population). Moreover, trends in case detection rates will also be affected by changes in the estimated incidence.

FIGURE 4

Trend in notification rates of tuberculosis, Western Pacific Region, 1993–2001 60 50 40 30 20 10

1993

1994

1995

1996

1997

1998

1999

2000

2001

All types

New smear-positive

For individual countries, notification increased slightly in China and Viet Nam after 1998, but decreased in Cambodia and the Philippines (Table 2, below, and Figure 5, overleaf).

TABLE 2

Trend in case notification (rates per 100 000) in Cambodia, China, the Philippines and Viet Nam, Western Pacific Region, 1995–2001 1995 Cambodia All New S + China All New S + Philippines All New S + Viet Nam All New S + Western Pacific Region All New S + 48 20 58 22 51 23 51 24 49 24 49 23 48 22 76 51 99 65 111 70 112 70 112 68 117 69 115 68 347 140 399 125 295 118 222 99 198 100 168 88 139 77 29 11 38 14 34 15 36 17 36 17 37 17 38 17 146 111 145 117 149 121 158 129 175 143 157 123 143 107 1996 1997 1998 1999 2000 2001

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

FIGURE 5

Trend in notification of smear-positive cases (rate per 100 000) in Cambodia, China, the Philippines and Viet Nam, Western Pacific Region, 1995–2001

150 125 100 75 50 25 0 1995 Cambodia

1996

1997 Philippines

1998 Viet Nam

1999

2000

2001 China

Western Pacific Region

1.5 Prevalence of HIV infection among tuberculosis patients Tuberculosis patients have been included in the surveillance sentinel groups for human immunodeficiency virus (HIV) infection prevalence surveys in Cambodia and Viet Nam. HIV sero-prevalence in newly detected tuberculosis cases increased from 6% in 2000 to 8.4% in Cambodia (2002 survey). HIV sero-prevalence in 2001 was 4.9% in Malaysia; 3% in Fiji; 1.2% in New Zealand; 1% in Papua New Guinea and the Northern Mariana Islands; 0.5% in Hong Kong, China and Macao, China; and 0.3% in Singapore.

1.6 Primary multidrug resistance Primary multidrug resistance (combined resistance to at least rifampicin and isoniazide) was found in China in 2000, ranging from 2.9% to 5.3% of newly detected cases in three provinces (Guangdong 5.3%, Zhejiang 4.3% and Shandong 2.9%) (see profiles of high-burden countries in Annex 1).

CHAPTER

Review of DOTS implementation and treatment results Twenty-two countries achieved 97% DOTS coverage or above. mong the 33 countries and areas of the Region that reported in 2001, 30 had at least part of their population served by DOTS units, compared to 18 in 1998. Twenty-nine countries had a tuberculosis manual, 20 had a special budget for tuberculosis control, 26 had a centralized system for the procurement and distribution of tuberculosis drugs, 15 had a system to prevent the sale of rifampicin to the general public, 22 had a reference laboratory and 19 had a mechanism for collecting notification of tuberculosis cases from private practitioners.

2.1 Population with access to DOTS The population in the Region with access to DOTS increased slightly from 67% in 2000 to 68% in 2001 (Table 1, page viii). DOTS was applied in 52% of operational health units (2528 out of 4841) in the Region; for China, the percentage was 49% (1560 out of 3164 health units). Twenty-two countries achieved 97% DOTS coverage or above (American Samoa; Brunei Darussalam; Cambodia; Cook Islands; Fiji; French Polynesia; Guam; Hong Kong, China; Kiribati; Macao, China; Malaysia; the Marshall Islands; Mongolia; Nauru; New Zealand; Niue; the Northern Mariana Islands; the Philippines; Samoa; Singapore; Tonga; and Viet Nam). The population with access to DOTS was 90% in Solomon Islands, 80% in the Lao Peoples’ Democratic Republic, 70% in the Federated States of Micronesia, 68% in China, 65% in Vanuatu, 54% in Australia, 46% in Japan and 13% in Papua New Guinea. Among the countries that made the biggest progress compared to the previous year were Vanuatu (50% to 65%), Japan (36% to 46%), the Lao People’s Democratic Republic (70% to 80%), the Philippines (90% to 97%) and Papua New Guinea (8% to 13%) (Table 1).

2.2 DOTS enrolment In 2001, 78% of all cases and 89% of new smear-positive cases in the Region were diagnosed and treated under DOTS (Table 1). This marks a rapid improvement since 1999, when the figures were 69% for all cases and 78% for new smear-positive cases. The increase was particularly marked in the Philippines (from 28% in 1999 to 100% in 2001) and Japan (from 37% in 1999 to 50% in 2001).

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

FIGURE 6

Trends in population with access to DOTS and DOTS enrolment rate (all cases) in the Western Pacific Region, 1998–2001

1995

1996

1997

1998

1999

2000

2001

DOTS enrolment rate (all types)

Population with access to DOTS

2.3 Treatment results of new smear-positive cases In DOTS areas, the treatment success rate was 92.3% for the cohort of 320 046 new pulmonary smear-positive cases treated in 2000 (they represented 83% of the 385 434 cases notified that year) (Table 16, page 28). The cure rate among reported cases was 88.9%, completed treatment 3.5%, defaulted 2%, treatment failures 1.1%, died 1.9% and transferred out 1.4%. The percentage of cases not evaluated was 1.3%. In China, 89% of new smear-positive cases were registered for treatment results (191 280 out of 213 766 notified in 2000) and the treatment success rate was 95%. In non-DOTS areas, the treatment success rate was 69.8% out of 38 139 cases (which in turn comprise 66% of the 57 741 cases notified in 2000) (Table 17, page 29). In China, 97% of the 22 486 cases notified in 2000 were evaluated and the treatment success was 81.3%.

In DOTS areas, the treatment success rate was 92.3% for the cohort of 320 046 new pulmonary smearpositive cases treated in 2000.

2.4 Treatment results of re-treatment cases In DOTS areas, 54 043 re-treatment cases registered in 2000 were evaluated (including relapses, failures and returns after treatment interruption). The treatment success rate for these was 86.6%. The cure rate was 83.5%, completed treatment 3%, defaulted 1.3%, treatment failures 2%, died 2.2%, transferred out 0.9% and 7.2% of the cases were not evaluated (Table 18, page 30). In non-DOTS areas, the treatment success rate for re-treatment cases was 31.3% (Table 19, page 31). Out of 728 re-treated cases registered in 2000, 57% were not evaluated; therefore, the cure rate was only 23%, completed treatment 8.4%, defaulted 2.2%, treatment failures 4.1%, died 2.1% and transferred out 3.6%.

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

FIGURE 7

Treatment success in DOTS and non-DOTS areas, 2000 cohort

% 100

New smear-positive cases

100

Re-treatment cases

DOTS

Non-DOTS Not evaluated

0 Others

DOTS Treatment success

Non-DOTS

CHAPTER

Tuberculosis control in highburden countries In 2001, the seven high-burden countries accounted for 86% of the Region’s population and 94% of all estimated incident cases (or more than 1.9 million new cases by year).

even countries in the Region – Cambodia, China, the Lao People’s Democratic Republic, Mongolia, Papua New Guinea, the Philippines and Viet Nam – have been identified as high-burden countries for tuberculosis. In 2001, these seven countries accounted for 86% of the Region’s population and 94% of all estimated incident cases (or more than 1.9 million new cases by year). They notified 88% of all cases (711 581 out of 811 263 cases) and 91% of the smear-positive cases in the Region (344 296 out of 379 060 cases). The average case detection was 33% for all types and 40% for the new smear-positive cases. DOTS expansion made the best progress in this group of countries. In 2001, 71% of the population of these countries had access to DOTS and the DOTS enrolment rate for pulmonary new smear-positive cases was 83%. Treatment success exceeded 85% in five of these countries, including China. Mongolia and Viet Nam have reached the targets of 70% case detection and 85% treatment success (for new smear-positive cases). In 2001, Mongolia passed the WHO targets for the first time, two years after achieving full DOTS coverage in 1999. Viet Nam has been maintaining high case detection and treatment success for several years. Cambodia, China and the Philippines have all exceeded the 85% treatment success target.

3.1 Tuberculosis control policies and DOTS components in high-burden countries All high-burden countries are using WHO-recommended national tuberculosis guidelines and have central procurement and distribution systems for tuberculosis drugs as well as a national reference laboratory. Five countries allot a separate budget for tuberculosis control. DOTS is implemented in all public hospitals in Cambodia, Mongolia, the Philippines and Viet Nam, and in 80% of hospitals in the Lao People’s Democratic Republic, 58% in China and 13% in Papua New Guinea. Most of the countries use sputum smear microscopy for diagnosis, the exception being Papua New Guinea, where it is used in some units only. Directly observed treatment (DOT) is applied in all public health units within DOTS areas. Treatment and smear microscopy examinations are free of charge for the patients in six countries, while China has a patient fee system. Reporting of treatment results is based on cohort analysis in all units in Cambodia, the Lao People’s Democratic Republic, Mongolia, Papua New Guinea and Viet Nam, and in some units in China and the Philippines. Screening and treatment of contact children is carried out in some units only.

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

3.2 Notification in high-burden countries In 2001, the notification rate for all cases exceeded 100 per 100 000 population in four of the seven high-burden countries: 143 in Cambodia, 139 in the Philippines, 138 in Mongolia and 115 in Viet Nam. These seven notified a higher proportion of pulmonary smear-positive cases (48% of all cases) than other areas of the Region, where they accounted for 35% of all cases. The estimated incidence4 of smear-positive cases was 59 per 100 000 in the seven high-burden countries, compared to 22 per 100 000 in the others. However, at 40%, the case detection rate for smear-positives was lower in the high-burden countries compared to 66% in the other countries. The case detection rate was 34% in China, where more than 70% of the estimated cases of the Region reside; therefore DOTS expansion in China is a pre-condition for reaching the WHO target of 70% case finding in the Region. The notification rate of new smear-positive cases increased between the years 1995 and 2001 in Mongolia. It also rose slightly in China, the Lao People’s Democratic Republic and Viet Nam. Cambodia and the Philippines have seen a decrease since 1999. Fluctuations in the Papua New Guinea results are mostly due to significant variations in the reporting system; only the cases registered in DOTS areas were reported in 2001 (Figure 8, below).

FIGURE 8

Trend in notification rate (per 100 000) of new smear-positive cases, high tuberculosis burden countries in the Western Pacific Region, 1995–2001

150 125 100 75 50 25 0 1995 1996 1997 1998 1999 Lao PDR Viet Nam

2000

2001

Cambodia Papua New Guinea

China Philippines

Mongolia Western Pacific Region

3.3 DOTS implementation in high-burden countries DOTS has made faster progress in high-burden countries than in others. By the end of 2001, 71% of their population had access to DOTS, compared to 47% in other countries. Nearly all of the populations of Cambodia, Mongolia and Viet Nam can access DOTS. DOTS coverage has also risen to 97% in the Philippines (from 75% in 2000), 80% in the Lao People’s Democratic Republic (from 70% in 2000), and 13% in Papua New Guinea (from 8% in 2000). The proportion of population with access to DOTS in China remained the same as the previous year at 68% (Table 3, overleaf). 4

Based on the 2001 update of estimated cases from WHO, Geneva.

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

TABLE 3

DOTS in high-burden countries, Western Pacific Region, 1998–2001 (%) Population with Case detection access to DOTS rate* new S+ Country Cambodia China Lao PDR Mongolia Papua New Guinea Philippines Viet Nam High-burden countries Other countries Western Pacific Region 1998 100 64 71 97 9 17 96 63 24 58 2001 100 68 80 100 13 97 100 71 47 68 1998* 54 33 39 57 41 70 83 43 66 44 41 33 27 72 9 57 84 40 66 41 DOTS enrolment new S+ 2001 100 89 100 100 100 100 100 93 47 89 100 89 99 89 20 14 97 76 33 72 DOTS case detection rate* new S+ 1998 54 30 39 51 8 10 81 32 22 32 2001 41 29 27 72 9 57 84 37 31 37

2001** 1998

About 93% of the new pulmonary smear-positive cases were detected and treated by DOTS in high-burden countries compared to 47% in other countries.

* Case detection rates and DOTS case detection rates have been made available since the publication of estimated cases in Global Burden of Tuberculosis, 1999. ** Updated estimates are given for 2001.

The DOTS enrolment rate is also much greater in the high-burden countries. About 93% of the new pulmonary smear-positive cases were detected and treated by DOTS in high-burden countries compared to 47% in other countries (the DOTS enrolment rate was 83% for all types in high-burden countries compared to 42% in other countries). The highest increase for population with access to DOTS was in the Philippines – from 17% in 1998 to 97% in 2001. In China, an increase of 4 percentage points since 1998 translates as 70 million more people with access to DOTS (Figure 9, below). FIGURE 9

Comparison of population with access to DOTS in high-burden countries, Western Pacific Region, 1998 and 2001

Cambodia China Lao PDR Mongolia Papua New Guinea Philippines Viet Nam Western Pacific Region % 0 20 40 1998

60 2001

100

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

3.4 Treatment results in high-burden countries Better treatment outcomes were observed in the high-burden countries with the greatest DOTS enrolment. Treatment success in DOTS areas was 93% in high-burden countries (new smearpositive cases registered in 2000), compared to 73% in other countries. The proportion of patients not evaluated5 was only 1% in high-burden countries, compared to 9% in other countries (Table 4, below). The cure rate was 90% in high-burden countries (53% in others), died 1.7% (8.3% in others), treatment failure 1% (5.4%) and defaulted 2% (2.7%) (Table 4). Patients treated under DOTS benefited from better management and follow-up (including sputum examinations at the end of treatment to confirm that the patient had been “cured”). By country, the treatment success for pulmonary new smear-positive cases exceeded 85% in five countries, while it was 82% in the Lao People’s Democratic Republic (compared to 62% in 1997) and 63% in Papua New Guinea (Table 4). The Philippines’ figures improved from 83% in 1997 to 88% in 2001. Cambodia, China and Viet Nam have also maintained high treatment success rates since 1997.

TABLE 4

Treatment outcomes of new smear-positive cases in seven high-burden countries, cohort 2000 in DOTS areas, Western Pacific Region Registered Not evaluated Cured Completed Defaulted Failed number (% ) (%) treatment (%) (%) (%) 14 775 19 1280 1392 1389 422 50 196 53 169 312 623 7396 320 019 0.0 1.8 0.0 0.1 4.7 0.1 0.1 1.1 8.8 1.3 87.8 94.6 72.8 83.2 38.6 72.6 89.9 89.7 52.6 88.9 3.5 0.0 8.7 3.7 24.2 15.2 2.2 3.1 20.2 3.5 3.9 0.8 8.5 4.2 25.6 5.8 1.8 2.0 2.7 2.0 0.3 1.0 0.4 3.3 0.5 1.2 1.0 1.0 5.4 1.1 Died Transferred Treatment (%) out (%) success (%)* 3.6 1.0 6.8 2.7 2.4 2.3 3.1 1.7 8.3 1.9 0.8 0.9 2.8 2.8 4.0 2.8 1.9 1.4 2.1 1.4 91.4 94.6 81.5 86.8 62.8 87.8 92.1 92.8 72.8 92.3

Country Cambodia China Lao PDR Mongolia Papua New Guinea Philippines Viet Nam High-burden countries Other countries Western Pacific Region

*Treatment success is the sum of cured and completed treatment.

Among the cohort of new smear-positive pulmonary patients registered for a treatment outcome in 2000.

PART II

Tables Table 5 Notification of tuberculosis cases by type, Western Pacific Region, 2001 Table 6 Age and sex distribution of new sputum smear-positive cases in DOTS and non-DOTS areas, Western Pacific Region, 2001 Table 7 Notification rate per 100 000 of new smear-positive cases by age and sex in DOTS and non-DOTS areas,Western Pacific Region, 2001 Table 8 Trend in notified tuberculosis cases (all types) in DOTS and non-DOTS areas Table 9 Trend in notified cases (new smear-positives) in DOTS and non-DOTS areas Table 10 Trend in tuberculosis notification rates per 100 000 population (all types) Table 11 Trend in tuberculosis notification rates per 100 000 population (smear-positives) Table 12 Trend in tuberculosis notification (number of all types) in DOTS and non-DOTS areas, 1998–2001 Table 13 Trend in tuberculosis notification (number of new smear-positives) in DOTS and non-DOTS areas, 1998–2001 Table 14 Trend in tuberculosis notification (rate for all types) in DOTS and non-DOTS areas, 1998–2001 Table 15 Trend in tuberculosis notification (rate for new smear-positives) in DOTS and non-DOTS areas, 1998–2001 Table 16 Treatment outcome of new smear-positive cases registered in 2000 in DOTS areas Table 17 Treatment outcome of new smear-positive cases registered in 2000 in non-DOTS areas Table 18 Treatment outcome of re-treatment cases registered in 2000 in DOTS areas Table 19 Treatment outcome of re-treatment cases registered in 2000 in non-DOTS areas 17

19 20 21 22 23

24 26

26 28 29 30 31

Tables

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

TABLE 5

Notification of tuberculosis cases by type, Western Pacific Region, 2001 Pulmonary Sputum positive Country American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong, China Japan Kiribati Republic of Korea Lao PDR Macao, China Malaysia N. Mariana Islands Marshall Islands Micronesia, FS Mongolia Nauru New Caledonia New Zealand Niue Palau Papua New Guinea Philippines Pitcairn Islands Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis and Futuna Total 379 060 47 52 36 178 57 307 228 38 32 852 4 56 54 202 32 60 40 71 0 5347 40 78 84 17 106 49 19 33 14 024 19 15 12 357 118 0 8 73 80 55 23 40 75 28 50 1 62 0 0 1 90 81 33 50 3 861 118 0 1 9 14 56 40 6 196 54 0 1 9 27 13 18 462 59 341 13 55 23 55 29 5379 25 60 1496 42 413 43 40 1483 0 43 0 New 2 228 95 14 361 212 766 2 73 24 47 1853 11 408 64 11 805 1533 157 8309 19 15 8 1631 2 34 68 0 75 44 100 40 53 75 26 32 34 32 64 34 56 33 27 8 46 67 53 18 % out of % out of new % of all S+ out the total pulmonary Relapse of all pulmonary 67 23 100 46 53 86 49 100 54 80 94 34 41 68 40 71 40 62 38 39 26 65 67 68 48 0 29 9 721 19 729 0 1 0 1 233 1248 6 3145 85 26 0 0 0 0 113 0 2 11 0 100 52 58 90 53 100 54 80 96 39 46 74 50 75 47 62 38 39 26 70 67 72 56 0 236 74 1658 203 252 0 62 6 2 3294 14 836 24 14 912 533 206 5139 31 23 23 757 1 14 63 0 Sputum negative % out of the total 0 24 34 9 42 0 34 13 3 45 42 13 40 22 44 35 53 41 24 21 33 22 17 1 372 27 2430 0 0 47 8 3 824 6621 74 3797 231 48 1382 8 14 21 1025 0 14 108 0 25 22 29 0 22 29 0 26 18 5 11 19 39 10 10 10 9 % out of the total 33 38 13 13 3 980 216 19 170 485 221 2 183 45 63 7262 35 489 189 37 268 2382 465 14 830 58 56 95 3526 3 64 377 0 0 3470 107 133 0 22 1536 292 0 11 0 173 90 679 0 811 263 Extrapulmonary All types

TABLE 6

Age and sex distribution of new sputum smear-positive (S+) cases in DOTS and non-DOTS areas, Western Pacific Region,* 2001 New S+ males Country American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong, China Japan Kiribati Republic of Korea Lao PDR Macao, China Malaysia N. Mariana Islands Marshall Islands Micronesia, FS Mongolia Nauru New Caledonia New Zealand Niue Palau Papua New Guinea Philippines Pitcairn Islands Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis and Futuna Western Pacific Region % 0-14 15-24 25-34 35-44 45-54 55-64 >=65 New S+ females Total 0-14 15-24 25-34 35-44 45-54 55-64 0 7 0 1687 9963 0 1 3 4 58 250 3 326 134 10 374 0 8 0 48 1 0 1 0 17 0 0 1 15 24 0 1 3 2574 1 8 0 1428 7175 0 2 4 2 34 330 4 390 102 1 353 0 2 1 28 0 0 3 0 5 0 0 1 9 7 0 0 5 2530 >=65 Total 0-14 15-24 New S+ males and females 25-34 35-44 45-54 55-64 >=65 Total 0 2 0 0 0 1 0 1 0 2 20 100 2 44 47 34 25 21 55 228 0 0 0 0 0 0 0 0 0 0 829 6983 54 1055 2335 3127 3093 2831 1866 14 361 6491 69 021 2618 33 621 45 966 37 585 35 722 27 964 29 290 212 766 0 0 0 0 0 0 0 0 2 2 2 24 0 13 13 18 8 6 4 62 3 22 5 12 2 3 7 8 8 45 1 15 0 3 7 13 13 5 7 48 197 592 19 167 219 245 254 234 715 1853 1880 3305 8 395 1013 860 1569 1843 5720 11408 1 29 8 17 14 6 6 9 4 64 1270 4249 68 1781 2305 1908 1619 1493 2631 11805 66 575 14 130 233 291 349 284 227 1528 11 46 1 14 24 37 35 12 34 157 222 2446 84 1223 1704 1666 1385 1287 960 8309 0 9 0 6 7 0 4 2 0 19 1 33 8 14 8 9 12 4 1 56 0 3 1 2 1 0 2 2 0 8 29 768 38 489 528 304 134 73 65 1631 0 1 0 0 1 1 1 0 0 3 3 8 1 2 9 2 5 6 9 34 5 38 4 16 16 10 5 5 17 73 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 217 11 192 136 61 43 14 5 462 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 7 1 4 2 3 1 1 2 14 24 80 2 11 26 58 85 75 100 357 3 140 62 56 53 35 43 28 11 288 0 0 0 0 0 0 0 0 0 0 0 4 0 0 3 1 1 2 1 8 0 0 0 0 0 0 0 0 26 1 17 9 8 11 9 0 55 5174 16 729 87 4146 8676 11 113 9628 7735 12 817 54 202 0 0 0 0 0 0 0 16 234 105 472 3097 43 430 63 357 57 399 54 060 43 954 54 551 319 848 15 100.00 1 14 20 18 17 14 17 100.00

0 0 0 0 0 0 0 0 0 0 0 1 1 23 20 18 18 13 35 128 1 21 27 16 0 0 0 0 0 0 0 0 0 0 0 0 29 600 1302 1601 1406 1403 1037 7378 25 455 1033 1526 1213 19 121 28 520 25 544 25 759 20 789 22 799 143 745 1405 14 500 17 446 12 041 0 0 0 0 0 0 2 2 0 0 0 0 0 6 8 11 7 4 2 38 0 7 5 7 2 5 1 2 4 4 5 23 3 7 1 1 0 1 4 10 9 3 6 33 0 2 3 3 6 79 100 162 196 200 518 1261 13 88 119 83 3 220 576 632 1319 1513 3840 8103 5 175 437 228 4 10 7 3 3 5 3 35 4 7 7 3 23 942 1415 1419 1293 1103 1361 7556 45 839 890 489 8 79 136 172 215 182 161 953 6 51 97 119 0 9 17 26 25 11 23 111 1 5 7 11 48 713 1198 1221 1011 934 738 5863 36 510 506 445 0 1 3 0 4 2 0 10 0 5 4 0 3 8 4 2 4 2 0 23 5 6 4 7 0 2 0 0 2 1 0 5 1 0 1 0 13 236 268 179 86 45 36 863 25 253 260 125 0 0 1 1 0 0 0 2 0 0 0 0 0 1 7 1 5 6 6 26 1 1 2 1 1 7 2 7 4 2 12 35 3 9 14 3 0 0 0 0 0 0 0 0 0 0 0 0 4 0 0 1 1 31 0 0 0 39 101 0 0 3 6 25 0 0 8 2756 72 0 0 1 19 24 0 1 5 6319 29 0 0 1 39 20 0 0 4 8457 26 0 0 0 70 19 0 0 8 7054 9 0 0 0 66 21 0 2 4 5205 4 0 0 1 76 8 0 1 0 7643 245 0 0 7 277 148 0 4 29 37 473 7 0 0 0 1 31 0 0 1 48 91 0 0 1 5 31 0 0 9 1390 64 0 0 1 7 29 0 2 4 2357 32 0 0 2 19 15 0 1 4 2656

1430 24 962 40 030 39 561 38 547 31 529 38 317 214 376 1667 18 468 23 327 17 838 15 513 12 425 1 12 19 18 18 15 18 100.00 2 18 22 17 15 12

*Breakdown of cases by age and sex was not available for the Philippines.

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

TABLE 7

Notification rate per 100 000 of new sputum smear-positive cases by age and sex in DOTS and non-DOTS areas, Western Pacific Region, 2001 Western Pacific Region* 0–14 15–24 25–34 Males 35–44 45–54 55–64 >=65 Total 0–14 15–24 25–34 Females 35–44 45–54 55–64 >=65 Total 0–14 15–24 Males and females 25–34 35–44 45–54 55–64 >=65 Total Population 208 696 710 130 963 661 154 190 079 120 294 576 95 722 295 59 709 423 54 667 272 824 244 016 189 488 306 122 365 550 147 455 225 114 644 560 91 278 229 57 526 734 67 348 448 790 107 052 398 185 016 253 329 211 301 645 304 234 939 136 187 000 524 117 236 157 122 015 720 1 614 351 068 Number of new S+ cases 1430 24 962 40 030 39 561 38 547 31 529 38 317 214 376 1667 18 468 23 327 17 838 15 513 12 425 16 234 105 472 3097 43 430 63 357 57 399 54 060 43 954 54 551 319 848 Rates per 100 000 0.7 19.1 26.0 32.9 40.3 52.8 70.1 26.0 0.9 15.1 15.8 15.6 17.0 21.6 24.1 13.3 0.8 17.1 21.0 24.4 28.9 37.5 44.7 19.8

TABLE 8

Trend in notified tuberculosis cases (all types) in DOTS and non-DOTS areas American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong, China Japan Kiribati Republic of Korea Lao PDR Macao, China Malaysia N. Mariana Islands Marshall Islands Micronesia, FS Mongolia Nauru New Caledonia New Zealand Niue Palau Papua New Guinea Philippines Pitcairn Islands Samoa Singapore Tokelau Solomon Islands Tonga Tuvalu Vanuatu Viet Nam Wallis and Futuna WPR

Year 1977 1978 1979 1980 1981 1982 1983 1984 1985

7 8 2 2 6 6 8 12 5 8 9 13 5 15 2

1251 1292 230 1542 216 1457 196 1386 285 1270 245 1219 276 8158

257 95 67 183 78 64 30 205 81 71 37 210 73 55 10 180 58 41 98 654 19 163 48 49

7191 89 245 6623 80 629 7903 76 455

97 40 94 81 910

10 264 10 441 442 11 094 1101 11 168 585 10 970 11 894 455 11 634 671 10 577 571 10 569 420 10 735 389 11 068 320 10 944 274 10 686 343 10 873 1951 994 1905 1135 1307 1440 1923 2165 2437 2234 2382 329 11 059 294 11 420 318 12 075 349 11 708 354 11 778 455 12 902 589 13 539 463 14 115 0 14 908 449 15 057 465 14 830 46 40 26

8 6 4 6 7

1075 1107 1123 1160 1094 1325 1514 1652 2994 2819 2433 2538 2233 1659 1611

608 595 542 108 474 128 448 107 437 161 415 144 402 104 359 98 320 74 296 111 295 110 303 130 348 140 335 140 317 149 274 4 132 352 0 0 307 2

7 14 9 17 10 17 14 20 26 13 38 17 3

2212 107 108 2446 118 587 2232 108 813 2525 112 307 2418 116 821 2742 104 715 2954 106 300 3505 151 863 3678 151 028 2877 153 129 3235 163 740 4261 183 113 3396 217 272 2497 317 008

36 2760 355 59 2964 411 58 2800 452 59 2710 266 49 2425 313

62 89 71

150 131 68 650 7 184 11 821

222 855 294 647 308 161 346 198 353 240 355 645 457 427 534 450 611 088 650 256 714 475 766 627 796 087 888 409 784 409

8065 70 916 146 89 803 7729 65 867 187 98 532 7527 63 940 193 7301 62 021 127 91 572 7843 61 521 111 85 669

64 33 178 43 062 49 18 92 43 506

75 12 67 74 15 73 58 12 75 64 15 66 16 37 60 49 32 97 27 28 11 77 7 68

43 2179 324 0 45 12 173 51 206 41 2065 302 50 23 171 43 185 9 188 43 875

7572 117 557 29 185 66 48

1299 256 10 241 151 564 20 165 73 54 1088 238 10 145 226 899 36 230 75 37 906 212 10 325 265 095 17 199 79 49 907 189 9106 313 604 16 173 63 34

37 2143 337 0 54

7545 58 567 103 87 169 7432 56 690 129 88 789 7269 56 496 110 87 419 7021 54 357 208 74 460 6704 53 112 121 70 012 6510 51 821 6283 50 612 68 63 904 57 864

1952 377 2 49 32 124 46 941 1760 292 35 27 131 47 557 90 55 505

1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

29 1616 334 9 24 22

954 126 10 691 362 114 15 162 64 41 952 128 1016 143 950 1011 7906 367 799 6501 375 481 10 903 376 246 16 148 1 218 58 75 1 252 59 40 210 49 12 240 83 6 82 70

29 1666 372 1 14 24 118 52 463 37 1617 488 35 25 144 52 270

44 1591 382 1 23 23 140 47 536 309 19 16 234 54 509

3401 207 371 2540 236 172 5516 174 189 5335 180 044 8041 235 496 5087 276 295 7977 208 301

6534 48 956 100 48 070 6537 47 437 46 999

67 52 111 61 151 171 0 0

1516 1418 1730 3010 3010 2987 2915 3348 3109 3526

26 1512 364 1 23 30 147 56 594 4 433 480 49 1722 367 32 28 114 52 994 711 162

991 160 13 270 344 218 15 112 363 804

1 25 2 41 1 19 2 5

4 225 89 94 1 203 0 0 0 0 0 0

6319 44 590 253 38 155 6212 43 078 0 33 196

45 1677 332 0 23 19 152 51 763 11 723 716 0 51 1889 352 1 20 36 0 37 1889 289 1 22 0 32 1977 318 0 21 0 79 55 739 4 774 721 0 74 711 0 942 481

6 0 6 0 4 3 3

1073 1073 1145 899

0 14 599 357 829 0 14 857 469 358 0 15 629 418 903 0 16 946 457 349

0 200 86 0 171 91 2 166 105 3 192 93

6501 42 122 327 31 134 6983 42 190 32 26 202

0 56 94 93 0 108

0 205 323 0 0 328

0 15 1

0 184 84 964 14 834 722

7673 44 016 276 30 008 7087 40 800 253 23 936 7578 39 384 210 21 782 7262 35 489 189 37 268

97 49 138 66 42 102 75 34 91 58 56 95

0 102 367 0 0 348

0 11 291 159 866

0 22 2120 295 0 30 18 178 87 449 0 839 121 0 31 1654 289 0 22 0 43 1728 303 0 24 0 22 1536 292 0 11 0 117 88 879 0 823 421 0 152 89 792 0 806 970 0 173 90 679 0 811 263

1073 272 19 266 460 169 1043 307 18 891 463 373 980 216 19 170 485 221

2 32 12 189 145 807 0 0 0 12 121 128 495 0 3470 107 133

1 144 59 54 2 183 45 63

4 86 344 3 64 377

TABLE 9

Trend in notified tuberculosis cases (new smear-positives) in DOTS and non-DOTS areas American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong, China Japan Kiribati Republic of Korea Lao PDR Macao, China Malaysia N. Mariana Islands Marshall Islands Micronesia, FS Mongolia Nauru New Caledonia New Zealand Niue Palau Papua New Guinea Philippines Pitcairn Islands Samoa Singapore Tokelau Solomon Islands Tonga Tuvalu Vanuatu Viet Nam Wallis and Futuna WPR

Year 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

881 741 807 0 765 6 723 3 690 6 596 9 634 2 583 5 3 5801 5316 5507 5235 8715 7173 8246 5842 5132 8507 536 1 557 68 12 910 9560 90 184 84 898 19 236 25 628 38 367 53 078 60 949

145 41 101 32 114 41 111 52 97 39 98 32 79 48 82 52 99 48 86 49 75 45 65 44 76 43 83 63 34 4 75 40 4 39 53

13 373 13 198 12 806 12 291 12 214 12 649 13 010 13 277 4142 13 808 4110 13 745 4042 14 405 3918 14 592 3768 14 710 3670 15 498 3564 15 285 15 540 2429 15 210

22 4 21 34 633 10 38 211 34 43 868 17 46 735 14 45 688 42 561 48 515 49 083 45 066 39 040 33 968 30 700 28 790 17 736 99 16 630 526 459 765 752 726 886 1234 1508 1719 1526 1533 133 124 140 158 108 171 141 204 304 226 0 133 157

6050 6313 6622 6819 6766 7320 7251 6660 6682 6653 6924 6718 6711 6774 6752 6754 6954 6861 6688 7271 7596 7802 7960 8156 8309 22 14 0 21 14 19 12 8 15 0 0 11 3 28 4 5 22 5 4 6 11 34 60 10 5 2 6

852 903 883 967 17 275 867 19 006 942 20 676 870 18 657 1061 21 291 363 320 271 276 234 185 128 92 87 200 622 622 1171 1356 1513 1389 1631 40 37 33 32 35 2 42 0 0 91 61 47 76 57 81 69 74 68 0 0 1 1 0 0 8 11 9 4 7 0 812 92 279 573 87 401 1652 94 768 652 86 695 1195 83 353 2107 71 663 1914 73 373 2267 67 056 462 59 341 69 66 55 62 4 0 4 870 39 571 606 50 624 839 72 150 1273 63 655 951 97 070 611 489 2 21 18 0 15 0 10 0 14 0 7

1285 182 1375 174 1197 184 1266 153 32 1062 174 30 25 20 998 176 860 130 992 155 949 155 839 101 740 115 794 137 823 149 840 117 88

29 41 28

57 52 52

22 917 22 934 57 388 78 049 118 202 148 558 150 982 161 230 208 493 226 410 186 522 178 366 199 654 94 522 100 286 184 312 267 476

32 23 59 18 10 34 33 243 25 23 25 23 18 12 7 3 49 33 014 7 55 32 612 3 55 30 426 3 51 34 217 5 36 30 381 7 26 34 530 7 46 39 486 2 39 35 095 16 17 7 5 30 728 35 865

6 32 7 18 8 14 4 10 18

841 130 0 17 155 16

5 84 38 659 2 41 36 534

11 058 104 729 3 0 0 0 0 11 101 134 488 0 12 065 168 270 0 12 686 188 529 0 13 865 214 462

1 60 38 40 0 68 0 0 0 0 0 0

14 777 184 18 375 0 14 367 0 11 754

861 114 0 17 455 109 1 455 9

1 62 35 613 2 282 061 6 30 37 550 0 314 624 0 0 48 911 0 352 935

0 69 37 0 66 41 1 74 34 0 65 33

2116 12 867 144 11 420 1536 13 571 1869 11 935 1566 12 909 1940 11 853 1853 11 408 11 9957

0 17 10 14 26 0 11

0 26 0 0

90 1 16

6 171 0 203

432 113 0 12 480 140 0 16 465 93 0 10

0 66 53 647 1 375 801 0 38 54 873 0 393 244 0 43 53 805 0 393 801 0 63 53 169 0 385 434 0 56 54 202 0 379 060

50 10 359 59 54 9559 8 216

11 28

0 30 0 0

3 285 102 15 744 212 426 2 251 2 228 84 14 822 213 766 95 14 361 212 766

15 17 16 27 11 15 8

1 20 0 0 0 0

0 17 0 13 0 12

0 62 29 42 2 73 24 47

4 38 2 34

248 109 0 15 357 118 0 8

64 11 805

19 15

TABLE 10

Trend in tuberculosis notification rates per 100 000 population (all types) American Samoa 40 23 26 6 6 18 17 24 34 14 22 24 35 14 32 4 Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong, China Japan Kiribati Republic of Korea Lao PDR Macao, China Malaysia N. Mariana Islands Marshall Islands Micronesia, FS Mongolia Nauru New Caledonia New Zealand Niue Palau Papua New Guinea Philippines Pitcairn Islands Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis and Futuna WPR

Year 1976 1977 1978 1979 1980 1981 1982 1983 1984

10 207 9 9 133 11 121 10 106 167 206 59 118 107 142 137 136 117 135 99 56 79 130 188 56 143 152 29 30 29 38 34 36 36 37 38 10 106

44 43 30 33 33 28 25 28 24 32 28 23 22 29 34 28 71 32 21 5 0 0 10 15 6 10 29 26 25 21 20 23 17 22 32

81 68 55 55 49 39 31 40 46 47 44 37 34 32 33 27 45 39 41 0 39 40 46 40 26 19

58 176 82 76 68 51 37 49 42 45 31 40 27 33 60 32 156 141 161 158 149 145 138 145 137 135 130 123 116 112 106 111 49 64 0 0 0 0 0 35 40 113 109 96 99 106 115 105 112 104

87 505 78 70 66 61 56 54 52 51 49 47 46 45 43 42 41 39 38 36 34 34 34 35 32 31 28 329 0 409 40 333 298 250 225 141 173 71 162 243 307 322 208 179 163 202 169 315 178 100 229 211 212 212 208 177 165 149 134 110 107 105 74 69 57 65 51 46 79 45 23 41 24 27 29 37 40 44 42 44 150 217 146 101 94 72 60 76 70 77 83 88 80 103 134 105 0 103 104 218 236 254 411 196

89 80 80 83 81 78 82 78 70 67 67 66 65 62 61 60 61 63 59 58 63 64 66 68 68 66 98 66 0 143 139 89 109 76 146 153 441 435 305 320 80 136 71 74

65 30 21 14 19 22 38 45 34 54 128 107 26 18 93 100 85 73 64 103 79 72

76 71 71 70 71 65 77 86 91 162 148 125 127 109 79 75 78 90 72 111 95 69 66 48 69 69 79 84 82 85 36 0 0 0 0 0 33 24 74 0 111 0 50 0 41 29

20 20 19 17 15 14 14 13 12 11 10 9 9 9 10 10 9 8 10 9 67

38 50 100 64 113 67 142 100 154 217 93 271 121 25

65 338 79 84 77 84 78 83 84 106 108 85 90 118 87 67 238 260 234 233 236 204 204 284 276 274 279 308 362 516 330 377 269 272 347 399 295 222 198 168 139

52 123 154 23 38 37 37 31 27 25 23 119 172 126 192

74 68 95 75 100 69 471 52 225 0 45 150 48 288 0 100 56 113

221 152 128 163 155 77 140 134 145 95 97 62 79 90 96 156 96 73 92 47 0 103 98 63 76 86

115

134 23 80 79 91 76 75 78 77 86 82 81 72 81 82 74 71 76 99 29 45.7 79 45.5 27 48.2 0 57.9

117 205 112 118

9 148 8 123 8 8 110 95

99 134 88 130 83 117

11 161 14 21 25 30 33 33 33 33 105 180 85 94 88 5 6

84 125 76 140 68 102

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

7 106 6 6 6 6 6 6 6 94 80 52

49 400 36 338

18 18 22 27

116

450 50

25 275 15 300 29 313

63 122 60 153 59 120 94

23 288 19 200

90 65 135 130 187 116 177 245 259 236 71

106 120

103 151 171

69 64 77 122 120 116 111 125 131 138

16 29 27 31 22 19 13 18 25 14

54 109 62 104 59 57 56 57 61 47 53 37 91 93 74 79 71 63 74 63

23 375 33 311 211

50 156 100 50 256 112 29 88 0 178 0 0

0 50 50 0 0 0 0 0

11 0 10 0 6 5 4

6 6 6 5 6 5 5

0 0 0 0 85 91 65

146 145 149 158 175 157 143

0 98 0 80 67 56 108

0 75 83 103 74 79 75

20 360 22 21 0 0

5 100 9 10 0 50

111 100 50.8 112 112 117 115 0 50.6 0 49.2 0 49.0 0 47.7

30 180 22 24 11 0 0 0

9 100 9 10 0 0

TABLE 11

Trend in tuberculosis notification rates per 100 000 population (smear-positives) American Samoa 0 18 9 18 26 6 14 8 Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong, China Japan Kiribati Republic of Korea Lao PDR Macao, China Malaysia N. Mariana Islands Marshall Islands Micronesia, FS Mongolia Nauru New Caledonia New Zealand Niue Palau Papua New Guinea Philippines Pitcairn Islands Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis and Futuna WPR

Year 1976 1977 1978 1979 1980 1981 1982 1983 1984

7 6 5 6 5 5 5 4 4 4 84 75 76 71 115 92 104 73 63 101 3 2 3 24 150 103 111 6 0 10 0 5 4 3 0 0 1 1 2 1 1 0 0 0 0 32 25 28 111 117 121 129 143 123 107 8 7 9 11 14 15 17 17 17 17 24 21 5 0 0 0 5 0 0 10 2 3 4 5 6

21 24 17 18 18 15 15 12 12 14 12 10 9 10 11 8 10

31 30 23 28 35 26 21 29 33 30 27 26 23 24 75 75 72 69 65 63 19 22 19 37 27 0 0 0 0 0 27 30 0 32 23 28 23 29 27 42 60

12 12 11 11 11 10 11 11 11 11 11 12 12 12 13 12 12 12 12 11 10 11 9 10 9 9

42 39 7 36 17 56 28 23 92 100 113 119 114 105 118 117 107 93 80 72 67 41 129 239 0 180 14 60 69 64 76 38 41 26 25 22 22 21 17 25 12 10 17 16 15 18 24 28 31 29 28 29 27 30 41 28 43 32 46 69 51 0 30 35

53 47 48 49 50 48 50 49 44 42 41 41 40 39 38 37 36 37 35 33 35 36 36 36 37 37 47 23 0 22 37 20 39 25 0 30 0 18 27 18 29 46 29 24 18 8 15 0 8 8 21 12 13 6 0 65 18 147 20 25 61 16 13 19 18 20 29 14 15 44 20 15 11 19 20 17 14 14 11 9 6 4 4 9 25 25 46 52 56 58 64 18 0 0 0 0 0 33 16 25 23 20 19 20 24 0 14 0 15 0 18 15 3 2 1 1 2 2 2 2 2 0 0 50 50 0 0 50 0 0 50 69 53 24 41 0 111 0 0 20 14 38 15 27 46 41 44 9 142 132 140 125 118 99 100 88 77 2 2 2 2 33 0 29 23 41 67 33 17 43 30 31 30 32 28 29 25 32 26 18 23 35 24 17 13 1 13 11 9 6 8 4 10 8 8 36 38 40 36 40 72 90 123 107 162 21 19 16 12

59 55 58 50 52 43 40 34 39 37 32 28 30 31 31

94 88 81 83 68 75 70 50 58 57 35 40 45 47 37 27

24 32 44 29 34 329 19 125 25 22 26 23 19 13 7 38 88 38 38 63 88 88 25 16 17 0 17 16 0 50 50 0 0 0 0 0 17 9 16 12 16 10 15 8 88 63 63 22 11 60 0 0 0 0 0 0

69 58 51 46 51 28 40 43 42 39 27 18 31 24 61 59 57 52 57 49 53 62 54 47 53 55 26 38 18 0 37 21 23 32 28 56 51 49 51 65 70 70 68 69 68 16.6 14 17.5 0 19.6 0 21.7 7 22.9 0 23.7 0 23.5 0 23.4 0 22.3

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

39 44

8 9 9 8 9 8 7 9

18 0 17 18 15 14 13 10

31 14 13 13 14 13 8 9

31 29 23 28 34 20 27 25

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

TABLE 12

Trend in tuberculosis notification (number of all types) in DOTS and non-DOTS areas, 1998–2001 Brunei Darussalam N. Mariana Islands 0 14 115 0 97 0 14 908 0 66 75 0 0 58 0 0 0 7802 26 0 7960 15 27 0 0 19 0 0 N. Mariana Islands 0 0 Hong Kong, China Republic of Korea French Polynesia American Samoa

Macao, China

Cook Islands

Cambodia

Australia

Lao PDR

1998

DOTS Non-DOTS

6 0

424 475

0 0

16 946 0

336 535 120 814

2 0

166 0

105 0

0 0

0 7673

0 44 016

276 0

30 008 0

2149 16

463 0

1999

DOTS Non-DOTS

4 0

511 562

272 0

19 266 0

346 200 113 969

3 0

192 0

93 0

0 0

5831 1256

40 800 0

253 0

23 936 0

2437 0

0 0

2000

DOTS Non-DOTS

3 0

490 553

307 0

18 891 0

348 436 114 937

1 0

144 0

59 0

54 0

6011 1567

15 397 23 987

210 0

0 21 782

1617 617

449 0

15 057

2001

DOTS Non-DOTS

0 3

485 495

216 0

19 170 0

362 172 123 049

2 0

183 0

45 0

63 0

5907 1355

17 809 17 680

189 0

0 37 268

1618 764

465 0

14 830

TABLE 13

Trend in tuberculosis notification (number of new smear-positives) in DOTS and non-DOTS areas, 1998–2001 Brunei Darussalam Hong Kong, China Republic of Korea French Polynesia American Samoa Macao, China Cook Islands

Cambodia

Australia

Lao PDR

1998

DOTS non-DOTS

6 0

116 87

0 0

13 865 0

191 290 23 172

1 0

74 0

34 0

0 0

0 1869

0 11 935

50 0

10 359 0

1494 14

226 0

1999

DOTS non-DOTS

3 0

153 133

102

15 744

188 525 23 901

0 0

65 0

33 0

0 0

1566 0

12 909 0

59 0

9559 0

1719 0

0 0

2000

DOTS non-DOTS

2 0

122 129

84 0

14 822 0

191 280 22 486

0 0

62 0

29 0

42 0

1517 423

4415 7438

54 0

0 8216

1526 0

133 0

8156

2001

DOTS non-DOTS

0 2

99 129

95 0

14 361 0

188 480 24 286

2 0

73 0

24 0

47 0

1425 428

5709 5699

64 0

0 11 805

1533 0

157 0

8309

Malaysia

Kiri\bati

China

Guam

Japan

Fiji

Malaysia

Kiri\bati

Japan

Guam

China

Fiji

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

Papua New Guinea

Wallis and Futuna

Solomon Islands

Marshall Islands

Pitcairn Islands

New Caledonia

Micronesia, FS

New Zealand

Philippines

Singapore

WPR total

Mongolia

Viet Nam

Vanuatu

Tokelau

Samoa

Tuvalu

Tonga

Nauru

Palau

Niue

839 142 0 49 0 138 2725 190 0 0 102 0 0 367 1 0 15 0 2845 8446 18 286 141 580 0 0 22 0 0 2120 295 0 0 0 30 0 0 18 178 84 599 2850 0 0 496 000 343 142 823 421 42 0 102 0 3348 0 0 0 0 0 0 348 0 2 32 1214 31 825 113 982 0 0 31 0 1654 0 289 0 0 0 22 0 0 0 86 31 88 426 453 0 0 566 869 256 552 806 970 34 0 91 0 3109 0 4 0 0 86 344 0 0 0 0 0 2534 9587 96 371 32 124 0 0 43 0 590 1138 303 0 0 0 24 0 0 0 105 47 89 792 0 0 0 600 545 206 425 811 263 56 0 95 0 3526 0 3 0 0 64 89 288 0 0 0 0 3470 0 107 133 0 0 0 22 0 749 787 292 0 0 0 11 0 0 0 121 52 90 679 0 0 0 629 458 181 805 78 22 74 26 69 31 59 41

0 10 975

Papua New Guinea

Wallis and Futuna

Solomon Islands

Marshall Islands

Pitcairn Islands

New Caledonia

Micronesia, FS

New Zealand

Philippines

Singapore

WPR total

Mongolia

Viet Nam

Vanuatu

Tokelau

Samoa

Tuvalu

Nauru

Tonga

Palau

Niue

393 257 0 11 0 28 1213 143 0 0 30 0 0 81 0 0 7 0 418 1689 10 292 61 371 0 0 7 0 0 480 140 0 0 0 16 0 0 0 0 38 53 147 1726 0 0 282 785 110 472 393 802 17 0 16 0 1513 0 0 0 0 0 0 69 0 1 20 0 254 1660 20 477 52 896 0 0 17 0 465 0 93 0 0 0 10 0 0 0 24 19 53 561 244 0 0 306 904 86 898 385 434 11 0 15 0 1389 0 4 0 0 38 74 0 0 0 0 0 403 1864 49 991 17 065 0 0 13 0 105 143 109 0 0 0 15 0 0 0 26 37 53 169 0 0 0 327 595 57 839 379 060 15 0 8 0 1631 0 2 0 0 34 21 47 0 0 0 0 462 0 59 341 0 0 0 12 0 175 182 118 0 0 0 8 0 0 0 46 10 54 202 0 0 0 336 438 42 622 89 11 85 15 78 22 72 28

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

TABLE 14

Trend in tuberculosis notification (rate for all types) in DOTS and non-DOTS areas, 1998–2001 Brunei Darussalam Hong Kong, China Republic of Korea French Polynesia American Samoa

Macao, China

Cook Islands

Cambodia

Australia

Lao PDR

Population x 1000 1998 DOTS Non-DOTS Population x 1000 1999 DOTS Non-DOTS Population x 1000 2000 DOTS Non-DOTS Population x 1000 2001 DOTS Non-DOTS

63 9.5 0.0 64 6.3 0.0 68 4.4 0.0 70 0.0 4.3

18 445 2.3 2.6 18 641 2.7 3.0 19 138 2.6 2.9 19 338 2.5 2.6

313 0.0 0.0 320 85.0 0.0 328 93.5 0.0 335 64.5 0.0

10 751 157.6 0.0 10 981 175.4 0.0 13 104 144.2 0.0 13 441 142.6 0.0

1 255 091 26.8 9.6 1 265 979 27.3 9.0 1 275 133 27.3 9.0 1 284 972 28.2 9.6

20 10.0 0.0 20 15.0 0.0 20 5.1 0.0 20 10.1 0.0

822 20.2 0.0 834 23.0 0.0 814 17.7 0.0 823 22.2 0.0

227 46.3 0.0 231 40.3 0.0 233 25.3 0.0 237 19.0 0.0

161 0.0 0.0 164 0.0 0.0 155 34.8 0.0 158 39.8 0.0

6671 0.0 115.0 6729 86.7 18.7 6860 87.6 22.8 6961 84.9 19.5

125 920

46 115 65.1 0.0 46 505 51.5 0.0 46 740 0.0 46.6 47 069 0.0 79.2

5358 40.1 0.3 5525 44.1 0.0 5279 30.6 11.7 5403 29.9 14.1

440 105.2 0.0 440 0.0 0.0 444 101.1 0.0 449 103.7 0.0

21 450 0.0 65.8 21 877 0.0 68.1 22 218 67.8 0.0 22 633 65.5 0.0

0.0 332.5 35.0 126 187 0.0 85

32.3 297.6 0.0 127 096 0.0 83

12.1 253.3 18.9 127 335 0.0 84

14.0 224.9 13.9 0.0

TABLE 15

Trend in tuberculosis notification (rate for new smear-positives) in DOTS and non-DOTS areas, 1998–2001 Brunei Darussalam Hong Kong, China Republic of Korea French Polynesia American Samoa Macao, China Cook Islands

Cambodia

Australia

Lao PDR

Population x 1000 1998 DOTS Non-DOTS Population x 1000 1999 DOTS Non-DOTS Population x 1000 2000 DOTS Non-DOTS Population x 1000 2001 DOTS Non-DOTS

63 9.5 0.0 64 4.7 0.0 68 3.0 0.0 70 0.0 2.9

18 445 0.6 0.5 18 641

313 0.0 0.0 320

10 751 129.0 0.0 10 981 143.4 0.0 13 104 113.1 0.0 13 441 106.8 0.0

1 255 091 15.2 1.8 1 265 979 14.9 1.9 1 275 133 15.0 1.8 1 284 972

20 5.0 0.0 20 0.0 0.0 20 0.0 0.0 20

822

227

161 0.0 0.0 164 0.0 0.0 155

6671 0.0 28.0 6729 23.3 0.0 6860 22.1 6.2 6961 20.5 6.1

125920 0.0 9.5 126187 10.2 0.0 127096 3.5 5.9 127335 4.5 4.5

83 60.2 0.0 85 69.4 0.0 83 65.1 0.0 84 76.1 0.0

46 115 22.5 0.0 46 505 20.6 0.0 46 740 0.0 17.6 47 069 0.0 25.1

5358 27.9 0.3 5525 31.1 0.0 5279 28.9 0.0 5403 28.4 0.0

440 51.4 0.0 440 0.0 0.0 444 29.9 0.0 449 35.0 0.0

21 450 0.0 36.4 21 877 0.0 36.4 22 218 36.7 0.0 22 633 36.7 0.0

9.0 15.0 0.0 834 0.0 231

0.8 31.9 0.7 19 138 0.0 328

7.8 14.3 0.0 814 0.0 233

0.6 25.6 0.7 19 338 0.0 335

7.6 12.4 27.1 0.0 823 0.0 237 0.0 158

0.5 28.4 0.7 0.0

14.7 10.1 1.9 0.0

8.9 10.1 29.7 0.0 0.0 0.0

Malaysia

Kiri\bati

Japan

China

Guam

Fiji

Malaysia

Kiri\bati

Japan

Guam

China

Fiji

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

Papua New Guinea

N. Mariana Islands

Wallis and Futuna

Solomon Islands

Marshall Islands

Pitcairn Islands

New Caledonia

Micronesia, FS

New Zealand

Philippines

Singapore

70 0.0 138.6 74 0.0 89.2 73 103.0 0.0 76 76.4 0.0

61 0.0 80.3 63 66.7 0.0 51 66.5 0.0 52 108.1 0.0

134

2624

11 0.0 0.0 11 0.0 0.0 12

206 3680 49.5 0.0 0.0 10.0

2 50.0 0.0 2

17 4602 72 164 88.2 61.8 25.3 196.2

170 12.9 0.0

3491 0.0 60.7 3541 46.7 0.0 4018 14.7 28.3 4108 18.2 19.2

417 70.7 0.0 460 62.8 0.0 447 67.7 0.0 463 63.1 0.0

2 0.0 0.0 2 0.0 0.0 1 0.0 0.0 1 0.0 0.0

99 30.3 0.0 100 22.0 0.0 99 24.2 0.0 99 11.1 0.0

10 0.0 13.0 10 0.0 0.0 10 0.0 0.0 10 0.0 0.0

182 0.0 97.8 187 46.0 16.6 197 53.4 23.9 202 59.9 25.8

77 896 108.6 3.7 79 228 111.6 0.6 78 137 114.9 0.0 79 175 114.5 0.0

14 0.0 0.0 14 0.0 0.0 14 0.0 0.0 15 0.0 0.0

1 657 782 29.9 20.7 1 673 517 33.9 15.3 1 688 065 35.6 12.2 1 702 484 37.0 10.7

0.0 103.8 103.0 137 7.2 2680

0.0 183.5

210 3719 0.0 0.0 0.0

18 4706 73 601 25.8 43.2 154.9

172 18.0 0.0

74.5 124.9 0.0 123 0.0 2533

0.0 177.8

9.4 100.0 2 0.0 0.0 2 0.0 0.0

0.0 233.2

215 3778 0.0 39.9 9.1 0.0

19 4809 75 653 0.0 52.7 127.4 42.5

159 27.1 0.0

74.1 122.7 32.7 0.0 126 0.0 2559 0.0 13

0.0 199.3

220 3808 0.0 29.1 2.3 7.6

20 4920 77 131 0.0 0.0 70.5 0.0 138.9 0.0

159 13.8 0.0

75.5 137.8 24.0 0.0 0.0 0.0

N. Mariana Islands

Papua New Guinea

Wallis and Futuna

Solomon Islands

Marshall Islands

Pitcairn Islands

New Caledonia

Micronesia, FS

New Zealand

Philippines

Singapore

70 0.0 37.1 74 0.0 20.3 73 37.1 0.0 76 25.0 0.0

61 0.0 18.0 63 27.0 0.0 51 21.5 0.0 52 28.9 0.0

134 0.0 20.9 137 11.7 0.0 123 12.2 0.0 126 6.4 0.0

2624 46.2 5.4 2680 56.5 0.0 2533

206 3680 0.0 2.2

17 4602 72 164 9.1 14.3 85.0

170 4.1 0.0

3491 0.0 13.7 3541 13.1 0.0 4018 2.6 3.6 4108 4.3 4.4

417 33.6 0.0 460 20.2 0.0 447 24.4 0.0 463 25.5 0.0

2 0.0 0.0 2 0.0 0.0 1 0.0 0.0 1 0.0 0.0

99 16.2 0.0 100 10.0 0.0 99 15.1 0.0 99 8.0 0.0

10 0.0

182 0.0

77 896 68.2 2.2 79 228 67.6 0.3 78 137 68.0 0.0 79 175 68.5 0.0

14 0.0 0.0 14 0.0 0.0 14 0.0 0.0 15 0.0 0.0

1 657 782 17.1 6.7 1 673 517 18.3 5.2 1 688 065 19.4 3.4 1 702 484 19.8 2.5

0.0 14.6 0.0 11 0.0 0.0 12 0.0

0.0 41.2 0.0 2

0.0 36.7

0.0 20.9 10 187

210 3719 0.0 0.0 0.0

18 4706 73 601 5.4 27.8 71.9

172 9.9 0.0

0.0 111.1

0.0 12.8 0.0 10.2 10 197

1.9 50.0 2 0.0 0.0 2 0.0 0.0

0.0 35.3

215 3778 0.0 2.0 0.0

19 4809 75 653 0.0 8.4 66.1 22.6

159 8.2 0.0

54.8 32.7 0.0 2559

0.0 13.2 0.0 18.8 10 202

0.0 17.7 13

0.0 38.8

220 3808 0.0 0.6 1.2

20 4920 77 131 0.0 0.0 9.4 0.0 76.9 0.0

159 7.6 0.0

63.7 16.0 0.0

0.0 22.8 0.0 5.0

0.0 15.5

WPR total

Mongolia

Viet Nam

Vanuatu

Tokelau

Samoa

Tuvalu

Nauru

Tonga

Palau

Niue

WPR total

Mongolia

Viet Nam

Vanuatu

Tokelau

Samoa

Tuvalu

Tonga

Nauru

Palau

Niue

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

TABLE 16

Treatment outcome of new smear-positive cases registered in 2000 in DOTS areas Outcomes of treatment (%) Country American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong, China Japan Kiribati Republic of Korea Lao PDR Macao, China Malaysia N. Mariana Islands Marshall Islands Micronesia, FS Mongolia Nauru New Caledonia New Zealand Niue Palau Papua New Guinea Philippines Pitcairn Islands Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis and Futuna Total 320 046 1.3 88.9 3.5 2.0 1.1 1.9 1.4 92.3 26 53 169 0.0 0.1 76.9 89.9 11.5 2.2 3.8 1.8 0.0 1.0 7.7 3.1 0.0 1.9 88.5 92.1 13 105 118 0 15 0.0 93.3 0.0 0.0 6.7 0.0 0.0 93.3 0.0 0.0 0.0 84.6 0.0 66.1 7.7 84.8 26.3 0.0 7.6 6.8 0.0 1.0 0.0 7.7 6.7 0.8 0.0 0.0 0.0 92.3 84.8 92.4 422 50 196 4.7 0.1 38.6 72.6 24.2 15.2 25.6 5.8 0.5 1.2 2.4 2.3 4.0 2.8 62.8 87.8 Not evaluated Completed Transferred Treatment Registered (% ) Cured treatment Defaulted Failed Died out success 0 114 84 14 775 191 280 0 62 62 43 1517 4984 54 0 1392 160 0 27 11 14 1389 0 0 14 0 50.0 21.4 28.6 0.0 0.0 0.0 0.0 50.0 0.0 0.0 0.0 0.1 81.5 63.6 92.9 83.2 0.0 27.3 0.0 3.7 0.0 9.1 0.0 4.2 0.0 0.0 0.0 3.3 0.0 0.0 7.1 2.7 18.5 0.0 0.0 2.8 81.5 90.9 92.9 86.8 0.0 0.0 72.8 81.3 8.7 8.1 8.5 4.4 0.4 0.0 6.8 5.6 2.8 0.6 81.5 89.4 0.0 0.0 0.0 0.0 12.7 0.0 80.6 0.0 93.0 70.3 47.2 83.3 4.8 96.8 0.0 5.3 22.5 7.4 8.1 0.0 0.0 4.3 2.0 0.0 0.0 1.6 0.0 8.0 5.5 1.9 4.8 1.6 7.0 3.9 10.0 7.4 1.6 0.0 0.0 8.2 0.0 0.0 85.5 96.8 93.0 75.6 69.7 90.7 5.3 0.0 0.0 1.8 19.3 41.7 87.8 94.6 54.4 21.4 3.5 0.0 1.8 3.6 3.9 0.8 0.0 0.0 0.3 1.0 7.9 16.7 3.6 1.0 11.4 16.7 0.8 0.9 73.7 63.1 91.4 94.6

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

TABLE 17

Treatment outcome of new smear-positive cases registered in 2000 in non-DOTS areas Outcomes of treatment (%) Country American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong, China Japan Kiribati Republic of Korea Lao PDR Macao, China Malaysia N. Mariana Islands Marshall Islands Micronesia, FS Mongolia Nauru New Caledonia New Zealand Niue Palau Papua New Guinea Philippines Pitcairn Islands Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis and Futuna Total 38 139 13.3 57.0 12.8 5.2 5.6 2.0 4.1 69.8 37 100.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 137 0.0 0.0 61.3 19.7 0.0 19.0 0.0 61.3 6165 0.0 0.0 67.3 14.4 5.3 3.6 9.4 67.3 4 45 59 25.0 0.0 74.6 25.0 33.3 1.7 0.0 55.6 23.7 0.0 2.2 0.0 0.0 0.0 0.0 0.0 8.9 0.0 50.0 0.0 0.0 25.0 88.9 25.4 3231 62 0.8 0.0 80.9 53.2 1.6 11.3 3.1 19.4 1.3 1.6 1.6 12.9 10.7 1.6 82.5 64.5 423 5364 78.3 74.0 2.4 13.8 5.0 8.9 1.4 0.4 0.0 2.2 11.1 0.7 1.9 0.0 7.3 22.7 22 486 2.9 81.3 0.0 4.0 7.4 1.6 2.8 81.3 Not evaluated Completed Transferred Treatment Registered (% ) Cured treatment Defaulted Failed Died out success 2 124 0.0 14.5 0.0 33.9 100.0 37.1 0.0 3.2 0.0 0.0 0.0 9.7 0.0 1.6 100.0 71.0

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

TABLE 18

Treatment outcome of re-treatment cases registered in 2000 in DOTS areas Outcomes of treatment (%) Country American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong, China Japan Kiribati Republic of Korea Lao PDR Macao, China Malaysia N. Mariana Islands Marshall Islands Micronesia, FS Mongolia Nauru New Caledonia New Zealand Niue Palau Papua New Guinea Philippines Pitcairn Islands Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis and Futuna Total 54 043 7.2 83.5 3.0 1.3 2.0 2.2 0.9 86.6 5 8806 0.0 3.5 100.0 74.0 0.0 4.7 0 0 0 0 0 0 0.0 3.3 100.0 78.7 1 0.0 100.0 0.0 0 0 0 0.0 100.0 3 0.0 0.0 100.0 0 0 0 0.0 100.0 68 2.9 29.4 35.3 0 0 0 5.9 64.7 8 50.0 0.0 50.0 0 0 0 0.0 50.0 20 126 0.0 0.8 25.0 57.1 60.0 14.3 0 0 0 0 0 0 0.0 4.8 85.0 71.4 51 37 0.0 0.0 51.0 67.6 9.8 16.2 0 0 0 0 0 0 2.0 0.0 60.8 83.8 218 605 9 0.0 13.1 0.0 26.6 46.4 88.9 26.1 20.8 0.0 0 0 0 0 0 0 0 0 0 7.8 0.0 0.0 52.8 67.3 88.9 827 43 252 0.0 8.0 85.4 86.5 4.6 2.2 0 0 0 0 0 0 0.1 0.4 90.0 88.6 7 0.0 0.0 85.7 0 0 0 14.3 85.7 Not evaluated Completed Transferred Treatment Registered (% ) Cured treatment Defaulted Failed Died out success

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

TABLE 19

Treatment outcome of re-treatment cases registered in 2000 in non-DOTS areas Outcomes of treatment (%) Country American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong, China Japan Kiribati Republic of Korea Lao PDR Macao, China Malaysia N. Mariana Islands Marshall Islands Micronesia Mongolia Nauru New Caledonia New Zealand Niue Palau Papua New Guinea Philippines Pitcairn Islands Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis and Futuna Total 728 56.7 22.9 8.4 2.2 4.1 2.1 3.6 31.3 1 100.0 0.0 0.0 0 0 0 0.0 0.0 15 73.3 0.0 20.0 0 0 0 0.0 20.0 131 2.3 58.8 1.5 0 0 0 19.1 60.3 13 564 0.0 70.6 23.1 15.2 7.7 9.4 0 0 0 0 1 0 7.7 0.0 30.8 24.6 4 0.0 25.0 50.0 0 0 0 0.0 75.0 Not evaluated Completed Transferred Treatment Registered (% ) Cured treatment Defaulted Failed Died out success

PART III

Charts Chart 1 Notification of all cases (rate per 100 000) by country, Western Pacific Region, 2001 Chart 2 Notification of new smear-positive cases (rate per 100 000) by country, Western Pacific Region, 2001 Chart 3 Notification rate of new smear-positive cases by age and sex in DOTS areas, Western Pacific Region, 2001 Chart 4 DOTS enrolment rate in high-burden countries, Western Pacific Region, 2001 Chart 5 DOTS enrolment rate of new smear-positive cases in high-burden countries, Western Pacific Region, 1997 and 2001 Chart 6 DOTS case detection rate of new smear-positive cases in high-burden countries, Western Pacific Region, 2001 Chart 7 Treatment success of new smear-positive cases under DOTS in high-burden countries, Western Pacific Region, 2001 Chart 8 DOTS progress in high-burden countries in the Western Pacific Region, 1998–2001 34

Charts

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

CHART 1

Notification of all cases (rate per 100 000) by country, Western Pacific Region, 2001

Kiribati Cambodia Philippines Mongolia Viet Nam Marshall Islands Hong Kong, China Macao, China Vanuatu Republic of Korea Micronesia, FS Papua New Guinea Malaysia Brunei Darussalam Solomon Islands Western Pacific Region Lao PDR Guam Singapore China New Caledonia Japan Nauru Fiji French Polynesia Samoa Tonga Cook Islands New Zealand Australia American Samoa 0 5 4 29 28 24 22 19 14 11 10 10 37 38 48 44 40 66 65 63 71 75 86 79 115 108 104 104 143 139 138

225

100

150

200

250

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

CHART 2

Notification of new smear-positive cases (rate per 100 000) by country, Western Pacific Region, 2001

Cambodia Philippines Kiribati Viet Nam Mongolia Malaysia Macao, China Guam Marshall Islands Lao PDR Brunei Darussalam Vanuatu Hong Kong, China Solomon Islands Republic of Korea Western Pacific Region China Nauru New Caledonia French Polynesia Cook Islands Papua New Guinea Japan Fiji Singapore Tonga Samoa Micronesia, FS American Samoa New Zealand Australia 0 3 2 1 6 10 10 9 9 9 9 8 8 17 16 15 30 29 28 28 28 27 25 25 22 37 35 64 68 77 76

107

100

125

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

CHART 3

Notification rate of new smear-positive cases by age and sex* in DOTS areas, Western Pacific Region, 2001 60

0-14

15-24

25-34 35-44 45-54 Age group (years) Female 2001

55-64 Total 2001

>=65

Male 2001

*Population by age and sex is taken from Demographic Tables for the Western Pacific Region, 2000–2005.

CHART 4

DOTS enrolment rate* in high-burden countries, Western Pacific Region, 2001

Cambodia Lao PDR Viet Nam China Mongolia Papua New Guinea Philippines Western Pacific Region 0% 25% 50% 75% New S+ 2001

100%

All types 2001

*Population of notified cases enroled under DOTS strategy out of all notified cases.

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

CHART 5

DOTS enrolment rate* of new smear-positive cases in highburden countries, Western Pacific Region, 1997 and 2001 Cambodia Lao PDR Viet Nam China Mongolia Papua New Guinea Philippines Western Pacific Region % 0 25 New S+ 1997

75 New S+ 2001

100

*Population of notified cases enroled under DOTS strategy out of all notified cases.

CHART 6

DOTS case detection rate of new smear-positive cases in highburden countries, Western Pacific Region, 2001 Cambodia China Lao PDR Mongolia Papua New Guinea Philippines Viet Nam Western Pacific Region % 0 25 Detection by DOTS (DOTS detection rate)

100

Detection by non-DOTS

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

CHART 7

Treatment success of new smear-positive cases under DOTS in high-burden countries, Western Pacific Region, 2001 Cambodia China Lao PDR Mongolia Papua New Guinea Philippines Viet Nam Western Pacific Region % 0 25 Successful

50 Others

100 Not evaluated

CHART 8

DOTS progress in high-burden countries in the Western Pacific Region, 1998–2001 100 95 Treatment success new S+ (%) 90 85 80 75 70 65 60 55 50 0 10 20 30 40 50 60 70 80 90 100 DOTS detection rate new S+ (%) Papua New Guinea (from 2000) Lao PDR China Cambodia Philippines Mongolia Target zone Viet Nam

2001 1998

Annexes Annex 1 Profiles of high-burden countries in the Western Pacific Region Annex 2 Definitions 40

Annexes

ANNEX

Profiles of high-burden countries in the Western Pacific Region even countries in the Region have been identified as having a high burden of tuberculosis. Cambodia, China, the Philippines and Viet Nam are among the 22 globally defined high-burden countries (based on estimated incidence); the Lao People’s Democratic Republic, Mongolia and Papua New Guinea are defined as high-burden countries in the regional context. The following country profiles for the seven high-burden countries in the Western Pacific Region have been updated using information provided during the last regional meeting of the NTP managers in Cebu, Philippines (December 2002).

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

TABLE A1

DOTS enrolment and treatment success rates are high. Increased case detection is expected in the coming year following expansion of DOTS to more operational districts.

Key indicators for tuberculosis control, 1998–2001 Key Indicators Total population x 1000 Notification all cases Notification new S+ New S+ out of all cases, % Detection rate all cases, % Detection rate new S+, % Population with access to DOTS, % DOTS enrolment rate (new S+, %) DOTS case detection rate (new S+, %) Treatment success under DOTS (new S+, %) Prevalence of HIV infection among tuberculosis cases, % 1998 10 715 16 946 13 865 82 24 54 100 98 53 91 5.2 (1997) 2001 13 441 19 170 14 361 75 24 41 100 98 40 91 8.4 (2002)

Cambodia Sentinel Surveillance 2002, NCHADS, Cambodia).

is ranked the 20th high burden country for tuberculosis globally and fourth in the Region (by estimated incidence of all cases). The NTP has set up DOTS in all

77 operational districts in 145 tuberculosis units and in 381 health centres (40%) at village level, in order to monitor the continuation phase of treatment. DOTS enrolment and treatment success rates are high. Increased case detection is expected in the coming year following expansion of DOTS to more operational districts. Prevalence of HIV infection among tuberculosis patients is a major concern and has increased, from 6% in 2000 to 8.4% in 2002 (in a sentinel group of 2358 tuberculosis patients in 21 provinces, HIV/AIDS

DOTS Progress (1) Political commitment

DOTS started in 1994 Clear policies, guidelines and plans in line with DOTS Regular Interagency Coordinating Committee meetings 90% of management posts filled

(2) Diagnosis by microscopy

Smear microscopy available in 145 tuberculosis units Culture and drug sensitivity testing at central level Quality assurance at central and district level 90% of diagnostic centres provide good quality services

(3) DOT and tuberculosis drugs

Available > 95% of the time 98% DOTS enrolment of new smear-positive cases In all province and district hospitals and 40% of the health centres

(4) Monitoring

Training and supervision according to plan Reporting from all tuberculosis units

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

TABLE A2

Multidrug resistance (combined resistance to at least rifampicin and isoniazide) was found to be high in China, ranging from 2.9% to 5.3% of newly detected cases in three provinces.

Key indicators for tuberculosis control, 1998–2001 Key Indicators Total population x 1000 Notification all cases Notification new S+ New S+ out of all cases, % Detection rate all cases, % Detection rate new S+, % Population with access to DOTS, % DOTS enrolment rate (new S+, %) DOTS case detection rate (new S+, %) Treatment success under DOTS (new S+, %) Treatment success new S+, % DOTS (non-DOTS) Primary multidrug resistant tuberculosis (new S+, %) Guangdong Zhejiang Shandong — (2000) 5.3 4.3 2.9 1998 1 255 697 457 349 214 462 47 32 33 64 74 89 30 96 2001 1 284 972 485 221 212 766 44 34 33 68 75 89 29 96 (81)

China

has the second highest tuberculosis burden globally and is ranked highest in the Region with 70% of estimated all cases and 61% of all notified cases in 2001. The case detection rate for new

smear-positive cases (out of estimated cases) was 33%. About 68% of the population has access to DOTS. Treatment success was 82% for new smear-positive cases (cohort 2000 in DOTS areas). A new NTP started in 2002 in 31 provinces (after the World Bank Health V project and Ministry of Health projects terminated in 2001). Multidrug resistance (combined resistance to at least rifampicin and isoniazide) was found to be high in China, ranging from 2.9% to 5.3% of newly detected cases in three provinces (2000). A joint monitoring mission in November 2002 identified several major constraints: insufficient human resources at central and provincial levels, inadequate financial support from prefectures/counties, lack of budgeted planning, weak drugs procurement and management capacity, and difficulty maintaining quality of DOTS in the context of rapid programme expansion and ensuring complementary funding from different sources.

DOTS Progress (1) Political commitment

DOTS started in 1991 Tuberculosis manual and guidelines in line with DOTS ICC meeting Support from CIDA, DFB, GFATM, JICA, KNCV, WB, WHO 2003 DOTS expansion plan available

(2) Diagnosis by microscopy

Smear microscopy available in 31 provinces, 321 prefectures and 1857 counties (65%) Culture available in 31 provinces, 216 prefectures and 230 counties (8%) Drug sensitivity testing in 15 provinces and 21 prefectures Quality assurance in all microscopy centres Adequate quality in 70–90% of diagnosis centres

(3) DOT and tuberculosis drugs (4) Monitoring

89% DOTS enrolment of new smear-positive cases Available > 95% of the time Training, supervision according to plan, joint monitoring mission in five provinces in November 2002 Reporting <80% of tuberculosis units

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

TABLE A3

Full DOTS coverage is expected by the end of 2003. Also, DOTS will be decentralized in health posts at village level in three pilot provinces.

Key indicators for tuberculosis control, 1998–2001 Key Indicators Total population x 1000 Notification all cases Notification new S+ New S+ out of all cases, % Detection rate all cases, % Detection rate new S+, % Population with access to DOTS, % DOTS enrolment rate (new S+, %) DOTS case detection rate (new S+, %) Treatment success under DOTS (new S+, %) 1998 5163 2165 1508 70 25 39 71 99 39 62 2001 5403 2382 1533 64 19 27 78 100 26 82

The Lao People’s Democratic Republic success reaching 82%. posts at village level in three pilot provinces.

was ranked the fifth highburden country for

tuberculosis in the Region in 2001. DOTS had started in 16 provinces and 92 districts by the end of 2002. The two remaining provinces (with 32 districts) will start DOTS in 2003. The case detection rate for smear-positive cases was 26% in 2001 with treatment

DOTS is implemented in the government hospital service, from central to district hospital level, in 163 DOTS units covering 74.5% of the population. Tuberculosis drugs are free for hospitalized patients (in government hospitals). DOTS is not extended to the private sector (clinics and pharmacies). Full DOTS coverage is expected by the end of 2003. Also, DOTS will be decentralized in health

DOTS Progress (1) Political commitment

DOTS started in 1995 No ICC established, 2003 plan available 50–80% of tuberculosis staff positions filled Tuberculosis manual and guidelines in line with DOTS strategy

(2) Diagnosis by microscopy

95% of laboratory technicians trained for tuberculosis Culture and drug sensitivity testing not available Quality assurance at central level and provinces in all centres by random sampling Adequate quality in 70–90% of diagnosis centres

(3) DOT and tuberculosis drugs (4) Monitoring

Available > 95% of the time 100% DOTS enrolment of new smear-positive cases Training and supervision follow plans <80% of tuberculosis units report to the central level

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

TABLE A4

Mongolia passed WHO targets for the first time in 2001, attaining a DOTS case detection rate of 72% and treatment success of 87% for new smearpositive cases.

Key indicators for tuberculosis control, 1998–2001 Key Indicators Total population x 1000 Notification all cases Notification new S+ New S+ out of all cases, % Detection rate all cases, % Detection rate new S+, % Population with access to DOTS, % DOTS enrolment rate (new S+, %) DOTS case detection rate (new S+, %) Treatment success under DOTS (new S+, %) 1998 2579 2915 1356 47 55 57 97 89 51 86 2001 2559 3526 1631 46 70 72 100 100 72 87

Mongolia

was ranked the seventh highest burden country for tuberculosis in the Region in 2001. It passed WHO targets for the first time in 2001, attaining a DOTS case

detection rate of 72% and treatment success of 87% for new smear-positive cases, two years after attaining full DOTS coverage (21 aimags and eight districts) in 1999. DOTS was also extended to all prisons in 1999 (with a cure rate of 65% in 2001). Next, the programme will be targeted towards developing mechanisms for implementing Global Fund support, increasing quality of DOTS in rural areas (by collaborating with poverty projects and involving family doctors) and strengthening the quality of laboratory services.

DOTS Progress (1) Political commitment

DOTS started in 1995 2003 plan available Tuberculosis manual and guidelines in line with DOTS Regular Inter Agency Coordination Committee meetings Support from DANIDA extended up to 1994 Global Fund

(2) Diagnosis by microscopy

Diagnosis centres are adequate Effective quality assessment system Adequate quality in > 90% of the diagnosis centres

(3) DOT and tuberculosis drugs

Operational guidelines are available in tuberculosis manual Drugs available 70–95% of the time 100% DOTS enrolment of new smear-positive cases

(4) Monitoring

>80% of tuberculosis staff positions are filled Training plans available and implemented Supervision according to plan >80% of tuberculosis units are submitting reports

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

TABLE A5

DOTS started in 1997 and covered eight provinces (18% of the population) by the end of 2002. In 2001, 3470 cases were notified in DOTS provinces.

Key indicators for tuberculosis control, 1998–2001 Key Indicators Total population x 1000 Notification all cases Notification new S+ New S+ out of all cases, % Detection rate all cases, % Detection rate new S+, % Population with access to DOTS % DOTS enrolment rate (new S+, %) DOTS case detection rate (new S+, %) Treatment success under DOTS (new S+, %) Primary multidrug resistance (2000) 1998 4599 11 291 2107 19 98 41 9 20 8 93 2001 4920 3470 462 13 29 9 13 100 8 63 1

Papua New Guinea centres (non-DOTS provinces). Treatment success (new smear-positives, cohort 2000) was 63%.

was ranked as having the sixth highest burden of tuberculosis

in the Region in 2001. DOTS started in 1997 and covered eight provinces (18% of the population) by the end of 2002. In 2001, 3470 cases were notified in DOTS provinces through the tuberculosis quarterly reporting system. Also, 15 897 “on treatment” tuberculosis cases all types (including 1122 sputum positive cases) were reported through the monthly health information system from 571 health

The priorities are to strengthen programme management in the central and regional levels, expand DOTS in the 12 remaining provinces, improve funding from provinces and districts, upgrade laboratory services (providing refresher training for province laboratory staff, laboratory equipment and consumables, and development of quality assessment) and increase supervision from provinces to districts and from districts to below.

DOTS Progress (1) Political commitment

DOTS started in 1997 Insufficient human resources in central unit 2003 plan available Tuberculosis manual and guidelines in line with DOTS ICC was funded in 2002 and taken over by the Coordination Committee of the Global Fund

(2) Diagnosis by microscopy

Inadequate laboratory services with shortage of staff in periphery Quality assessment is not routinely carried out 70 to 90 of the evaluated centers have satisfactory quality

(3) DOT and tuberculosis drugs

Operational guidelines are available in the new manual Drugs are available 70–95% of the time 100% DOTS enrolment of new smear-positive cases

(4) Monitoring

Training plan is available and implemented in phases Supervision guidelines are not routinely used >80% of the tuberculosis units (in DOTS provinces) report to central level

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

TABLE A6

DOTS started in 1996 and was rapidly expanded to cover 97% of the population. The DOTS case detection rate also rose rapidly to 57% in 2001.

Key indicators for tuberculosis control, 1998–2001 Key Indicators Total population x 1000 Notification all cases Notification new S+ New S+ out of all cases, % Detection rate all cases, % Detection rate new S+, % Population with access to DOTS, % DOTS enrolment rate (new S+, %) DOTS case detection rate (new S+, %) Treatment success under DOTS (new S+, %) 1998 72 944 159 866 71 663 45 70 70 17 14 10 83 2001 77 131 107 133 59 341 55 46 57 97 100 57 88

The Philippines Region in 2001. It reported 13% of all cases notified in the Region in 2001.

was ranked as having the seventh highest tuberculosis burden globally and second in the

DOTS started in 1996 and was rapidly expanded to cover 97% of the population. The DOTS case detection rate also rose rapidly to 57% in 2001 (from only 10% in 1998), while the treatment success rate is 88%. Smear microscopy is available in each rural health unit or municipality with one validation centre in each province or city. Tuberculosis reference laboratories (national and regional) can perform culture and drug sensitivity tests. Shortages of tuberculosis staff at the central and regional levels and training at province and hospital levels are major constraints. Delayed procurement and distribution of tuberculosis drugs are also a recurrent problem, resulting in drug shortages and absence of buffer stock. In municipalities, local government units may buy variable and budget-driven amounts of drugs (Category 3) for smear-negative or extrapulmonary cases. A Public-Private Mix DOTS pilot project aims at involving the private sector in DOTS.

DOTS Progress (1) Political commitment

DOTS started in 1996 Strong central NTP unit (but shortage of staff) New Manual of Procedures diffused in line with DOTS Funding gap < 30% Provinces and municipalities have allocated funds for staffing Regular ICC meeting with partners Inadequate advocacy and promotion to increase demand Lack of involvement of the private sector

(2) Diagnosis by microscopy

Diagnosis centres adequate and well staffed Quality assessment system is in place but the laboratory network needs to be strengthened

(3) DOT and tuberculosis drugs

Operational guidelines are available in the new Manual of Procedures 100% DOTS enrolment of new smear-positive cases Tuberculosis drugs subject to quality criteria Delayed procurement and delivery of drugs, available less than 70% of the time in one year

(4) Monitoring

Inadequate monitoring and supervision >80% of the tuberculosis units submit reports but with some delay

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

TABLE A7

About 1% of Viet Nam’s tuberculosis patients were infected by HIV, although in some provinces more than 5% of tuberculosis cases were due to HIV.

Key indicators for tuberculosis control, 1998–2001 Key Indicators Total population x 1000 Notification all cases Notification new S+ New S+ out of all cases, % Detection rate all cases, % Detection rate new S+, % Population with access to DOTS, % DOTS enrolment rate (new S+, %) DOTS case detection rate (new S+, %) Treatment success under DOTS (new S+, %) Prevalence of HIV infection among tuberculosis cases, % Primary multidrug resistance 1998 77 562 87 449 54 873 63 60 83 96 97 81 91 2001 79 175 90 679 54 202 60 63 84 100 100 83 92 1 (2000)

Viet Nam Programme of Immunization).

was ranked 13th among the 22 highest burden countries globally (2000) and third in the Region, with 11% of all cases in 2001. About 1% of Viet Nam’s

tuberculosis patients were infected by HIV, although in some provinces more than 5% of tuberculosis cases were due to HIV (in 2000). Major constraints are low case detection in remote areas, fast development of the private sector, rapid turnover of staff in the context of health sector reforms, increased HIV prevalence among tuberculosis cases, and stigmatization of tuberculosis among health staff and the general public. NTP priorities are to improve the quality of DOTS in remote areas, step up tuberculosis education in the community, and coordinate and integrate tuberculosis control with other programmes (the HIV programme and the Expanded

DOTS Progress (1) Political commitment Strong NTP central unit, 2003 implementation plan available, NTP manual in line with DOTS, no funding gap, regular ICC meetings (2) Diagnosis by microscopy Microscopy services available and well staffed With effective quality assessment system, 70–90% of centres are of adequate quality Two National Reference Laboratories (culture, drug sensitivity testing, training, monitoring, research), 61 province laboratories (smear examination, culture, quality assessment, training, supervision) and 623 district laboratories (smear examination, quality assessment) Quality assessment by double reading, all positive and 10% negative (3) DOT and tuberculosis drugs Operational guidelines are available in the tuberculosis manual >80% of new smear-positives are under DOTS Tuberculosis drugs available, >95% with quality assessment (4) Monitoring Training plan and supervision guidelines are available and implemented, >80% of reporting units submit their reports

ANNEX

Definitions

Definitions of tuberculosis cases A case of tuberculosis: A patient in whom tuberculosis has been bacteriologically confirmed, or has been diagnosed by a clinician. Any person given treatment for tuberculosis should be recorded. All types: The sum of new smear-positive pulmonary, relapse, new smear-negative pulmonary and extrapulmonary cases. New smear-positive pulmonary: A patient who has never received treatment for tuberculosis or has taken anti-tuberculosis drugs for less than four weeks and who has one of the following: • Two or more initial sputum smear examinations positive for acid fast bacilli (AFB); or • one sputum examination positive for AFB plus radiographic abnormalities consistent with active pulmonary tuberculosis as determined by a treating medical officer; or • one sputum specimen positive for AFB and at least one sputum specimen that is culture positive for AFB. New smear-negative pulmonary: A case of pulmonary tuberculosis that does not meet the above definition for smear-positive tuberculosis: Extrapulmonary tuberculosis: Tuberculosis of organs other than the lungs: e.g. pleura, lymph nodes, abdomen, genito-urinary tract, skin, joints and bones, meninges, 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: Relapses, failures and defaulters. Relapse: A patient previously treated for tuberculosis and declared cured or treatment completed, who is later diagnosed with bacteriologically positive (culture smear) tuberculosis.

Definitions of treatment outcome Cured: A patient who is sputum smear-negative in the last month of treatment and on at least one previous occasion. Completed treatment: A patient who has completed treatment but who does not meet the criteria to be classified as a cure or a failure. Treatment success: The sum of patients who are cured and those who have completed treatment. 6

WHO, IUATLD, KNCV. Revised International Definitions in Tuberculosis Control. Int J Tuberc Lung Dis 2001; 5: 213–215.

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

Died: A patient who dies for any reason during the course of treatment. Failure: A patient who is sputum smear-positive at five months or later during the course of 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: Patients who did not have the treatment outcome evaluated. Note: In countries where culture is current practice, patients can be classified as cured or a failure on the basis of culture results.

Indicators to assess treatment outcome Cure rate: Proportion of cured cases out of all cases registered in a certain period (in 2000 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 cure rate of 85% 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 2000 (reported in 2002) is compared to the number of cases notified as smear-positive in 2000 (reported in 2001). Differences may arise because NTPs do not compile data at the end of each calendar year, diagnoses may be incorrect, patients are lost between diagnosis and the start of treatment, or records are lost. Second, only a fraction of registered cases was evaluated for outcome. All registered cases should be evaluated. Third, data on the six standard, mutually exclusive outcomes of treatment are compiled. These figures are reported as percentages of all registered cases, so that the possible outcomes plus the fraction of cases not evaluated sum to 100%. When a country states the number of patients registered for treatment, but gives no outcomes, no result is reported rather than zero treatment success. Although treatment outcomes are expressed as percentages, they are referred to as rates. The six possible outcomes plus the fraction of cases not evaluated total 100%. If the number of registered cases is lower than the sum of the six outcomes or is missing, the denominator for treatment success will be the number evaluated or the number of smear-positive cases notified in the previous year, whichever is greater.

Case detection rate and DOTS detection rate DOTS. The recommended strategy for tuberculosis control. It comprises • government commitment to ensuring sustained, comprehensive tuberculosis control activities; • case detection by sputum smear microscopy among symptomatic patients selfreporting to health services; • standardized short-course chemotherapy using regimens of six to eight months, for at least all confirmed smear-positive cases. Good case management includes DOT during the intensive phase for all new sputum smear-positive cases, the continuation phase of rifampicin-containing regimens and the whole re-treatment regimen; • a regular, uninterrupted drug supply of all essential anti-tuberculosis drugs; and • a standardized recording and reporting system that allows assessment of casefinding and treatment results for each patient and of the tuberculosis control programme performance overall.

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2003

Targets for tuberculosis control were established by the World Health Assembly: • to cure 85% of the sputum smear-positive tuberculosis cases detected; and • 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 will be incomplete. The estimated case detection rate is defined as: Annual new smear-positive notifications (country) Case detection rate (%) = Estimated annual new smear-positive incidence (country) DOTS detection rate refers to case detection under DOTS: 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 2001 in this report was provided by WHO, Geneva. Population with access to DOTS: The country’s population that has access to units implementing DOTS. DOTS Enrolment Rate (%): This indicates a proportion of cases enroled 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 Annual notification of new S+ under DOTS DOTS enrolment rate (New S+) (%) = Total of annual notifications of new S+

TUBERCULOSIS CONTROL IN THE WHO WESTERN PACIFIC REGION 2000

WORLD HEALTH ORGANIZATION Regional Office for the Western Pacific Stop TB United Nations Avenue 1000 Manila, Philippines Tel No: +632 528 8001 Fax No: +632 521 1036 E-mail: stoptb@wpro.who.int Website: http://www.wpro.who.int ISBN: 92 9061 043 3

Основные сведения

Организация Всемирная организация здравоохранения (ВОЗ / WHO)

Тип документа Publications

Дата принятия 31 декабря 2003 г.

Источник Всемирная организация здравоохранения